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Pelvic Arteries: Revascularization
T. Gregory Walker, MD, FSIR
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KEY FACTS

  • Terminology

    • Procedure

      • Post Procedure

        TERMINOLOGY

        • Definitions

          • Aortoiliac occlusive disease: Stenotic or occlusive disease involving abdominal aorta &/or iliac arteries
            • Also known as Leriche syndrome
              • Classically described as clinical triad
                • Buttock & thigh claudication
                • Absent or decreased femoral pulses
                • Impotence
            • Usually due to peripheral artery disease (PAD)
              • Concurrent atherosclerosis prevalent elsewhere
                • Same atherosclerosis risk factors
            • Varying degrees of severity
              • Range from asymptomatic to rest pain & tissue loss
                • Depends on adequacy of collateral vessels, quality of infrainguinal arterial runoff
            • Intermittent claudication (IC): Reproducible muscular leg pain after walking, relieved with rest
              • Imbalance of supply and demand of blood flow
              • Stable clinical course in 75% of patients
                • Decreasing ankle-brachial index (ABI) best predictor of deterioration
              • Sudden worsening suggests need for intervention
            • Buttock claudication: Reproducible cramping pain in buttocks occurring during normal exertion
              • Results from poor perfusion of pelvic muscles; caused by proximal arterial blockage
                • e.g., distal aorta, common iliac arteries (CIAs)/internal iliac arteries
              • Decreasing ABI best predictor of deterioration
            • Acute limb ischemia (ALI): Sudden interruption of arterial blood flow to extremity
              • Usually due to arterial embolus or thrombosis
                • Embolic source may be cardiac or aneurysm
              • Occurs infrequently if only pelvic arteries involved
                • Typically requires concurrent infrainguinal lesion
          • Nonatherosclerotic pelvic arteriopathies
            • External iliac artery (EIA) endofibrosis: Entity specific to endurance athletes, particularly cyclists
              • Caused by repetitive flexion-extension of hip; causes stress lesions in arterial wall
                • Results in intimal subendothelial fibrosis with wall thickening & reduced luminal caliber
              • 90% of cases located in EIA
                • Unilateral in most cases (88%)
              • Presents with exercise-related claudication
                • Limits athlete's performance ability
              • Surgical bypass is mainstay of treatment
            • Fibromuscular dysplasia (FMD): Noninflammatory, nonatherosclerotic disorder affecting long unbranched medium-sized arterial segments
              • 5% reported incidence of iliac artery involvement in patients with renal/carotid artery FMD
                • EIA most commonly involved
                • Usually medial fibroplasia subtype: 80–90%
              • Unusual cause of lower extremity claudication
                • May present with acute limb ischemia from progressive obstruction/microemboli; usually responds well to angioplasty
                • Rarely presents with dissection/rupture; may require surgical bypass
          • Trans-Atlantic Inter-Society Consensus (TASC) II: Comprehensive PAD management document; classifies anatomic lesions, makes treatment recommendations
            • TASC II classification of aortoiliac lesions
              • Type A lesion
                • Unilateral/bilateral CIA stenoses
                • Unilateral/bilateral single short (≤ 3 cm) EIA stenoses
              • Type B lesion
                • Short (≤ 3 cm) infrarenal aortic stenosis
                • Unilateral CIA occlusion
                • Single/multiple EIA stenoses, totaling 3-10 cm; common femoral artery (CFA) uninvolved
                • Unilateral EIA occlusion not involving origins of internal iliac arteries or CFAs
              • Type C lesion
                • Bilateral CIA occlusions
                • Bilateral EIA stenoses 3-10 cm long; stenoses do not extend into CFAs
                • Unilateral EIA stenosis extending into CFA
                • Unilateral EIA occlusion involving internal iliac &/or CFA origins
                • Heavily calcified unilateral EIA occlusion with/without internal iliac/CFA origin involvement
              • Type D lesion
                • Infrarenal aortoiliac occlusion
                • Diffuse disease of aorta & both iliac arteries
                • Diffuse multiple stenoses unilaterally involving CIA & EIA plus CFA
                • Unilateral combined occlusions of CIA & EIA
                • Bilateral EIA occlusions
                • Iliac stenoses in AAA not amenable to endovascular aneurysm repair (EVAR); other lesions requiring open aortic/iliac surgery
            • TASC II categories: Treatment recommendations
              • Type A: Endovascular procedures recommended
                • Should be 1st-line treatment
              • Type B: Endovascular procedures recommended
                • Unless concurrent surgery for adjacent lesions
              • Type C: Open revascularization recommended
                • Endovascular procedures recommended only if potential for poor healing after open surgery
              • Type D: Endovascular procedures not recommended as 1st-line treatment
            • TASC III Consensus guidelines currently being considered
          • American College of Cardiology & American Heart Association Guidelines for PAD Management
            • Document addressing diagnosis & management of atherosclerotic, aneurysmal, & thromboembolic PAD
        • Pertinent Vascular Anatomy

          • CIA: Origin at aortic bifurcation; divides into external & internal iliac arteries
            • Typically 4-6 cm long, ≤ 1 cm in diameter
            • Extraperitoneal inferolateral course along medial psoas muscle margin; bifurcates at pelvic brim
          • EIA: Extends from CIA bifurcation to inguinal ligament
            • Typically 8-10 cm long, 6-8 mm in diameter
            • Anteroinferior course along psoas muscle medially
            • Gives origin to 2 major branches
              • Inferior epigastric artery
                • Arises immediately above inguinal ligament; cephalad course deep to rectus abdominis
                • Anastomoses with superior epigastric artery (continuation of internal mammary artery)
                • May give rise to obturator artery, or accessory obturator artery (anatomic variant seen in 30%)
              • Deep circumflex iliac artery
                • Courses along iliac crest of pelvis
                • Anastomoses with iliolumbar/superior gluteal artery; important collateral in iliac occlusions
          • Internal iliac (hypogastric) artery: Originates at CIA bifurcation; divides into 2 trunks
            • Anterior division: Various branches supply bladder, uterus, external genitalia, prostate, & rectum; also supply buttock & posterior thigh muscles
            • Posterior division: Various branches supply psoas, iliacus, gluteal, & erector spinae muscles

        PREPROCEDURE

        • Indications

          • Contraindications

            • Preprocedure Imaging

              • Getting Started

                PROCEDURE

                • Patient Position/Location

                  • Procedure Steps

                    • Alternative Procedures/Therapies

                      POST PROCEDURE

                      • Things to Do

                        OUTCOMES

                        • Complications

                          • Expected Outcomes

                            Selected References

                            1. Taeymans K et al: The CERAB technique: tips, tricks and results. J Cardiovasc Surg (Torino). 57(3):343-9, 2016
                            2. Grimme FA et al: Editor's choice--first results of the covered endovascular reconstruction of the aortic bifurcation (CERAB) technique for aortoiliac occlusive disease. Eur J Vasc Endovasc Surg. 50(5):638-47, 2015
                            3. Groot Jebbink E et al: Geometrical consequences of kissing stents and the covered endovascular reconstruction of the aortic bifurcation configuration in an in vitro model for endovascular reconstruction of aortic bifurcation. J Vasc Surg. 61(5):1306-11, 2015
                            4. Ichihashi S et al: Iliac artery stent placement relieves claudication in patients with iliac and superficial femoral artery lesions. Cardiovasc Intervent Radiol. 36(3):623-8, 2013
                            5. Abello N et al: Long-term results of stenting of the aortic bifurcation. Ann Vasc Surg. 26(4):521-6, 2012
                            6. Dattilo PB et al: Clinical outcomes with contemporary endovascular therapy of iliac artery occlusive disease. Catheter Cardiovasc Interv. 80(4):644-54, 2012
                            7. Rastogi N et al: Symptomatic fibromuscular dysplasia of the external iliac artery. Ann Vasc Surg. 26(4):574, 2012
                            8. Davies MG et al: Outcomes of reintervention for recurrent disease after percutaneous iliac angioplasty and stenting. J Endovasc Ther. 18(2):169-80, 2011
                            9. Ichihashi S et al: Long-term outcomes for systematic primary stent placement in complex iliac artery occlusive disease classified according to Trans-Atlantic Inter-Society Consensus (TASC)-II. J Vasc Surg. 53(4):992-9, 2011
                            10. Pulli R et al: Early and long-term comparison of endovascular treatment of iliac artery occlusions and stenosis. J Vasc Surg. 53(1):92-8, 2011
                            11. Willson TD et al: External iliac artery dissection secondary to endofibrosis in a cyclist. J Vasc Surg. 52(1):219-21, 2010
                            12. Sharafuddin MJ et al: Kissing stent reconstruction of the aortoiliac bifurcation. Perspect Vasc Surg Endovasc Ther. 20(1):50-60, 2008
                            13. Norgren L et al: Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 33 Suppl 1:S1-75, 2007
                            14. Greiner A et al: Kissing stents for treatment of complex aortoiliac disease. Eur J Vasc Endovasc Surg. 26(2):161-5, 2003
                            Related Anatomy
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                            Related Differential Diagnoses
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                            References
                            Tables

                            Tables

                            KEY FACTS

                            • Terminology

                              • Procedure

                                • Post Procedure

                                  TERMINOLOGY

                                  • Definitions

                                    • Aortoiliac occlusive disease: Stenotic or occlusive disease involving abdominal aorta &/or iliac arteries
                                      • Also known as Leriche syndrome
                                        • Classically described as clinical triad
                                          • Buttock & thigh claudication
                                          • Absent or decreased femoral pulses
                                          • Impotence
                                      • Usually due to peripheral artery disease (PAD)
                                        • Concurrent atherosclerosis prevalent elsewhere
                                          • Same atherosclerosis risk factors
                                      • Varying degrees of severity
                                        • Range from asymptomatic to rest pain & tissue loss
                                          • Depends on adequacy of collateral vessels, quality of infrainguinal arterial runoff
                                      • Intermittent claudication (IC): Reproducible muscular leg pain after walking, relieved with rest
                                        • Imbalance of supply and demand of blood flow
                                        • Stable clinical course in 75% of patients
                                          • Decreasing ankle-brachial index (ABI) best predictor of deterioration
                                        • Sudden worsening suggests need for intervention
                                      • Buttock claudication: Reproducible cramping pain in buttocks occurring during normal exertion
                                        • Results from poor perfusion of pelvic muscles; caused by proximal arterial blockage
                                          • e.g., distal aorta, common iliac arteries (CIAs)/internal iliac arteries
                                        • Decreasing ABI best predictor of deterioration
                                      • Acute limb ischemia (ALI): Sudden interruption of arterial blood flow to extremity
                                        • Usually due to arterial embolus or thrombosis
                                          • Embolic source may be cardiac or aneurysm
                                        • Occurs infrequently if only pelvic arteries involved
                                          • Typically requires concurrent infrainguinal lesion
                                    • Nonatherosclerotic pelvic arteriopathies
                                      • External iliac artery (EIA) endofibrosis: Entity specific to endurance athletes, particularly cyclists
                                        • Caused by repetitive flexion-extension of hip; causes stress lesions in arterial wall
                                          • Results in intimal subendothelial fibrosis with wall thickening & reduced luminal caliber
                                        • 90% of cases located in EIA
                                          • Unilateral in most cases (88%)
                                        • Presents with exercise-related claudication
                                          • Limits athlete's performance ability
                                        • Surgical bypass is mainstay of treatment
                                      • Fibromuscular dysplasia (FMD): Noninflammatory, nonatherosclerotic disorder affecting long unbranched medium-sized arterial segments
                                        • 5% reported incidence of iliac artery involvement in patients with renal/carotid artery FMD
                                          • EIA most commonly involved
                                          • Usually medial fibroplasia subtype: 80–90%
                                        • Unusual cause of lower extremity claudication
                                          • May present with acute limb ischemia from progressive obstruction/microemboli; usually responds well to angioplasty
                                          • Rarely presents with dissection/rupture; may require surgical bypass
                                    • Trans-Atlantic Inter-Society Consensus (TASC) II: Comprehensive PAD management document; classifies anatomic lesions, makes treatment recommendations
                                      • TASC II classification of aortoiliac lesions
                                        • Type A lesion
                                          • Unilateral/bilateral CIA stenoses
                                          • Unilateral/bilateral single short (≤ 3 cm) EIA stenoses
                                        • Type B lesion
                                          • Short (≤ 3 cm) infrarenal aortic stenosis
                                          • Unilateral CIA occlusion
                                          • Single/multiple EIA stenoses, totaling 3-10 cm; common femoral artery (CFA) uninvolved
                                          • Unilateral EIA occlusion not involving origins of internal iliac arteries or CFAs
                                        • Type C lesion
                                          • Bilateral CIA occlusions
                                          • Bilateral EIA stenoses 3-10 cm long; stenoses do not extend into CFAs
                                          • Unilateral EIA stenosis extending into CFA
                                          • Unilateral EIA occlusion involving internal iliac &/or CFA origins
                                          • Heavily calcified unilateral EIA occlusion with/without internal iliac/CFA origin involvement
                                        • Type D lesion
                                          • Infrarenal aortoiliac occlusion
                                          • Diffuse disease of aorta & both iliac arteries
                                          • Diffuse multiple stenoses unilaterally involving CIA & EIA plus CFA
                                          • Unilateral combined occlusions of CIA & EIA
                                          • Bilateral EIA occlusions
                                          • Iliac stenoses in AAA not amenable to endovascular aneurysm repair (EVAR); other lesions requiring open aortic/iliac surgery
                                      • TASC II categories: Treatment recommendations
                                        • Type A: Endovascular procedures recommended
                                          • Should be 1st-line treatment
                                        • Type B: Endovascular procedures recommended
                                          • Unless concurrent surgery for adjacent lesions
                                        • Type C: Open revascularization recommended
                                          • Endovascular procedures recommended only if potential for poor healing after open surgery
                                        • Type D: Endovascular procedures not recommended as 1st-line treatment
                                      • TASC III Consensus guidelines currently being considered
                                    • American College of Cardiology & American Heart Association Guidelines for PAD Management
                                      • Document addressing diagnosis & management of atherosclerotic, aneurysmal, & thromboembolic PAD
                                  • Pertinent Vascular Anatomy

                                    • CIA: Origin at aortic bifurcation; divides into external & internal iliac arteries
                                      • Typically 4-6 cm long, ≤ 1 cm in diameter
                                      • Extraperitoneal inferolateral course along medial psoas muscle margin; bifurcates at pelvic brim
                                    • EIA: Extends from CIA bifurcation to inguinal ligament
                                      • Typically 8-10 cm long, 6-8 mm in diameter
                                      • Anteroinferior course along psoas muscle medially
                                      • Gives origin to 2 major branches
                                        • Inferior epigastric artery
                                          • Arises immediately above inguinal ligament; cephalad course deep to rectus abdominis
                                          • Anastomoses with superior epigastric artery (continuation of internal mammary artery)
                                          • May give rise to obturator artery, or accessory obturator artery (anatomic variant seen in 30%)
                                        • Deep circumflex iliac artery
                                          • Courses along iliac crest of pelvis
                                          • Anastomoses with iliolumbar/superior gluteal artery; important collateral in iliac occlusions
                                    • Internal iliac (hypogastric) artery: Originates at CIA bifurcation; divides into 2 trunks
                                      • Anterior division: Various branches supply bladder, uterus, external genitalia, prostate, & rectum; also supply buttock & posterior thigh muscles
                                      • Posterior division: Various branches supply psoas, iliacus, gluteal, & erector spinae muscles

                                  PREPROCEDURE

                                  • Indications

                                    • Contraindications

                                      • Preprocedure Imaging

                                        • Getting Started

                                          PROCEDURE

                                          • Patient Position/Location

                                            • Procedure Steps

                                              • Alternative Procedures/Therapies

                                                POST PROCEDURE

                                                • Things to Do

                                                  OUTCOMES

                                                  • Complications

                                                    • Expected Outcomes

                                                      Selected References

                                                      1. Taeymans K et al: The CERAB technique: tips, tricks and results. J Cardiovasc Surg (Torino). 57(3):343-9, 2016
                                                      2. Grimme FA et al: Editor's choice--first results of the covered endovascular reconstruction of the aortic bifurcation (CERAB) technique for aortoiliac occlusive disease. Eur J Vasc Endovasc Surg. 50(5):638-47, 2015
                                                      3. Groot Jebbink E et al: Geometrical consequences of kissing stents and the covered endovascular reconstruction of the aortic bifurcation configuration in an in vitro model for endovascular reconstruction of aortic bifurcation. J Vasc Surg. 61(5):1306-11, 2015
                                                      4. Ichihashi S et al: Iliac artery stent placement relieves claudication in patients with iliac and superficial femoral artery lesions. Cardiovasc Intervent Radiol. 36(3):623-8, 2013
                                                      5. Abello N et al: Long-term results of stenting of the aortic bifurcation. Ann Vasc Surg. 26(4):521-6, 2012
                                                      6. Dattilo PB et al: Clinical outcomes with contemporary endovascular therapy of iliac artery occlusive disease. Catheter Cardiovasc Interv. 80(4):644-54, 2012
                                                      7. Rastogi N et al: Symptomatic fibromuscular dysplasia of the external iliac artery. Ann Vasc Surg. 26(4):574, 2012
                                                      8. Davies MG et al: Outcomes of reintervention for recurrent disease after percutaneous iliac angioplasty and stenting. J Endovasc Ther. 18(2):169-80, 2011
                                                      9. Ichihashi S et al: Long-term outcomes for systematic primary stent placement in complex iliac artery occlusive disease classified according to Trans-Atlantic Inter-Society Consensus (TASC)-II. J Vasc Surg. 53(4):992-9, 2011
                                                      10. Pulli R et al: Early and long-term comparison of endovascular treatment of iliac artery occlusions and stenosis. J Vasc Surg. 53(1):92-8, 2011
                                                      11. Willson TD et al: External iliac artery dissection secondary to endofibrosis in a cyclist. J Vasc Surg. 52(1):219-21, 2010
                                                      12. Sharafuddin MJ et al: Kissing stent reconstruction of the aortoiliac bifurcation. Perspect Vasc Surg Endovasc Ther. 20(1):50-60, 2008
                                                      13. Norgren L et al: Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 33 Suppl 1:S1-75, 2007
                                                      14. Greiner A et al: Kissing stents for treatment of complex aortoiliac disease. Eur J Vasc Endovasc Surg. 26(2):161-5, 2003