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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
- Classically described as clinical triad
- Usually due to peripheral artery disease (PAD)
- Concurrent atherosclerosis prevalent elsewhere
- Same atherosclerosis risk factors
- Concurrent atherosclerosis prevalent elsewhere
- Varying degrees of severity
- Range from asymptomatic to rest pain & tissue loss
- Depends on adequacy of collateral vessels, quality of infrainguinal arterial runoff
- Range from asymptomatic to rest pain & tissue loss
- 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
- Results from poor perfusion of pelvic muscles; caused by proximal arterial blockage
- 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
- Usually due to arterial embolus or thrombosis
- Also known as Leriche syndrome
- 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
- Caused by repetitive flexion-extension of hip; causes stress lesions in arterial wall
- 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
- 5% reported incidence of iliac artery involvement in patients with renal/carotid artery FMD
- External iliac artery (EIA) endofibrosis: Entity specific to endurance athletes, particularly cyclists
- 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
- Type A lesion
- 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
- Type A: Endovascular procedures recommended
- TASC III Consensus guidelines currently being considered
- TASC II classification of aortoiliac lesions
- American College of Cardiology & American Heart Association Guidelines for PAD Management
- Document addressing diagnosis & management of atherosclerotic, aneurysmal, & thromboembolic PAD
- Aortoiliac occlusive disease: Stenotic or occlusive disease involving abdominal aorta &/or iliac arteries
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
- Inferior epigastric artery
- 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
- CIA: Origin at aortic bifurcation; divides into external & internal iliac arteries
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
- Taeymans K et al: The CERAB technique: tips, tricks and results. J Cardiovasc Surg (Torino). 57(3):343-9, 2016
- 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
- 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
- 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
- Abello N et al: Long-term results of stenting of the aortic bifurcation. Ann Vasc Surg. 26(4):521-6, 2012
- Dattilo PB et al: Clinical outcomes with contemporary endovascular therapy of iliac artery occlusive disease. Catheter Cardiovasc Interv. 80(4):644-54, 2012
- Rastogi N et al: Symptomatic fibromuscular dysplasia of the external iliac artery. Ann Vasc Surg. 26(4):574, 2012
- Davies MG et al: Outcomes of reintervention for recurrent disease after percutaneous iliac angioplasty and stenting. J Endovasc Ther. 18(2):169-80, 2011
- 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
- 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
- Willson TD et al: External iliac artery dissection secondary to endofibrosis in a cyclist. J Vasc Surg. 52(1):219-21, 2010
- Sharafuddin MJ et al: Kissing stent reconstruction of the aortoiliac bifurcation. Perspect Vasc Surg Endovasc Ther. 20(1):50-60, 2008
- 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
- Greiner A et al: Kissing stents for treatment of complex aortoiliac disease. Eur J Vasc Endovasc Surg. 26(2):161-5, 2003
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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
- Classically described as clinical triad
- Usually due to peripheral artery disease (PAD)
- Concurrent atherosclerosis prevalent elsewhere
- Same atherosclerosis risk factors
- Concurrent atherosclerosis prevalent elsewhere
- Varying degrees of severity
- Range from asymptomatic to rest pain & tissue loss
- Depends on adequacy of collateral vessels, quality of infrainguinal arterial runoff
- Range from asymptomatic to rest pain & tissue loss
- 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
- Results from poor perfusion of pelvic muscles; caused by proximal arterial blockage
- 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
- Usually due to arterial embolus or thrombosis
- Also known as Leriche syndrome
- 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
- Caused by repetitive flexion-extension of hip; causes stress lesions in arterial wall
- 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
- 5% reported incidence of iliac artery involvement in patients with renal/carotid artery FMD
- External iliac artery (EIA) endofibrosis: Entity specific to endurance athletes, particularly cyclists
- 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
- Type A lesion
- 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
- Type A: Endovascular procedures recommended
- TASC III Consensus guidelines currently being considered
- TASC II classification of aortoiliac lesions
- American College of Cardiology & American Heart Association Guidelines for PAD Management
- Document addressing diagnosis & management of atherosclerotic, aneurysmal, & thromboembolic PAD
- Aortoiliac occlusive disease: Stenotic or occlusive disease involving abdominal aorta &/or iliac arteries
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
- Inferior epigastric artery
- 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
- CIA: Origin at aortic bifurcation; divides into external & internal iliac arteries
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
- Taeymans K et al: The CERAB technique: tips, tricks and results. J Cardiovasc Surg (Torino). 57(3):343-9, 2016
- 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
- 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
- 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
- Abello N et al: Long-term results of stenting of the aortic bifurcation. Ann Vasc Surg. 26(4):521-6, 2012
- Dattilo PB et al: Clinical outcomes with contemporary endovascular therapy of iliac artery occlusive disease. Catheter Cardiovasc Interv. 80(4):644-54, 2012
- Rastogi N et al: Symptomatic fibromuscular dysplasia of the external iliac artery. Ann Vasc Surg. 26(4):574, 2012
- Davies MG et al: Outcomes of reintervention for recurrent disease after percutaneous iliac angioplasty and stenting. J Endovasc Ther. 18(2):169-80, 2011
- 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
- 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
- Willson TD et al: External iliac artery dissection secondary to endofibrosis in a cyclist. J Vasc Surg. 52(1):219-21, 2010
- Sharafuddin MJ et al: Kissing stent reconstruction of the aortoiliac bifurcation. Perspect Vasc Surg Endovasc Ther. 20(1):50-60, 2008
- 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
- Greiner A et al: Kissing stents for treatment of complex aortoiliac disease. Eur J Vasc Endovasc Surg. 26(2):161-5, 2003
