Initial Management of Iliac Artery Stenosis

Diagnostic Evaluation

The American College of Radiology recommends duplex ultrasound imaging of the aortoiliac segment and lower extremity to determine concordance between clinical symptoms and peripheral arterial disease (PAD) 1
Cross-sectional imaging with computed tomography angiography (CTA) or magnetic resonance angiography (MRA) is recommended to reveal the exact nature and level of stenosis and underlying atherosclerotic plaque to plan treatment strategy 1, 3

The American College of Radiology recommends antiplatelet therapy (single-agent) to reduce the risk of major adverse cardiovascular events (MACE) and cardiovascular mortality in symptomatic patients 2, 4, 3
High-dose statin therapy is indicated for all patients with PAD if tolerated (class IA recommendation) 2, 5, 3
Antihypertensive therapy should be administered to all patients with hypertension and PAD to reduce the risk of MACE including stroke, myocardial infarction, heart failure, or cardiovascular death 2, 5

A supervised exercise program should be initiated in all patients with non-limb-threatening PAD to improve maximum walking distance 1, 2, 5
Several randomized controlled trials have demonstrated significant improvement in disease-specific quality of life measurements, walking distance, and treadmill walking performance following SET 5, 6

Endovascular intervention should be considered when optimal medical therapy and supervised exercise programs fail to control symptoms or in cases of critical limb ischemia 3
For TASC A and B lesions, percutaneous transluminal angioplasty (PTA) alone or in combination with stent placement in patients with suboptimal results after PTA is usually appropriate 7

Surgical revascularization is typically reserved for patients who fail endovascular therapy or have extensive disease not amenable to endovascular treatment 4, 8
Recent studies have demonstrated no significant differences in short- and long-term secondary patency comparing endovascular revascularization and open surgery for treatment of aortoiliac occlusive disease 8

Stenotic (>50%) superficial femoral artery (SFA) should be addressed at the time of iliac intervention, as it is a predictor of iliac intervention failure 7
Covered balloon-expandable stents have demonstrated significantly higher patency rates than bare metal stents at 18, 24, 48, and 60 months in the COBEST trial 4, 8