Management of Iliac Stenosis with Bilateral Lower Limb Claudication

Initial Management Approach

The American College of Radiology recommends conservative medical management as the first-line approach for patients with claudication symptoms due to iliac stenosis without significant occlusion 1, 2
Initial management should include antiplatelet therapy (75-325 mg ASA daily) to reduce risk of major adverse cardiac events, as recommended by the American College of Cardiology 3, 4
Risk factor modification, including treatment of hypertension, diabetes, and hyperlipidemia, is recommended by the American College of Radiology 2, 3
Supervised exercise therapy (SET) is recommended to improve maximum walking distance, as suggested by the American College of Radiology 2, 3
Cilostazol (100 mg twice daily) may be considered as an effective therapy to improve symptoms and increase walking distance in patients with claudication, according to the American College of Cardiology 4

Endovascular procedures are indicated for patients with vocational or lifestyle-limiting disability due to claudication, inadequate response to exercise and pharmacological therapy, and a favorable risk-benefit ratio, as recommended by the American College of Cardiology 4, 5, 6
Translesional pressure gradients should be obtained to evaluate significance of iliac arterial stenoses of 50-75% diameter before intervention, as suggested by the American College of Cardiology 6
Stenting is effective as primary therapy for common iliac artery stenosis and occlusions (TASC A and B lesions), according to the American College of Cardiology 6
Surgical interventions are indicated for patients with significant functional disability, unresponsive to exercise or pharmacotherapy, and with reasonable likelihood of symptomatic improvement, as recommended by the American College of Cardiology 4, 5, 8

For TASC A and B lesions, endovascular therapy is the treatment of choice, with primary stenting and percutaneous transluminal angioplasty with selective stenting showing high success rates, as recommended by the American College of Radiology 7
For TASC C lesions, both endovascular and surgical approaches are appropriate, with primary stenting highly recommended, according to the American College of Radiology 7
For TASC D lesions, a comprehensive approach is needed, with catheter-directed stent placement plus femoral angioplasty or surgical options preferred for complex disease, as suggested by the American College of Radiology 2, 7

Endovascular intervention should not be performed prophylactically in asymptomatic patients with PAD, as recommended by the American College of Cardiology 5, 6
Surgical intervention is not indicated to prevent progression to limb-threatening ischemia in patients with intermittent claudication, according to the American College of Cardiology 6, 8
A preoperative cardiovascular risk evaluation should be undertaken in patients in whom major vascular surgical intervention is planned, as recommended by the American College of Cardiology 6, 8