Management of Bilateral Iliac Artery Stenosis

Diagnostic Evaluation

The American College of Radiology recommends cross-sectional imaging with CT angiography (CTA) or MR angiography (MRA) to determine the exact nature and level of stenosis, extent of atherosclerotic plaque, and to plan the treatment strategy 2, 3
The American College of Cardiology suggests that translesional pressure gradients (with and without vasodilation) should be obtained to evaluate the significance of angiographic iliac arterial stenoses of 50% to 75% diameter before intervention 4
Assessment of ankle-brachial index (ABI) is necessary to determine the severity of ischemia and guide treatment selection, as recommended by the American College of Cardiology 5

The American College of Radiology recommends primary stenting as the first-line treatment for bilateral iliac artery stenosis >50% (TASC C lesion) with a high appropriateness rating (8/9) 1, 2
Percutaneous transluminal angioplasty (PTA) alone may be appropriate (6/9 rating) but is generally less effective than primary stenting for complex lesions, according to the American College of Radiology 2
Surgical revascularization is also appropriate (7/9 rating) but typically reserved for cases where endovascular therapy fails, as suggested by the American College of Radiology 2

Primary stenting is effective for common iliac artery stenoses and occlusions (Level of Evidence: B), according to the American College of Cardiology 4
Covered balloon-expandable stents have demonstrated significantly higher patency rates than bare metal stents at 18, 24, 48, and 60 months (95.1%, 82.1%, 79.9%, 74.7% for covered stents versus 73.9%, 70.9%, 63% and 62.5% for bare metal stents), as reported by the American College of Radiology 1
Recent studies support an endovascular-first approach even for TASC C and D lesions, with similar 5- to 6-year patency rates to open surgery, according to the American College of Radiology 1

Single-agent antiplatelet therapy is recommended for all symptomatic patients to reduce the risk of major adverse cardiovascular events (MACE) and cardiovascular mortality, as suggested by the American College of Radiology 1, 3
High-dose statin therapy is indicated for all patients with peripheral arterial disease if tolerated, according to the American College of Radiology 1, 3
A supervised exercise program should be initiated to improve walking distance and reduce the need for secondary revascularization procedures, as recommended by the American College of Radiology 1

Any stenotic (>50%) superficial femoral artery (SFA) should be addressed at the time of iliac intervention, as it is a predictor of iliac intervention failure, according to the American College of Radiology 6
Multivariate analysis has identified several independent predictors of iliac intervention failure: hypertension, hypercholesterolemia, chronic renal insufficiency, poor tibial runoff, external iliac artery disease, female gender, smoking, diabetes mellitus, and presence of a distal bypass, as reported by the American College of Radiology 6

Endovascular revascularization (EVR) is associated with increased secondary interventions but decreased length of hospital stay and fewer postoperative complications compared to open surgery, according to the American College of Radiology 1
A meta-analysis comparing EVR, covered endovascular reconstruction of aortic bifurcation, and open surgery showed that open surgery has improved 3- and 5-year primary patency but similar secondary patency to endovascular approaches, as reported by the American College of Radiology 1
Open surgery has increased 30-day morbidity and mortality compared with endovascular approaches, according to the American College of Radiology 1