Treatment of Severe Atherosclerosis of the Abdominal Aorta and Bilateral Iliac Arteries

Initial Assessment and Classification

The European Society of Cardiology recommends diagnostic evaluation including duplex ultrasound imaging of the aortoiliac segment and lower extremities to determine the extent of disease 3, 4
Cross-sectional imaging with CT angiography (CTA) or MR angiography (MRA) is recommended by the American College of Radiology to reveal the exact nature and level of stenosis for treatment planning 3, 4
The Trans-Atlantic Inter-Society Consensus (TASC) classification should be used to guide treatment selection based on lesion complexity, as recommended by the American Heart Association 5, 6
Ankle-brachial index (ABI) measurement is essential to determine the severity of ischemia and guide treatment decisions, according to the American College of Cardiology 3, 4

The European Society of Cardiology recommends that all patients receive comprehensive cardiovascular risk factor modification regardless of intervention strategy 2, 4
High-dose statin therapy is indicated for all patients to improve walking distance and reduce cardiovascular events, as recommended by the American College of Cardiology 2, 4
Single antiplatelet therapy is recommended by the American Heart Association to reduce the risk of major adverse cardiovascular events 3, 4
Antihypertensive therapy should be administered to all patients with hypertension, according to the American College of Cardiology 4
Supervised exercise therapy should be initiated in all patients with non-limb-threatening disease to improve maximum walking distance, as recommended by the European Society of Cardiology 2, 4

Endovascular therapy is the treatment of choice for TASC A and B lesions with high technical success rates and excellent long-term patency, according to the European Society of Cardiology 1, 3, 2
Primary percutaneous transluminal angioplasty (PTA) with selective stenting is highly effective for TASC A and B lesions, as recommended by the American College of Radiology 3, 6
For common iliac artery lesions, primary stenting can be considered with patency rates comparing favorably to surgical revascularization, according to the European Society of Cardiology 1, 7
Endovascular-first approach is recommended for TASC C lesions due to low morbidity and mortality with >90% technical success rate, as recommended by the European Society of Cardiology 7, 6
Primary stenting has demonstrated significantly higher 12-month primary patency rates (92.1%) compared to selective stenting (82.9%) for TASC C lesions, according to the American College of Radiology 6

Surgical revascularization should be considered when endovascular therapy fails or is not technically feasible, as recommended by the American College of Radiology 3, 2
Aorto-bifemoral bypass surgery is indicated for extensive disease involving the infrarenal aorta and iliac arteries in suitable surgical candidates, according to the European Society of Cardiology 7, 2

For ilio-femoral lesions, a hybrid procedure combining endarterectomy or bypass at the femoral level with endovascular therapy of iliac arteries is indicated, as recommended by the European Society of Cardiology 2
In cases of extensive disease, covered endovascular reconstruction of the aortic bifurcation can be considered with reported 1- and 2-year primary patency rates of 87% and 82%, respectively, according to the European Society of Cardiology 2

All patients should receive antiplatelet therapy following intervention, as recommended by the American College of Radiology 3, 6, 4
Regular follow-up with vascular studies is essential to monitor patency, according to the American College of Cardiology 4, 8
Patients should be enrolled in a clinical surveillance program after endovascular revascularization, as recommended by the European Society of Cardiology 1, 7