Unilateral Retroperitoneal Iliofemoral Bypass

Treatment Algorithm for Iliac Occlusive Disease

The initial approach for management of localized iliac disease, if feasible, is usually balloon dilation with percutaneous transluminal angioplasty (PTA). There is little evidence to support routine primary stenting after successful iliac PTA other than for a few specific indications, such as lesion recoil, an eccentric lesion, or a dissection following dilation. In general, the results with PTA are less satisfactory than after open surgical reconstruction, but considering the low morbidity and the option of repeating the procedure, PTA is justified for localized iliac stenoses or short occlusions. The only lesion not amenable to PTA is the less common focal iliac coral-reef plaque, which is best managed by endarterectomy.

Extensive iliac endarterectomy is rarely performed in contemporary practice since those times when it was more routinely pursued in the 1960s. The long-term results for localized endarterectomy are excellent; however, most patients with localized disease previously treated by endarterectomy are now treated by PTA. Extensive endarterectomy is tedious and time consuming, and it is associated with greater blood loss than bypass grafting and a risk of sexual dysfunction in male patients.

Although aortobifemoral bypass is the gold standard for managing patients with diffuse aortoiliac occlusive disease, other suitable options exist for those with unilateral iliac disease. A femorofemoral bypass is often indicated with extensive unilateral iliac disease in the presence of a normal donor iliac artery in patients in all risk categories. An axillofemoral bypass is indicated in patients with a high anesthetic risk for which a femorofemoral bypass is not possible because of the extent of donor iliac disease. A unilateral iliofemoral bypass is a third option, provided that the aorta and ipsilateral common iliac artery are normal or only minimally diseased.