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Selecting Treatment for Patients with Aortoiliac Occlusive Disease


Patients with aortoiliac occlusive disease (AIOD) represent a subset of patients with peripheral artery disease whose condition can involve the infrarenal aorta, common and/or external iliac arteries, and the common femoral arteries. Since the turn of the century there has been a rapid increase in the number of endovascular interventions performed for revascularization of patients with AIOD and a concomitant decline in the number of open surgical procedures.

This trend toward an endovascular-first strategy has been fueled in part by improvements in stent design, the availability of stent grafts and reentry devices for treating chronic total occlusions, and a generalized patient preference toward less invasive procedures. However, in contrast to infrainguinal occlusive disease, no published randomized, controlled trials yet exist on which to base recommendations for therapy. Thus, the paradigm shift in treatment has occurred without the benefit of strong supporting evidence. Without the backing of trial data, treatment selection for patients with AIOD has come to be based upon the patient’s condition, technical considerations, operator experience with different open and endovascular revascularization procedures, and the patient’s preference.

Conservative Medical Treatment

Peripheral arterial disease is a reflection of systemic atherosclerosis and represents a risk factor for cardiovascular death. Thus, all patients with AIOD require medical therapy to reduce atherosclerotic risk factors in accordance with American Heart Association guidelines. This includes smoking cessation, management of diabetes, and antiplatelet, statin, and antihypertensive therapy. A program of supervised exercise therapy in compliant patients has been shown to reduce symptoms of intermittent claudication and improve functional status. It is unclear whether unsupervised exercise programs are similarly effective.

In our practice, for patients with intermittent claudication alone, this regimen of conservative treatment has been prescribed and revascularization has been reserved for patients who have failed medical therapy and have severe lifestyle-limiting symptoms or vocational impairment. Others have argued that the relatively favorable risk-to-benefit ratio of endovascular therapy as compared to medical management should lead to a more liberal approach to revascularize patients who come to the hospital with intermittent claudication. However, we do not currently recommend this more aggressive approach because the relative efficacy and durability of endovascular therapy compared to exercise and medical management have not yet been established.

The Claudication: Exercise versus Endoluminal Revascularization (CLEVER) study is a randomized, controlled trial that is under way to help clarify the relative roles of conservative treatment and endovascular therapy for patients with AIOD and intermittent claudication. Patients with AIOD are randomized to a supervised exercise program, unsupervised home-based exercise program, or endovascular treatment. The primary endpoint is maximum walking duration on a graded treadmill test.

Criteria Influencing Choice of Revascularization Techniques

In our opinion, revascularization should be considered for patients with severe claudication that limits lifestyle or work and in patients with critical limb ischemia. Options for revascularization of AIOD include open surgery, endovascular procedures, and hybrid procedures (combined open and endovascular components) ( Box 1 ). Open procedures include both direct anatomic and extraanatomic techniques.

Box 1
Revascularization Options for Aortoiliac Occlusive Disease

Open Surgery

  • Direct anatomic

    • Aortobifemoral bypass

    • Aortounifemoral bypass

    • Aortoiliac endarterectomy

    • Descending thoracic aorta to femoral bypass

    • Ascending aorta-to-femoral bypass

    • Iliofemoral bypass

  • Extra-anatomic bypass

    • Axillofemoral bypass

    • Femorofemoral bypass

Endovascular Therapy

  • Iliac angioplasty

  • Primary iliac stenting

  • Aortic or iliac artery stent grafting

Hybrid Approach

  • Common femoral artery repair and iliac angioplasty and stenting

  • Iliac angioplasty and stenting and femorofemoral bypass

Our own practice has experienced a shift away from treating AIOD patients with the gold standard treatment of aortobifemoral bypass (ABF) or extra-anatomic bypasses toward the less invasive option of endovascular therapy. When selecting treatment for patients with AIOD, we consider patient, operator, resource, and anatomic factors in deciding on the most appropriate revascularization technique ( Box 2 ). As discussed in the following sections, in decision making, the interplay among these factors can be complex.

Box 2
Factors Affecting Treatment Selection

Patient

  • Medical comorbidities

  • Patient’s age and expected lifespan

  • Presence or absence of critical limb ischemia

  • Acute presentation

  • Body habitus

  • Previous abdominal surgery

  • Patient’s preference

Operator and Resources

  • Access to angiographic facility

  • Expertise with both open and endovascular techniques

Anatomic and Technical

  • Complex AIOD lesions

  • Iliac stenosis/occlusion

  • Status of common femoral artery

  • Profunda femoris artery as outflow for reconstruction

  • Small external iliac arteries

  • Previous failed attempt at revascularization

  • High risk lesion for distal embolization

  • Need for concomitant procedures

Patient Factors

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