docAortoiliac occlusive disease
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Aortoiliac occlusive disease
Case Conference Farrell Adkins, PGY-3 Case 65 yo man presents with chief complaint of leg pain Case Left Pressure Right Ratio Pressure Ratio Arm 152 150 Upper Thigh 156 1.02 122 0.80 Above Knee 144 0.94 120 0.79 Below Knee 124 0.81 90 0.59 DP 136 0.96 96 0.63 PT 144 0.94 96 0.63 Toe 88 0.57 66 0.43 Case Aortoiliac occlusive disease Common cause of ischemic symptoms in the lower extremities of middle‐aged and elderly patients Risk factors: smoking, hypertension, hyperlipidemia, diabetes Natural history: initial lesion terminal aorto or proximal common iliac arteries; slow progression proximally and distally; occlusion of the distal aorta to the level of the renal arteries Anatomy Diagnosis Symptoms: à Claudication— cramping pain, tiredness, or fatigability of involved muscle groups induced by ambulation and quickly relieved by rest Thighs, hips, and buttocks Calf pain—rarely alone, more common when combined with femoropopliteal disease à Erectile dysfunction—secondary to reduced hypogastric perfusion à Leriche syndrome Diagnois Symptoms: à Critical limb ischemia—rest pain and progressive tissue loss; more common when combined with femoropopliteal disease à Blue toe syndrome Collateral Circulation Collateral Circulation Diagnosis Exam: à Diminished or absent femoral pulses à Bruit present over lower abdomen or groins à Atrophy of the lower extremity musculature à Hair loss on legs or toes à Dependent rubor à Pallor on elevation à Gangrene or chronic ulcerations Diagnosis Noninvasive testing: à Ankle‐brachial Index (ABI) Normal — 1.0 or slightly greater Claudication — 0.5 to 0.9 Rest pain — less than 0.5 à Segmental pressure measurements/Pulse volume recording (PVR) Four‐cuff technique Pressure drop of more than 20 mmHg between levels indicative of significant disease in that segment Calcifications may cause vessels to become “noncompressible”—digital artery pressure less than 30 mmHg indicates severe ischemia PVR provides waveforms which may reveal a pattern suggestive of proximal occlusive disease Diagnosis Noninvasive testing: à Arterial duplex Difficult due to retroperitoneal location of aorta and iliac vessels Body habitus and overlying bowel gas my complicate procedure Diagnosis Angiography à Usually performed from femoral approach à Provides detailed image of arterial segments and type of pathology involved à Risks: allergic reaction, contrast‐induced nephropathy Patterns of Aortoiliac Disease Patterns of Aortoiliac Disease Type I à Disease confined to infrarenal aorta and common iliac arteries à Makes up 10% of patients Type II à Disease extends into external iliac artery and frequently to common femoral bifurcation à 25% of patients Type III à Combined with femoropopliteal or tibial disease à 65% of patients Treatment Preoperative Evaluation: à 40% of patients also demonstrate coronary artery disease (CAD) à If indicated, CAD should be controlled prior to aortoiliac repair à If not a candidate for coronary repair, consider extraanatomic bypass à Severe pulmonary disease—period of preoperative preparation Treatment Modalities: à Medical Therapy à Catheter‐based angioplasty with/without stent à Endarterectomy à Arterial reconstruction with anatomic bypass à Arterial reconstruction with extraanatomic bypass Treatment Medical Therapy à Risk factor modification: Smoking cessation BP control Statin therapy Control of diabetes mellitus à Exercise program à Pharmacotherapy: Pentoxifylline Cilostazol Aspirin therapy Treatment Endovascular Treatment à Best results obtained with TASC‐A,B lesions à Can be performed at the same time as diagnostic angiogram à Long‐term results related to extent of initial disease Initial patency approaches 100% Iliac patency 70‐90% at 3 years As low as 50% at 5 years; 70‐75% in most series TASC‐II Classification of Aortoiliac Disease Type A à Unilateral or bilateral stenosis of CIA à Short stenosis (<3cm) of unilateral of bilateral EIA TASC‐II Classification of Aortoiliac Disease Type B à Short stenosis of infrarenal aorta (<3cm) à Unilateral CIA occlusion à Single or multiple stenoses totalling 3‐10cm involving EIA not extending into CFA à Unilateral EIA occlusion not involving origin of internal iliac or CFA TASC‐II Classification of Aortoiliac Disease Type B TASC‐II Classification of Aortoiliac Disease Type B TASC‐II Classification of Aortoiliac Disease Type C à Bilateral CIA occlusion à Bilateral EIA stenosis 3‐10cm not extending to CFA à Unilateral EIA stenosis extending into CFA à Unilateral EIA occlusion that involves origin of internal iliac or CFA à Heavily calcified unilateral EIA occlusion without involvement of origin of internal iliac or CFA TASC‐II Classification of Aortoiliac Disease Type C TASC‐II Classification of Aortoiliac Disease Type C TASC‐II Classification of Aortoiliac Disease Type D à Infrarenal aortic occlusion à Diffuse disease involving aorta and both iliac à à à à arteries requiring treatment Diffuse multiple stenoses of the CIA, EIA, and CFA Unilateral occlusion of CIA and EIA Bilateral occlusion of EIA Iliac stenoses in patients with AAA requiring treatment and not amenable to endograft placement TASC‐II Classification of Aortoiliac Disease Type D TASC‐II Classification of Aortoiliac Disease Type D Treatment Endarterectomy à Reserved for Type I disease à Cannot be used in the setting of associated aneruysmal disease à Patency operator dependant 60‐94% at 5 years Treatment Anatomic Bypass à Aortofemoral bypass Transabdominal or retroperitoneal approach End‐to‐end or end‐to‐ side anastomosis PTFE or Dacron graft Treatment Aortofemoral bypass Treatment Aortofemoral bypass Treatment Aortofemoral Bypass à Patency Rates 5 yr patency % (range) 10 yr patency % (range) Indication Claudication CLI Claudication CLI Limb based 91 (90‐94) 87 (80‐88) 86 (85‐92) 81 (78‐83) Patient based 85 (85‐89) 80 (72‐82) 79 (70‐85) 72 (61‐76) de Vries S, Hunink M. Results of aortic bifurcation grafts for aortoiliac occlusive disease: a meta-analysis. J Vasc Surg 1997;26(4):558-569. Treatment Extraanatomic Bypass à Useful in patients with hostile abdomen or poor cardiopulmonary status à Rarely perform as well as aortobifemoral bypass in diffuse aortoiliac disease à Seldom recommended for claudication alone Axillofemoral bypass Axillobifemoral bypass Femoral‐to‐femoral bypass Treatment Extraanatomic bypass à Patency Rates Procedure 5 yr patency % (range) Axillo uni femoral bypass 51 (44‐79) Axillo bi femoral bypass 71 (50‐76) Femoral femoral bypass 75 (55‐92) Question 65 yo male with COPD complains of 4 month hx of left leg rest pain. PVR demonstrates an ABI of 0.7 on the right and 0.5 on the left. Aortogram demonstrates left external iliac occlusion and 50% stenosis of right common iliac artery. What is the appropriate treatment? A. Balloon angioplasty and stenting left iliac artery B. Aortobifemoral bypass with proximal end‐to‐end anastamosis C. Femorofemoral bypass D. Axillobifemoral bypass E. Aortobifemoral bypass with proximal end‐to‐side anastamosis Question 75 yo male with acute onset left leg ischemia and severe pain. Exam demonstrates no distal pulses in the left leg and sharp cyanotic demarcation at the proximal thigh. Which artery is affected? A. External iliac artery B. Superficial femoral artery C. Profunda femoral artery D. Internal iliac artery Citations de Vries S, Hunink M. Results of aortic bifurcation grafts for aortoiliac occlusive disease: a meta‐analysis. J Vasc Surg 1997;26(4):558‐569. Reddy DJ, Shepard AD. Aortoiliac Disease. In: Mulholland et. al. Greenfield’s Surgery: Principles and Practice, 4th ed. Philadelphia, PA: Lippincott, 2006:1634‐1649. TASC II Working Group. Inter‐Society Consensus for the Management of PAD, TASC II. 2007.
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