Strategies for managing aortoiliac occlusions: access, treatment and outcomes

Abstract

Treatment of severe aortoiliac disease has dramatically evolved from a dependence on open aortobifemoral grafting to hybrid and endovascular only approaches. Open surgery has been the gold standard treatment of severe aortoiliac disease with excellent patency rates, but with increased length of stay and major complications. In contrast, endovascular interventions can successfully treat almost any lesion with decreased risk, compared to open surgery. Although primary patency rates remain inferior, secondary endovascular interventions are often minor procedures resulting in comparable long-term outcomes. The risks of renal insufficiency, embolization and access complications are not insignificant; however, most can be prevented or managed without significant clinical consequence. Endovascular therapies should be considered a first-line treatment option for all patients with aortoiliac disease, especially those with high-risk cardiovascular comorbidities.

Keywords: access; aortic occlusion; aortoiliac occlusion; atherosclerosis; endovascular; iliac occlusion; iliac stenosis; stent.

Figure 1. Representation of technique for crossing aortic occlusion and preparing for treatment

(A) From the brachial approach, the sheath is advanced to the proximal edge of the occlusion and the wire is drilled through the occlusion with progressive advancement of the catheter. (B) After crossing the lesion, femoral access is obtained and the wire is snared to obtain through-and-through access. (C) A small angioplasty balloon is used to dilate the occlusion prior to sheath advancement. (D) The same technique is used on the contralateral side, followed by advancement of sheaths to the aortic bifurcation from the femoral arteries. From Current Vascular Surgery 2014; used with permission from People's Medical Publishing House-USA (PMPH-USA).

Figure 2. Endovascular intervention of patient with infrarenal aortic and iliac occlusions

(A) Initial flow channel with angioplasty balloon created after crossing lesion. (B) Lysis catheter in place through occlusion in aorta and left iliac artery. (C) Attempt at crossing right iliac occlusion by drilling wire and subsequent advancement of sheath. (D) Snaring the wire after crossing the lesion to obtain brachiofemoral access. (E) Advancement of bilateral sheaths to the bifurcation. (F) Placement of an aortic and bilateral ‘kissing’ common iliac stents. (G) Treatment of remaining common and external iliac artery with self-expanding stents. At completion, the aorta and bilateral iliac arteries are patent without significant stenosis.