Iliac Disease: Core Curriculum

2. Iliac Disease Diagnosis Indications Technical Issues Treatment Options - PTA - Surgical Complications Prognosis

3. Physical examination signs of peripheral ischemia distal embolization status of the peripheral pulses. Rest and exercise ABI

4. Iliac Disease: Diagnosis Noninvasive imaging modalities Pressure Gradients Duplex ultrasound (DUS) scans Magnetic resonance angiography (MRA) Computed tomography angiography (CTA)

5. Pressure Gradients obtained during revascularization of iliac occlusion 

6. Iliac Disease: Duplex Ultrasound DUS has proved to be cost-effective and accurate for the detection of significant vascular stenoses and is therefore often used as the first diagnostic modality. 1, 2 The poor monophasic duplex waveform at the common femoral artery is in itself an accurate marker of aortoiliac obstructive disease. Other waveforms are nondiagnostic for aortoiliac disease.3 

8. Iliac Disease: MR Angiography Enhanced MR angiography showed significant improvement (P < .001) compared with unenhanced MR angiography for diagnosis of clinically significant aortoiliac occlusive disease

9. Iliac Disease: MR Angiography

10. Iliac Disease: Computed Tomography Angiography

11. Morphological Stratification of Iliac Lesions

12. Morphological Stratification of Iliac Lesions

13. Iliac Disease Diagnosis Indications Technical Issues Treatment Options - PTA - Surgical Complications Prognosis

14. Indications for Revascularization Relief of symptomatic lower extremity ischemia, including claudication, rest pain, ulceration or gangrene, or embolization causing blue toe syndrome

15. Iliac artery revascularization before cardiac surgery Significant bilateral disease in order to allow the intra-aortic balloon pump insertion Specific Indications for Revascularization

16. Iliac Disease Diagnosis Indications Technical Issues Treatment Options - PTA - Surgical Complications Prognosis

17. Iliac Disease: Angiography Diagnostic aortogram: Inflow and outflow of the target lesion Run-off angiography: Visualization of the lower extremity circulation

19. Anticoagulation Aspirin (325 mg) once a day several days prior to the procedure Heparin (2500-5000 IU) after access has been obtained and prior to the intervention Iliac Disease: Technical Issues

20. Iliac Disease Diagnosis Indications Technical Issues Treatment Options - PTA - Surgical Complications Prognosis

21. Percutaneous transluminal angioplasty (PTA) with or without implantation of a stent is still considered as the gold standard in the treatment of a peripheral lesion.

22. Endovascular treatment of iliac stenoses High technical success rates Low morbidity Iliac PTA/stenting High rates of patency Improvement in functional outcome for the individual patient Interventional Management of Iliac Lesions

24. Mostly claudicants, not severe disease, 15% in initial failure rate with PTA, started in 1983 Holm also had easy lesionMostly claudicants, not severe disease, 15% in initial failure rate with PTA, started in 1983 Holm also had easy lesion

26. Contraindications (Relative) to Iliac Balloon Angioplasty Occlusion Long lesions (>5 cm) Aortoiliac aneurysm Atheroembolic disease Extensive bilateral aortoiliac disease

27. Iliac Disease: Stent Placement Balloon expandable stent Greater radial force Useful in extremely calcified stenoses and especially occlusions of the common iliac artery Allow greater precision for placement Useful in Ostial Lesions Self-expandable stent Used predominantly in : cross-over techniques and tortuous vessels occlusions of the external iliac artery

29. Interventional Management of Iliac Lesions

30. Complex long-segment and bilateral iliac occlusions can be safely treated via endovascular means with high rates of symptom resolution. Initial technical success, low morbidity, and mid-term durability are comparable to results with open reconstruction.  Interventional Management of Iliac Lesions

31. The Aortoiliac Kissing Stent Technique Reconstructs the aortic bifurcation by simultaneous deployment of bilateral CIA stents The kissing stent technique was developed to avoid complications during PTA of the aortic bifurcation, such as dissection, thrombosis, or significant residual stenosis. Primary placement of kissing stents has been shown to be safe and technically practicable, even in aortoiliac segments with complex atherosclerotic disease. 2

32. The proximal ends of the stents extend into the aorta such that two adjacent stent walls come into apposition for at least one centimeter in the native aorta Not Stable Stents positioned in this manner reshape the aortic bifurcation more or less anatomically �Non-crossing� group

33. �Crossing� Group The distal end of the stents slip over each other into a crossover position Stable The stents do not really imitate the aortic bifurcation perfectly

34. Remove the vascular sheath when the activated clotting time (ACT) falls to <160 seconds Continue oral aspirin (325 mg/day) indefinitely / Clopidogrel? Perform ABIs and duplex scanning prior to hospital discharge Follow-up the patient with non - invasive testing to document continued patency.

35. Iliac Disease: surgical Treatment Aortoiliac bypass Aortofemoral bypass PTA Vs surgery 157 iliac lesions was treated with PTA or bypass surgery No significant difference between PTA or surgery for death, amputations, or loss patency at 3 years No significant difference in the hemodynamic (ankle-brachial index) result of a successful procedure between the surgery group and the PTA group

36. PTA Vs surgery

37. Ankle- Barchial Index in Randomized Iliac Lesions

38. Iliac Disease Diagnosis Indications Technical Issues Treatment Options - PTA - Surgical Complications Prognosis

42. Iliac Disease Diagnosis Indications Technical Issues Treatment Options - PTA - Surgical Complications Prognosis

44. Iliac Disease: Favorable predictors Short, focal lesion Large vessel size Common iliac (as opposed to external iliac) Single lesion ( as oppsosed to multiple serial lesions) Male gender Lesser Rutherford category (Claudication as opposed to critical limb ischemia) Presence of good runoff

45. Ideal Iliac PTA Lesions Stenotic lesion Non-calcified Discrete (< 3cm) Patent run � off vessels (> 2) Non- diabetic patients

47. Patency after iliac PTA by Clinical and Lesion variables

49. Long-term success

50. Endovascular Treatment of Symptomatic Iliac Occlusions

51. Iliac Disease:Outcomes

52. Iliac Disease: Primary Patency

53. Iliac Disease: Secondary Patency