Iliac Artery Stenosis and Treatment
David A. Weatherford, MD, RVT

Symptomatic atherosclerotic narrowing of the blood vessels supplying the lower extremities is estimated to affect 10% of the US population over the age of 70. Although great advances have been made in the rehabilitation of amputees, 30% of below-knee amputees fail to re-establish an ambulatory status, and up to 50% of these patients have been shown to require a subsequent contralateral amputation.

The iliac artery servers as the inflow source for the lower extremity and is vital for the maintenance of limb viability. Patients with iliac artery disease may complain of thigh and buttock pain with exercise, rest pain or tissue loss. Pulses may be full at rest but diminished after exercise. The non-invasive vascular lab is valuable in assisting the diagnosis.

Novel options, not available even a few years ago, exist for the management of iliac artery stenosis. For isolated stenoses, management includes balloon angioplasy with endovascular stent placement. Investigations have suggested that covering stents with various artificial materials may prolong patency. After this outpatient procedure, patients can be conveniently followed with vascular ultrasound.

More often, iliac artery stenoses present in combination with ipsilateral lower extremity disease. In this setting, this iliac stenosis is treated via an endovascular approach (angioplasty and stent placement) while simultaneous lower extremity bypass or angioplasty is performed. These procedures are performed during the same anesthesia allowing a comprehensive approach to complex vascular cases.

The radiographs in figure 1 illustrate the management of a patient at New Hanover Regional Medical Center with an occluded iliac artery and severe lower extremity pain. Angioplasty and stent placement of the high-grade contralateral iliac stenosis was successfully performed, followed by a femoral-to-femoral artery bypass. The patient was afforded an early discharge and avoided the difficult recovery associated with an aorto-bifemoral bypass. The patient is currently asymptomatic and has returned to an active lifestyle.

In summary, patients presenting with lower extremity vascular insufficiency will undoubtedly continue to increase in number and iliac artery stenoses will continue to require close consideration. Regardless of the management options utilized, long-term patency and perioperative outcomes are excellent. Advances in endovascular techniques have enabled the vascular surgeon to offer patients more treatment options with potentially easier recoveries and reduced hospital stays. As minimally invasive surgery has supplanted numerous traditional open procedures, endovascular surgery also promises to offer effective care of iliac artery stenosis and numerous other areas of vascular insufficiency in the coming years.