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Aortoiliac Occlusive Disease

Practice Essentials

Aortoiliac occlusive disease (AIOD) is a manifestation of peripheral arterial disease (PAD) in which obstructing plaques caused by atherosclerotic occlusive disease occur in the infrarenal aorta and iliac arteries, ultimately resulting in partial or total vascular occlusion. The atherosclerotic plaques may induce symptoms either by obstructing blood flow or by breaking apart and embolizing atherosclerotic and/or thrombotic debris to more distal blood vessels. If the plaques are large enough to impinge on the arterial lumen, reduction of blood flow to the extremities occurs.

Several risk factors exist for development of the arterial lesions, and recognition of these factors enables physicians to prescribe nonoperative treatment that may alleviate symptoms as well as prolong life.

AIOD is common in patients with PAD. Significant lesions in the aortoiliac arterial segment are exposed easily by palpation of the femoral pulses. Any diminution of the palpable femoral pulse indicates that a more proximal obstruction exists.

Obstructive lesions may be present in the infrarenal aorta, common iliac artery, internal iliac (hypogastric) artery, external iliac artery, or combinations of any or all of these vessels. Occasionally, degenerated nonstenotic atheromatous disease exists in these vessels and may manifest by atheroembolism to the foot, the “blue toe” or “trash foot” syndrome. Generally, patients with aortoiliac PAD have a poorer general prognosis than those with more distal PAD.

Before prosthetic grafts for aortic bypasses became available, the first direct surgical reconstructions on the aorta were performed using the technique of thromboendarterectomy (TEA), first described by Dos Santos of Lisbon in 1947.
 The initial procedure was performed on a patient with superficial femoral artery (SFA) obstruction, and Dos Santos termed the procedure disobliteration. Wylie adapted this technique to the aortoiliac region and, in 1951, performed the first aortoiliac endarterectomy in the United States.

With the discovery of suitable prosthetic graft materials for aortic replacement in the 1960s, surgical treatment of AIOD became available to even more patients.

In 1964, Dotter first performed percutaneous iliac angioplasty using a coaxial system of metal dilators.
 This procedure proved to have limited application, because of the cumbersome nature of the device. However, Dotter’s early work paved the way for Grüntzig, who, in 1974, developed a catheter with an inflatable polyvinyl chloride balloon that could be passed over a guide wire.
 This device became the cornerstone for the percutaneous treatment of arterial occlusive lesions today.

In 1985, Palmaz introduced the first stent that helped to improve the results of angioplasty for arterial occlusive disease.
 Since the advent of angioplasty and stenting, the technology has evolved at an astronomic rate. The design and quality of endovascular devices, as well as the ease and accuracy of performing the procedures, have improved. These improvements have led to improved patient outcomes following endovascular interventions for AIOD.

Surgical treatment of AIOD has been well standardized for many years, and the outcomes are quite good. However, the additional techniques of percutaneous transluminal angioplasty (PTA) and stenting have provided more alternatives to open surgery and have made successful approaches available to patients who may have been considered at an unacceptably high risk for conventional open surgical repairs.

Catheter-based endovascular treatments for AIOD offer the advantages of less morbidity, faster recovery, and shorter hospital stays. In fact, most endovascular interventions today are simply performed as outpatient procedures.

This article reviews the risk factors for development of atherosclerotic occlusive disease of the aorta and iliac arteries and describes the natural history, diagnosis, and treatment of the disease.

For patient education resources, see the Cholesterol Center, as well as High Cholesterol and Cholesterol FAQs.

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