Indications

Endovascular repair is considered an attractive treatment option for many patients, and it may be a primary option for those in whom open surgery poses significant risk. Severe disease burden including total occlusion may make endovascular repair technically challenging, however, so it is most commonly reserved for those with significant unilateral or bilateral iliac artery disease burden without the presence of aortic occlusion. But with the evolution of endovascular technology, it is no longer unusual to consider treating even more complex proximal occlusion, including Infrarenal aortic occlusion, with this approach. Benefits of an endovascular approach include reduction in perioperative mortality and the opportunity to treat distal lesions during the same procedure. Although the 2- to 5-year primary patency rates as low as 60% are considerably inferior to the rates for open bypass, assisted primary patency and secondary patency are almost similar to those achieved by open reconstructions, so these percutaneous interventions should be reserved for select patients [4–7].

Complications of endovascular interventions include those related to access, contrast use, and radiation, as well as the specific complications related to the treatment of the arteries themselves. Major complications such as bleeding, embolization into visceral arteries causing end organ damage, or rupture of the vessel can be devastating.

Any consideration of endovascular therapy for AIOD should address the inflow and outflow disease. It may be advantageous to employ a totally endovascular approach or a hybrid approach using a combination of endovascular and open techniques. The major advantage of endovascular therapy is the limitation of the morbidity and mortality resulting from an open approach. For a hybrid approach, inflow is generally established with an endovascular strategy, whereas the outflow through the femoral arteries may need either a femoral endarterectomy or profundaplasty.

Iliac Artery Stenting

Definitive endovascular management of iliac disease is traditionally accomplished with bilateral iliac stenting, often referred to as “kissing iliac stents.” The stenting is completed via bilateral retrograde common femoral artery (CFA) access and requires 6- to 8-French sheaths. Both balloon-expandable and self-expanding stents have demonstrated technical success, though covered stents demonstrated long-term superiority in the COBEST trial [8]. Normal common iliac artery size ranges from 8 mm to 14.5 mm in males and 8 mm to 10.5 mm in females, so standard iliac stents range from 6 to 10 mm in diameter [9, 10]. Simultaneous expansion of stents is recommended to prevent malalignment and stent occlusion. Extension into the distal aorta is also recommended. Percutaneous transluminal angioplasty (PTA) alone has demonstrated similar rates of technical success, but because of its poor rates of primary and secondary patency (as low as 50% at 4 years), it is no longer recommended [11].

Several configurations for endovascular reconstructions for aortoiliac arteries are shown in Fig. 26.1. The choice depends on the anatomy of the segment that need to be treated.