Continuing Education Activity

The aortoiliac occlusive disease is defined by atherosclerotic blockage of the distal abdominal aorta and iliac arteries. Patients commonly present with cramping in the lower extremities that are aggravated by exercise and sexual dysfunction. This activity reviews the evaluation and management of aortoiliac occlusive disease and highlights the role of the interprofessional team in the management of patients with this condition.

Objectives:

• Describe the etiology of aortoiliac occlusive disease.
• Review the typical presentation of a patient with the aortoiliac occlusive disease.
• Identify the common complications of interventions for patients with the aortoiliac occlusive disease.
• Explain the importance of improving care coordination among the interprofessional team to improve outcomes for patients affected by the aortoiliac occlusive disease.

Introduction

Aortoiliac occlusive disease (AIOD) is a variant of peripheral artery disease affecting the infrarenal aorta and iliac arteries. Similar to other arterial diseases, aortoiliac occlusive disease obstructs blood flow to distal organs through narrowed lumens or by embolization of plaques. The presentation of AOID can range from asymptomatic to limb-threatening emergencies. Obstructive lesions are usually present in the infrarenal aorta, common iliac artery, internal iliac (hypogastric) artery, external iliac artery, or combinations of any of these vessels. Many risk factors exist for the development of the AIOD, and recognition of these factors enables providers to prescribe medical treatment that may relieve symptoms as well as prolong life. With the discovery of prosthetic graft materials for aortic replacement, surgical treatment of AIOD became available to patients in the 1960s.

Etiology

Aortoiliac occlusive disease (AIOD) is a variation of peripheral artery disease, specifically affecting the lower aorta. In the same manner as peripheral artery disease, AIOD is typically caused by atherosclerosis. Inciting factors for atherosclerosis and AIOD include diabetes mellitus, elevated homocysteine levels, hypertension, hyperlipidemia, hypertension, and tobacco usage.[1] Risk factors also include age, family history, race, and sex. Another rare but significant etiology is large vessel vasculitis, specifically Takayasu arteritis.[2][3]

Epidemiology

The exact prevalence of aortoiliac occlusive disease (AIOD), and peripheral artery disease, in general, is difficult to determine since many patients are asymptomatic. Estimates have ranged from 3.56% to greater than 14% for the general population.[4][5] Multiple studies support an increased prevalence in older populations, estimating 14%-20% over 70 years old and 23% over 80 years old.[6][7] A higher preponderance exists in male and non-Hispanic black populations, as well as those affected by the above-mentioned risk factors.[8][9]

Pathophysiology

Underlying etiology risk factors expose endothelial cells to injury through various mechanisms. Endothelial injury and dysfunction contribute to atherosclerosis and its complications by the following:[10]

• Enhanced expression of leukocyte adhesion molecules
• Increased inflammatory cytokines
• Reduced production of nitric oxide
• Increased superoxide anion formation
• Hindrance of cell function from increased serum free fatty acids and insulin
• Increased production of endothelial vasoconstrictors
• Vascular smooth muscle dysfunction and loss of integrity
• Increased expression of prothrombotic factors

History and Physical

Patients are commonly seen with complaints of cramping pain, occurring during and after exercise and relieved by rest. This condition is known as claudication. A detailed history and physical examination are vital to determine the severity of the disease and distinguish it from other diagnoses. Typically, more proximal muscle cramping is related to a higher degree of stenosis. In a particular subset, patients present with a triad of buttock claudication, erectile dysfunction, and absent femoral pulses in a grouping known as Leriche syndrome.[11] This syndrome was first identified by Dr. René Leriche, a renowned French surgeon.[12]

Patients may present on an emergent visit due to sequelae of severe stenosis or an acute embolic event, causing chronic limb-threatening ischemia.[13] The diagnostic criteria for chronic limb-threatening ischemia (CLTI) are pain with rest, presence of gangrene, or lower limb ulceration for greater than two weeks in the setting of peripheral artery disease.[14]

Evaluation

Ankle-brachial index (ABI) is generally the first screening test for the diagnosis of arterial diseases due to its low cost, reliability, and non-invasive nature. This recommendation, in combination with pulse volume recordings, has been supported by the 2016 American heart association (AHA) guideline and the US preventive services task force.[15][16][17] An index of less than 0.9 is indicative of arterial disease.[18] Duplex ultrasonography and computed tomography (CT) angiogram can also assist in diagnosis while providing detailed information about the location and degree of stenosis.[19][20][21][22] Magnetic resonance arteriography may subject the patient to undue contrast burden and overestimate the degree of stenosis.[19]

Blood testing should also be obtained to identify underlying risk factors. Lipid profile, hemoglobin A1c, lipoprotein A, and serum homocysteine levels may identify the etiology.[1] In the setting of thrombosis, past or present, prothrombin time (PT), activated partial thromboplastin time (aPTT), and platelet count should be obtained. If no clear contribution from routine labs is found, further testing for anticardiolipin antibody, antithrombin III, factor II (prothrombin) C-20210a, factor V Leiden, protein C, and protein S may be of benefit. Due to its association with coronary artery disease, an electrocardiogram should also be obtained.[5]

Treatment / Management

Onset and presenting severity dictates the treatment and management of aortoiliac occlusive disease (AIOD). Diagnosis of chronic limb-threatening ischemia (CLTI) needs urgent intervention to prevent further necrosis and the formation of gangrene. Patient risk, limb staging, and anatomic pattern (PLAN) can assist in the staging of disease.[14]

Medical management is available for non-acute cases, especially in poor surgical candidates. Primary measures include the outpatient optimization and management of diabetes mellitus, hyperlipidemia, hypertension, prothrombotic states, and tobacco use.[15][23][24] Appropriate healthy diet and exercise are also advised.[25][26] Supervised exercise programs may increase the walking distance from 180% to 340%.[27]

Claudication symptoms are treatable with cilostazol or pentoxifylline. Cilostazol is a phosphodiesterase III inhibitor that may also provide benefits in graft patency and the prevention of stenosis after surgical intervention.[28] Pentoxifylline, a methylxanthine derivative, also provides relief but is less effective than cilostazol.

Anti-thrombotic Agents

The clopidogrel versus aspirin in patients at risk of ischemic events (CAPRIE) trial exhibited better antiplatelet management using clopidogrel over aspirin by lowering death rates from ischemic stroke, myocardial infarctions, or other vascular-related causes. Other antiplatelet agents have not been studied head-to-head, but dual antiplatelet therapy is not indicated for primary treatment. Vorapaxar, an antagonist of the protease-activated receptor (PAR-1), has shown improvements in acute limb ischemia events when administered with antiplatelet agents.[29][30] The use of vitamin K antagonists has not shown improvements in outcomes by itself or in combination with aspirin.[31][32] Subset studies of patients with peripheral artery disease have shown reduced major adverse limb events when taking rivaroxaban with aspirin.[33][34]

Surgical and Endovascular Revascularization

Revascularization options include aortoiliac bypass, aortobifemoral bypass (AFB), percutaneous transluminal angioplasty (PTA), which can be with or without stent placement, and thromboendarterectomy (TEA).[1][35][36]

Open surgical revascularization bypasses the area of stenosis or occlusion through the use of a vascular conduit. Options for surgical bypass include aortoiliac bypass graft or axillary-bifemoral bypass graft.

An aortoiliac bypass graft requires greater exposure and aortic clamping, making it less suitable for some patients.[37] This surgery uses an abdominal excision to expose the infrarenal and bilateral iliac arteries. The aorta is then clamped, and a Y-shaped polytetrafluoroethylene (PTFE) graft is used to anastomose the aorta and iliac arteries. The 5-year patency rates are above 90%.[38]

An axillary-bifemoral bypass is less demanding and may be used for less optimized surgical candidates. In this procedure, an extra-anatomic anastomosis is formed by tunneling the PTFE graft from the axillary artery to the bilateral common femoral arteries. Similar variations include femorofemoral bypass and axillopopliteal bypass. The AFB has a patency rate of 85-90% at five years and 75-80% at ten years, making it a more common option for surgical intervention.[1][39]

Percutaneous transluminal angioplasty (PTA) is a valid alternative to open surgical approaches. The PTA is completed using an inflatable balloon device over a guidewire placed across the lesion (atherosclerotic plaque), which is inflated, compressing the plaque against the native arterial wall.[38] The PTA exhibits primary patency rates of nearly 90% at one year, as well as primary assisted and secondary patency of 92.3%.[40][41][42] Research has shown that covered stents provide better outcomes than bare-metal stents.[43] The endovascular treatments have also proven beneficial for use in challenging, calcified lesions.[44]

Differential Diagnosis

The following differentials should always be considered in patients presenting with symptoms and signs of aortoiliac occlusive disease (AIOD):

•  Vascular

  • Arterial aneurysm
  • Arterial dissection
  • Embolism
  • Giant cell arteritis (GCA) and Takayasu arteritis
  • Venous claudication
• Non-vascular

  • Musculoskeletal pain
  • Neurogenic claudication

Prognosis

The prognosis is poor without intervention, though the development of self-compensating collateral circulation may improve outcomes.[45] More distal locations are associated with worse outcomes.[46] Medical management provides benefits and may prolong the time until or eliminate the need for surgical management.

The prognosis after surgical intervention is optimistic. Thirty-day mortality was 2-3%. AFB's primary patency rates at 5 and 10 years are 86.2% and 77.6%, respectively. Ten-year limb salvage rates and overall survival is 97.7% and 91.7%, respectively.[47] The endovascular intervention has lower in-hospital mortality of 0.6%, and a primary patency rate of 96%, and 94% at one and two years, respectively.[44] A meta-analytic comparison between open bypass and endovascular intervention is provided in Table 1.[48]

Complications

Complications of untreated aortoiliac occlusive disease (AOID) include weakness, fatigue, impotence, and sexual dysfunction as a result of decreased blood flow.[1] Heart failure, myocardial infarction, gangrene, and amputation are also increased in unmanaged AOID.[49][50][51][52] Surgical and endovascular treatment risks include thrombosis of the graft, wound infection, bleeding, and complications from anesthesia.

Deterrence and Patient Education

The patients are educated on lifestyle modifications and risk reduction techniques to prevent disease progression. This frequently includes smoking cessation, increased physical activity, and dietary modifications. Patients should get regular follow up after every 3-6 months. If a prosthetic graft is placed, the patients should know that the risk of getting its infection remains there for the rest of their life. Therefore prophylactic antibiotic is necessary whenever a dental procedure, gastrointestinal or urological instrumentation is planned.

Pearls and Other Issues

Because the patients with the aortoiliac occlusive disease often have other comorbidities such as chronic obstructive pulmonary disease, diabetes, or hypertension, the preoperative workup is essential to prevent post-operative complications. In many cases, a cardiology referral is needed to assess the heart. Exercise stress testing, or nuclear myocardial perfusion scan in patients who are not able to ambulate, is recommended. Smoking should be discontinued for at least four weeks to prevent pulmonary complications of the surgery, and ongoing abstinence should be strongly encouraged.

Enhancing Healthcare Team Outcomes

Management of the aortoiliac occlusive disease requires strong interprofessional communication and care coordination, including the primary care team, vascular surgeons, interventional radiologists, and cardiologists. The education of the patient and family is essential for all involved team members to help improve patient outcomes.

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Disclosure: Joseph Heaton declares no relevant financial relationships with ineligible companies.

Disclosure: Yusuf Khan declares no relevant financial relationships with ineligible companies.