Journal of Vascular and Endovascular Therapy

Description

Aortoiliac occlusive disease, or peripheral artery disease affecting the suprainguinal vessels, can lead to a range of clinical symptoms from claudication to more severe, chronic limbthreatening ischemia. Although open surgical reconstruction has traditionally been the reference standard, endovascular options have become significantly more robust in recent years, owing to both improved devices and increasing experience with advanced techniques. This review will discuss the demographics, presentation, and evaluation of chronic aortoiliac occlusive disease, as well as explore the options, both open and endovascular, for revascularization. Aortoiliac Occlusive Disease (AIOD) generally refers to the presence of atherosclerosis of the suprainguinal arteries, resulting in stenosis or occlusion of the vessel lumen. Described by Leriche and More as a triad of proximal claudication, sexual dysfunction, and absent femoral pulses, clinical manifestations of AIOD can range from asymptomatic to severe, limb-threatening ischemia.

Takayasu Arteritis

AIOD has been managed traditionally with open surgery; this includes both endarterectomy and aortoiliac or aorto femoral bypass grafting. Although these techniques have demonstrated excellent long-term patency, they are associated with high rates of morbidity and mortality. For younger, relatively fit patients, and those with particularly complex or long segment lesions, open surgery may still be considered the preferred option. With the advent of endovascular techniques, however, treatment of AIOD with angioplasty, stents, and stent grafts has now replaced open bypass in many clinical scenarios. Here, we review the epidemiology, clinical presentation, and contemporary management of chronic AIOD. Although Aorto Femoral Bypass (AFB) has historically been the treatment of choice for Aortoiliac Occlusive Disease (AIOD), rates of AFB have declined, while utilization of aortoiliac Angioplasty Stenting (AS) has increased dramatically. The objective of the current study was to determine the effect of these trends on treatment outcomes in a contemporary single-institution experience with AIOD. Aortoiliac occlusive disease is most frequently a chronic condition related to the deposition of atherosclerotic plaque at the level of the aortic bifurcation. Other causes of abdominal aortic occlusion include less common entities, such as acute occlusion related to embolus or occlusion related to vacuities, such as Takayasu arteritis. The prevalence of the disease is unknown because many patients are asymptomatic as a result of the development of rich collateral networks. Symptoms of aortoiliac occlusive disease may range from calf claudication to the more classic Leriche syndrome of impotence, bilateral buttocks claudication, diminished femoral pulses, and aortic occlusion. The identification of arterial collateral pathways is clinically significant for proper anatomic interpretation of CT images, surgical planning, and avoiding morbidity from vascular injury. A few notable collateral pathways require reporting by the radiologist because they can change surgical management. The Winslow pathway has been described in multiple reports as showing iatrogenic damage to the pathway due to the failure to recognize this artery as a collateral source of blood supply to the lower extremities.

End-To-End Anastomosis

Using the internal mammary artery for coronary artery bypass surgery in a patient who is dependent on this artery for lower extremity arterial flow can cause lower extremity claudication. The superficial course of this artery may also put it at risk to be inadvertently cut during transverse abdominal surgery. The gonadal artery collateral pathway may be theoretically ligated during renal and scrotal surgeries, thus compromising lower extremity vascularity. Collateral pathways may be seen as direct end-to-end anastomosis of arteries, also referred to as inosculation, or via small branching networks of arterioles. After reading this pictorial essay, the reader should be aware of the common and rare collateral pathways seen in aortoiliac occlusive disease. The embryologic development of the abdominal and lower extremity arteries allows collateralization flow. The rudimentary arterial supply is divided into the ventral, lateral, and dorsal components. The embryologic ventral system develops into the celiac trunk, superior mesenteric artery, and inferior mesenteric artery; the dorsal system develops into the inferior epigastria arteries, internal thoracic arteries, and lumbar arteries; and the lateral system develops into renal and gonadal arteries. Systemic-systemic collateral pathways arise from connections of the embryonic dorsal arterial system. These arteries start as somatic branches from the dorsal aorta. The arteries later divide into the intercostal arteries in the thorax and the lumbar arteries in the abdomen. The dorsal arterial branches coalesce anteriorly to form a longitudinal vessel, which transverses the anterior body. These branches later form the internal mammary artery superiorly and inferior epigastria artery inferiorly with potential connections between the two arteries. A series of arteries arises from the ventral aspect of the paired dorsal aorta. These arteries initially feed the yolk-sac in the embryo. These arteries are known as the omphalomesenteric arc during the embryonic development and feed both the yolk-sac and primitive gut. As the yolk-sac and gut are divided, the gut becomes associated with the mesentery.The separate omphalomesenteric arcs then fuse with the natural fusion of the dorsal aortas to form a single abdominal aorta. Three trunks—namely the celiac, superior mesenteric, and inferior mesenteric arteries—develop from the omphalomesenteric arc along the ventral aorta. The arteries shift caudal with the development of the fetus. A common origin allows communication between the different trunks and their branches and even fusion of two trunks, as seen in patients with a common celio-superior mesenteric trunk.