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Patients with iliac artery stenosis often will have concomitant lower extremity or aortic peripheral arterial disease. Isolated iliac occlusive disease typically produces ipsilateral hip, thigh, or buttock claudication, whereas when found concomitantly with superficial femoral or tibial occlusive disease, it can manifest as limb-threatening ischemia (rest pain, nonhealing wounds, or gangrene). When to intervene on an isolated iliac artery stenosis depends on the degree of patient symptoms and patient risk factors, which may increase the risk of an intervention. A trial of cilastazol can be instituted first but typically is not as successful in the face of isolated iliac artery occlusive disease. Modification of atherosclerotic risk factors should be undertaken as soon as recognized in order to improve long-term patient outcomes. This may include smoking cessation, hypertension control, lipid profile improvement, and diabetes management.
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Obviously, patients should be mobile enough to gain benefit from an iliac artery intervention. Preprocedural imaging may be obtained with duplex ultrasound or computed tomographic angiogram if further anatomic delineation is essential. Ankle brachial indices with or without segmental pressures should be obtained as a baseline prior to all peripheral interventions.
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PREOPERATIVE PREPARATION
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Patients should be started as soon as possible prior to the procedure on an antiplatelet agent, aspirin being used most commonly. A statin also should be started for its plaque stabilization properties as well as its long-term cardiac and neuroprotective effects. Patients should be prepared mentally for a procedure under local anesthesia by explaining what they can expect before, during, and after the procedure, as well as what will be expected of them. They should be instructed on how to manage their medications prior to the procedure, especially anticoagulants and drugs that interact adversely with contrast agents. Because the procedure will use a contrast agent, renal function should be checked before the procedure in order to modify the procedure, if needed, to protect kidney function. Pre- and intraprocedural hydration also can help prevent contrast-induced nephropathy. Patients should have the ability to cooperate during the procedure, including being still, lying flat, and holding their breath when instructed.
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Local anesthesia with moderate sedation is used most commonly during iliac artery stenting. A monitoring nurse or anesthesiologist may be appropriate depending on the degree of patient risk factors. A combination of anxiolytic and pain medication delivered intravenously is usually adequate and adjusted based on multiple patient factors. Local anesthesia is administered by the surgeon after sterile preparation and draping of both groin regions. Care should be taken to ensure that the agent is infiltrated down to the artery and includes the tract leading to the skin. Depending on the duration of the procedure and patient comfort, additional sedation, pain medication, or local anesthetic may be necessary.
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Patients should be supine on a table compatible with fluoroscopy, preferably in ...