Cardiology >  Aortoiliac Disease 

Background 

Aortoiliac disease refers to a form of peripheral arterial disease (PAD) involving atherosclerotic narrowing or occlusion of the distal abdominal aorta and/or iliac arteries. This impairs blood flow to the lower extremities, leading to ischemic symptoms such as claudication, rest pain, and in advanced stages, tissue loss. It may also cause erectile dysfunction in men (Leriche syndrome). 

II) Classification/Types 

By Anatomy: 

• • Aortic Involvement: Typically distal abdominal aorta at or below the renal arteries. 

• • Common Iliac Artery Disease: More common than isolated aortic disease. 

• • External Iliac Artery Disease: May extend into femoral arteries. 

By Severity: 

• • Asymptomatic (detected via ABI or imaging) 

• • Intermittent Claudication (pain with walking, relieved by rest) 

• • Critical Limb Ischemia (rest pain, non-healing ulcers, gangrene) 

By Pathology: 

• • Atherosclerotic (most common) 

• • Inflammatory (e.g., Takayasu arteritis) 

• • Post-surgical or post-radiation stenosis 

• • Embolic occlusion 

III) Pathophysiology 

Atherosclerotic plaque formation leads to luminal narrowing, decreased perfusion, and ischemia. Chronic ischemia results in muscle fatigue and pain on exertion. In advanced cases, impaired perfusion at rest may cause ulceration, gangrene, or limb-threatening ischemia. Collateral circulation may temporarily compensate but is often insufficient as disease progresses. 

IV) Epidemiology 

• • Sex: More common in men 

• • Age: Incidence increases after age 50 

• • Geography: Higher prevalence in high-income countries due to lifestyle factors 

• • Comorbidities: Strongly associated with smoking, diabetes, hypertension, and hyperlipidemia 

Etiology

I) Causes 

• • Atherosclerosis (primary cause) 

• • Thromboembolism 

• • Aortic dissection extending into iliac vessels 

• • Vasculitis (e.g., Takayasu arteritis, giant cell arteritis) 

• • Trauma 

• • Radiation arteritis 

• • Iatrogenic (e.g., post-surgical scarring or graft stenosis) 

II) Risk Factors 

• • Smoking (most important modifiable risk) 

• • Age >50 

• • Diabetes mellitus 

• • Hypertension 

• • Hyperlipidemia 

• • Chronic kidney disease 

• • Family history of cardiovascular disease 

• • Male sex 

• • Sedentary lifestyle 

Clinical Presentation

I) History (Symptoms) 

• • Intermittent claudication: Cramping pain in buttocks, thighs, or calves with exertion 

• • Erectile dysfunction: Especially with bilateral iliac disease (Leriche syndrome) 

• • Rest pain: Often worse at night, relieved by dangling the leg 

• • Non-healing wounds or ulcers: Especially on toes or lateral malleoli 

• • Cold or numb lower extremities 

• • Decreased walking distance or walking-induced fatigue 

II) Physical Exam (Signs) 

Vital Signs: 

• • May be normal unless advanced systemic atherosclerosis 

Vascular Exam: 

• • Diminished or absent femoral, popliteal, or pedal pulses 

• • Bruits over aorta or iliac arteries 

• • Cool or pale lower limbs 

• • Delayed capillary refill 

• • Buerger’s test: Pallor on elevation, rubor on dependency 

Neurologic/Other: 

• • Sensory changes or muscle atrophy in chronic ischemia 

• • Erectile dysfunction in men (suggests Leriche syndrome) 

Differential Diagnosis (DDx)

• • Lumbar spinal stenosis (neurogenic claudication) 

• • Peripheral neuropathy 

• • Chronic venous insufficiency 

• • Deep vein thrombosis 

• • Popliteal artery entrapment 

• • Thromboangiitis obliterans 

• • Musculoskeletal disorders (e.g., hip osteoarthritis) 

Diagnostic Tests

Initial Tests: 

• • Ankle-Brachial Index (ABI): 

• • • ABI <0.9 confirms PAD; <0.4 indicates severe disease 

• • Segmental Limb Pressures and Pulse Volume Recordings: 

• • • Localizes site and severity of disease 

Imaging: 

• • Duplex Ultrasound: 

• • • Non-invasive evaluation of flow and stenosis 

• • CT Angiography (CTA): 

• • • Excellent for detailed anatomy, surgical planning 

• • MR Angiography (MRA): 

• • • Alternative for patients with contrast contraindications 

• • Digital Subtraction Angiography (DSA): 

• • • Gold standard; used for intervention planning 

Labs: 

• • Lipid profile 

• • HbA1c and fasting glucose 

• • Serum creatinine (prior to contrast studies) 

Treatment

I) Medical Management 

Risk Factor Modification: 

• • Smoking cessation 

• • Blood pressure control (goal <130/80 mmHg) 

• • Statins (LDL goal <70 mg/dL for symptomatic PAD) 

• • Antiplatelet therapy (aspirin or clopidogrel) 

• • Glycemic control in diabetics 

Symptom Relief: 

• • Cilostazol (PDE-3 inhibitor): Increases walking distance 

• • Structured supervised exercise therapy (first-line for claudication) 

II) Interventional/Surgical 

Indications: 

• • Lifestyle-limiting claudication not improved with medical therapy 

• • Critical limb ischemia (rest pain, ulcers, gangrene) 

Endovascular Options: 

• • Balloon angioplasty with or without stenting (preferred in many cases) 

Surgical Options: 

• • Aorto-bifemoral bypass (for extensive disease) 

• • Endarterectomy (localized lesions) 

• • Extra-anatomic bypass (axillobifemoral graft in high-risk patients) 

7. Patient Education, Screening, Vaccines

• • Smoking cessation counseling 

• • Encourage daily walking programs 

• • Adherence to statin, antiplatelet, and antihypertensive therapy 

• • Foot care education to prevent ulcers 

• • Monitor skin for signs of ischemia 

• • Diet: Low in saturated fats and refined sugars 

Vaccinations: 

• • Annual influenza vaccine 

• • Pneumococcal vaccine 

• • COVID-19 vaccine 

Consults

• • Vascular Surgery: For revascularization planning 

• • Interventional Radiology/Cardiology: For angioplasty or stenting 

• • Wound Care: If ulcers or gangrene present 

• • Podiatry: Preventive foot care and offloading 

• • Endocrinology: Diabetes optimization 

• • Primary Care/Internal Medicine: Risk factor control 

Follow-Up

• • ABI monitoring every 6–12 months 

• • Lipid panel and HbA1c every 3–6 months 

• • Reinforce walking program and medication adherence 

• • Monitor for signs of progression: increased claudication, rest pain, skin changes 

• • Post-revascularization surveillance: Duplex ultrasound or CTA as needed 

• • Adjust therapy based on symptoms and test findings