Part 6/Chapter 36/9-min read

Aortoiliac Occlusive Disease

Aortoiliac occlusive disease framed first as an inflow problem before the device decision: aortic bifurcation, common iliac, external iliac, and iliofemoral inflow placed inside the patient's symptom and risk profile. The chapter frames endovascular, hybrid, and open inflow reconstruction.

Edited by Tal M. Hörer MD, PhD · David T. McGreevy MD, PhD·Version 1 · Last published ·7 sections · 20 references

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Definition and presentation

Aortoiliac occlusive disease is a limitation of arterial inflow caused by or occlusion of the aortic bifurcation, common iliac arteries, external iliac arteries, or the combined iliofemoral segment . As a manifestation of systemic atherosclerosis, this inflow disorder must be understood alongside walking disability, coexisting vascular disease and patient-centered functional goals, not only the angiographic lesion . Clinical presentation ranges across a spectrum of lower-extremity ischemia:

  • Asymptomatic peripheral artery disease.
  • Chronic symptomatic , presenting as exertional disability.
  • Chronic limb-threatening ischemia (), presenting with , , or tissue loss.
  • Acute limb ischemia.

The disease occurs in isolation or as part of a multilevel pattern alongside femoropopliteal and infrapopliteal disease . Complete occlusion at the aortic bifurcation produces Leriche syndrome: the triad of bilateral buttock, thigh, or hip claudication, erectile dysfunction, and absent or diminished femoral pulses .

Classification and stratification

Aortoiliac morphology is described using TASC II. The following summary follows the aortoiliac categories reproduced in ESVS 2024 Figure 8; each semicolon separates an alternative qualifying pattern .

ClassificationCategory and Aortoiliac patterns
  • A
    Aortoiliac patterns
    Common-iliac stenosis on one or both sides; single external-iliac stenosis <=3 cm on one or both sides.
  • B
    Aortoiliac patterns
    Infrarenal aortic stenosis <=3 cm; unilateral common-iliac occlusion; external-iliac stenoses totaling 3–10 cm without common-femoral extension; unilateral external-iliac occlusion sparing the internal-iliac origin and common femoral artery.
  • C
    Aortoiliac patterns
    Bilateral common-iliac occlusions; bilateral external-iliac stenoses 3–10 cm without common-femoral extension; unilateral external-iliac stenosis extending into the common femoral artery; unilateral external-iliac occlusion involving the internal-iliac origin or common femoral artery; heavily calcified unilateral external-iliac occlusion.
  • D
    Aortoiliac patterns
    Infrarenal aortoiliac occlusion; diffuse aortic and bilateral iliac disease; diffuse unilateral common-iliac/external-iliac/common-femoral stenoses; ipsilateral common- and external-iliac occlusions; bilateral external-iliac occlusions; iliac stenosis with an abdominal aortic unsuitable for endograft placement.

This is an anatomic classification, not an automatic contemporary instruction to stent A/B lesions or operate on C/D lesions.

For CLTI, combine Patient risk, Limb severity and ANatomic complexity (). grades wound, ischemia and foot infection separately from 0 to 3 and combines them into threatened-limb stages; it does not classify iliac stenoses. The original WIfI classification and grading tables provide the full definitions . GLASS describes the infrainguinal target arterial path, with inflow disease assessed separately. Thus aortoiliac repair may be sufficient for selected rest-pain presentations or may support additional distal reconstruction when needed for tissue healing .

Medical and antithrombotic therapy

Baseline medical management for aortoiliac disease includes blood-pressure control, statin therapy, smoking cessation, and structured exercise. Medical therapy is a prerequisite step in claudication and an ongoing requirement for secondary prevention across all disease stages .

High-intensity lipid lowering is part of vascular prevention; European guidance targets below 1.4 mmol/L (55 mg/dL) and at least a 50% reduction from baseline . For persistent lifestyle-limiting claudication despite adherence to medical treatment and exercise, ESVS 2024 supports considering cilostazol or naftidrofuryl (Class IIa, Level A). Cilostazol 100 mg twice daily is an option, but must not be used in heart failure; stop ineffective treatment after reassessment rather than continuing indefinitely .

For stable peripheral artery disease, rivaroxaban 2.5 mg twice daily plus aspirin reduces major cardiovascular events and major adverse limb events compared with aspirin alone, but increases the risk of major bleeding . Following lower-extremity revascularization, the same low-dose rivaroxaban and aspirin regimen reduces composite ischemic limb and cardiovascular events, with an associated increase in major bleeding . The antithrombotic regimen is individualized based on patient age, renal function, bleeding risk, and concomitant therapy. The dedicated European companion reference is the ESVS 2023 guideline on antithrombotic therapy for vascular diseases .

Revascularization thresholds and treatment decision

The threshold for intervention is dictated by the clinical goal and the patient's presentation. In claudication, the threshold is qualitative: intervention is reserved for persistent, patient-defined disability after guideline-directed medical therapy and structured exercise have failed to provide functional improvement . In CLTI, the threshold is lower because the endpoint is limb salvage and wound healing; inflow correction is judged by whether it enables tissue repair or adequately supports a required distal reconstruction .

Treatment selection follows a stepwise anatomic and risk assessment:

  1. Decide whether inflow correction alone meets the clinical goal (relieving focal claudication) or whether it serves as a prerequisite for a distal target arterial path (CLTI).
  2. Attempt endovascular therapy for short, focal aortoiliac disease.
  3. Consider hybrid repair for concomitant iliac and common femoral disease.
  4. For extensive disease, compare endovascular, hybrid and open reconstruction using operative risk, expected durability, access, runoff and feasible reconstruction sites; heavy calcification alone does not make open surgery preferable.
  5. Decline intervention in favor of observation or palliative care for prohibitive-risk patients or when life expectancy is severely limited.

Aortoiliac management and revascularization pathways

Stable claudication
  • Presentation or threshold
    Symptoms controlled or improving with exercise
    Preferred pathway
    Continued medical therapy and structured exercise
    Citation

  • Refractory claudication

    Presentation or threshold
    Persistent functional disability despite medical therapy and exercise
    Preferred pathway
    Revascularization matched to anatomy and risk
    Citation

  • CLTI

    Presentation or threshold
    Rest pain, gangrene, or tissue loss
    Preferred pathway
    Inflow correction as a primary or staged component of the limb plan
    Citation

  • Short, focal disease

    Presentation or threshold
    TASC A or B iliac stenosis or occlusion
    Preferred pathway
    Endovascular revascularization
    Citation

  • Concomitant iliofemoral disease

    Presentation or threshold
    Iliac inflow disease with common-femoral disease requiring reconstruction
    Preferred pathway
    Consider hybrid iliac intervention plus femoral /reconstruction, preserving profunda outflow
    Citation

  • Extensive aortoiliac disease

    Presentation or threshold
    Disabling claudication, low operative risk, long life expectancy; complex C/D lesions involving both the iliac arteries and the aorta up to the renal arteries
    Preferred pathway
    Open reconstruction may be considered (ESVS IIb B); compare endovascular/hybrid alternatives rather than treating TASC class as a mandate
    Citation

  • Prohibitive risk

    Presentation or threshold
    Limited life expectancy or prohibitive operative risk
    Preferred pathway
    No intervention or palliative wound care
    Citation

Endovascular and open techniques

For an established clinical indication, endovascular repair is attractive for suitable iliac lesions. COBEST supports a covered-stent advantage in more complex TASC C/D disease; its five-year report was a post hoc follow-up with only 77 of the original 125 patients assessed . DISCOVER provides a more recent randomized comparison in 174 limbs with common-iliac stenosis >3 cm or occlusion. Two-year freedom from binary restenosis was 89.1% with covered and 84.7% with bare balloon-expandable stents (P=0.40), without demonstrated superiority. These different populations do not support mandatory covered stents for every iliac lesion .

Hybrid repair combines endovascular iliac inflow restoration with open femoral reconstruction. It is indicated when common femoral or iliofemoral disease restricts outflow, ensuring both a durable inflow channel and a usable femoral outflow bed .

AISBR versus ABF, 2022
  • Design and population
    Retrospective single-center TASC D comparison; 75 AISBR and 24 ABF
    Decision-relevant result
    Five-year primary patency 50.8% versus 88.1%; AISBR had lower perioperative burden
    Comparability limit
    Treatment selection was not randomized; AISBR is not necessarily

  • Kissing stents versus ABF, 2017

    Design and population
    Dorigo and colleagues’ historical comparison in complex aortoiliac disease
    Decision-relevant result
    Relevant reading on a different bifurcation construct
    Comparability limit
    A distinct historical construct, not direct evidence for contemporary covered reconstruction

  • CERAB versus ABF, 2024

    Design and population
    VQI observational study; propensity-matched 229 CERAB and 929 ABF
    Decision-relevant result
    One-year primary patency 96.6% versus 98.3% (P=0.6); freedom from reintervention 62.5% versus 92.9%
    Comparability limit
    Residual confounding and short follow-up; nonsignificance does not establish equivalence

  • CERAB meta-analysis, 2024

    Design and population
    11 retrospective series, 579 patients; predominantly TASC C/D
    Decision-relevant result
    Pooled primary patency 94.4% at one year and 83.8% at three years
    Comparability limit
    No randomized ABF control; pooled single-arm outcomes cannot rank the procedures

Patency, reintervention, perioperative morbidity and patient benefit are different outcomes. The evidence supports an individualized choice, not a universal institutional ranking.

Anatomic variants and calcification

Severe calcification complicates both endovascular and open planning. For endovascular repair, assess access, lesion crossing, expansion and rupture risk. For open repair, assess whether safe arterial control and usable anastomotic sites are available. Calcification may therefore narrow either option; it is not, by itself, evidence that open reconstruction is preferable. The comparative decision remains anatomy- and patient-specific .

When standard external iliac or common femoral outflow is occluded, deep femoral perfusion becomes critical. Profunda-dependent runoff requires the reconstruction to be planned around the profunda femoris arteries. Depending on extent, this may necessitate extending the reconstruction distally to include open aortoprofunda bypass if isolated iliac approaches are inadequate to establish durable inflow .

Areas of controversy

The optimal approach for complex aortic bifurcation occlusion remains unsettled. The relative superiority of open aortobifemoral bypass versus advanced endovascular techniques, including kissing stents and the CERAB technique, varies by institution, with decision-making driven heavily by local expertise, patient operative risk, and individual calcification patterns rather than definitive trial evidence . Coverage and expansion mechanism are separate questions. COBEST and DISCOVER compare covered with bare stents; they do not establish superiority of balloon-expandable over self-expanding covered stent-grafts . ESVS 2024’s permissive preference for self-expanding iliac stents concerns bare-metal devices (IIb B), whereas its covered-stent recommendation concerns selected TASC C/D lesions (IIb B). Neither should be converted into a class-wide recommendation for one covered-graft expansion mechanism .

Further reading

  • Covered endovascular reconstruction of the aortic bifurcation: A systematic review aggregated data and individual participant data meta-analysis. (2024). Covered reconstruction of the aortic bifurcation; technical outcome synthesis.

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