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Internal Iliac Artery Stenosis – How To Diagnose And Manage Its Symptoms

Internal iliac artery stenosis (IIAS) is one of the arterial tree's probable localization of atherosclerosis.

When a patient complains of proximal walking discomfort, this condition is often overlooked in the diagnostic procedure.

An ache that arises while walking and affects the lower back, hip, buttock, or thigh indicates proximal claudication or pseudoclaudication.

Claudication is a kind of vasculogenic discomfort, while pseudoclaudication is caused by lumbar spinal stenosis, hip osteoarthritis, venous congestion, bone metastasis, sciatica, etc.

Lower extremity arterial disease (LEAD) is a common condition that affects 202 million individuals globally.

When a patient complains of proximal walking discomfort, most doctors assume it is caused by pseudoclaudication.

Internal iliac artery stenosis is one of the arterial tree's probable localization of atherosclerosis.

When a patient complains of proximal walking discomfort, this condition is often overlooked in the diagnostic procedure.

Indeed, walking-related discomfort in the lower back, hip, buttock, or thigh implies proximal claudication or pseudo claudication.

Claudication is a kind of vasculogenic discomfort, while pseudo claudication is caused by lumbar spinal stenosis, hip osteoarthritis, venous congestion, bone metastasis, sciatica, etc.

Occurrence Of Internal Iliac Artery Stenosis

The incidence and frequency of internal iliac artery stenosis in the general population have not been determined.

Although unilateral internal iliac artery stenosis is presumably uncommon, it is often coupled with common iliac artery stenosis.

Proximal claudication occurs in 5–14 percent of patients with mild-to-moderate distal lower extremity arterial disease (LEAD), which is prevalent in patients with patent aortobifemoral bypasses, approximately 28 percent, and nearly 35 percent of patients after bilateral internal iliac artery (IIA) embolization before endovascular aneurysm repair.

Symptoms

The predominant symptom is the lower back, hip, buttock, or thigh claudication, tiredness, discomfort, or pain occurring in particular muscle groups alimenting by the internal iliac artery during exercise-induced ischemia alleviated by rest.

However, the presentation of proximal claudication is often unusual and may mirror other non-vascular disorders, leading to an incorrect diagnosis.

Furthermore, when internal iliac artery stenosis is severe, discomfort may arise during rest and lead to gluteal necrosis.

Finally, internal iliac artery stenosis causes a variety of functional impairments, including walking impairment, which leads to occupational incapacity, and sexual impairment, which manifests as erectile dysfunction.

These two deficits hurt the patient's quality of life.

Although it is difficult to prevent these impairments with routine non-invasive diagnostics, it is essential to detect the condition to reduce the current two-year wait in diagnosis when the disease is not accompanied by distal LEAD.

Clinical Assessment

Claudication usually ceases after 10 minutes of stopping walking, and a physical examination should rule out pseudoclaudication.

Hip osteoarthritis is characterized by discomfort in the groin caused by internal or external rotation of the hip.

Hip pain often radiates into the knee, but lumbar spinal stenosis causes pain to radiate beyond the spinal region into the buttocks.

Digital subtraction angiography (DUS) may diagnose internal iliac artery stenosis, mainly if the patient is a candidate for revascularization.

On anteroposterior views, the external iliac artery conceals the IIA at the level of the gluteal canal.

The mean resting gradient cut-off for determining whether or not the stenosis is substantial is examined, with values ranging from 5 to 10 mm Hg.

When the cut-off point is less than 15 mm Hg, the Exercise-TcPO2 has 79 percent sensitivity and 86 percent specificity for detecting central lesions (stenosis 75 percent) in the arterial tree of the pelvic circulation.

Exercise-NIRS is a non-invasive technique for assessing tissue oxygen saturation.

Lifelong treatment should include removing or adjusting atherosclerotic modifiable risk factors such as smoking, hypertension, diabetes mellitus, and dyslipidemia to decrease unfavorable cardiovascular events like stroke and acute myocardial infarction.

The justification for revascularization is based on the patient's functional impairment after a lack of response to exercise therapy and well-conducted medical treatment.

Medical Treatment

Aspirin at daily dosages of 75–325 mg is suggested as a safe and effective therapy to lower the risk of myocardial infarction, stroke, and vascular mortality.

Clopidogrel (75 mg per day) is an alternative to aspirin for reducing ischemia events in individuals with symptomatic LEAD without increasing bleeding.

All LEAD patients should take lipid-lowering medicines to decrease their LDL cholesterol to less than 100 mg/dL, and when the risk is high, less than 70 mg/dL is desirable.

According to these recommendations, a high-intensity statin should be given for individuals 75 and a moderate-intensity statin for patients >75. (50).

In the Heart Protection Study trial, simvastatin (an HMG coenzyme-A reductase) decreased the incidence of the primary vascular event by 22% in LEAD patients compared to placebo.

Antihypertensive medicines should be given to LEAD people with hypertension to attain 140 mm Hg systolic over 90 mm Hg diastolic (in non-diabetic patients) or 130 mm Hg systolic over 80 mm Hg diastolic.

Angiotensin-converting enzyme inhibitors (ACEI) should be favored in asymptomatic or symptomatic LEAD to lower the risk of adverse cardiovascular events.

Ramipril 10 mg/day reduced the risk of myocardial infarction, stroke, or vascular mortality in LEAD patients by 25%.

Ramipril increased pain-free and maximal treadmill walking times vs. placebo. In practice, ACEI should be introduced cautiously over one month while monitoring creatinine clearance.

Antidiabetic medicines should decrease microvascular problems and enhance cardiovascular outcomes in diabetic individuals.

Others LEAD patients may enhance walking distance with cilostazol or pentoxifylline.

Revascularization

When medical therapy and supervised exercise fail to improve a patient's walking ability, revascularization may be suggested.

Endovascular therapy is more common in isolated internal iliac artery stenosis since surgical revascularization is technically more complex and has a greater risk.

There is no randomized comparison of primary stent implantation against percutaneous transluminal angioplasty (PTA) or surgery for internal iliac artery stenosis.

Several short-term studies have evaluated endovascular therapy (PTA alone or stenting).

Seven out of nine patients with buttock claudication experienced pain alleviation after one month of follow-up following PTA alone or stenting.

In another research, 21 patients followed for 14.7±5.7 months experienced complete relief from buttock claudication and a substantial increase in walking distance from 85 m to 225 m following endovascular therapy.

Endovascular treatment of internal iliac artery stenosis has an excellent technical success rate (absence of stenosis after surgery 30%) and a low complication rate (in 3 out of 34 patients).

In their research (34 individuals), 79% achieved total or partial pain alleviation.

In another trial, the same group revascularized the IIA directly in 40 patients undergoing aortic or iliofemoral bypasses.

Proximal claudication vanished following revascularization in 23 of 27 individuals.

The IIA's 1-year and 5-year patency rates were 89 and 72.5%, respectively.

People Also Ask

How Is Iliac Artery Treated?

Direct surgical reconstruction has historically been used to treat iliac artery aneurysms. Endovascular stent grafts have been created to assist patients with peripheral artery aneurysms with an effective, less intrusive therapeutic alternative.

How Is Iliac Stenosis Treated?

Treatment options vary from a) conservative care, which includes exercise therapy, lifestyle adjustments, and antiplatelet medication, to b) minimally invasive endovascular treatment, including percutaneous transluminal angioplasty (PTA) with or without stent implantation and antiplatelet therapy.

How Do You Unblock The Iliac Artery?

A small balloon is used in angioplasty to unblock clogged arteries.

The balloon is repeatedly inflated and deflated to force the plaque against the arterial wall. The balloon is deflated and removed when the artery has been unblocked.

The enlarged artery allows blood to flow freely.

What Causes Iliac Artery Blockage?

The problem is caused by atherosclerosis, a buildup of a waxy material called plaque in the arteries that includes cholesterol, fat, and calcium.

Plaque may constrict or harden the iliac arteries, decreasing blood flow to the pelvis and legs.

Conclusion

When a patient complains of proximal walking discomfort, this condition is often overlooked in the diagnostic procedure.

When a patient complains of proximal walking discomfort, a physician should check for internal iliac artery stenosis.

The research is quite limited, and guidelines and suggestions must be followed to handle internal iliac artery stenosis.

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