where is the iliac artery

Common iliac artery: Anatomy, branches, supply | KenhubImpact factor 3.915 Silence CiteScore 3.7More on impact › Article Internal iliac arterial stenosis: diagnosis and how to manage it in 2015The lower extremity (LEAD) arterial disease is a highly prevalent disease that affects 202 million people worldwide. The stenosis of the inner iliac artery (IIAS) is one of the LEAD locations. This diagnosis is often neglected when a patient has a proximal walking pain as most doctors evoke a pseudo-claudication. Surprisingly, the management of IIAS is not reported in the Transatlantic Inter-Society II Consensus or in the report of the guidelines of the American College Foundation/American Heart Association. The objectives of this review are to present the current knowledge of the disease, how it should be managed in 2015 and what future research trends are. Lower extremity (LEAD) arterial disease is a highly prevalent disease caused mainly by atherosclerosis, a systemic disease process that alters the normal structure and function of the vessels (). Therefore, the risk factors of LEAD are well identified: non-modifiable risk factors such as age, gender and inheritance; and modifiable risk factors such as smoking, hypertension, diabetes and dyslipemia (). It is common to define proximal LEAD and distal LEAD depending on the ischemia area supplied by the damaged artery (). Twenty to 50% of patients with LEAD are asymptomatic (). When the claudication is present, the distal LEAD is typically characterized by calf pain and is based on common illic lesions and/or external illic arteries and/or femoropopliteal lesions (). Contrary to the distal LEAD, proximal LEAD is characterized by back pains, hips, buttocks or thighs and is based on common and/or isolated internal iliac lesions (, , ).Inner iliac arterial stenosis (IIAS) is one of the possible locations of atherosclerosis in the arterial tree. This disease is often lost in the diagnostic process when a patient has a proximal walking pain. In fact, a pain that appears during walking and involves the lower back, the hip, the buttock or the thigh suggest proximal claudication or proximal pseudoclaudication (). Claudication is a vasculogenic pain while pseudoclaudication results from diseases such as spinal lumbar stenosis, hip osteoarthritis, venous congestion, or bone metastasis, sciatica, etc. (–) (Figure; Table ). Figure 1. Main causes of proximal claudication and pseudoclaudication. Table 1. Differential diagnosis of internal iliac arterial stenosis. Unfortunately, due to almost similar symptoms, vascular origin is largely neglected when a patient has a proximal member pain as most doctors evoke a pseudo-claudication (). A number of explanations may be proposed. First, the claudication was historically defined by a fatigue, discomfort or pain that occurs in the calves during the effort due to exercise-induced ischemia and relieved with rest (). Second, the ankle-brachial index (ABI) is used as standard for the diagnosis of LEAD (). In fact, LEAD is defined by an ABI ≤0.90 (), but the latter may remain within the normal limit in case of gluteal artery lesions isolated () or higher (). Finally, the management of IIAS is not reported in the Transatlantic Inter-Society II (TASC II) or in the report of the guidelines of the American College Foundation/American Heart Association (AHA) (, ).Incidence and Prevalence of IIASIncidence and prevalence of IIAS have not been established in the general population. Although isolated IIAS is probably rare, IIAS is often associated with common iliac arterial stenosis. The prevalence of proximal claudication is 5 to 14% in patients with mild to moderate distal LEAD (, ), high among patients with aortobifemoral patent bypasses (), approximately 28%, and almost 35% of patients after the embolization of the bilateral internal iliac artery (IIA) before the repair of endovascular aneurysm (). Symptoms and functional impairment The main symptom is the lower part of the back, the hip, the buttock or the thigh claudication that defines the proximal claudication, a fatigue, discomfort or pain that occurs in specific muscle groups feeding by IIA during the effort due to exercise-induced ischemia and relieved with rest (, ). However, the presentation of proximal claudication is often atypical and can imitate other non-vascular diseases that can induce misleading diagnoses (, ) (Figure ). In addition, pain may appear at rest when the IIAS is severe, and may lead to even gluteal necrosis (). Finally, IIAS induces different functional deficiencies: the deterioration of walking leading to the disability of work, and the sexual deterioration as erectile dysfunction (, ). These two impediments reduce the patient's quality of life (–). To avoid these impediments, although it is difficult with non-invasive conventional tests, it is of interest to diagnose the disease in order to decrease the delay of diagnosis, which is currently 2 years, when the disease is not associated with distal LEAD (). Strategies and TestsClinical evaluation Patients usually report a gradual decrease in their walking capacity, which is evaluated by maximum walking distance (). Claudication traditionally for within 10 min after the end of walking (, ). The maximum foot distance often harms both with the increase of the arterial stenosis and with the deterioration of the collateral network's functionality, which reduces blood flow to the IIA-released muscles (). The maximum foot distance can be evaluated by different methods: medical interview, questionnaires (), standardized test of running tape that is recommended (), 6-minute test when patients cannot walk on a running tape (), and GPS technology recently (). Physical examination should rule out a pseudo-claudication (). The osteoarthritis of the hip is associated with pain typically in the groin caused by the internal or external rotation of the hip (). The pain of the hip is often radiated on the knee, while spinal lumbar stenosis is associated with discomfort that radiates beyond the spinal zone in the buttocks (). In addition, the active lumbar extension can induce discomfort that is relieved with flexion. Finally, the pain due to bone metastasis is compounded by direct pressure on bones. Different questionnaires have been developed to help doctors distinguish vascular claudication from pseudo-claudication. The most used are the World Health Organization (WHO)/Rose Questionnaire, the Edinburgh Claudication Questionnaire and the San Diego Questionnaire (, , ) [Readers will find these complete questionnaires in the same article published in Vascular Medicine ()]. Pulse palpations, the auscultation of the lower extremities and the abdomen in search of a vascular breath have to be done in the patient (). The measurement of ABI defined as the highest systolic pressure in the pediatric dorsalis or posterior tibial artery divided by the pressure measurement of the higher arm can be useful, although it can be insensitive in the case of isolated internal iliac lesions (, ). It has been suggested that the pressure measurement of the penis be an alternative method to diagnose stenosis (). The brain-penile index (PBI), defined as penis pressure on the relationship of the highest systolic brachyal, is rarely used in routine investigations, and its accuracy is 69.3% (confidence interval of 95%: 58.6–78.7) for the detection of an arterial stenosis or occlusion at least one side compared to arteriograms (). Therefore, a normal PBI (prop.0.60) cannot rule out the presence of injuries in the internal illic arteries (). Classical ImagesThe duplex ultrasound (DUS) of the vascular abdominal circulation can help evoke the diagnosis () (Table). In fact, the sensitivity and specificity of the DUS to assess aorto-iliac disease (stenosis) compared to the arteryography are 91% and 93%, respectively (). However, no study has evaluated the sensitivity and specificity of the DUS in the specific evaluation of the IIAS. Sensitivity and specificity obtained for aorto-iliac disease are probably higher than expected in the IIAS assessment because IIA is deeper and more difficult to evaluate with DUS. Some authors have also suggested indirectly evaluating IIA by studying gluteal artery with DUS, but the results must be confirmed in the larger population (). Table 2. Different tests that can be used to diagnose internal iliac stenosis. Computed-tomodensitometric angiography (CTA) and magnetic resonance angiography (MRA), "semi-invasive" tests can be an option for the diagnosis of IIAS especially when a patient is a candidate for revascularization (Figure ) (Figure ) (). Figure 2. Results of the computed-tomodensitometric angiography: occlusion of the right internal iliac artery. Arrow, occlusion of the right internal iliac artery. Digital subtraction Angiography, an invasive technique remains the gold standard for the diagnosis of IIAS with oblique projections to avoid losing the diagnosis of IIAS (). In fact, the external illic artery hides the IIA at the level of the gluteal channel in antero-posterior views (). On the other hand, as suggested by the American College of Cardiology (ACC) and the AHA, when conducting an arteriogram of lower extremity in which the significance of an obstructive lesion (transstenotic pressure gradient environments) should be obtained. The cut of medium rest gradient to determine whether stenosis is significant is discussed that it goes from 5 () to 10 mm Hg (). The peripheral fractional flow reserve (p-FFR), which is defined as the relation of the distal average pressure with stenosis to the average aortic pressure in hyperemia, could also be a valuable test (–). Functional Evaluation of IIAS during the Outing Both the pressure of transcutaneous exercise oxygen (Exercise-TcPO2) and the exercise of infrared spectroscopy (NIRS) measurements made on running tape have been proposed to estimate the ischemia induced by exercise at the level of buttocks (, , , ). Exercise-TcPO2 reflects skin oxygenation while NIRS reflects muscle oxygenation. However, at least at the level of glutes, the skin and the muscles below are vascularized by the same arterial trunk, the internal artery. Compared to the same study, NIRS and Exercise-TcPO2 provided, respectively, 55% (range, 41.6–67.9%) and 82% (range, 69.6–90.5%) of precision (95% confidence) to predict the presence of arteriographically proven lesions (). Exercise-TcPO2 has sensitivity of 79% and specificity of 86% to detect significant lesions (stenosis ≥75%) in the blood tree of the pelvic circulation when the cutting point is lower then −15 mm Hg () (Figure ). The Exercise-NIRS provides a non-invasive method of measuring the tissue oxygen saturation [StO(2)]. Different parameters have been proposed using different running tape protocols (, , ). Time to 50% of the recovery from StO(2) to the reference base [T(50)] √70 s produced a sensitivity of 89% and a specificity of 85% for PAD (). To predict a significant injury in the arteries to hypogastric circulation, it was considered a recovery time √240 s as a cutting value (). Figure 3. Exercise-TcPO2 procedure in a patient. Case history: a 59-year-old woman, a former hypertension and hyperlipidemia former smoker always reports pain in her right ass when she walks although she had surgery for spinal lumbar stenosis 2 years earlier. The discomfort has worsened progressively in the last 4 months and now forces her to rest after walking 250 m at a normal rate. Pain is interfering with your ability to do your job. It has a normal femoral pulse and a normal ankle-brachial index. (A): patient on a treadmill with five TcPO2 probes (one in each buttock, one in each calf, and one in the chest) and a 12-letter electrocardiogram. High Law (B): TcPO2 probe scheme. Low right (C): typical recordings of Exercise-TcPO2 measurements that show a right buttock ischemia with a DROP (such as the rest of oxygen pressure) less than −15 mm Hg. There is no specific management of IIAS (, ). The medical address is the same as the LEAD. To reduce adverse cardiovascular events such as stroke and acute myocardial infarction, life therapy should include the elimination or modification of atherosclerotic modifiable risk factors such as smoking, hypertension, diabetes mellitus and dyslipidemia (). Daily exercise and favorable diet that limits the atherosclerotic process (, ) is recommended. The indication of revascularization depends on the patient's functional impairment (e.g. normal work or other important activities for the patient) after the lack of adequate response to well-managed exercise therapy and medical treatment (). The morphology of the lesion is also an important criterion for the choice of revascularization (, ).Intervention of lifestyle and atherosclerotic risk factors Modifications The cessation of smoking is needed because it continues to smoke compared to the cessation of smoking. It was found that it increases the risk of death, myocardial infarction and amputation (). Patients who are smokers or former smokers should be asked about the state of tobacco use in each visit and be assisted to stop (). The WHO study group has proposed that guidelines for the prevention of cardiovascular diseases include a low-fat diet (400 g/d for five intakes per day) be encouraged (). Therefore, dietary evaluation should be done in clinical practice with a specific validated tool (). Patients with proximal claudication could benefit from the home-based or supervised training program with at least three sessions of 35 to 45 min per week for a minimum of 12 weeks (, ). Therefore, physical activity must be highly recommended (). Medical Treatment In addition to lifestyle changes, anti-aggregating agents such as aspirin in daily doses of 75 to 325 mg are recommended as safe and effective therapy to reduce the risk of myocardial infarction, stroke and vascular death (). Chlopidogrel (75 mg per day) may be an alternative antiplatelet therapy, as it seems to be more effective than aspirin to prevent ischemic events in patients with LEAD without increasing hemorrhagic events (CEPRIE study) ().We also recommend low-duration drugs for all patients with LDL to achieve a LDL cholesterol goal target less than 100 mg per DL target, and when the risk is high According to these guidelines, in case of atherosclerotic cardiovascular disease, a high-intensity statin should be used for patients of ≤75 years or a moderate-intensity statin for patients of 75 years of age (). In the heart protection study trial, simvastatin (a hydroxymethyl glutaryl (HMG) coenzyme-A reductase) has significantly reduced the risk of a major vascular event by 22% (confidence interval of 95%: 15–29) in patients with LEAD compared to placebo (). Antihypertensive drugs should be given to patients with LEAD hypertension to achieve a target In diabetic patients, antidiabetic drugs should be given to achieve a goal of Hemoglobin A1c below 7% to reduce microvascular complications and improve cardiovascular ­outcomes (). Other drugs such as cilostazole or pentoxifylline can be used in patients with LEAD to improve walking distance (). RevascularizationRevascularization can be proposed to patients who have a significant deterioration of walking and after not improving after the medical treatment and supervised exercise training (, ). In the case of isolated IIAS, endovascular treatment is the most used procedure since surgical revascularization is technically more demanding and carries a greater risk for the patient (, ). Contrary to stenosis relative to the common illic artery or the external illic artery, there is no randomized comparison of the placement of primary stent versus percutaneous transluminal angioplasty (PTA) or comparison with the surgery for IIAS (, ). Several studies have evaluated endovascular therapy (single PPT or stenting) in short series of patients. Thompson et al. have shown that the procedures for PTA alone or stent were safe without any complication in nine patients with nalachination: seven out of nine had pain relief after 1 month of follow-up (). Another study, including 21 patients followed during 14.7 ± 5.7 months, found that all patients had a complete relief from the clotting of the glotoco and a significant increase in the walking distance from 85 m to 225 m after the endovascular treatment (PTA alone or stent) (). In 2013, Prince et al. has shown that the endovascular treatment of IIAS has a high rate of technical success (i.e. absence or stenosis after the procedure less than 30%) and a low complication rate (in 3 of 34 patients). In their study (34 patients included), 79% of patients had total or partial relief from the pain of symptoms (). Morse et al., Smith et al., Adlakha et al., and Huetink et al. have also reported different symptomatic cases of IIAS that were successfully treated by endovascular procedures (–). Batt et al. They have also shown good results for angioplasty of the upper lesions of the gluteal artery (, ). Paumier et al. have suggested that in case of common iliac stenosis, aorto-iliac bypasses with a reimplantation of IIA should be discussed (). The same group performed another study in 40 patients, in which a direct revascularization of the IIA was performed to the aorto-iliofemoral bypasses. Proximal claudication after revascularization disappeared in 23 to 27 patients who had previous proximal claudication (). The IIA rate of return was 89% to 1 year and 72.5% to 5 years (). Uncertainty Zones Diagnostic Algorithm To date, no algorithm has been proposed to perform the diagnosis IIAS taking into account the cost of the tests and their possible results to help the diagnosis. Studies on the sensitivity and specificity of several tests such as ultrasound, CTA, or MRA exams are missing in the specific IIAS evaluation. In this case, we propose our diagnostic algorithm (Figure ). Figure 4. Diagnostic algorithm. ABI, ankle-brachial index; Exercise-TcPO2, transcutaneous pressure measurement exercise of oxygen; Exercise-NIRS, infrared spectroscopy; CT scan. Percutaneous Transluminal Angioplasty Alone or Stenting Comparison of primary stent versus angioplasty relative to common illic artery or external artery showed that there were no substantial differences in the technical results and clinical results of the two treatment strategies both in the short and long term (2 years) (). Since the angioplasty followed by selective stent placement is less expensive than the direct placement of a stent, the choice of primary stent or does not have to be studied for IIAS. Evaluation of other atherosclerotic locations An electrocardiogram, carotid and aortic DUS should be discussed because LEAD is associated half the time with other atherosclerotic locations (). Guidelines A specialized multidisciplinary committee organized by ACC and AHA has presented general guidelines for the management of LEAD in 2013 (). Surprisingly, neither this committee nor the TASC II working group mentioned how to manage IIAS (, ). In 2014, the Society for Cardiovascular Angiography and Intervention (SCAI) has published an expert consensus statement on aorto-iliac arterial management (Aorto-iliac). In this statement, the experts considered:- proper care to treat a patient with moderate symptoms to severe hip clutch buttock or loss of important tissue (Regtherford Classification: 2–6) with IIA ≥50% stenosis and/or rest means translesional gradient ≥5 mm Hg;- may be appropriate care to treat a patient with IAS ≥50% with vasculogen ins. Conclusion This review shows that when a patient has a proximal walking pain, the doctor should look for IIAS. We also find that literature is very low and that guidelines and recommendations need to be addressed to know how to manage IIAS. Conflict of interest The authors state that the investigation was conducted in the absence of commercial or financial relations that could be interpreted as a potential conflict of interest. References 1. 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Eur J Vasc Endovasc Surg (2011) 42:78–82. doi:10.1016/j.ejvs.2011.03.01442 Silence 65. Steg PG, Bhatt DL, Wilson PW, D'Agostino R Sr., Ohman EM, Rother J, et al. One-year cardiovascular event rates in external patients with aterotrombosis. JAMA (2007) 297:1197–206. doi:10.1001/jama.297.11.1197297 Silence Keywords: stenosis, management, methods, surgery, peripheral artery disease Cytation: Mahé G, Kaladji A, Le Faucheur A and Jaquinandi V (2015) Internal iliac stenosis: diagnosis and how to manage it in 2015. Front. Cardiovasc. Med. 2:33. doi: 10.3389/fcvm.2015.00033 Received: 08 April 2015; Accepted: 18 August 2015; Published: 01 September 2015 Edited by:Reviewed by: Copyright: © 2015 Mahé, Kaladji, Le Faucheur and Jaquinandi. This is an open access article distributed under the terms of the . It is permitted to use, distribute or reproduce in other forums, provided that the author or the original licensor is credited and that the original publication is cited in this journal, in accordance with the accepted academic practice. No use, distribution or reproduction is permitted that does not comply with these terms. *Correspondence: Guillaume Mahé, Pôle Imagerie et Explorations Fonctionnelles, CHU Pontchaillou, Rennes, 2 avenue Henri Le Guilloux, Cedex 9 35033, France, maheguillaume@yahoo.fr

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