Aortoiliac Disease

Causes

• Atherosclerosis (Primary Cause):
  • The buildup of plaque, composed of cholesterol, fats, calcium, and other substances, hardens and narrows the arteries, reducing blood flow.
• Risk Factors for Atherosclerosis (and thus Aortoiliac Disease):
  • Smoking: The strongest risk factor. Nicotine damages artery walls and accelerates plaque buildup.
  • High Cholesterol (Hyperlipidemia): High levels of LDL ("bad") cholesterol contribute to plaque formation.
  • High Blood Pressure (Hypertension): Damages artery walls, making them more susceptible to plaque.
  • Diabetes Mellitus: High blood sugar damages blood vessels throughout the body, including the aorta and iliac arteries.
  • Age: The risk significantly increases with age, typically affecting individuals over 50.
  • Family History: A family history of PAD, heart disease, or stroke increases individual risk.
  • Obesity: Contributes to other risk factors like diabetes, high blood pressure, and high cholesterol.
  • Lack of Physical Activity: Sedentary lifestyle is associated with increased risk.
  • Chronic Kidney Disease.
• Rare Causes:
  • Aortitis: Inflammation of the aorta (e.g., Takayasu's arteritis, giant cell arteritis).
  • Radiation Therapy: Previous radiation to the abdominal area.
  • Trauma or Injury to Arteries.

Symptoms

• Claudication:
  • Pain, cramping, aching, or fatigue in the legs, hips, or buttocks that occurs during physical activity (e.g., walking, climbing stairs) and resolves with rest.
  • The location of the pain depends on where the artery is narrowed; aortoiliac disease often causes pain in the buttocks, thighs, and calves.
• Erectile Dysfunction: In men, particularly with blockages at the aortic bifurcation (Leriche Syndrome), impotence can be a symptom due to reduced blood flow to the pelvic area.
• Buttock and Thigh Pain: Often more prominent with aortoiliac involvement.
• Leg Weakness or Heaviness during activity.
• Numbness or Tingling: In the legs or feet.
• Non-Healing Sores or Ulcers: On the toes, feet, or legs, indicating severe blood flow restriction (critical limb ischemia).
• Changes in Skin and Hair:
  • Coolness of the lower extremities.
  • Pallor (paleness) of the skin when legs are elevated.
  • Reddish-blue discoloration when legs are dangling.
  • Loss of hair on the legs and feet.
  • Shiny skin appearance.
• Weak or Absent Pulses: In the femoral, popliteal, and pedal arteries (in the groin, behind the knee, and on the foot).
• Atrophy: Wasting away of calf muscles.
• Gangrene: (Severe, late-stage) Tissue death due to complete lack of blood flow, leading to infection and potentially limb amputation.

Diagnosis

• Medical History and Physical Exam: The doctor will inquire about symptoms (especially claudication), risk factors (smoking, diabetes, etc.), and family history. The exam involves checking pulses in the legs and feet, looking for skin changes, and listening for bruits (abnormal sounds) over arteries.
• Ankle-Brachial Index (ABI):
  • A non-invasive test that compares blood pressure measurements in your ankle to those in your arm.
  • A low ABI indicates reduced blood flow to the legs, suggestive of PAD.
• Doppler Ultrasound:
  • Uses sound waves to evaluate blood flow through the arteries and identify areas of narrowing or blockage.
  • Can also measure blood pressure at various points along the legs.
• CT Angiography (CTA):
  • Uses CT scans with contrast dye to create detailed images of blood vessels, clearly showing the location and severity of blockages in the aorta and iliac arteries.
• MR Angiography (MRA):
  • Uses MRI with contrast dye to visualize blood vessels, similar to CTA but without radiation exposure.
• Conventional Angiography (Catheter Angiography):
  • An invasive procedure considered the "gold standard" for detailed visualization. A catheter is inserted into an artery (usually in the groin), and contrast dye is injected to highlight the arteries on X-ray.
  • Often performed just before or during an intervention to treat the blockage.

Treatment

• Lifestyle Modifications (Crucial for all stages):
  • Smoking Cessation: The most important step to halt disease progression.
  • Regular Exercise Program: Especially supervised exercise therapy for claudication, which can improve walking distance and reduce pain.
  • Healthy Diet: Low in saturated/trans fats, cholesterol, and refined sugars; rich in fruits, vegetables, and whole grains.
  • Weight Management: Achieve and maintain a healthy weight.
• Medications:
  • Statins: (e.g., atorvastatin, rosuvastatin) To lower cholesterol and stabilize plaque.
  • Antiplatelet Medications: (e.g., aspirin, clopidogrel - Plavix) To prevent blood clots from forming on existing plaque.
  • Blood Pressure Medications: To control hypertension.
  • Diabetes Medications: To control blood sugar levels.
  • Cilostazol (Pletal): A medication specifically for claudication symptoms, improving walking distance.
  • Pentoxifylline: Less commonly used for claudication.
• Endovascular Procedures (Minimally Invasive):
  • Angioplasty and Stenting: A catheter with a balloon is inserted into the narrowed artery and inflated to widen it. A stent (mesh tube) may be placed to keep the artery open. Often preferred for shorter, less complex blockages.
  • These procedures are performed through small punctures, usually in the groin.
• Surgical Procedures (for severe or extensive blockages):
  • Bypass Grafting: A synthetic tube or a vein from another part of the body is used to create a bypass around the blocked segment of the aorta or iliac artery, rerouting blood flow.
  • Endarterectomy: Surgical removal of plaque from the inside of the artery.
• Foot Care: Meticulous foot care is essential, especially for individuals with diabetes, to prevent infections and non-healing wounds.

Living With Aortoiliac Disease

How well someone does with aortoiliac disease depends less on which procedure they had than on whether the medications are taken every day, walking continues, and the smoking stops. The same plaque is nearly always present in the heart and neck arteries, so the treatment protects far more than the legs.

The medications are for the heart, not only the legs

A high-intensity statin such as atorvastatin or rosuvastatin and an antiplatelet, usually clopidogrel or aspirin, are continued for life regardless of whether the legs feel better, because people with this disease die far more often of heart attack and stroke than of the leg disease itself. In selected patients, low-dose rivaroxaban is added to aspirin to reduce limb and heart events. Blood pressure and diabetes targets are the standard ones, and an ACE inhibitor such as lisinopril is preferred when one is needed.

Walking through the pain is the treatment

Supervised exercise, walking to near-maximal pain, resting, and repeating for 30 to 45 minutes three times a week, improves walking distance more than any drug and compares well with stenting in trials. It is covered by Medicare for claudication. Doing it at home works when there is a structure; our walking challenge is a starting point, and early morning or indoor walking avoids the heat. Our PAD leg pain article covers what improvement to expect.

Smoking, and what it is confused with

Continued smoking sharply raises the chance of amputation and of a bypass or stent failing, so quitting is a treatment rather than advice; the nicotine dependence page covers medications that make it realistic. Buttock and thigh pain on walking is also caused by spinal stenosis, but that pain eases with bending forward or sitting rather than standing still, and the ankle-brachial index separates the two. Hip osteoarthritis hurts with the first steps and at night rather than after a set distance.

Feet, aneurysms, and erections

Reduced blood flow means a blister or cut heals slowly and infects easily, so daily foot inspection and prompt care for any wound matter, especially with diabetes; our foot care guide sets out the routine. The same aortic disease predisposes to an abdominal aortic aneurysm, so a one-time ultrasound screen is arranged. Erectile dysfunction from aortoiliac blockage often improves after revascularization and is worth raising.

After a stent or bypass

Iliac stents stay open well for years, but they are checked with ultrasound at intervals, and antiplatelet treatment is never stopped without asking the vascular team. Sudden return of pain, a cold or pale foot, or new numbness means a stent or graft may have blocked and is an emergency. Our cardiovascular team manages the risk factors between vascular surgery visits. The NHLBI and MedlinePlus publish patient guidance on peripheral artery disease.

If you have leg pain on walking and have never had an ankle-brachial index, or still smoke, schedule a visit.