Management Of Aortoiliac Occlusive Disease Research Articles

Impact of operative approach and patient frailty on outcomes for aorto-iliac occlusive disease with critical limb threatening ischemia.

Multiple treatment modalities exist for the management of aorto-iliac occlusive disease (AIOD) including endovascular (endo), extra-anatomic bypass (EAB), and anatomic bypass (AB). The goal of this study was to examine the impact of revascularization strategy and patient frailty on outcomes for AIOD in patients with critical limb threatening ischemia (CLTI). Patients undergoing revascularization for CLTI and AIOD were identified from the NSQIP database over 5years. Demographics, procedural characteristics, and outcomes were recorded. Modified frailty index (mFI-5) was calculated for each patient. Patients were compared based on the type of procedure and frailty (mFi>0.6). From 2017 to 2021, 1777 patients underwent revascularization for CLTI from AIOD. Patients were majority male (56%) with a mean age of 68. A total of 1346 patients (76%) underwent an open operation of which 669 were EAB. When endo (431 patients) was compared with open repair, endo was associated with a higher incidence of tissue loss at presentation (42% vs 33%, p < 0.001), lower rates of bleeding (6.5% vs 15.5%, p < 0.001), fewer MI/stroke (1.6% vs 4.6%, p = 0.004), and fewer wound complications (2.6% vs 11.2%, p < 0.001). There was no difference in re-intervention, amputation, or death based on frailty. For frail patients (184 patients), type of repair did not impact re-intervention, major amputation, or mortality, though there was increased MI/stroke with EAB and increased wound complications with AB/EAB. AIOD revascularization strategies for patients with CLTI have similar 30-day re-intervention, major amputation, and mortality rates. Endovascular repair has less surgical wound complications and is better suited for frail patients.

A Cost-Consequence Analysis Comparing Balloon-Expandable Covered Stents for the Management of Aortoiliac Occlusive Disease.

To compare procedural and long-term costs associated with the use of Balloon-Expandable Covered Stents (BECS) in the management of Aortoiliac Occlusive Disease (AIOD). A cost-consequence model was developed to simulate the intra- and post-operative management of patients with AIOD from the perspective of private health-payers. The study assessed the costs of the LifeStream (BD, Franklin Lakes, New Jersey), iCAST/Advanta V12 (Getinge, Goteborg, Sweden), BeGraft Peripheral (Bentley, Hechingen, Germany), and Viabahn Balloon Expandable (VBX) (W.L. Gore, Flagstaff, Arizona) BECS devices. Device costs were identified from the Australian Prosthesis List, whereas clinical outcomes of BECS were estimated from a systematic review of the literature. Costs were calculated over 24 and 36 month time horizons and reported in US dollars. Long-term, per-patient cost of each device at 24 and 36 months was $6253/$6634 for the LifeStream; $6359/$6869 for the iCAST/Advanta V12; $4806 (data available to 24 months) for the BeGraft Peripheral; and $4839/$5046 for the Viabahn VBX, respectively. Most of the cost difference was attributed to the number of stents required per treated limb and frequency of clinically-driven target lesion revascularization events. Best-available clinical evidence and economic modeling demonstrates that the BeGraft Peripheral and Viabahn VBX were of similar cost and the least costly options at 24 months, whereas at 36 months, the lowest cost BECS option for the treatment of AIOD was the Viabahn VBX. This analysis supports economically informed decision-making for health-payers managing systems that care for patients with AIOD. Stent length and avoiding reintervention were identified as key areas of cost-saving for future BECS development.

Contemporary approaches for the management of aorto-iliac occlusive disease.

Aortoiliac occlusive disease (AIOD) secondary to peripheral arterial disease remains a challenging condition to manage due to anatomical complexities and comorbidities. Operative morbidity and mortality rates are high, and best-practice guidelines have traditionally been limited by a paucity of good quality evidence to aid decision-making. The advent of endovascular technology has enabled the clinician in providing a less invasive option in patients unsuitable for open surgery, but durability of endovascular approaches has remained questionable. However, emerging data on the contemporary management of aortoiliac occlusive disease is demonstrating comparable success rates between open and endovascular surgery. The purpose of this review is to provide an overview on the evolution of techniques, the contemporary management, limitations in the body of evidence and future treatment adjuncts aimed at improving success of intervention in aortoiliac occlusive disease.

Different Methods of Endovascular Techniques in Management of Aorto-Iliac Occlusive Disease

Different Methods of Endovascular Techniques in Management of Aorto-Iliac Occlusive Disease

Management of Extensive Aorto-Iliac Disease: A Systematic Review and Meta-Analysis of 9319 Patients.

Despite advances in endovascular management of aorto-iliac occlusive disease (AIOD) including covered endovascular reconstruction of aortic bifurcation (CERAB) techniques, guidelines for management of symptomatic Trans-Atlantic Inter-Society Consensus (TASC II) type C/D lesions favour open surgical revascularisation. This meta-analysis investigates outcomes in patients with TASC II C/D lesions treated with open bypass procedures (OS), standard endovascular treatments (SEV) or CERAB. Multiple databases (MEDLINE, EMBASE and the Cochrane database) were searched to identify studies reporting endovascular and open treatment of extensive AIOD. Studies were independently assessed. Outcomes reported included 30-day morbidity/mortality and patency rates. A total of 9319 patients undergoing intervention for extensive AIOD were identified from 66 studies. Median patient age was 64years (n = 3204) for SEV, 58years (n = 240) for CERAB and 59years for OS (n = 5875). Pooled meta-analysis for 30-day morbidity in patients undergoing SEV, CERAB and OS was 9, 10 and 15%, respectively. Thirty-day mortality rate was 0.79, 0 and 3% in the SEV, CERAB and OS groups, respectively. In these groups, one-year primary and secondary patency was 90, 88, 96 and 96, 97, and 97% whilst three-year primary and secondary patency was 78, 82, 93 and 93, 97, 97% respectively. Five-year primary and secondary patency was 71 and 89% for SEV and 88 and 95% for OS, respectively. CERAB data were only available to 3years. This meta-analysis shows that thirty-day morbidity and mortality favours endovascular techniques. Primary patency remains better with OS in both early and midterms;; however, secondary patency is comparable in all groups. These findings suggest that SEV/CERAB may be considered as an alternative to OS in higher-risk patients.

Endovascular management of aorto-iliac occlusive disease (Leriche syndrome)

Bypass grafting is the standard of care for chronic aorto-iliac occlusive disease (AIOD, aka Leriche Syndrome) but is associated with mortality rates of up to 25% if surgical re-intervention is necessary. Despite a recent shift towards an endovascular-first strategy for TransAtlantic InterSociety Consensus II ("TASC II") C and D lesions, reports from Leriche Syndrome are still limited. 15 high-risk patients (11 male, 4 female), mean age of 60.6 years, with chronic aorto-iliac occlusive disease were retrospectively reviewed. Retrograde approaches via the bilateral femoral arteries for aortic occlusion less than 4cm in length and/or antegrade fashion from the brachial artery for juxtarenal type lesions were made. For the latter, thrombolysis prior to angioplasty was also performed. Intraluminal or if necessary, subintimal angioplasty was performed with deployment of either bare metal stents or stentgrafts in a kissing-stent fashion. A total of 28 iliac arteries and 14 occluded abdominal aorta were treated with 100% technical success, of which 25% success were achieved by using subintimal technique. Two minor complications occurred, including vascular rupture and distal emboli in one patient apiece, which were successfully managed via endovascular fashion. There were no complications of renal artery emboli. Primary and secondary patency rates at 1, 3 and 5 years were 92.3% and 100%; 83.9% and 100%; and 83.9% and 100%, respectively. Endovascular therapy for chronic aorto-iliac occlusion has a high technical success rate, with good short- and mid-term primary and secondary patency rates and may provide a valid alternative to surgery for high-risk patients.

AAA 12. Juxtarenal Aortoiliac Occlusive Disease—Contemporary Results of Surgical Management and Outcome in a Tertiary Care Center in North India

Peripheral artery disease involving the abdominal aorta and iliac arteries due to atherosclerosis is one of the most common therapeutic challenges faced by vascular surgeons. Although there is a paradigm shift in the management of aortoiliac occlusive disease, most patients with extensive aortoiliac disease with juxtarenal aortic occlusion are being referred to vascular surgeons for aortobifemoral bypass as endovascular treatment is complex and long-term data are not available about its durability. During the last 3 years, 15 patients have been managed surgically at our institute with promising results. All patients were planned for conventional aortobifemoral bypass surgery. The surgical technique included control of bilateral renal arteries and suprarenal aortic clamp placement, infrarenal aortotomy and thrombectomy, thorough aortic flushing, and shifting of the clamp to the infrarenal aorta, followed by standard bypass grafting. Aortic clamp time and renal ischemia time were recorded. Fifteen patients (mean age, 54 years) had tissue loss (minor, eight; major, four); claudication pain was the most common symptom. Smoking (86%), diabetes (36%), hypertension (18%), and coronary artery disease (8%) were the most important risk factors. There were no patients with postoperative renal dysfunction or any need for renal replacement therapy. At mean follow-up of 14 months, all the patients were doing fine with good distal blood flow in limbs, confirming graft patency (Figs 1 and 2). Aortobifemoral bypass remains the “gold standard” in management of juxtarenal aortoiliac occlusive disease because of durable bypass with good long-term results. Risk of renal ischemia is low if the procedure is planned well. We used coated polyester graft in all patients, which has shown good midterm graft patency. This study helps in identifying such complex diseased patients and how they can be managed surgically to improve their long-term survival.Fig 2Postoperative computed tomography angiogram scans showing patent grafts with good distal outflow (anteroposterior and lateral views).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

First-in-Human Experience With the Gore Balloon-Expandable Covered Endoprosthesis in Iliac Artery Occlusive Disease

Purpose: To report the first-in-human iliac artery experience of a new balloon-expandable covered endoprosthesis. Methods: A prospective, single-center pilot study recruited 30 symptomatic patients (mean age 64 years; 18 men) to evaluate the safety and early efficacy of the new Gore balloon-expandable covered endoprosthesis for the treatment of de novo or restenotic common and/or external iliac artery lesions. According to protocol, up to 2 discrete lesions could be treated with a maximum total treated length ≤110 mm. Follow-up included clinical evaluation with duplex ultrasound at 1, 6, and 12 months. Data are presented through 12-month follow-up. The primary safety endpoint was a composite of device- or procedure-related death, myocardial infarction, or amputation in the treated leg within 30 days of the index procedure. Multiple performance outcomes were also evaluated. Results: The primary 30-day safety endpoint was 0%. Per-subject estimates of primary patency, freedom from target lesion revascularization, and freedom from target vessel revascularization were 100% at 1 and 6 months and 96.6% at 12 months. Estimates of assisted primary and secondary patency were both 100% at 12 months. Freedom from major adverse events at 12 months was 100%. Most patients experienced improvements in Rutherford category, ankle-brachial index, and functional status that were sustained to 12 months. Conclusion: This positive first-in-human experience with the Gore balloon-expandable covered endoprosthesis suggests this device will have an important role in the management of aortoiliac occlusive disease.

Comparison of results of endovascular stenting and bypass grafting for TransAtlantic Inter-Society (TASC II) type B, C and D iliac occlusive disease.

IntroductionThe priority use of endovascular techniques in the management of aortoiliac occlusive disease has increased in the last decade. The aim of the present article is to report 1- and 2-year results of iliac artery stenting (IAS) and aortoiliac grafting in the management of patients with TASC II type B, C and D iliac lesions and chronic limb ischaemia.Material and methodsIn this prospective, non-randomised, one-centre clinical study, iliac artery stents and vascular grafts used for the treatment of patients with symptomatic lesions in the iliac artery were evaluated. This study enrolled 2 groups: 54 patients in the stent group and 47 patient in the surgery group.ResultsThe primary patency rates at 1 and 2 years were 83% and 79.9% after IAS and 97.1% and 97.1% after surgical reconstruction, respectively (p = 0.015). The assisted primary stent patency at 1 and 2 years was 87.9% and 78.2%, respectively. The complication rate was 7.4% in the stent group and 6.3% in the surgery group. There was no perioperative mortality in either group.ConclusionsOur results reveal that patients with severe aortoiliac occlusive disease (TASC II types B, C and D) can be treated with IAS or surgically with satisfactory results. Iliac artery stenting is associated with decreased primary patency compared with the surgery group. Iliac artery stenting should be considered with priority in elderly patients or in patients with severe comorbidities.

The Results of Self-Expandable Kissing Stents in Aortic Bifurcation.

Purpose:Kissing stent reconstruction is a widely used technique for the management of aortoiliac occlusive disease involving the aortic bifurcation or proximal common iliac arteries. The purpose of this study was to evaluate the results of self-expandable kissing stents in the aortic bifurcation.Materials and Methods:We reviewed medical records of the patients treated with a kissing stent retrospectively from January 2007 to December 2012. The primary and secondary patencies were determined with Kaplan-Meier analysis, and Cox regression was used to determine the factors associated with patency.Results:A total of 21 patients were included, and all were male (median age 53±15 years, range 48–78 years). Major symptoms were claudication (n=16, 61.9%), rest pain (n=5, 23.8%) and gangrene (n=5, 23.8%). Tans-Atlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) II classification was A 2 (9.5%), B 5 (23.8%), C 7 (33.3%) and D 8 (38%). The mean follow-up was 40.7 months. Major complication occurred in only one case which consisted of distal limb ischemia by emboli. Six patients developed symptomatic restenosis or occlusion. There was no major amputation, but minor amputation occurred in 3 patients. There were 2 mortalities not associated with the procedure (lung cancer and intracranial hemorrhage). Primary patency was 89.6% at 1 year, 74.7% at 3 years and 64.0% at 5 years. Secondary patency was 94.1% at 1 year, 88.2% at 3 years and 68.6% at 5 years. No risk factors for restenosis or occlusion were identified.Conclusion:Self-expandable kissing stents can be used successfully with comparable patency for endovascular treatment of symptomatic atherosclerotic occlusive lesions in the aortic bifurcation area.

Surgical Treatment of Aortoiliac Occlusive Disease with Concomitant Superficial Femoral Artery Occlusion

Introduction: Aortofemoral bypass is a standard method for the surgical treatment of aortoiliac occlusive disease. Most of the patients with aortoiliac occlusive disease have multisegment arterial occlusions extending to the popliteal or distal arterial system. In this research early and long term results of aortobifemoral bypass and aortobifemo-ral bypass with combined femoropopliteal bypass were assessed.Patients and Methods: From March 2002 to October 2011, 833 patients underwent bypass procedures for aortoiliac occlusive disease with concomitant superficial femoral artery occlusion. The patients and surgical procedures were studied prospectively. The patients were divided into 2 groups. Group I (n: 632) consisted of patients who only recevied aortobifemoral bypass. Group II (n: 201) comprised of patients in whom aortobifemoral bypass was combined with femoro-popliteal bypass.Results: In the early (30 days) and late (42 months) follow up periods, the rate of amputation (8 patients in Group I vs. 16 patients in Group II in the early period; p < 0.05 and 8 patients in Group I vs. 11patients in Group II in the late follow-up; p < 0.05) and mortality (2 patients in Group I and 5 patients in Group II in the early period and 8 patients in Group I vs. 11 patients in Group II in the late follow-up; p < 0.05) were higher in Group II. Moreover, graft patency (0.4% thrombosis rate in Group I vs. 5.4% thrombosis rate in Group II in the long run; p < 0.05), freedom from symptoms (claudication, rest pain and necrosis, 3 patients vs. 9 patients, 9 patients vs. 27 patients and 8 patients vs. 17 patients in Group I and Group II, respectively in the longterm follow-up; p < 0.05) and consequences (mortality, amputation, graft infection and graft extraction rates in the longterm, all p < 0.05) were significantly lower in Group II. Conclusion: Aortobifemoral bypass procedure is an efficient, safe and durable technique for the surgical management of aortoiliac occlusive disease (AIOD) combined with superficial femoral artery occlusion. In this circumstance profunda femoris artery plays the major role for the perfusion of limb.

The Current Management of Aortic, Common Iliac, and External Iliac Artery Disease: Basic Data Underlying Clinical Decision Making

The management of aortoiliac occlusive disease is a rapidly evolving field in vascular medicine and surgery. There are multiple approaches that must be considered, ranging from medical management to endovascular and open surgical procedures. The introduction of percutaneous endovascular techniques has significantly changed the landscape of the field forever. We will compare and contrast different treatment strategies and critically review the available literature to allow for evidence-based clinical decisions to be made about the surgical and endovascular management of aortoiliac occlusive disease.

Combined Direct Repair and Inline Inflow Stenting in the Management of Aortoiliac Disease Extending Into the Common Femoral Artery

Describe a hybrid approach to simplify management of complex aortoiliac occlusive disease (AIOD) extending into the common femoral artery (CFA). Retrospective review of 56 patients who underwent hybrid management of AIOD extending into CFA between January 2003 and February 2007. Two distinct hybrid approaches were compared: Inline (iliac stenting continuous with an open CFA reconstruction, 38 limbs in 37 patients) and tandem (noncontiguous stenting of an upstream iliac segment, 20 limbs in 19 patients). The median follow-up duration was 15 ± 12 months in the inline group and 24 ± 12 months in the tandem group. Technical success was achieved in all but 1 procedure. Clinical and hemodynamic responses to the interventions and limb loss rates were comparable in both groups. Survival table analysis showed no significant difference between inline and tandem reconstructions. Inline stenting represents a lesser invasive revascularization choice in complex AIOD with contiguous involvement of the CFA.

Endovascular management of aorto-iliac occlusive disease

As the techniques for endovascular treatment of aortic bifurcation disease become more widely known, it is not enough for interventional radiologists (IR) to be merely technically excellent at the procedural aspects of this important intervention. They must also become expert at managing the patient, and establishing direct contact not only with the patient, but also with the patient's primary doctor, usually their general practitioner. Younger IR physicians may have not had the opportunity to perform as many arterial catheter studies as their grayer counterparts for two main reasons: the shift towards non-invasive studies (US/CTA/MRA), and the encroachment of other specialties on the endovascular field of play. This is not a cause for despair. If you offer the best service, with the best results, you will, in time, get the referrals. However, you must be prepared to offer more than a glorified angiography service: critical to this is the establishment of an Interventional Radiology Clinic, as this then becomes the target for referrals from a variety of other specialties.

Kissing Stent Reconstruction of the Aortoiliac Bifurcation

Kissing stent reconstruction of the aortoiliac bifurcation is a widely used technique for the management of aortoiliac occlusive disease involving the aortic bifurcation or proximal common iliac arteries. New advances in delivery systems and stent design have enabled better anatomic results with kissing stenting. Long-term patency is generally excellent, although several factors may adversely affect patency and should be taken into account when devising the stenting configuration and selecting the device to be used. Geometric variables related to individual aortic anatomy and disease pattern (patient dependent) and stenting configuration (operator dependent) may have an impact on long-term patency. Kissing stent aortoiliac reconstruction is effective and durable, even with complex aortoiliac disease and long-segment occlusions. In our experience, TASC (TransAtlantic Inter-Society Consensus) C and D class disease is not necessarily a contraindication to aortoiliac stent reconstruction, especially in poor operative risk patients. Most restenoses are amenable to endovascular treatment, with excellent long-term assisted patency.

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Bifurcated Endoprosthesis for Treatment of Aortoiliac Occlusive Lesions

To report our initial experience with a bifurcated endoprosthesis in the management of aortoiliac occlusive disease. From May 2001 to February 2004, 112 patients were referred to our institution for the management of aortoiliac disease. Among these, 5 (6%) patients (3 men; mean age 57.8 years) with severe ischemia owing to TASC C or D iliac occlusions were selected for endovascular treatment with a bifurcated stent-graft. An Excluder stent-graft was placed after preliminary recanalization (thrombolysis and/or balloon dilation) the day before. The patients were followed clinically and ultrasonographically every 3 months during the first year and semiannually thereafter. Technical success was achieved in all patients. Endovascular aortoiliac bifurcation reconstruction restored iliac artery flow immediately in all cases. There were no procedure-related complications. The mean ankle-brachial index (ABI) was significantly improved, from 0.66+/-0.04 before the procedure to 0.94+/-0.06 immediately after the procedure (p<0.01). The aortoiliac reconstructions remained patent during the mean 17-month follow-up (range 3-36), and the ABIs were stable. There was no mortality or amputation required in this series. Endovascular placement of a bifurcated stent-graft appears to be technically feasible, effective, and safe in the management of aortoiliac occlusive disease.

Duplex Selection Facilitates Single Point-of-service Endovascular and Surgical Management of Aortoiliac Occlusive Disease

We attempted to optimize management of aortoiliac occlusive disease by using duplex imaging to aid in selection of favorable lesions for percutaneous transluminal angioplasty (PTA)/stenting, by avoiding nontherapeutic arteriography, and by providing single point-of-service care in which endovascular and open surgical reconstruction were combined. One-hundred consecutive patients with symptomatic (91 claudication, 9 limb threat) inflow occlusive disease based on clinical examination and physiologic testing underwent physician-directed duplex scanning of the infrarenal aorta through the femoral bifurcation. Iliac lesions suited to endovascular intervention were defined as focal (length <5 CM), high-grade stenoses with a peak velocity >300 cm/sec and velocity ratio >2 by duplex and were differentiated from unfavorable (diffuse/long iliac stenosis, occlusions, aneurysms, femoral occlusive disease) inflow lesions. Patients with favorable iliac lesions according to duplex were considered candidates for PTA/stenting in an endo-capable operating room, without prior diagnostic angiography. On the basis of duplex imaging, 38 patients possessed endovascularly favorable iliac lesions, 58 patients had unfavorable aortoiliofemoral disease, and 4 obese patients had inadequate studies. Duplex interpretation correctly classified disease distribution/severity in 92% of 50 patients who subsequently underwent intraoperative or diagnostic arteriography. Thirty-one of the 45 (69%) total interventions performed in this patient group were based on duplex findings alone. Of 29 patients with favorable lesions by duplex scanning who had intervention, 25 (86%) received iliac PTA/stenting, while 4 patients required inflow surgical reconstruction for nonfocal iliac disease demonstrated on operative arteriography. Duplex imaging correctly identified the need for concomitant outflow reconstruction/bypass in 11 of the 25 (44%) patients treated by iliac PTA/stenting. Primary and assisted patency rates of iliac PTA/stenting were 83% and 100% at 24 months by life-table analysis. Duplex imaging in patients with symptomatic aortoiliac occlusive disease can provide sufficient information to permit endovascular and surgical intervention without formal diagnostic arteriography in most patients.

Eighteen-year experience with femoro-femoral bypass.

The role of femoro-femoral bypass in the management of aorto-iliac occlusive disease has evolved during the past two decades. The aim of the present study was to evaluate the early and long-term outcomes of femoro-femoral bypass grafts performed at the University of Hong Kong Medical Centre during an 18-year period. From 1981 to 1998, a retrospective analysis of 61 patients who underwent femoro-femoral bypass at the University of Hong Kong Medical Centre was undertaken. Data on demographic features and results of surgical intervention were reviewed. Early outcomes (morbidity, mortality and improvement of clinical category) and long-term outcomes (graft patency, patient survival and limb salvage rates) were analysed. The postoperative morbidity and mortality rates were 16% and 7%, respectively. Clinical success was achieved in 48 patients (79%) after operation. The primary patency of femoro-femoral bypass was 86%, 79% and 71% at 1, 3 and 5 years, respectively. The limb salvage rate was 85% at 3 years. The cumulative survival rate of the study population was 89%, 82% and 73% at 1, 3 and 5 years, respectively. Femoro-femoral bypass was successful in relieving ischaemic pain and limb salvage in approximately 80% of patients. A 5-year patency rate of 71% was achieved. Femoro-femoral bypass remains a valuable surgical procedure for limb salvage in poor-risk patients with unilateral iliac artery occlusion.

Impact of intravascular ultrasonography in the endovascular management of aortoiliac occlusive disease

Intravascular ultrasonography (IVUS) is one of several new imaging technologies that have been applied in the treatment of arterial occlusive disease. Endovascular procedures are increasing annually, and arteriography, which is thought to be the “gold standard” for assessing adequacy of endovascular therapy, appears to have flaws. IVUS, a new imaging technique that expands the understanding of atherosclerotic lesions, images a vessel in a cross-sectional plane and provides information about the morphology of the lesion and the vessel wall. IVUS clearly visualizes the spatial relationship between a deployed stent and the vessel wall; this information is not usually obtainable with arteriography. We conducted 2 studies at our institution to evaluate the use of IVUS in the endovascular treatment of atherosclerotic aortoiliac occlusive disease. The first study showed that actual vessel size and lumen diameter were underestimated 62% of the time by arteriography and that 40% of stents (P < .01) placed in the iliac arterial system were underdeployed, which might be related to treatment failure. The second study showed that the use of IVUS had a positive effect on the long-term patency of angioplastied and stented iliac lesions—all of these reconstructions have remained patent to date. IVUS appears to be the best means of assessing morphology of the arterial occlusive lesions and the results of endovascular intervention. IVUS provides valuable information related to diagnosis and treatment that can alter the conduct of endovascular procedures.