On the Basis of Morphological Criteria

Aortic Lesions

• Chronic aortic occlusion (AHA category 4 aortic lesions). Surgical treatment from the following options: aortobifemoral (Figs. 5.5.3, 5.5.4) or bilateral aortoiliac by-pass; uni- or bilateral thoraco-iliofemoral bypass in cases of a very calcified infrarenal aorta or very hostile abdomen; in patients at very high surgical risk, axillobifemoral by-pass.

• Acute aortic thrombosis. Surgical treatment from the following options: aortobifemoral or bilateral aor-toiliac by-pass; in the patient with cardiac failure, ax-

illobifemoral by-pass; only limited reports regarding local fibrinolysis with subsequent PTA; there is no sufficient evidence to recommend this technique; in cases treated by endovascular technique, endoprosthetic exclusion of the pathological aortic segment is necessary in theory.

Acute aortic embolic occlusion. Surgical treatment: transfemoral or transaortic aortoiliac embolectomy. Aortic stenosis:

• AHA categories 1 and 2 aortic lesions. Endovascular treatment of choice: simple PTA and stent in infrarenal aorta when lesion is more than 10 mm from the aortic bifurcation; kissing balloon and kissing stent when aortic bifurcation is pathological.

• Complicated and embolic aortic plaque (AHA category 3 aortic lesions). Surgical treatment of choice: transaortic endarterectomy or aortic exclusion and bilateral aortoiliac or aortobifemoral graft reconstruction; in the high-risk patient, exclusion of the pathological segment with an endoprosthesis

Fig. S.S.3 Aortobifemoral by-pass graft: aortic anastomosis
Fig. S.S.4 Aortobifemoral by-pass graft: femoral anastomosis

can be considered where technically and clinically feasible (proximal point of the lesion at more than 15 mm from the renal arteries; distal point of the lesion at more than 10 mm from the aortic bifurcation; absence of polar renal arteries; in the case of a pervious inferior mesenteric artery, the absence of a significant stenosis in at least one hypogastric artery).

In the presence of diffuse infrarenal aortic stenosis (AHA category 3 aortic lesions). Surgical treatment of choice: in high-risk patients endovascular treatment can be considered.

Iliac Lesions

• Chronic iliac stenosis or occlusion:

• TASC type A or AHA categories 1 and 2 iliac lesions: endovascular treatment of choice (Figs. 5.5.5, 5.5.6).

• TASC type D or AHA category 4 iliac lesions: surgical treatment of choice.

• TASC type B iliac lesions: endovascular treatment is currently more often used, but in the absence of evidence for recommendation.

• TASC type C iliac lesions: surgical treatment is currently used more often, but in the absence of evidence for recommendation.

• AHA category 3 iliac lesions: endovascular treatment has a significantly lower chance of initial success or long-term benefit than surgical treatment.

Acute iliac thrombosis: surgical treatment of choice; iliofemoral or aortofemoral by-pass graft; in the patient at high surgical risk: femoro-femoral or axillofemoral by-pass graft; the reports regarding fibrinolysis with subsequent PTA are not sufficient to recommend this technique.

Acute iliac embolic occlusion: surgical treatment of choice; transfemoral embolectomy.

Fig. 5.5.5 Short-segment right common iliac artery stenosis

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Fig. 5.5.5 Short-segment right common iliac artery stenosis

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