Management of Iliac Artery Occlusive Disease

Variant: 1   Adult. Nonsmoker, sedentary lifestyle. Left lower-extremity claudication on walking, asymmetrically diminished left femoral pulse. No symptoms at rest. Initial management.
Procedure Appropriateness Category
Best medical management including supervised exercise program only Usually Appropriate
Risk factor analysis and lipid profile and ABIs Usually Appropriate
Antiplatelet adjunctive therapy Usually Appropriate
US duplex Doppler lower extremity Usually Appropriate
CTA abdomen and pelvis with bilateral lower extremity runoff with IV contrast May Be Appropriate
MRA abdomen and pelvis with bilateral lower extremity runoff with IV contrast May Be Appropriate
Plethysmography and pulse volume recording May Be Appropriate
Catheter-directed angiography Usually Not Appropriate
Anticoagulation adjunctive therapy Usually Not Appropriate
Variant: 2   Adult. Long history of claudication. Acute-onset left lower-extremity pain. Absent left femoral pulse by palpation, faint audible DP and PT Doppler signals. Initial management.
Procedure Appropriateness Category
Anticoagulation adjunctive therapy Usually Appropriate
CTA abdomen and pelvis with bilateral lower extremity runoff with IV contrast Usually Appropriate
Catheter-directed angiography Usually Appropriate
MRA abdomen and pelvis with bilateral lower extremity runoff with IV contrast Usually Appropriate
US duplex Doppler lower extremity May Be Appropriate
Ankle brachial index May Be Appropriate
Risk factor analysis and lipid profile May Be Appropriate
Plethysmography and pulse volume recording Usually Not Appropriate
Variant: 3   Adult. Known atrial fibrillation and spine surgery performed within the past month. Sudden-onset right lower-extremity pain. Diminished pulses in right lower-extremity. CTA demonstrates isolated filling defect in right common iliac artery. Initial therapy.
Procedure Appropriateness Category
Anticoagulation adjunctive therapy Usually Appropriate
Catheter-directed mechanical thrombectomy Usually Appropriate
Surgical revascularization Usually Appropriate
Antiplatelet adjunctive therapy May Be Appropriate
Catheter-directed thrombolytic therapy May Be Appropriate (Disagreement)
Percutaneous transluminal angioplasty iliac artery Usually Not Appropriate
Primary stent placement iliac artery Usually Not Appropriate
Variant: 4   Adult. Past medical history of heavy smoking. Severe claudication without rest pain. CTA demonstrates bilateral common iliac artery stenosis at or greater than 90% (TASC A). Initial therapy.
Procedure Appropriateness Category
Antiplatelet adjunctive therapy Usually Appropriate
Best medical management including supervised exercise program Usually Appropriate
Bilateral primary stent placement iliac artery May Be Appropriate
Anticoagulation adjunctive therapy May Be Appropriate
Bilateral percutaneous transluminal angioplasty iliac artery Usually Not Appropriate
Surgical revascularization Usually Not Appropriate
Variant: 5   Adult. Past medical history significant for diabetes mellitus, hypertension, and smoking. Increasing claudication of right lower-extremity involving right buttock for the last 3 months. CTA pelvis with runoff reveals short-segment occlusion of the right common iliac artery (TASC B). Initial therapy.
Procedure Appropriateness Category
Antiplatelet adjunctive therapy Usually Appropriate
Best medical management including supervised exercise program Usually Appropriate
Primary stent placement aortoiliac arterial segment May Be Appropriate
Anticoagulation adjunctive therapy May Be Appropriate
Percutaneous transluminal angioplasty aortoiliac arterial segment Usually Not Appropriate
Surgical revascularization Usually Not Appropriate
Variant: 6   Adult. Past medical history significant for diabetes mellitus, hypertension, and heavy smoking. Gradually increasing claudication of bilateral lower extremities for at least 2 months. CTA pelvis with runoff reveals bilateral common iliac artery occlusion without any involvement of the external or internal iliac artery (TASC C). Initial therapy.
Procedure Appropriateness Category
Antiplatelet adjunctive therapy Usually Appropriate
Best medical management including supervised exercise program Usually Appropriate
Anticoagulation adjunctive therapy May Be Appropriate
Bilateral primary stent placement aortoiliac arterial segment May Be Appropriate
Bilateral percutaneous transluminal angioplasty aortoiliac arterial segment Usually Not Appropriate
Surgical revascularization Usually Not Appropriate
Variant: 7   Adult. Worsening claudication and small ischemic ulcers on digits of both feet. CTA demonstrates diffuse atherosclerosis involving distal aorta and both common and external iliac arteries with multiple stenoses at or greater than 50%, bilateral mid-superficial femoral artery stenoses at or greater than 70% with 2-vessel tibial runoff bilaterally (TASC D). Initial therapy.
Procedure Appropriateness Category
Hybrid revascularization with endovascular stenting of aortoiliac disease and infrainguinal bypass Usually Appropriate
Percutaneous stent placement aortoiliac arterial segment plus superficial femoral Usually Appropriate
Antiplatelet adjunctive therapy Usually Appropriate
Surgical revascularization Usually Appropriate
Percutaneous stent placement aortoiliac arterial segment May Be Appropriate
Anticoagulation adjunctive therapy May Be Appropriate
Best medical management including supervised exercise program only Usually Not Appropriate
Percutaneous transluminal angioplasty aortoiliac arterial segment Usually Not Appropriate
Matthew J. Scheidt, MDa; Parag J. Patel, MDb; Nicholas Fidelman, MDc; Charles Y. Kim, MDd; Mikhail C.S.S. Higgins, MD, MPHe; Osmanuddin Ahmed, MDf; Marcelo S. Guimaraes, MDg; Minhaj S. Khaja, MD, MBAh; Alexander Lam, MDi; Jeffrey J. Siracuse, MD, MBAj; Jason W. Pinchot, MDk.

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.





















































The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document.  The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged.  The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination