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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

Panel Members
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.
Summary of Literature Review
Introduction/Background
Initial Therapy Definition
Discussion of Procedures by Variant
Variant 1: Adult. Nonsmoker, sedentary lifestyle. Left lower-extremity claudication on walking, asymmetrically diminished left femoral pulse. No symptoms at rest. Initial management.
Variant 1: Adult. Nonsmoker, sedentary lifestyle. Left lower-extremity claudication on walking, asymmetrically diminished left femoral pulse. No symptoms at rest. Initial management.
A. Anticoagulation adjunctive therapy
Variant 1: Adult. Nonsmoker, sedentary lifestyle. Left lower-extremity claudication on walking, asymmetrically diminished left femoral pulse. No symptoms at rest. Initial management.
B. Antiplatelet adjunctive therapy
Variant 1: Adult. Nonsmoker, sedentary lifestyle. Left lower-extremity claudication on walking, asymmetrically diminished left femoral pulse. No symptoms at rest. Initial management.
C. Best medical management including supervised exercise program only
Variant 1: Adult. Nonsmoker, sedentary lifestyle. Left lower-extremity claudication on walking, asymmetrically diminished left femoral pulse. No symptoms at rest. Initial management.
D. Catheter-directed angiography
Variant 1: Adult. Nonsmoker, sedentary lifestyle. Left lower-extremity claudication on walking, asymmetrically diminished left femoral pulse. No symptoms at rest. Initial management.
E. CTA abdomen and pelvis with bilateral lower extremity runoff with IV contrast
Variant 1: Adult. Nonsmoker, sedentary lifestyle. Left lower-extremity claudication on walking, asymmetrically diminished left femoral pulse. No symptoms at rest. Initial management.
F. MRA abdomen and pelvis with bilateral lower extremity runoff with IV contrast
Variant 1: Adult. Nonsmoker, sedentary lifestyle. Left lower-extremity claudication on walking, asymmetrically diminished left femoral pulse. No symptoms at rest. Initial management.
G. Plethysmography and pulse volume recording
Variant 1: Adult. Nonsmoker, sedentary lifestyle. Left lower-extremity claudication on walking, asymmetrically diminished left femoral pulse. No symptoms at rest. Initial management.
H. Risk factor analysis and lipid profile and ABIs
Variant 1: Adult. Nonsmoker, sedentary lifestyle. Left lower-extremity claudication on walking, asymmetrically diminished left femoral pulse. No symptoms at rest. Initial management.
I. US duplex Doppler lower extremity
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.
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.
A. Ankle brachial index
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.
B. Anticoagulation adjunctive therapy
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.
C. Catheter-directed angiography
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.
D. CTA abdomen and pelvis with bilateral lower extremity runoff with IV contrast
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.
E. MRA abdomen and pelvis with bilateral lower extremity runoff with IV contrast
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.
F. Plethysmography and pulse volume recording
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.
G. Risk factor analysis and lipid profile
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.
H. US duplex Doppler lower extremity
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.
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.
A. Anticoagulation adjunctive therapy
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.
B. Antiplatelet adjunctive therapy
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.
C. Catheter-directed mechanical thrombectomy
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.
D. Catheter-directed thrombolytic therapy
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.
E. Percutaneous transluminal angioplasty iliac artery
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.
F. Primary stent placement iliac artery
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.
G. Surgical revascularization
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.
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.
A. Anticoagulation adjunctive therapy
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.
B. Antiplatelet adjunctive therapy
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.
C. Best medical management including supervised exercise program
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.
D. Bilateral percutaneous transluminal angioplasty iliac artery
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.
E. Bilateral primary stent placement iliac artery
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.
F. Surgical revascularization
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.
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.
A. Anticoagulation adjunctive therapy
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.
B. Antiplatelet adjunctive therapy
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.
C. Best medical management including supervised exercise program
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.
D. Percutaneous transluminal angioplasty aortoiliac arterial segment
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.
E. Primary stent placement aortoiliac arterial segment
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.
F. Surgical revascularization
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.
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.
A. Anticoagulation adjunctive therapy
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.
B. Antiplatelet adjunctive therapy
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.
C. Best medical management including supervised exercise program
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.
D. Bilateral percutaneous transluminal angioplasty aortoiliac arterial segment
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.
E. Bilateral primary stent placement aortoiliac arterial segment
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.
F. Surgical revascularization
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.
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.
A. Anticoagulation adjunctive therapy
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.
B. Antiplatelet adjunctive therapy
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.
C. Best medical management including supervised exercise program only
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.
D. Hybrid revascularization with endovascular stenting of aortoiliac disease and infrainguinal bypass
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.
E. Percutaneous stent placement aortoiliac arterial segment
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.
F. Percutaneous transluminal angioplasty aortoiliac arterial segment
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.
G. Surgical revascularization
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.
H. Surgical revascularization
Summary of Highlights
Supporting Documents

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.

Gender Equality and Inclusivity Clause
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 Names and Definitions

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.
References
1. Aboyans V, Ricco JB, Bartelink MEL, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J 2018;39:763-816.
2. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA Guidelines for the Management of Patients with Peripheral Arterial Disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Associations for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (writing committee to develop guidelines for the management of patients with peripheral arterial disease)--summary of recommendations. Journal of Vascular & Interventional Radiology. 17(9):1383-97; quiz 1398, 2006 Sep.J Vasc Interv Radiol. 17(9):1383-97; quiz 1398, 2006 Sep.
3. Klein AJ, Feldman DN, Aronow HD, et al. SCAI expert consensus statement for aorto-iliac arterial intervention appropriate use. Catheterization & Cardiovascular Interventions. 84(4):520-8, 2014 Oct 01.Catheter Cardiovasc Interv. 84(4):520-8, 2014 Oct 01.
4. Rossi M, Iezzi R. Cardiovascular and Interventional Radiological Society of Europe guidelines on endovascular treatment in aortoiliac arterial disease. Cardiovascular & Interventional Radiology. 37(1):13-25, 2014 Feb.Cardiovasc Intervent Radiol. 37(1):13-25, 2014 Feb.
5. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017;135:e686-e725.
6. Cao P, Eckstein HH, De Rango P, et al. Chapter II: Diagnostic methods. [Review]. Eur J Vasc Endovasc Surg. 42 Suppl 2:S13-32, 2011 Dec.
7. Jansen SCP, van Nistelrooij LPJ, Scheltinga MRM, Rouwet EV, Teijink JAW, Vahl AC. Successful Implementation of the Exercise First Approach for Intermittent Claudication in the Netherlands is Associated with Few Lower Limb Revascularisations. European Journal of Vascular & Endovascular Surgery. 60(6):881-887, 2020 Dec.
8. Murphy TP, Cutlip DE, Regensteiner JG, et al. Supervised exercise versus primary stenting for claudication resulting from aortoiliac peripheral artery disease: six-month outcomes from the claudication: exercise versus endoluminal revascularization (CLEVER) study. Circulation 2012;125:130-9.
9. Djerf H, Millinger J, Falkenberg M, Jivegard L, Svensson M, Nordanstig J. Absence of Long-Term Benefit of Revascularization in Patients With Intermittent Claudication: Five-Year Results From the IRONIC Randomized Controlled Trial. Circ., Cardiovasc. interv.. 13(1):e008450, 2020 01.
10. Menke J, Larsen J. Meta-analysis: Accuracy of contrast-enhanced magnetic resonance angiography for assessing steno-occlusions in peripheral arterial disease. Ann Intern Med. 2010; 153(5):325-334.
11. Fakhry F, Spronk S, van der Laan L, et al. Endovascular Revascularization and Supervised Exercise for Peripheral Artery Disease and Intermittent Claudication: A Randomized Clinical Trial. JAMA. 314(18):1936-44, 2015 Nov 10.
12. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33 Suppl 1:S1-75.
13. Muela Mendez M, Morata Barrado PC, Blanco Canibano E, Garcia Fresnillo B, Guerra Requena M. Preoperative mapping of the aortoiliac territory with duplex ultrasound in patients with peripheral arterial occlusive disease. J Vasc Surg. 68(2):503-509, 2018 08.
14. Garcia-Rivera E, Cenizo-Revuelta N, Ibanez-Marana MA, et al. Doppler Ultrasound as a Unique Diagnosis Test in Peripheral Arterial Disease. Ann Vasc Surg. 73:205-210, 2021 May.
15. Darwood R, Berridge DC, Kessel DO, Robertson I, Forster R. Surgery versus thrombolysis for initial management of acute limb ischaemia. Cochrane Database Syst Rev 2018;8:CD002784.
16. Taha AG, Byrne RM, Avgerinos ED, Marone LK, Makaroun MS, Chaer RA. Comparative effectiveness of endovascular versus surgical revascularization for acute lower extremity ischemia. J Vasc Surg 2015;61:147-54.
17. Enezate TH, Omran J, Mahmud E, et al. Endovascular versus surgical treatment for acute limb ischemia: a systematic review and meta-analysis of clinical trials. Cardiovasc Diagn Ther 2017;7:264-71.
18. Eikelboom JW, Connolly SJ, Bosch J, et al. Rivaroxaban with or without Aspirin in Stable Cardiovascular Disease. N Engl J Med 2017;377:1319-30.
19. Schmit K, Dolor RJ, Jones WS, et al. Comparative effectiveness review of antiplatelet agents in peripheral artery disease. J Am Heart Assoc 2014;3:e001330.
20. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). The Lancet 1996;348:1329-39.
21. Foley TR, Singh GD, Kokkinidis DG, et al. High-Intensity Statin Therapy Is Associated With Improved Survival in Patients With Peripheral Artery Disease. J Am Heart Assoc. 6(7), 2017 07 15.
22. Liu J, Wu Y, Li Z, Li W, Wang S. Endovascular treatment for intermittent claudication in patients with peripheral arterial disease: a systematic review. [Review]. Ann Vasc Surg. 28(4):977-82, 2014 May.
23. Klaphake S, Buettner S, Ultee KH, van Rijn MJ, Hoeks SE, Verhagen HJ. Combination of endovascular revascularization and supervised exercise therapy for intermittent claudication: a systematic review and meta-analysis. [Review]. J Cardiovasc Surg (Torino). 59(2):150-157, 2018 Apr.
24. Pandey A, Banerjee S, Ngo C, et al. Comparative Efficacy of Endovascular Revascularization Versus Supervised Exercise Training in Patients With Intermittent Claudication: Meta-Analysis of Randomized Controlled Trials. [Review]. JACC Cardiovasc Interv. 10(7):712-724, 2017 04 10.
25. Schlieder I, Richard M, Nacar A, et al. Active Tobacco Use in Patients with Claudication Does Not Affect Outcomes after Endovascular Interventions. Ann Vasc Surg. 60:279-285, 2019 Oct.
26. Bath J, Lawrence PF, Neal D, et al. Endovascular interventions for claudication do not meet minimum standards for the Society for Vascular Surgery efficacy guidelines. J Vasc Surg. 73(5):1693-1700.e3, 2021 05.
27. Bekken J, Jongsma H, Ayez N, Hoogewerf CJ, Van Weel V, Fioole B. Angioplasty versus stenting for iliac artery lesions. [Review]. Cochrane Database Syst Rev. (5)CD007561, 2015 May 29.
28. Jongsma H, Bekken J, Ayez N, Hoogewerf CJ, Van Weel V, Fioole B. Angioplasty versus stenting for iliac artery lesions. Cochrane Database Syst Rev. 12:CD007561, 2020 12 01.
29. Ye W, Liu CW, Ricco JB, Mani K, Zeng R, Jiang J. Early and late outcomes of percutaneous treatment of TransAtlantic Inter-Society Consensus class C and D aorto-iliac lesions. J Vasc Surg. 2011;53(6):1728-1737.
30. Goode SD, Cleveland TJ, Gaines PA, collaborators St. Randomized clinical trial of stents versus angioplasty for the treatment of iliac artery occlusions (STAG trial). Br J Surg 2013;100:1148-53.
31. Deloose K, Bosiers M, Callaert J, et al. Primary stenting is nowadays the gold standard treatment for TASC II A & B iliac lesions: the definitive MISAGO 1-year results. J Cardiovasc Surg (Torino). 58(3):416-421, 2017 Jun.
32. Sonetto A, Faggioli G, Pini R, et al. Kissing Stent Technique for TASC C-D Lesions of Common Iliac Arteries: Clinical and Anatomical Predictors of Outcome. Ann Vasc Surg. 71:288-297, 2021 Feb.
33. Suzuki K, Mizutani Y, Soga Y, et al. Efficacy and Safety of Endovascular Therapy for Aortoiliac TASC D Lesions. Angiology. 68(1):67-73, 2017 Jan.
34. de Donato G, Bosiers M, Setacci F, et al. 24-Month Data from the BRAVISSIMO: A Large-Scale Prospective Registry on Iliac Stenting for TASC A & B and TASC C & D Lesions. Ann Vasc Surg. 2015;29(4):738-750.
35. Ichihashi S, Higashiura W, Itoh H, Sakaguchi S, Nishimine K, Kichikawa K. Long-term outcomes for systematic primary stent placement in complex iliac artery occlusive disease classified according to Trans-Atlantic Inter-Society Consensus (TASC)-II. J Vasc Surg. 2011;53(4):992-999.
36. Mwipatayi BP, Ouriel K, Anwari T, et al. A systematic review of covered balloon-expandable stents for treating aortoiliac occlusive disease. J Vasc Surg. 72(4):1473-1486.e2, 2020 10.
37. Mwipatayi BP, Sharma S, Daneshmand A, et al. Durability of the balloon-expandable covered versus bare-metal stents in the Covered versus Balloon Expandable Stent Trial (COBEST) for the treatment of aortoiliac occlusive disease. J Vasc Surg. 64(1):83-94.e1, 2016 Jul.
38. DeCarlo C, Latz CA, Boitano LT, et al. An Endovascular-First Approach for Aortoiliac Occlusive Disease is Safe: Prior Endovascular Intervention is Not Associated with Inferior Outcomes after Aortofemoral Bypass. Ann Vasc Surg. 70:62-69, 2021 Jan.
39. Antonello M, Squizzato F, Bassini S, Porcellato L, Grego F, Piazza M. Open repair versus endovascular treatment of complex aortoiliac lesions in low risk patients. J Vasc Surg. 70(4):1155-1165.e1, 2019 10.
40. Dorigo W, Piffaretti G, Benedetto F, et al. A comparison between aortobifemoral bypass and aortoiliac kissing stents in patients with complex aortoiliac obstructive disease. J Vasc Surg. 65(1):99-107, 2017 Jan.
41. Gabel JA, Kiang SC, Abou-Zamzam AM Jr, Oyoyo UE, Teruya TH, Tomihama RT. Trans-Atlantic Inter-Society Consensus Class D Aortoiliac Lesions: A Comparison of Endovascular and Open Surgical Outcomes. AJR Am J Roentgenol. 213(3):696-701, 2019 09.
42. Lun Y, Zhang J, Wu X, et al. Comparison of midterm outcomes between surgical treatment and endovascular reconstruction for chronic infrarenal aortoiliac occlusion. Journal of Vascular & Interventional Radiology. 26(2):196-204, 2015 Feb.J Vasc Interv Radiol. 26(2):196-204, 2015 Feb.
43. Mayor J, Branco BC, Chung J, et al. Outcome Comparison between Open and Endovascular Management of TASC II D Aortoiliac Occlusive Disease. Ann Vasc Surg. 61:65-71.e3, 2019 Nov.
44. Rocha-Neves J, Ferreira A, Sousa J, et al. Endovascular Approach Versus Aortobifemoral Bypass Grafting: Outcomes in Extensive Aortoiliac Occlusive Disease. Vasc Endovascular Surg. 54(2):102-110, 2020 Feb.
45. Tsai TT, Rehring TF, Rogers RK, et al. The Contemporary Safety and Effectiveness of Lower Extremity Bypass Surgery and Peripheral Endovascular Interventions in the Treatment of Symptomatic Peripheral Arterial Disease. Circulation. 132(21):1999-2011, 2015 Nov 24.
46. Salem M, Hosny MS, Francia F, et al. Management of Extensive Aorto-Iliac Disease: A Systematic Review and Meta-Analysis of 9319 Patients. Cardiovascular & Interventional Radiology. 44(10):1518-1535, 2021 Oct.Cardiovasc Intervent Radiol. 44(10):1518-1535, 2021 Oct.
47. Grandjean A, Iglesias K, Dubuis C, Deglise S, Corpataux JM, Saucy F. Surgical and endovascular hybrid approach in peripheral arterial disease of the lower limbs. Vasa. 45(5):417-22, 2016 Sep.
48. Ilano AG, Garvin RP, Ryer EJ, Dove JT, Elmore JR. Patency and limb salvage after femoral endarterectomy and iliac stenting are not affected by severity of iliac disease. J Vasc Surg. 65(5):1336-1343, 2017 05.
49. Jorshery SD, Luo J, Zhang Y, Sarac T, Ochoa Chaar CI. Hybrid surgery for bilateral lower extremity inflow revascularization. J Vasc Surg. 70(3):768-775.e2, 2019 Sep.
50. Maitrias P, Deltombe G, Molin V, Reix T. Iliofemoral endarterectomy associated with systematic iliac stent grafting for the treatment of severe iliofemoral occlusive disease. Journal of Vascular Surgery. 65(2):406-413, 2017 02.J Vasc Surg. 65(2):406-413, 2017 02.
51. Zavatta M, Mell MW. A national Vascular Quality Initiative database comparison of hybrid and open repair for aortoiliac-femoral occlusive disease. J Vasc Surg. 67(1):199-205.e1, 2018 01.
52. Bredahl K, Jensen LP, Schroeder TV, Sillesen H, Nielsen H, Eiberg JP. Mortality and complications after aortic bifurcated bypass procedures for chronic aortoiliac occlusive disease. J Vasc Surg. 62(1):75-82, 2015 Jul.
53. National Academies of Sciences, Engineering, and Medicine; Division of Behavioral and Social Sciences and Education; Committee on National Statistics; Committee on Measuring Sex, Gender Identity, and Sexual Orientation. Measuring Sex, Gender Identity, and Sexual Orientation. In: Becker T, Chin M, Bates N, eds. Measuring Sex, Gender Identity, and Sexual Orientation. Washington (DC): National Academies Press (US) Copyright 2022 by the National Academy of Sciences. All rights reserved.; 2022.
Disclaimer
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