Aortoiliac Occlusive Disease Workup

  • Author: Kenneth E McIntyre Jr, MD; Chief Editor: Vincent Lopez Rowe, MD   more...
 
Updated: Aug 19, 2011
 

Laboratory Studies

  • Examine a serum lipid profile that includes total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides (TG). Furthermore, in younger patients or those with a strong family history of atherosclerosis at any early age, lipoprotein (a) and homocysteine levels should be determined.
  • If a history of diabetes exists, a glycosylated hemoglobin level (Hgb A1c) should be checked. Excellent control of diabetes reduces long-term complications, and the American Diabetic Association (ADA) currently recommends that the Hgb A1c be less than 7%.
  • If a patient has a history of thrombosis in any venous or arterial segment or a family history of a clotting disorder, an evaluation for hypercoagulability is necessary. Tests include routine prothrombin time, partial thromboplastin time, platelet count, factor V-Leiden, factor II (prothrombin) C-20210a, anticardiolipin antibody, baseline protein C, protein S, and antithrombin III levels.
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Imaging Studies

  • Contrast aortography is not always required, unless interventional therapy (percutaneous transluminal angioplasty /stent or surgical revascularization) is planned. Serum creatinine is checked to validate a baseline level prior to the use of contrast agents that may be nephrotoxic.
  • Computerized tomographic arteriography (CTA) is an excellent modality for planning operative or endovascular treatments. CTA has the advantage of producing 3-dimensional images of the arterial system that are as accurate as those of conventional catheter arteriography. However, iodinated contrast agent is still required to obtain the images in CTA, although direct arterial cannulation is not needed.
  • As an alternative to conventional angiography, the surgeon may consider magnetic resonance angiography (MRA) or arterial duplex mapping as definitive imaging studies for planning surgery. MRA is overly sensitive and may show significant arterial stenoses that are simply not present.
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Other Tests

  • The Doppler-derived ABI is a simple office-based examination that confirms the diagnosis of peripheral arterial disease (PAD) if the value is less than 0.9. The ABI also can grade the severity of peripheral arterial disease (PAD). Note that Doppler-derived segmental arterial pressures do not reflect the severity of AIOD accurately.
    • In addition, the ABI is not very sensitive in identifying patients with mild occlusive lesions in the aortoiliac segment. A treadmill exercise stress test should be recommended for those patients with mild iliac occlusive disease who have symptoms suggestive of claudication even though the ABI is normal at rest. Following exercise, the blood flow through stenotic vessels increases and the pressure decline across these lesions is augmented.
    • Moreover, if the blood pressure cuff is unable to compress the vessels adequately, the Doppler-derived pressures may be falsely elevated. This may occur in patients with diabetes or end-stage renal disease. In the event that supranormal (falsely elevated) Doppler-derived pressures are encountered, pulse volume recordings (PVR) may be useful in evaluating leg perfusion. The PVR waveform reflects the volume of blood in the leg during an individual cardiac cycle. A normal waveform demonstrates a brisk upstroke, a sharp systolic peak, and a downstroke with a dicrotic notch. With significant peripheral arterial disease (PAD), the dicrotic notch is lost, the slope of the upstroke and downstroke decline, the amplitude of the waveform is reduced, and the contour of the systolic peak is more rounded.
  • Because an association of coronary disease in patients with peripheral arterial disease (PAD) exists, obtain an electrocardiogram even in patients without cardiac history.
  • For those patients being considered for an intra-abdominal aortic procedure, pulmonary function tests are important if a history of obstructive pulmonary disease or dyspnea is present. Many times the surgical approach needs to be altered based on the results of this preoperative evaluation.
  • If a patient has a history of thrombosis in any venous or arterial segment or a family history of a clotting disorder, an evaluation for hypercoagulability is necessary. Tests include routine prothrombin time, activated partial thromboplastin time, platelet count, factor V-Leiden, factor II (prothrombin) C-20210a, anticardiolipin antibody, protein C and protein S levels, and antithrombin III.
  • An intensive preoperative cardiac evaluation is reserved for patients with newly onset angina pectoris, unstable angina pectoris, or evidence of ventricular dysfunction based on dobutamine stress echocardiogram. Adenosine thallium perfusion tests are not routinely performed because of the high sensitivity and low specificity.
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Contributor Information and Disclosures
Author

Kenneth E McIntyre Jr, MD  Professor of Surgery, Chief, Division of Vascular Surgery, University of Nevada School of Medicine; Chief, Surgical Service, Chief, Vascular Surgery, Veterans Administration of Southern Nevada

Kenneth E McIntyre Jr, MD is a member of the following medical societies: American College of Surgeons, Society for Clinical Vascular Surgery, Society for Vascular Surgery, and Southern Association for Vascular Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Jeffrey Lawrence Kaufman, MD  Associate Professor, Department of Surgery, Division of Vascular Surgery, Tufts University School of Medicine

Jeffrey Lawrence Kaufman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society for Artificial Internal Organs, Association for Academic Surgery, Association for Surgical Education, Massachusetts Medical Society, Phi Beta Kappa, and Society for Vascular Surgery

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Travis J Phifer, MD  Chief, Division of Vascular Surgery, Professor, Department of Surgery and Radiology, Louisiana State University Health Sciences Center in Shreveport

Travis J Phifer, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Society for Academic Emergency Medicine, Society for Vascular Surgery, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD  Associate Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Pacific Coast Surgical Association, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, and Western Vascular Surgical Society

Disclosure: Nothing to disclose.

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