Occlusive disease of the internal iliac artery. Endovascular treatment options

Due to the increase of peripheral artery disease (PAD) worldwide with a prevalence of 10-25% in patients aged 65-80years, proximal PAD with involvement of the internal iliac artery (IIA) is also increasing. At the same time no national or international guidelines for the optimal management of occlusive processes of the IIA exist, consequently, there are no approved algorithms for optimal diagnostics and treatment. Occlusive processes of the IIA are often asymptomatic due to the extensive contralateral collateral system and to the femoral, lumbar and mesenteric arteries. Clinically, gluteal claudication and vascular impotence are the leading symptoms in symptomatic patients. There is often asignificant time delay between the onset of symptoms and diagnosis because difficulties in the diagnostics can arise, especially in isolated alterations of the IIA. Open surgical or endovascular approaches can be carried out for invasive treatment of proximal IIA lesions but measures for revascularization of distal lesions of parietal and visceral terminal branches require endovascular techniques. High rates of technical success and acceptable patency rates have been reported in the literature for endovascular management of IAA lesions; however, these do not always correlate with the clinical success. This article describes minimally invasive treatment strategies and techniques for direct and indirect revascularization of the pelvic circulation based on own retrospectively selected cases. Characteristics of planning and performing IIA procedures as well as unsolved problems and open questions are presented and discussed in the context of the currently available literature.