Original Article

Vascular

Aortoiliac occlusive disease – a novel

2023, Vol. 0(0) 1–10
© The Author(s) 2023
Article reuse guidelines:
classification system based on anatomical sagepub.com/journals-permissions
DOI: 10.1177/17085381231166975
journals.sagepub.com/home/vas
segments and disease severity for
management planning

Ngozi Lola Ogunsanya , Ross Milner, Chris L Delaney and

Phillip Puckridge

Abstract
Aims: The aim of this classification system is to provide vascular surgeons with a simple tool that categorises disease
severity by anatomical segment in aortoiliac occlusive disease and thus guide decision making and management strategies.
Disease of the common femoral arteries is included as the distal extent of disease with respect to access for both open and
endovascular intervention is essential to management planning.
Methods: The classification system designates diseased segment letters and numbers to guide treatment planning. The
degree of disease other than stenotic or occluded is not required. In a similar manner to the TNM classification, anatomy
and disease severity – based on angiography, CTA, and MRA – are categorised using a simple, user-friendly method. Two
clinical cases are presented to exemplify the clinical application of this classification system.
Results: A simple and useful classification system is presented and ease of use exemplified by two clinical cases.
Conclusions: Management strategies for peripheral artery disease in general, aortoiliac occlusive disease specifically, have
evolved rapidly in recent years. Existing classification systems, such as TASC II, steer the clinician towards specific
treatment approaches. However, the first step in the management decision-making process is the accurate identification of
the arterial segments that require treatment. None of the existing classification systems specifically address anatomy as an
entity in itself. This classification system provides an intuitive framework, based on letters and numbers, that provides
specific information on arterial segments and disease severity in aortoiliac occlusive disease on which clinicians can base
management decisions. It has been developed to bolster this aspect of the vascular surgery armamentarium; to be used as a
decision making and management planning tool, in partnership with, not instead of, existing classification systems.

Keywords
Aortoiliac occlusive disease, Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial
Disease II, classification system, peripheral artery disease

Classification systems play an important role in the man- asymptomatic to necrosis and gangrene, with no specific
agement of patients with peripheral artery disease. They consideration for patients with diabetes.
provide clinicians with accepted criteria for patient as- Three decades later, Rutherford3,4 developed classifi-
sessment, treatment and follow-up, and serve as a valuable cation systems for acute (ALI) and chronic limb ischaemia
research tool, facilitating the objective comparison of dif-
ferent treatment strategies.1 In order to set context for our
College of Medicine and Public Health, Flinders Medical Centre and Flinders
new classification system, a brief overview of some of the University Department of Vascular Surgery, Bedford Park, AU-SA,
existing classification systems is given subsequently. Australia
Both Fontaine and Rutherford designed classification
systems as tools for amputation risk stratification and to Corresponding author:
Phillip Puckridge, College of Medicine and Public Health, Flinders
quantify benefit of revascularisation. Medical Centre and Flinders University Department of Vascular Surgery,
The Fontaine classification,2 now over 60 years old, is Flinders drive, Bedford Park, AU-SA 5042, Australia.
based solely on patient symptomology, ranging from Email: [email protected]
2 Vascular 0(0)

(CLI), similarly based on symptomology, and incorporating system incorporates the common femoral segments as an
clinical findings with objective criteria. However, the CLI understanding of distal access and the extent of disease
classification precludes those patients with established di- thereof is essential to planning open and/or endovascular
abetic neuropathy, to whom rest pain does not apply, whilst intervention. As with the TASC II consensus document,9
the descriptives used in ALI classification, a useful aid in this classification system grades atherosclerotic lesions in
risk stratification for limb salvage, include Doppler findings, the aorto-iliac and femoral segments according to disease
often superfluous in the current clinical climate. Still rel- severity. TASC II provides a framework to compare ther-
evant and robust, Rutherford’s classification of ALI remains apeutic techniques; in contrast, our classification provides a
central to the clinical assessment of the acute vascular descriptive map on diseased segments which leads to a
patient to date. better understanding of which segments require intervention
Bollinger and colleagues5 adopted a more compre- and thus informs operative planning rather than recommend
hensive approach to classification, using increasing ex- specific treatment strategies.
pertise in angiography to classify lesions according to The classification system designates diseased segments
location and severity, subdividing the arterial system into for treatment. The degree of disease other than stenotic or
anatomic segments and scoring atherosclerotic lesions occluded is not required because the aim is to identify the
according to degree of stenosis, occlusion, and plaque extent of disease but not the haemodynamic significance of
burden. specific diseased segments. The reason being that a clinician
More recently, the dramatic increase in the prevalence of may decide that treatment may extend to or through an
diabetes and ‘the diabetic foot’ has shifted focus to below- arterial segment despite the lesion in one segment being
knee arterial disease as well as other important predictors of haemodynamically insignificant. As such, 50% stenosis on
limb loss aside from perfusion. cross-sectional imaging has been arbitrarily chosen as
Graziani et al.6 also used angiographic techniques to sufficient disease for which to consider treatment to extend
evaluate arterial disease in patients with tissue loss, clas- to or through.
sifying disease severity according to anatomy and degree of The TNM classification14 has had a major impact on
stenosis or occlusion and reporting high prevalence of tibial decision making in cancer treatment. In staging arterial
vessel disease in the studied diabetic subpopulation. occlusive disease in a similar manner by location (aortic,
The WIfI classification7 takes a more inclusive approach iliac, and femoral), disease extent (minimal or extensive
to the critical limb, including the three main determinants of depending on extent through each vessel), and degree of
limb loss – wound (W), ischaemia (I), and foot infection disease (stenosis or occlusion), we have created a sim-
(fI) – and embraces the previously excluded complex group plified approach using letters and numbers to describe
of diabetic patients. disease that informs decision making.
Perhaps most relevant to this paper is the TASC II Gross anatomy is designated as follows:
classification.7,8 The original document on the Management
of Peripheral Arterial disease, based on a large body of work A – aorta.
carried out by a European and North American working C – common iliac artery (CIA).
group and described in detail elsewhere,10 was published E – external iliac artery (EIA).
in 2000. F – common femoral artery (CFA) 5mm.
A more concise and internationally collaborative
update on key aspects of diagnosis and management was Disease categories assigned with suffix:
published in 2007, the objectives of which were to guide
decision making around open and endovascular inter- s – stenotic (>50%).
vention for occlusive vascular disease. These recom- o – occluded
mendations have been challenged by recognition of the 0 – no significant disease.
inter- and intra-observer variability in the assessment of
disease severity11,12 and by the advancement of endo- Laterality:
vascular techniques and devices, particularly in the aorta-
iliac segments.13 The latter in particular limits its use in R = right
predicting intervention in current practice. L = left
In this paper, we describe a novel classification system
for de novo aortoiliac occlusive disease. Two case examples For ease of description, sub-classifications of each gross
are presented to illustrate its application. The classification anatomical segment will be dealt with in turn.
Ogunsanya et al. 3

Figure 1. Diagrammatic representation and CT MPR of the aorta.

Aortic disease · 2 – disease extending from 5mm distal to the ostium

of the common iliac artery to iliac bifurcation + in-
The aorta is sub-classified into three anatomical areas volvement of internal iliac artery ostium.
(Figure 1). Numerical descriptives for anatomical disease · Suffixes s and o are designated as previously
extent are allocated as follows: described.
· Laterality designated as R: right and L: left, with each
· 0 – no aortic disease.
side described separately.
· 1 – aortic segment 5mm caudal to IMA to the
proximal 5mm of CIA.
· 2 – aortic segment 5mm caudal to IMA to 5mm
For example, CR1s CL2o = stenotic disease involving
caudal to renal arteries. the right common iliac artery, not extending to iliac bi-
· 3 – aortic segment 5mm caudal of renal arteries to
furcation and occlusive disease of the left common iliac
origin of lower renal artery. artery extending to and involving the internal iliac artery
· Suffixes s and o are designated as previously described.
origin.

For example, A1s indicates stenotic disease of the aorta

limited to the area 5 mm caudal to the IMA. External iliac disease
Figure 3 illustrates the classification of the external iliac
artery. The external iliac artery is designated as
E. Numerical descriptives for anatomical disease extent are
Common iliac disease
allocated as follows:
The common iliac artery is designated as C. Numerical
descriptives for anatomical disease extent are allocated as in · 0 – no external iliac disease.
Figure 2: · 1 – disease of the external iliac artery, specifically
arterial segment between the ostium of external iliac
· 0 – no common iliac disease. artery to the inguinal ligament/inferior epigastric
· 1 – disease of common iliac artery, specifically ar- artery.
terial segment 5mm distal to common iliac artery · Laterality designated as R: right and L: left with each
ostium to iliac bifurcation. side described separately.
4 Vascular 0(0)

Figure 2. Diagrammatic representation and CT MPR of the common iliac artery.

Figure 3. Diagrammatic representation and CT MPR of the external iliac artery.

Ogunsanya et al. 5

Figure 4. Diagrammatic representation and CT MPR of the femoral vessels.

For example, ER1o EL0 = occlusive disease of the right Case example 1
external iliac artery, no significant disease of the left external
A 67 year-old male presented with right gluteal pain on
iliac artery.
walking creating severe restriction to his walking distance. He
was an ex-smoker with a past medical history of hypertension,
hypercholesterolaemia, impaired glucose tolerance, and met-
Femoral disease abolic syndrome. On clinical examination of the lower limbs,
no pulses were palpable on the right, normal femoral, popliteal,
As in Figure 4, common femoral artery is designated as
and pedal pulses palpable on the left.
F. Numerical descriptives for anatomical disease extent are
Duplex ultrasound suggested a high-grade stenosis in the
allocated as follows:
right CIA. CT angiography demonstrated mild ectasia of the
infrarenal aorta with a narrowed distal aortic bifurcation;
· 0 – no common femoral disease.
calcific plaque extended from the distal infrarenal aorta into
· 1 – disease of common femoral artery, specifically
the right CIA creating a >90% stenosis with post-stenotic
arterial segment between inguinal ligament and in-
dilation (Figure 5). The left CIA was calcified but not
ferior epigastric artery.
stenotic (Figure 6). There was calcific plaque creating <50%
· Laterality designated as R: right and L: left with each
stenosis of the bilateral CFAs (Figures 6 and 7).
side described separately.
Classification:
For example, FR1s FL0 = stenotic disease of the right
common femoral artery, no significant disease of the left A1s
common femoral artery. CR1s, CL0
The two subsequent case examples will exemplify how ER0, EL0
this classification system can be utilised in clinical practice. FR0, FL0
The images selected are for illustrative purposes only as the
classification system requires comprehensive examination As the disease included the A1 segment of the aorta,
of all patient images. the treatment strategy needed to include the distal aorta to
6 Vascular 0(0)

Figure 5. CT MPR of the aorta and common iliac segments. Figure 6. CT MPR of the left external iliac and femoral arteries.

manage the technical aspects of the procedure. The At 5 year follow-up, patient had no residual symptoms,
authors recognise that this is possible in a multitude of no progression of disease, and no binary restenosis in the
ways. Although the CFAs had evident disease on CTA, it treated segments.
was not >50% on the imaging and not considered re-
quiring treatment as part of procedure or to manage this
patient. The classification reflects this and records the
femoral segments F as 0. Reviewing the classification
Case 2
one can see the treatment strategy needs to focus on A 72 year-old male reformed smoker with a past medical
treating the distal aorta and right CIA, with a solution for history of IHD, hypercholesterolaemia, and hypertension
the aortic bifurcation. In this case, a covered endovas- presented with a 2 year history of bilateral calf claudication.
cular reconstruction of the aortic bifurcation was per- His walking distance was severely limited, and he was
formed using the AFX stent in an off label manner unable to engage in a cardiovascular rehab program as part
(Figure 8). of his management of IHD. Clinical examination of the
Ogunsanya et al. 7

Figure 8. Completion angiography of AFX stent.

a >90% stenosis. The right CFA had a 70% stenosis

(Figure 11).
Classification:

A1s
Figure 7. CT MPR of the right external iliac and femoral arteries. CR0, CL1s
ER0, EL0
lower limbs found normal palpable right femoral and FR1s, FL0
popliteal pulses with absent right pedal pulses, and weak
palpable pulses in the left. The proposed classification system has identified
CT angiogram demonstrated calcified plaque at the stenotic disease in the right femoral artery which is an
aortic bifurcation extending a few millimetres proximal important consideration when planning either open or
to the bifurcation and through the left CIA nearly oc- endovascular intervention. Additionally, the classifica-
cluding it and extending to the mid-CIA (Figure 9). The tion of the distal aorta as A1s directs operative planning to
left internal iliac artery (IIA) origin had a separate ste- the proximal extent of management planning. Classifi-
nosis of 50% but not involving stenosis of the distal CIA. cation of A1s and CL1s provides the operator information
The right CIA had a 40% stenosis. Both external iliac and that any proposed procedure needs to account for the
left common femoral arteries were free of disease contralateral CIA, in this case the right hand side. Of the
(Figures 10 and 11). Distally (and not part of this clas- various treatment options, the authors chose a covered
sification) the left mid-superficial femoral artery (SFA) endovascular reconstruction of the aortic bifurcation
had a 50% stenosis, and the right popliteal artery had (CERAB) to treat the aortoiliac disease, with concurrent
8 Vascular 0(0)

Figure 9. CT MPR of the aorta and common iliac segments. Figure 10. CT MPR of the left external iliac and femoral arteries.

right femoral endarterectomy in order to provide access rapid growth in expertise and new technology in vascular
and facilitate treatment of the entire aortoiliac segment surgery.
(Figure 12). The Fontaine classification describes the severity of limb
The patient made an uneventful recovery. ischaemia based on symptoms of claudication distance, rest
pain, and tissue loss. Contemporary intervention for clau-
dicants (Stage II) is guided by the quality of life limitations
rather than a specific walking distance.
Discussion Rutherford’s classification of chronic limb ischaemia
Classification systems have played an important role in precludes those patients with diabetic neuropathy whilst the
vascular surgery for many years. As the speciality evolves, descriptives used in the acute limb ischaemia classification,
contemporary knowledge and novel technology not only a useful aid in risk stratification for limb salvage, include
demand and inform new classification systems but also Doppler findings which are perhaps superfluous in the
open existing systems up to scrutiny and a degree of clinical setting.
criticism. The objectives of the TASC II classification, revised in
In order to remain relevant and useful, classification 2007 to adopt then current practice and evidence, to guide
systems require a regular review and revision to reflect the decision making around open and endovascular
Ogunsanya et al. 9

Figure 11. CT MPR of the right external iliac and femoral

arteries.

intervention for occlusive vascular disease, have been

challenged both by the inter- and intra-observer
variability11,12 and by the progressive nature of endo-
vascular therapy.13 It is important to emphasise that Figure 12. Angiographic images of CERAB procedure and
unlike this classification system, the focus of TASC II is completion angiograms following concomitant right femoral
on treatment choice; it is not an anatomic classification endarterectomy.
system per se. We do, however, accept that our classi-
fication system will also be subject to a degree of inter- variability in determining disease extent and thus treat-
and intra-observer variability. ment choice, this does not diminish its primary role as a
This novel classification system aims to identify and classification system as illustrated by the two case examples
quantify occlusive disease in the aortoiliac (and femoral) described earlier.
segments without reference to treatment strategies. It is
purely a descriptive system, to be used early in the process
of planning intervention. Its simplicity, as illustrated by the
Conclusion
two cases, facilitates its use by trainee and established Unlike its general surgery counterpart, diagnostic challenge
vascular surgeons alike. Whilst there may be inter-user is unusual in vascular surgery. It is the interventional
10 Vascular 0(0)

strategy that requires careful thought and planning, par- 6. Graziani L, Silvestro A, Bertone V, et al. Vascular involve-
ticularly as endovascular technique and expertise continue ment in diabetic subjects with ischemic foot ulcer: a new
to evolve. The first step in this decision-making process is to morphologic categorization of disease severity. Eur J Vasc
accurately identify the arterial segments that require treat- Endovasc Surg 2007; 33(4): 453–460. DOI: 10.1016/j.ejvs.
ment. This simple classification system has been developed 2006.11.022
to bolster this aspect of the vascular surgery armamentar- 7. Mills JL Sr, Conte MS, Armstrong DG, et al. The society for
ium. We encourage our vascular colleagues – trainees and vascular surgery lower extremity threatened limb classification
specialists alike – to trial its use in their clinical practice and system: risk stratification based on wound, ischemia, and foot
provide feedback on their experience. infection (WIfI). J Vasc Surg 2014; 59(1): 220–34.e1-2. DOI: 10.
1016/j.jvs.2013.08.003. Epub 2013 Oct 12. PMID: 24126108.
Declaration of conflicting interests
8. Cerquiera LO, Duarte EG, Barros ALS, Cerqueira JR, et al.
The author(s) declared no potential conflicts of interest with re- WIfI classification: the society for vascular surgery lower
spect to the research, authorship, and/or publication of this article. extremity threatened limb classification system, a literature
review. J Vasc Bras 2020; 19: e20190070. DOI: 10.1590/
Funding 1677-5449.190070
The author(s) received no financial support for the research, au- 9. Management of peripheral arterial disease (PAD). Trans-
thorship, and/or publication of this article. Atlantic Inter-Society Consensus (TASC). Eur J Vasc
Endovasc Surg. 2000; 19(Suppl A): Si–Sxxviii, S1-250.
ORCID iD PMID: 10957904.11. Rosen RD, Sapra A. TNM Classi-
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Ngozi Lola Ogunsanya  https://orcid.org/0000-0003-2276-8275
Island (FL): StatPearls Publishing; 2022 Jan–. PMID:
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