Endovascular treatment of infrarenal aortic stenosis: Importance of multimodality imaging

We sought to describe the evolution in imaging and interventional options for endovascular treatment of significant infrarenal aortic stenosis. Balloon angioplasty and stent implantation for infrarenal aortic stenosis has generally required large-sized arterial access sheaths in the past, and was typically guided by visual size assessment. Computerized tomography angiography enables accurate preprocedural assessment of severity and extent of aortic atherosclerosis, degree of calcification, and luminal dimensions at both stenosis and reference sites, and visualizes possible aneurysm. Intraprocedural pressure gradient measurements evaluate the hemodynamic response to revascularization. On the other hand, intravascular ultrasound can further verify accuracy of equipment sizing. Small-profile stents and balloons can be used via small-sized sheaths, thereby rendering the procedure possible in patients with extensive peripheral arterial disease or small iliofemoral arteries. Improved non-invasive and intravascular imaging can guide with great accuracy infrarenal aortic stenosis procedures and may enable the use of reduced-size access sheaths and devices in fragile patients with vasculopathies.