Makindo Medical Notes

Related Subjects: Ankle-Brachial pressure Index (ABPI) and Peripheral Vascular Disease Peripheral Arterial Disease (PAD) Abdominal Aortic Aneurysm (AAA) Carotid Endarterectomy Buerger's disease (Thromboangiitis obliterans ) Leriche syndrome (aortoiliac occlusive disease)

About

• Leriche syndrome, named after French surgeon René Leriche, is a form of aortoiliac occlusive disease. It is characterized by thrombotic occlusion of the abdominal aorta just above the bifurcation into the common iliac arteries.

Aetiology

• Atherosclerotic Disease: Most commonly, the syndrome is caused by progressive atherosclerosis leading to thrombotic occlusion of the aortoiliac segment.
• Contributing Factors: Other contributing factors include inflammatory conditions, hypercoagulable states, and vasculitis. The compromised blood flow results from the involvement of the aortoiliac region, affecting branches such as the pudendal arteries, which arise from the internal iliac arteries.

Clinical Presentation

• Lower Limb Fatigue and Claudication: Patients often experience fatigue and pain in both lower limbs, particularly in the buttocks and thighs, due to reduced blood flow.
• Intermittent Buttock Ischemic Pain: Ischemic pain in the buttocks is a common complaint.
• Erectile Impotence: Men frequently develop erectile dysfunction because of decreased perfusion to the pelvic region.
• Pulses: On examination, the femoral pulses may be absent or significantly diminished.

Differential Diagnosis

• Buerger’s disease (thromboangiitis obliterans)
• Other forms of arteritis affecting the aortoiliac vessels
• Peripheral arterial disease of different aetiologies

Investigations

• Laboratory Tests: Initial workup should include a full blood count (FBC), urea and electrolytes (U&E), glucose, HbA1c, erythrocyte sedimentation rate (ESR), and electrocardiogram (ECG) to assess overall health and cardiovascular status.
• Imaging Studies: Definitive diagnosis is established through imaging such as computed tomography angiography (CTA) or conventional angiography, which can visualize the extent of aortoiliac occlusion.

Management

• Medical Management: Optimize treatment for peripheral vascular disease with antiplatelet agents, lipid-lowering medications, and strict management of cardiovascular risk factors (e.g., smoking cessation, control of diabetes and hypertension).
• Endovascular Interventions: Angioplasty with or without stenting may be considered for less extensive occlusions or in patients with high surgical risk.
• Surgical Management: In advanced cases, surgical revascularization is indicated:
  • Aortoiliac Endarterectomy: Surgical removal of the obstructive plaque from the aortoiliac region.
  • Aortobifemoral Bypass (AFB): A bypass graft is placed to restore blood flow from the aorta to the femoral arteries.

Conclusion

Leriche syndrome is a serious manifestation of aortoiliac occlusive disease that presents with a classic triad of lower limb claudication, buttock ischemic pain, and erectile dysfunction. Understanding its aetiology, which predominantly involves atherosclerotic changes in the aortoiliac vessels, is essential for timely diagnosis. A comprehensive approach—including laboratory tests and imaging studies—is vital for proper management. Treatment options range from medical management and endovascular interventions to surgical revascularization, tailored to the severity of the disease and the patient’s overall risk profile.