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Case 87 

Case 87
Chapter:
Case 87
Author(s):

Anne M. Covey

, Bradley B Pua

, Allison Aguado

, and David C. Madoff

DOI:
10.1093/med/9780199331277.003.0087
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Subscriber: null; date: 16 October 2019

History

  • A 69-Year-Old Diabetic Male with Atherosclerosis and Upper Thigh/Buttock Claudication

Diagnosis

Case 87 Leriche Syndrome

Findings

  • MIP from a contrast-enhanced magnetic resonance image (MRI) (Fig. 87.3) demonstrates abrupt cutoff of the abdominal aorta just below the origin of the superior mesenteric artery (arrow). The external iliac arteries (stars) are reconstituted by collaterals, including prominent inferior epigastric arteries (hollow arrows) and iliolumbar arteries (arrowhead).

  • Arterial-phase axial contrast-enhanced computed tomography (CT) (Fig. 87.4) confirms complete occlusion of the distal aorta and shows large inferior epigastric arteries (arrows) that serve as a collateral pathway to reconstitute the external iliac arteries.

Teaching Points

  • The constellation of bilateral buttock claudication, impotence (in men), and diminished femoral pulses is termed “Leriche syndrome.” Symptoms may be unilateral or bilateral, depending on the level of obstruction and efficacy of collateral pathways.

  • Leriche syndrome occurs in the setting of atherosclerotic aortoiliac occlusive disease usually distal to origin of the renal arteries. This is a differentiating factor from mid-aortic syndrome, which is seen in children and young adults and involves the origins of the renal arteries.

  • Collateral pathways that provide lower-extremity runoff in the setting of aortoiliac occlusive disease include (1) the “Winslow pathway” from the internal mammary or intercostal arteries to the external iliac arteries via the inferior epigastric arteries (as in this case); (2) lumbar to iliolumbar arteries; (3) superior hemorrhoidal (a branch of the inferior mesenteric artery) to inferior hemorrhoidal arteries; and (4) various additional communications between branches of the internal iliac artery and femoral arteries (e.g., superior gluteal to femoral circumflex).

Management

  • Diagnostic catheter angiography is rarely indicated because CT angiogram and magnetic resonance angiogram can provide the morphologic and physiologic information required to plan intervention.

  • Indications for intervention include disabling claudication and threatened limb.

  • Surgical options include aortofemoral bypass, axillofemoral bypass, femoral-femoral bypass, and aortic endarterectomy.

  • In some cases, stent placement can be performed, with the best results in single lesions <3 cm; however, this is an uncommon cause of Leriche syndrome.

Further Reading

Hardman RL, Lopera JE, Cardan RA, et al. Common and rare collateral pathways in aortoiliac occlusive disease: a pictorial essay. Am J Roentgenol. 2011; 197(3):W519–W524.Find this resource:

Kaufman J, Lee MJ. Abdominal aorta and iliac arteries. In: Vascular and Interventional Radiology: The Requisites. Elsevier-Mosby; 2004:261–270.Find this resource: