Simultaneous acute limb ischemia related to acute Leriche syndrome and pulmonary embolism without existing patent foramen ovale: a case report.

BACKGROUND: Aortoiliac occlusion disease, also called Leriche syndrome, is characterized by atherothrombotic obliteration of the aortic bifurcation and bilateral common iliac arteries; typically, it has a chronic presentation. Pulmonary embolism is more related to venous thromboembolism rather than arterial thromboembolic events. Therefore, cases of simultaneous acute Leriche syndrome and pulmonary embolism are rare. Existing intracardiac right-to-left shunt were detected in most previous cases. Herein, we present the first likely documented case wherein acute Leriche syndrome and pulmonary embolism occurred simultaneously without a patent foramen ovale. CASE PRESENTATION: A 58-year-old man with hyperlipidemia and coronary artery disease presented with a 4-h history of bilateral lower limb numbness. He was a heavy smoker with a history of stroke. Computed tomography angiography revealed pulmonary embolism and aortoiliac artery occlusion. Although a massive thrombus straddled the bilateral pulmonary arteries, orthopnea was his only presentation, without right ventricle failure. Cyanosis of the affected limbs was noted, and muscle strength in both limbs had regressed to grade 1. Owing to acute limb ischemia, he underwent an emergency operation to salvage the limbs. On postoperative day 5, the general condition of both the legs improved; the muscle strength improved to grade 4. He was then transferred to the general ward and enoxaparin was continued. Computed tomography angiography was repeated to evaluate the pulmonary embolism on postoperative day 8; the thrombus remained lodged in the bilateral main pulmonary arteries. Owing to persistent orthopnea and chest tightness with intermittent tachycardia, he underwent a staged operation for the pulmonary embolism on postoperative day 13. During the surgery, intraoperative transesophageal echocardiography showed no patent foramen ovale or an existing right-to-left shunt. Postoperatively, he was closely monitored in the intensive care unit for 3 days and then transferred to the general ward for 10 days. A final computed tomography angiography performed on postoperative day 18 revealed thrombus resolution. He was then discharged on postoperative day 30 without any in-hospital complications. CONCLUSION: We present a case that might be the first documented report of acute Leriche syndrome co-occurring with pulmonary embolism without an existing patent foramen ovale.

Evaluation of Therapeutic Effects on Collateral Circulation in Patients with Chronic Leriche Syndrome: a Case-Control Study of Intraluminal Stent Implantation and Surgical Bypass Grafting.

PURPOSE: The aim of the study was to compare the hemodynamic effects of endoluminal and open surgical treatment of chronic Leriche syndrome using arterial collaterals on CTA as a surrogate parameter. MATERIALS AND METHODS: This retrospective, single-center study included 30 patients with chronic Leriche syndrome. Fourteen patients underwent intraluminal stent implantation (endo group), and sixteen underwent surgical bypass grafting (surgical group). CTA was performed pre- and postoperatively, and a series of evaluation parameters (a1: sum of area of the systemic collateral pathways in the abdominal wall before operation, a2: sum of area of the systemic collateral pathways in the abdominal wall after operation, ar: area of lumen of the stent or artificial vessel, BSR: post- and preoperative blood supply ratio = (a2 + ar)/a1, RR: reduction rate of systemic collateral arteries after the operation = (a1-a2)/a1) were defined to quantitatively evaluate the hemodynamic effects of the treatments. Short-term clinical outcomes, including improvement of symptoms, postoperative complications and in-hospital stay, were also collected. Then, the effects of the two operations were compared. RESULTS: There was no significant difference in the baseline (a1, p = 0.301) and postoperative (a2, p = 0.802) collateral arteries, as well as BSR (p = 0.088) and RR (p = 0.592) between endo and surgical groups. There was also no significant difference in short-term clinical outcomes between the two groups. CONCLUSION: Our limited series suggests that intraluminal stent implantation may not be inferior to surgical bypass grafting regarding the undifferentiated short-term clinical outcomes as well as the chosen hemodynamic surrogate parameters.

[Neurological symptoms associated with aortoiliac occlusive disease: Leriche syndrome]. / Neurologische klachten door een aorta-iliacale occlusie.

Leriche syndrome was diagnosed in three patients aged 63, 71 and 73. They presented with a wide range of neurological symptoms such as impotence, pain or dysfunction of the lower extremities. Because a neurological diagnosis was initially suspected, there was a delay in two of the three patients before palpation for a distal pulse in the lower extremities was performed. A pulse was absent in all three patients. Duplex sonography, MR angiography and CT angiography revealed that a pulse was absent due to aortoiliac occlusive disease, also known as Leriche syndrome. They underwent treatment with covered endovascular reconstruction of the aortic bifurcation (CERAB), aortobifemoral bypass or intravenous thrombolysis. All patients significantly improved after treatment. Physicians should always consider aortoiliac occlusive disease in patients who present with neurological symptoms of the lower extremities and must check for a distal pulse in these patients.

Racial and Gender Disparity in Aortoiliac Disease Open Revascularization Procedures.

BACKGROUND: The impact of race and gender on surgical outcomes has been studied in infrainguinal revascularization for peripheral arterial disease. The aim of this study is to explore how race and gender affect the outcomes of suprainguinal bypass (SIB) for aortoiliac occlusive disease. MATERIALS AND METHODS: Patients who underwent SIB were identified from the procedure-targeted National Surgical Quality Improvement Program data set (2011-2016). Patients were stratified into four groups: nonblack males, black males (BM), nonblack females, and black females (BF). Primary outcomes were 30-d major adverse cardiac events, a composite of myocardial infarction, stroke, or death; postoperative bleeding requiring transfusion or intervention; major amputation and prolonged length of stay (>10 d). Predictors of outcomes were determined by multivariable logistic regression analysis. RESULTS: About 5044 patients were identified. BM were younger, more likely to be smokers, less likely to be on antiplatelet drug or statin, and to receive elective SIB (all P ≤ 0.01). BFs were more likely to be diabetic and functionally dependent (all P ≤ 0.02). Major adverse cardiac events were not significantly different among all groups. BM had a threefold higher risk of amputation (adjusted odds ratio [OR] [95% confidence interval (95% CI)], 3.10 [1.50-6.43]; P < 0.002). Female gender was associated with bleeding in both races, that association was more drastic in BF (OR [95% CI], 2.43 [1.63-3.60]; P < 0.0001), whereas nonblack females (OR [95% CI], 1.46 [1.19-1.80]; P < 0.0001). BF had higher odds of prolonged length of stay (OR [95% CI]: 1.62 [1.08-2.42]; P < 0.019). CONCLUSIONS: In this large retrospective study, we demonstrated the racial and gender disparity in SIB outcomes. BM had more than threefold increase in amputation risk as compared with nonblack males. Severe bleeding risk was more than doubled in BF. Race and gender consideration is warranted in risk assessment when patients are selected for aortoiliac disease revascularization, which in turn necessitate preoperative risk modification and optimization in addition to enhancing their access to primary preventive care measures.

Worsening renal failure due to renal steal by aortoiliac bypass.

Aortoiliac bypass surgery is the gold standard strategy for removing persistent ischaemia resulting from bilateral aortoiliac occlusive disease, a condition known as Leriche syndrome. However, the impact of aortoiliac bypass surgery on the blood flow of the renal artery is not fully understood. Here, we report a case of worsening renal failure caused by renal steal immediately after aortoiliac bypass for Leriche syndrome. The revascularisation of bilateral renal arteries dramatically improved the patient's renal function and allowed us to discontinue both haemodialysis and diuretics. This case demonstrates that in rare instances, haemodynamic change induced by aortoiliac bypass surgery affects the arteries feeding other organs. Careful preoperative evaluation for the corresponding branches of the aorta is indispensable. Optimal revascularisation should be performed to avoid serious complications after aortoiliac bypass if the patient is at risk of developing critical ischaemia.

Risk factors associated with postoperative prosthetic graft patency in Leriche syndrome.

BACKGROUND: In Leriche syndrome, postoperative graft thrombosis remains one of the most significant clinical challenges. METHODS: We reviewed 51 patients who underwent surgery for aortoiliac occlusive disease at our hospital from January 2007 to December 2014. The factors associated with graft patency were determined using the Cox proportional hazard model. RESULTS: The 2-year prosthetic graft patency rate was 72.5%. Younger age (p = 0.017, Odd ratio (OR) = 1.112), postoperative uncontrolled hypertension (p = 0.044, OR = 3.797), and associated Trans Atlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease II (TASC II) D femoropopliteal lesion (p = 0.008, OR = 11.139) were significantly related factors for prosthetic graft patency after surgical repair. The existing comorbidities of the patients that indicated the need for axillo-bifemoral bypass seemed to be related to lower graft patency or other complications. CONCLUSIONS: For better graft patency after an open surgical repair of Leriche syndrome, strict postoperative hypertension control and distal run-off resolution are necessary.

Lower extremity pain and numbness.

CLINICAL INTRODUCTION: A 45-year-old man with no past medical history presents with bilateral lower extremity pain and perineal numbness after walking 10-15 min. The pain starts in his bilateral buttocks and radiates down into his thigh and into his toes. He has no back pain, fever, difficulty urinating or stooling, incontinence or trauma. Social history is positive for smoking. Physical examination was only remarkable for non-dopplerable lower extremity pulses, and he was unable to ambulate down the ED hallway without becoming symptomatic. Ultrasound of his abdominal aorta (figure 1) was performed.emermed;35/7/419/F1F1F1Figure 1Transverse view of distal abdominal aorta, just proximal to the bifurcation. (A) The aorta without Doppler. (B) The same image with Doppler mode activated. QUESTION: What is the most likely diagnosis based on the image?A. Lumbar stenosisB. Abdominal aortic aneurysmC. Aortic thrombusD. Aortic dissection.

Endovascular management of total juxtarenal aortic occlusive disease in high-risk patients: technical considerations and clinical outcome.

BACKGROUND: To report our single-center experience in the endovascular treatment of juxtarenal aorto-iliac occlusions. METHODS: Between December 2008 and December 2012, 13 patients with total juxtarenal aorto-iliac occlusion, considered at high risk for open revascularization, were treated by endovascular means at our Department. Inclusion criteria were severe intermittent claudication, rest pain and distal tissue loss. Antegrade recanalization from percutaneous brachial access and retrograde angioplasty and stenting from percutaneous or surgical femoral accesses were performed. The renal arteries (RAs) were protected using filters or balloons. Aorto-iliac bare-metal stents were deployed in all patients. RESULTS: No death was registered. Technical success was 100%. In 11 patients (84.6%) the Ankle-Brachial Index increased to 0.9-1. Renal arteries were involved in 7 cases (53.8%): 3 chimney stent grafts deployment, 2 aorto-iliac stent fenestrations and 2 aorto-iliac stents placement above the renal arteries without renal function impairment. Complication rate was 38.5%: 2 cases of thrombus dislodgement into the RAs, 1 distal artery embolization, 1 common iliac artery rupture and 1 pseudo-aneurysm. All complications were treated percutaneously, except for the distal embolization treated surgically. The patient with iliac artery rupture underwent acute renal insufficiency requiring temporary dialysis after hemorrhagic shock because of retroperitoneal hematoma. Mean follow-up was 18 months (range 6-30 months). The primary and secondary patency was respectively 92.3% and 100%. CONCLUSION: Endovascular recanalization of juxtarenal aorto-iliac occlusion in selected patients is feasible and safe, with good early and mid-term results and should be considered in high risk patients.

DIFFERENCES IN ECG CHARACTERISTICS AND CO-MORBIDITIES AMONG PATIENTS WHO UNDERWENT ELECTIVE SURGICAL REPAIR.

The aim of the study was to assess differences in ECG features and prevalence of comorbidies between two groups of patiens: with Abdominal Aortic Aneurism (AAA) and Aorto-Iliac Occlusive Desieses-Lerish Syndrome (LS). Data was collected for all consecutive adult patients who underwent elective surgical repair of AAA (fusiform aneurysm) or LS at "The Center of Vascular and Heart Diseases" (Tbilisi, Georgia) between 2010 and 2014. We studied a prevalence of Arterial Hypertension (AHT); Diabetes mellitus (DM); Renal Failure (RF),Peripheral Artery Disease (PAD), Coronary Artery Disease (CAD) and rate of coronary revascularization in these patients; We also, investigate some of the electrocariographic characteristics: Corrected QT interval(QTC),QT dispersion(QTD). The majority of patients were mail (92% in both groups). Prevalence rate of CAD didn't differ significantly between groups with LS and AAA (37% and 39%P=0.7000 respectively). Rate of revascularization was (7% and 6% P=0.577 respectively). Prevalence rate of DM was higher in patients with LS compared with AAA (27%and 8%P=0.0000 respectively); PAD was more prevalent in LS group (98% and 48% P=0.0000 respectively). RF was less prevalent in patients with LS as compared with AAA (51% and 64%P=0.0200). Prevalence rate of AHT was significantly low in LS than in AAA (49% and 65%P=0.0000 respectively). A prevalence rate of increased QTd (>0.07ms) was high in LS group but the difference between these two groups was not statistically significant (16% and 9% P=0.1563 respectively). Absolute number of prolonged QTd was high in LS group in comparison with AAA and this difference was statistically significant (0.04±0.026 and 0.02±0.028 P=0.0092 respectively).QTC remained in normal range in both groups. Rates of CAD and coronary revascularization did not differ between patients with AAA and LS. The high incidence of DM and PAD was found in patients with LS as well as high HR and prolonged QTd. Prevalence Rate of AHT, RF was higher in patients with AAA as compared with LS group. These findings indicates: a)Different composition of risk factors in two groups. However, both groups of patients are at increased risk of development of coronary events and this circumstance may be considered as a predictor of worse prognosis. b) High incidence of renal failure in AAA group may contribute a progression of renal dysfunction in this patients during /after surgery.c) A prolonged QTd was high in LS group which may contribute heightened risk of fatal arrhythmias in this patients. Further studies are needed for evaluation a prevalence rate of prolonged QTd in the large population.

[Sequence of stages of hybrid operations in patients with Leriche syndrome and critical limb ischaemia].

Presented in the article are the results of treating a total of 108 patients with chronic critical lower limb ischaemia (CCLLI) confirmed according to the recommendations of the Transatlantic Inter-Society Consensus (TASC) 2007 [1]. All patients were diagnosed as having combined lesions of the aortoiliac and femoropopliteal segments of the arterial bed of the lower limbs. All patients underwent simultaneous hybrid operations: open reconstructive interventions in the infrarenal zone and stenting of iliac arteries. In the comparison group (n=14) the first stage consisted of restoration of the inflow pathways followed by open reconstruction of the femoropopliteal segment. In the Study Group (n=94) the first stage was infrainguinal reconstruction by the open technique followed by stenting of the arteries of the aortoiliac segment. It was shown that restoration the outflow pathways as the first stage was associated with a considerable decrease in the risk of intraoperative complications.

Aortic hybrid sutureless anastomosis on porcelain aorta.

PURPOSE: To describe a hybrid sutureless anastomosis technique between a prosthetic graft, an endograft, and a circumferentially calcified infrarenal aorta. TECHNIQUE: The technique is demonstrated in a 65-year-old man with flush distal aortoiliac occlusion and patent infrarenal porcelain aorta (IPA). After laparotomy, the IPA was occluded below the renal arteries by inflating an aortic balloon introduced via an axillary access. The IPA was transected in its distal part and aortic thrombectomy performed. A Zenith iliac extension was modified on a back table by cutting the terminal tip; the device was then was inserted and deployed into the IPA in a standard fashion and the sheath removed. A Dacron bifurcated graft was sutured in an end-to-end anastomosis to the endograft and terminal aorta. The 12-month computed tomography scan showed patency of the graft. CONCLUSIONS: This sutureless anastomosis technique seems safe and feasible and represents a valid alternative to standard surgical approaches in cases of heavy and circumferentially calcified infrarenal aorta.

[15-year experience with PTFE-grafts "Ecoflon" in Leriche s syndrome].

Analyzed herein are the outcomes of 1,079 reconstructions of the aortofemoral segment, performed for Leriche s syndrome using polytetrafluoroethylene grafts "Ecoflon" during the period from 1997 to 2012. Hospital lethality amounted to 3.1%, frequency of thromboses was 0.53% and that of amputations equalled 0.53%. The patients were followed up at terms varying from 6 to 180 months. Cumulative patency of the bypass grafts at 1 year amounted to 99.3±0.2%, at 5 years to 97.3±0.6%, at 10 year to 91.9±1.9%, and to 90.0±2.7% after 15 years. Primary patency amounted to 97.6±0.4%, 90.9±1.1%, 75.9±2.7% and 71.4±4.1%, respectively. Grafts infection occurred in 1.3% of cases (0.2% in the early, and 0.83% in the remote postoperative periods). False aneurysms of distal anastomoses were registered in 0.5% of cases. A total of 137 reoperations were performed (104 for graft thromboses, 9 for pseudoaneurysms of anastomoses, and 7 for graft infection). Seventeen operations were carried out for ischaemia relapse due to progression of the occluding process in patent grafts. The amputation rate amounted to 6.6%. Based on the obtained findings a conclusion is drawn that polytetrafluoroethylene grafts "Ecoflon" comply with the current standards of quality.

Arterial myocardial revascularization with right internal thoracic artery and epigastric artery in a patient with Leriche's syndrome.

Concomitant coronary artery disease (CAD) and Leriche's syndrome is clinical scenario which poses a challenge to cardiovascular surgeons. This report describes a case of arterial myocardial revascularization in a patient with CAD and Leriche's syndrome by means of right internal thoracic artery harvested with right epigastric artery in situ fashion, performed in addition to simultaneous aorto-bifemoral bypass.

Mid-term clinical outcome following endovascular therapy in patients with chronic aortic occlusion.

Although endovascular therapy (EVT) has been widely used for iliac lesions due to acceptable patency with stenting, EVT has not been established as primary treatment for aortic occlusion, partly because of uncertainty regarding long-term results. The purpose of this study was to investigate outcomes following EVT with stenting for chronic aortic occlusion. This study was a single-center retrospective analysis of a prospectively maintained database. Between September 2005 and May 2012, twenty-four lesions from 25 patients with a clinical diagnosis of chronic aortic occlusion (mean age, 71 years; 80 % male) were treated with EVT with stenting. Kaplan-Meier estimators were used to determine the patency rates according to Society for Vascular Surgery criteria. In results, lesion type was Trans Atlantic Inter-Society Consensus D in all patients. Mean lesion length was 145 mm. Initial success rate and procedural complication rate were 96 % (24/25) and 8 % (2/25), respectively. At 36 months, primary and secondary patency rates were 76 and 94 %, respectively. Restenosis was observed in 5 patients, all of whom underwent reintervention (four successful, one failure and intensity of medical treatment). EVT can be safely done in patients with chronic aortic occlusion. Procedural morbidity and mid-term durability were comparable to those of bypass surgery up to 3 years.

Síndrome de Leriche y trombo mural de aorta torácica / Leriche's syndrome and thoracic aortic mural thrombus

No disponible

Thoracic aortobifemoral bypass in treatment of juxtarenal Leriche syndrome (midterm results).

BACKGROUND: The standard surgical treatment of infrarenal aortoiliac obstructive disease is abdominal aortobifemoral bypass (AABFB). However, alternative surgical procedures may be considered in cases of juxtarenal Leriche syndrome and previous aortofemoral graft obstruction. We present midterm results of 20 consecutive patients who underwent thoracic aortobifemoral bypass (TABFB) either as primary or secondary procedure. METHOD: Between 1999 and 2010, 20 patients who were diagnosed to have juxtarenal Leriche syndrome (n = 17) and failure of previous AABFB graft (n = 3) were enrolled. The patients were classified according to the Rutherford classification. Mean follow-up period was 60.9 ± 38.3 months. Mean preoperative ankle-brachial index on the left lower extremity was 0.18 and on the right lower extremity was 0.20. RESULTS: Seventeen patients with the diagnosis of juxtarenal Lercihe syndrome were primarily and three patients were secondarily (for treatment of failed previous AABFB graft) treated using TABFB procedure. The mean ankle-brachial index at last follow-up was 0.75 on the left lower extremity and 0.76 on the right. One-year patency rate was 100%, and 5-year patency rate was 94%. CONCLUSION: TABFB precludes the risk of renal artery embolization in cases of juxtarenal obstruction, without adding any risk of morbidity and mortality. Its long-term patency is similar or even superior to conventional surgical bypass techniques. We propose its use as an initial treatment in juxtarenal Leriche syndrome as well as a remedial procedure in cases with previous AABFB graft occlusion.