Presentation
The patient, a 46-year-old man with a history of smoking and hypertension, was recovering from a heart attack when another problem was discovered. He initially presented to the emergency department with sudden-onset substernal chest pain that radiated to his left shoulder. His physical examination on presentation was notable for diminished (+1) femoral and peripheral pulses bilaterally, and an electrocardiogram showed ST-segment elevations in the inferior leads. Subsequently, he was referred for emergent cardiac catheterization, which was performed via a default transradial approach. Diagnostic coronary angiography identified an occluded circumflex artery as the culprit lesion for his acute myocardial infarction. The obstruction was eliminated with thrombectomy and a drug-eluting stent. He was admitted to the hospital for routine post-myocardial-infarction care.
Assessment
Once the patient was stabilized, a full clinical history could be obtained. When asked about his exercise tolerance, he admitted to severe limitations due to chronic, severe, bilateral thigh and calf claudication. He had no symptoms at rest. During a review of systems, he also reported chronic erectile dysfunction. The family history was significant for a maternal history of hypertension, hyperlipidemia, and premature coronary artery disease. He did not use illicit drugs or alcohol and had been taking no medications prior to admission. Results of a hemoglobin A1C test, urine drug screen, and complete blood count were unremarkable, as were results from fasting lipid, basic metabolic, and coagulation panels.
His ankle-brachial-index was consistent with bilateral lower extremity peripheral arterial disease (0.63 on the right and 0.59 on the left). Pulse volume recordings and segmental pressures suggested severe symmetric inflow disease (Figure 1).
Diagnosis
To further investigate the patient’s arterial anatomy, a transradial lower-extremity angiogram was ordered. An infrarenal aortic occlusion with reconstitution of external iliac arteries via lumbar collaterals was identified. This finding was consistent with Leriche syndrome, an occlusive disease of the aortic bifurcation. It is characterized by lower extremity claudication, erectile dysfunction, and diminished peripheral pulses (Figure 2; Video 1).(1) A high index of suspicion for this disorder should be maintained when patients with a history of heavy smoking report characteristic symptoms in the context of known coronary artery disease or its risk factors.
Management
The patient underwent kissing balloon angioplasty and stenting of the infrarenal aorta and common iliac arteries using the Frontrunner XP CTO (Cordis Corp, Bridgewater, NJ), a chronic total occlusion catheter, and the Pioneer Plus (Volcano Corp, San Diego, Calif), an intravascular ultrasound-guided re-entry catheter (Figure 3; Video 2) At a follow-up visit 1 month later, his claudication and erectile dysfunction had completely resolved. In addition, his repeat ankle-brachial index and pulse volume recordings had normalized (Figure 4).
Our patient demonstrated the classic clinical and diagnostic features of Leriche syndrome. Traditionally, such patients have been treated with surgical bypass. However, the feasibility of endovascular revascularization has been increasing due to advances in catheter-based technologies. In addition, catheter-based imaging, such as intravascular ultrasound, can further enhance the safety and success of these endovascular procedures. Compared to surgical bypass, endovascular repair offers decreased perioperative morbidity, a shorter hospital stay, and comparable patency rates.(2)
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– Moses Mathur, MD, MSc, Nazmul Huda, MD, Riyaz Bashir, MD
This article originally appeared in the April 2014 issue of The American Journal of Medicine.
