Updated: 3/1/2020

Leriche Syndrome (Aortoiliac Occlusive Disease)

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Snapshot
  • A 65-year-old man presents with buttock and hip pain, particularly during exercise. He has no pain at rest. He also reports having chronic erectile dysfunction. His past medical history includes hyperlipidemia and coronary artery disease. He has a 20-pack-year smoking history. On physical exam, there are bilateral diminished +1 femoral pulses. His ankle-brachial index is 0.6 on the left and 0.7 on the right.
Introduction
  • Clinical definition
    • a syndrome resulting from chronic peripheral artery disease of the aortic bifurcation, characterized by in claudication of the buttocks, absent femoral pulses, and sexual impotence
  • Epidemiology
    • demographics
      • affects older patients
      • men > women
    • risk factors
      • smoking
      • diabetes
      • renal disease
      • hyperlipidemia
  • Etiology
    • atherosclerosis
  • Pathogenesis
    • atherosclerotic disease can lead to obstruction of the arteries
      • aortoiliac obstruction leads to arterial insufficiency in the lower extremities, resulting in claudication
  • Associated conditions
    • coronary artery disease
Presentation
  • Symptoms 
    • buttock and hip claudication
    • exertional pain in early disease
    • rest pain in more severe disease
    • erectile dysfunction in men
  • Physical exam
    • absent or diminished femoral pulses
      • can be unilateral or bilateral
    • may have ischemic ulcers
Imaging
  • Doppler ultrasonography
    • indication
      • the diagnostic gold standard for arterial occlusion
    • findings
      • low-velocity flow through the artery
  • Computed tomography (CT)
    • indications
      • confirms diagnosis
      • pre-operative evaluation
    • findings
      • occlusion of the arteries
      • collateral circulation
Studies
  • Ankle-brachial index
    • less than or equal to 0.9 is diagnostic for peripheral artery disease
    • best initial test
  • Making the diagnosis
    • based on clinical presentation
Differential
  • Sciatica
    • distinguishing factor
      • normal ankle-brachial index
      • pain is not necessarily correlated with exertion
Treatment
  • Management approach
    • initial management includes anti-platelet therapy as well as optimizing treatment for underlying conditions, such as hypertension and hyperlipidemia
  • Conservative
    • cessation of smoking
      • indication
        • all patients
    • exercise regimen
      • indications
        • all patients as this encourage the development of collateral circulation
  • Medical
    • antiplatelet agents
      • indication
        • all patients
      • drugs
        • aspirin
        • clopidogrel
        • cilostazol
        • dipyramidole
  • Operative
    • aortoiliac angioplasty or stenting
      • indication
        • significant aortoiliac disease refractory to medical management
    • aortoiliac bypass surgery
      • indication
        • contraindication to angioplasty
    • amputation
      • indication
        • most severe cases in which limb is not salvageable
Complications
  • Acute ischemia
    • immediately threatened limb
      • managed with intravenous heparin and embolectomy 
  • Distal limb amputation

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