[Neurological symptoms associated with aortoiliac occlusive disease: Leriche syndrome]

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.

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.

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.

[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.

Long term data of endovascularly treated patients with severe and complex aortoiliac occlusive disease

AIM

This paper presents the recent data of the largest series (20 patients) of endovascularly treated patients and the first long term data of 9 patients with severe aortoiliac occlusive disease.

METHODS

Between 2003 and 2012, 20 consecutive patients (14 men; 70 %) with Leriche syndrome underwent recanalization with solely endovascular means at our centre. The treatment strategy comprised the antegrade (transbrachial) recanalization of the occluded segments followed by retrograde (transfemoral) angioplasty with selective stent placement in the infrarenal aorta and primary stent placement in the iliac arteries. Before discharge, after 30 days and every year after the procedure, a clinical, as well as a duplex ultrasonographic examination including measurement of the ankle-brachial index was done.

RESULTS

Bilateral success was achieved in 17 patients (85%). Unilateral success was achieved in three patients (15%). In one patient (5%) an early reocclusion of the stented segments occurred, necessitating bypass grafting. In nine patients long term data were evaluated. Here, the ankle brachial index (ABI) significantly increased (0.85 ± 0.15 vs. 0.51 ± 0.11 at baseline; P=0.002). Compared to baseline, the difference in the distribution of Rutherford category and the improvement of walking capacity were statistically significant (P=0.0006, P=0.01, respectively).

CONCLUSION

This study shows the feasibility of solely endovascular management of severe aortoiliac occlusive disease with a high rate of success and low rate of complications. Significant clinical improvement of patients in long term follow up makes the endovascular approach a viable alternative to open surgery.

[Long-term results of vascular surgery of Lerish syndrome in patients with type II diabetes Mellitus]

We analyzed long-term results of vascular surgery in 199 patients with diabetes and chronic limb ischemia. At the time of the study mean age of patients was 64.7+1.2 years. They all had severe course of disease. Results showed that in the majority of patients good clinical effect after aorto-femoral reconstructions persisted over a long period of time. Patency of aorto-femoral bypass and limb salvage rate after 9 years equaled 72 and 79%, respectively. This was associated with improved quality of life. Surgery for severe limb ischemia (50 % of patients had critical ischemia) helped to preserve the limb and achieve sustainable increase of pain-free walking distance in 85 % of patients. However 5-year survival rate was 75%. The leading cause of death was myocardial infarction. This was indicative of the lack of prevention of progression of coronary artery disease. Thus, despite the presence of diabetes aorto-femoral reconstructions in most patients reliably and continuously prevented development of critical ischemia and preserved lower limbs. Active prophylaxis of cardiac complications is necessary for improvement of long-term survival of patients after vascular reconstructive surgery.

[First experience with minilaparotomy for Leriche syndrome]

The authors present the first experience with reconstruction of the terminal part of the infrarenal aorta from minilaparotomy. There were 11 aortofemoral bifurcation shunts in patients with Leriche syndrome. In two cases conversion (general calcification of the aorta, visceral obesity) was necessary. Regression of extremity ischemia was obtained in all the patients.

[Correction of hemodynamic changes during aortofemoral bifurcation bypass surgery under combined epidural anesthesia]

Assessment of hemodynamic parameters in 50 patients before aortofemoral bifurcation bypass surgery could identify 3 types of baseline central hemodynamics and differentiate methods for correcting its disorders. It was ascertained that the development of the intraoperative reperfusion phenomenon during epidural block might predispose to the low cardiac output syndrome for which correction ganglionic blockers are effective at the stage of aortic ligation and a combination of inotropic agents and venous vasodilators is beneficial at the stage of reperfusion.

Late presentation of abdominal aortic occlusion in a patient with spinal cord injury

Although pressure ulcers are a common problem in patients with paraplegia, pressure is not the only cause of them. This case report illustrates that distal abdominal aortic obstruction resulted in multiple ulcers in a paraplegic patient.

[Significance of invasive monitoring of central hemodynamics for the timely correction of their disturbances in operations on the abdominal aorta]

Central hemodynamics was investigated with the thermistor Swan-Hanz catheter in 50 patients with the Leriche syndrome in whom aorto-femoral bifurcation shunting was performed. It was found that hemodynamic profiles of arterial hypotonia appearing at different stages of the operation can be expressed as hypovolemia, lower peripheral resistance of the vessels or the syndrome of low cardiac ejection. The therapeutic strategy (inotropic maintenance, vasodilators, infusion therapy) should be differentiated depending on the hemodynamic profile of hypotonia.

Internal mammary artery perfusing the Leriche's syndrome

Two cases of collateral perfusion of a lower extremity, by way of an internal mammary artery, in the presence of Leriche's syndrome are described. The importance of recognizing this condition prior to coronary artery bypass grafting is emphasized.

[Intraoperative acute aortic obstructive embolism]

We report a case of acute embolic obstruction of the aorta in a 36-year-old patient undergoing coronary artery bypass surgery. After declamping of the aorta at the end of extracorporeal circulation, blood pressure measured in the femoral artery dropped to 10-20 mmHg. Neither clinical signs of arterial hypotension nor a dysfunction of the arterial line could be observed. Cannulation of the left radial artery revealed a normal systemic blood pressure. After the end of surgery, pale and pulseless lower extremities were observed, suggesting arterial obstruction. A 6 X 3 cm embolus occluding the aortic bifurcation could be extracted with a Fogarty catheter; its origin was presumably an aneurysmatic area of the left ventricle. Surgical manipulation had mobilised the mural thrombus, which caused Leriche's syndrome after aortic declamping and defibrillation of the heart.

CONCLUSION

In case of sudden alterations of lower extremity perfusion, anaesthetists and surgeons should consider the rare complication of acute embolic obstruction of the aorta originating from intracardiac thrombotic material. Routine monitoring with transoesophageal echocardiography should thus be considered in patients at risk for intracardiac thrombus formation.

[Consecutive deep femoro-femoral shunting in Leriche's syndrome]

Reconstructive operations were carried out in the clinic on 437 patients with Leriche's syndrome in the recent 8 years. In 25 of them successive shunting of the vessels of the femoro-popliteal segment became necessary later because of inadequacy of the blood flow immediately after the first operation (15 patients) or consequent thrombosis of the femoral artery (10 patients). Trophic changes in the distal parts of the extremity, pain at rest or intermittent claudication occurring after 20-25 minutes of walking were the indications for resorting to successive shunting in the femoro-popliteal segment despite the maintained functioning of the shunt in the aortoiliac position. The deep femoral artery was used as the donor vessel in 12 operations among the 25 successive operations on patients with the Leriche's syndrome. It is noted that with the use of this vessel the successive operation becomes simpler technically and the length of the shunt can be reduced. Adequate restoration of blood flow in the extremity was attained in all patients after successive shunting of vessels in the femoral segment with the use of the deep femoral artery, and persisted for 6 to 12 months.

[Results of the treatment of patients with Leriche's syndrome and ulcerous-necrotic foot changes]

A comparative analysis of two groups of patients with Leriche's syndrome was conducted: 88 patients suffered only from intermittent claudication (stage III of the disease), while 128 patients had pyo-necrotic changes on the feet (stage IV). All patients were subjected to revascularization of the ischemic extremities by restorative operations with the use of a synthetic prosthesis. The necrotic lesions of the feet were encountered mostly in patients with a combined affection. Due to the severe condition of the patients, however, one-stage operations on the ++aorto-popliteal and femoropopliteal segments were not undertaken. An aortic deep femoral shunt was formed, but if ischemia of rest was maintained reconstruction in the femoropopliteal segment was performed in a second stage. Comparative analysis of the immediate and late-term results in patients of these two groups was conducted. It is shown that the operative risk is higher in stage IV than in stage III. But operations in patients with necrotic changes can be considered well grounded because the late-term results (preservation of the extremity, frequency of deep suppurations) hardly differ from those in patients with intermittent claudication.

[Evaluation of disorders of renal hemodynamics in Leriche's syndrome and vasorenal hypertension]

Combined assessment of changes in renal angio-architectonics and hemodynamics demonstrated significant disorders of those in cases of Leriche syndrome and vasorenal hypertension. These changes should not be neglected, if an adequate assessment of renal circulation and metabolism is to be made. It is in this way only that valid data on renal function can be obtained, an essential prerequisite for rational indications for the reconstruction of terminal abdominal aorta and renal arteries as well as the choice of an adequate scope and steps of intervention. In addition immediate and long-term prognosis of the course of the disease and the efficiency of intervention can thus be made.

[Functional and morphologic changes in the cardiovascular system in acute emboligenic arterial obstruction of the extremities]

Cardiovascular function was studied in 129 dogs during temporary occlusion of aortic terminal portions followed by blood flow recovery in the limbs. As ischemia grew in duration, the heart's functional reserves became exhausted, venous tone decreased, while arterial tone, total peripheral resistance and aortic pressure increased, a deficiency of circulating blood volume (CBV) built up, and cardiomyocyte metabolic disorders and lesions were intensified. The recovery of limb blood flow within 2 hours after a three-hour-long ischemia results in the recovery of cardiovascular function. Revascularization following 6 hours' ischemia is associated with the development of latent heart failure. Revascularization after 12 hours of ischemia results in reduced CBV, intropism and vascular tone, and marked metabolic and microcirculatory disorders and cardiomyocyte damage.