A 65-year-old man presented to our hospital due to intermittent claudication and swelling in his left leg. He had Leriche syndrome and deep vein thrombosis. We performed endovascular therapy (EVT) for Leriche syndrome, and a temporary filter was inserted in the inferior vena cava. He received anticoagulation therapy for deep vein thrombosis. The stenotic lesion in the terminal aorta was stented with an excellent postprocedural angiographic result and dramatic clinical improvement after EVT. This case suggests that EVT can be a treatment for Leriche syndrome.
Leriche syndrome is a chronic obstruction of the aortic bifurcation, extending to both the infrarenal aorta and the common iliac arteries, and is classically associated with a triad of symptoms comprising intermittent claudication, absent or diminished peripheral pulses, and erectile dysfunction in men [
Here we report a case of Leriche syndrome with DVT resembling May-Thurner syndrome that we treated with endovascular therapy (EVT).
A 65-year-old male presented to our hospital due to intermittent claudication of both legs and swelling in his left leg. The claudication had started 4 weeks earlier and was ongoing at the time of presentation, and the pain had worsened. His left lower limb had become swollen 2 weeks before admission. On admission, the pulsation of his bilateral femoral, popliteal, and anterior tibial arteries was weak. The ankle-brachial index (ABI) was significantly low bilaterally.
Ultrasonography showed that there were massive thrombi in the veins extending from the left external iliac vein to the left popliteal vein (Figure
Ultrasonography showed the left iliac vein was occluded with a thrombus.
(a) The left common iliac vein (Lt. CIV) was compressed by the left common iliac artery (Lt. CIA) resulting in formation of a venous thrombus at this point. (b) The thrombus was observed in left common iliac vein (dotted arrow). (c) CT showed that the terminal aorta was occluded from the level of renal artery to the bilateral common iliac arteries.
On day 1, a temporary inferior vena cava (IVC) filter was inserted to prevent pulmonary embolism. Oral warfarin administration and intravenous heparin infusion were started for DVT. Oral cilostazol (200 mg/day) was started for ischemia of the lower extremities. Coronary angiography (CAG) and aortography were done to plan the treatment strategy. There was 75% stenosis in the middle of the left circumflex coronary artery; however, he had no chest symptom, so we decided to continue observation with oral medication.
We planned the treatment strategy as follows. CT showed that the terminal aorta was occluded with thrombus. The high density area was observed in low density area (Figure
CT showed that the bilateral common iliac arteries were occluded with thrombus. The high density area was observed in low density area (dotted arrows).
Following local anesthesia, a 90 cm 6F sheath was inserted from the right brachial artery and advanced to the distal abdominal aorta. The 6F sheath was placed in the right femoral artery and a 7F sheath was placed in the left FA. The proximal fibrous cap of the occlusion site of terminal aorta was penetrated by using a multipurpose catheter and a 0.035-inch Radifocus guidewire (GW) (Terumo Corp., Japan). Then the Radifocus GW was exchanged for a Treasure XS12 (Asahi Intec Co., Aichi, Japan) and crossed from the aorta to the left external iliac artery. A Corsair PV (Asahi Intec Co., Aichi, Japan) was crossed from the left femoral artery to the aorta by the Rendez-Vous Technique, and we exchanged the GW for a Runthrough Ph guidewire (Terumo Corp., Japan). Next, we crossed the Corsair PV and Treasure XS12 from the right femoral artery to the aorta and exchanged the GW for the Runthrough Ph. The intraluminal position of the GW was confirmed by the intravascular ultrasound. After the two wires were successfully passed through, the thrombi were aspirated using a Thrombuster II for 8F aspiration catheter (Kaneka Medix Corp., Japan) and next with a 6F guide catheter Heartrail BL3.5 (Terumo Corp., Japan). The occluded segments of the bilateral iliac arteries were predilated simultaneously with either of the two 4.0 mm balloons. After that, an Epic 10 mm (98 mm) and a 10 mm (80 mm) stent (Boston Scientific, Natick, MA, USA) were inserted from the right common iliac artery and advanced to the aorta. Also, an Epic 10 mm (98 mm) and a 10 mm (60 mm) stent were inserted in the left iliac artery from the left common iliac artery and advanced to the aorta, and postdilatation of the bilateral stents was performed simultaneously with two 5.0 mm balloons. The final angiogram showed no thromboembolism in the distal arteries (Figures
(a) The proximal fibrous cap of the occlusion site of terminal aorta was penetrated by using a multipurpose catheter and a 0.035-inch Radifocus guidewire. (b) Treasure XS12 was crossed from the aorta to the left external iliac artery. (c) Another Treasure XS12 was advanced from the right femoral artery to the aorta. (d) The occluded segments of the bilateral iliac arteries were predilated with either of the two 4.0 mm balloons. (e, f) An Epic 10 mm (98 mm) and a 10 mm (80 mm) stent were inserted from the right common iliac artery and advanced to the aorta. Also, an Epic 10 mm (98 mm) and a 10 mm (60 mm) stent were inserted in the left iliac artery from the left common iliac artery and advanced to the aorta. (g) The postdilatation of the bilateral stents was performed simultaneously with two 5.0 mm balloons. (h) The final angiogram.
(a) Aortography showed that the terminal aorta was occluded from the level of the renal artery to the bilateral common iliac arteries. (b) After EVT, aortography showed that the bilateral common iliac arterial flow was restored. EVT: endovascular therapy.
The clinical course after the EVT is showed in Figure
Clinical course after endovascular therapy. ABI: ankle-brachial index, EVT: endovascular therapy, and POD: postoperative day.
After anticoagulant therapy and EVT, the venous thrombi in the left leg decreased as seen in the ultrasonography of leg veins.
In general, surgical treatment has been recommended as a revascularization therapy for Leriche syndrome [
There are a few case reports of simultaneous occurrence of DVT and Leriche syndrome [
In this case, the tissue at the occlusion site in the terminal aorta seemed to be soft tissue from the CT findings, so we speculated that the occlusion was not so old. Furthermore, the patient had received abdominal surgery for intestinal obstruction about 20 years before. At that time the long hospital stay had been needed due to wound complications. And there was possibility of the adhesion of the abdominal organ. The adhesiolysis during reoperation was associated with an increase of sepsis incidence, intra-abdominal complications and wound infection, and longer hospital stay [
We reported a case of Leriche syndrome accompanied with DVT treated with EVT for Leriche syndrome and the clinical course was excellent. EVT may be a treatment option for Leriche syndrome.
The authors declare that there is no conflict of interests regarding the publication of this paper.