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Leriche syndrome - intermittent buttock pain, erectile impotence, absent femorals due to aortoiliac disease as pudendal artery comes off internal iliac

About

• Cause of intermittent leg pain due to anaerobic muscle metabolism

Causes

• Chronic atherosclerosis/arteriosclerosis
• Buerger's disease, Arteritis, Takayasu's disease

Aetiology of Acute Ischaemia

• Thrombosis of atherosclerotic artery
• Embolism to normal artery

Sites

• Aorto-iliac: buttock and thigh and/or calf pain, impotence (Leriche syndrome)
• Iliac-femoral: thigh and/or calf pain
• Superficial femoral-popliteal artery : calf pain

Risks factors

• Age, smoking, HTN, cholesterol, diabetes
• History of MI or TIA or Ischaemic stroke or carotid disease

Clinical

• Defined as cramp-like pain felt in one or both calves, thighs or buttocks on exertion.
• It may cause the patient to limp.
• The pain recedes when exertion is stopped and so is intermittent.
• It is a key symptom of peripheral vascular disease and warrants assessment.
• Usually disease is in proximal large and medium-sized arteries
• There is progressive stenosis of the arteries with claudication coming on earlier and earlier.
• Eventually rest pain may occur, this often precedes ischaemia and gangrene of the affected limb.
• Also ischaemic ulcers, gangrene, skin changes, loss of pulses
• Usual risk factors, often male, smoker, hypercholesterolaemia, hypertension etc.
• May have associated vascular disease e.g. stroke or MI

Rest Pain

• Important symptoms when pain is at rest in foot or ankle
• Comes on in bed at night and patient holds foot over side of bed

Acute Ischaemia

• The limb is pale, cold and painful and pulseless ,li>Absent capillary return

Investigate

• FBC, U&E (may have CKD), LFTs, ESR, Lipids, Glucose, Hba1C,
• ECG: signs of old MI, AF, LVH
• Elevated lactate with acute ischaemia
• Treadmill for functional claudication distance
• Ankle-Brachial pressure Index ( see ABPI )
• Angiography to look for treatable disease

Management

• Best medical therapy - Aspirin, statin, smoking cessation. BP control, Diabetic control
• Arteriography and possible Angioplasty
• Bypass surgery may be considered in some
• Acute Ischaemia may require emergency revascularisation or amputation