The management of distal aortic occlusive disease
(Leriche syndrome) depends on surgical or non-surgical
options.[
6] The surgical treatment of Leriche syndrome
can be performed either as direct anatomic (ABF)
bypass or extra-anatomic (AXF) bypass.[8] Direct
anatomic bypasses include aortoiliac and aortofemoral
bypasses. Extra-anatomic bypasses include
axillofemoral bypasses. The non-surgical treatment
of Leriche syndrome mainly depends on endovascular
revascularization.[
9] Patients with aortoiliac occlusive
disease can be treated with percutaneous techniques,
such as balloon angioplasty or peripheral stenting.
However, in the presence of a diffuse disease,
angioplasty remains significantly ineffective when the
distal run-off would not be warranted.[
10] Therefore,
these aforementioned limitations may make the AXF
bypasses the primary therapeutic option for patients
with significant comorbidities and diffuse aortoiliac
occlusive disease.[
11]
The simultaneous presentation of coronary artery
disease (CAD) and peripheral arterial disease (PAD)
are not uncommon. Recent studies have reported
the rate of the concomitance about 40%.[7,12] In
addition, the coexistence of aortoiliac occlusive was
reported 4 to 15% in patients undergoing CABG
surgery.[13,14] The concomitance of PAD and CAD usually deserves a combined surgical approach, in
which both pathologies are treated at the same
session.[7] However, in case of deterioration in the
overall status of the patient, procedural priority
should be given to the more serious pathology. Briefly,
life-threatening manifestation is initially treated and
the other pathology is postponed, until the overall
condition becomes convenient.[7]
In the presented case, a combined procedure was
initially planned; however, the limb ischemia developed
instantly and prompt intervention was needed.
Thus, an AXF bypass was emergently performed to
salvage the right lower limb. Also, CABG operation
was postponed due to worsened overall status of
the patient. If the combined procedure had been
performed, multiple handicaps would have occurred.
In addition, STEMI and elevated troponin-T levels,
determinant factors of impaired cardiac contractility,
would increase the intraoperative mortality. Ischemia
period would be elongated due to CABG, leading
to irreversible neurological complications such as
dropped-foot, or even amputation. In addition,
an intraaortic balloon pump insertion would be
impossible, while it becomes crucial during CABG surgery. As a result, the strategy was primarily built
over the salvage of the leg.
Regarding the etiological progression of our case,
what was the reason for the instant appearance of
ischemic symptoms soon after the CAG? Although
the brachial artery approach was selected for the
percutaneous intervention, what caused the distal
impairment in tissue perfusion? Was the leg ischemia
following a CAG with brachial arterial access merely
a coincidence?
In this case, severe occlusive disease affecting the
distal aorta and both iliac arteries was considered as
the primary pathology. This knife-edge condition was
probably maintained, until an unusual physiological
status developed. The CAG and the preceding
NSTEMI were possibly directly or indirectly
responsible for all the ischemic process affecting the
right leg. Immobilization during the emergency room,
CAG unit and intensive care unit might precipitate
the symptoms of distal circulation. An excessive
consumption of the radiopaque infusion during the
CAG might also precipitate glomerulopathy causing
dehydration or overhydration, both of which have
the potential to change the hemodynamic variables.
A slight increase in BUN levels after CAG might be
a predictor of the probable opaque nephropathy which
altered the blood composition, as perfusion in the
microvascular network can be easily affected by the
minute changes in blood rheology.[15]
In conclusion, coexistence of CAD and aortoiliac
occlusive disease deserves a unique treatment strategy.
Both pathologies can be treated at the same session,
either by an endovascular or standard surgical
approach. Regarding the surgical treatment, ABF
bypass is the golden standard with high patency
rates. However, if the laparotomy is unable to be
performed due to various reasons, AXF bypass can
be easily performed instead. With the evolution of
the prosthetic vascular grafts, patency rates of AXF
bypass have been also increased. Combined surgery
should be considered in eligible patients with a good
overall status. Otherwise, more serious pathology
should primarily be treated, postponing the other
entity to be considered electively.
Declaration of conflicting interests
The authors declared no conflicts of interest with
respect to the authorship and/or publication of this
article.
Funding
The authors received no financial support for the
research and/or authorship of this article.