Aortoiliac occlusive disease refers to complete occlusion of the aorta distal to the renal arteries.
When the clinical triad of impotence, pelvis and thigh claudication, and absence of the femoral pulses are present, it may also be called Leriche syndrome, which usually affects younger (30-40 year old) males 9.
Aortoiliac occlusive disease is more common in the elderly with an advanced atherosclerotic disease. Acute onset is more common in female patients and is associated with poor outcome with approximately 50% mortality.
In acute cases, symptoms include the 6 Ps:
In chronic onset cases, mostly in arteriosclerosis, symptoms may include erectile dysfunction or impotence.
The condition can be acute or chronic.
Most often the occlusion occurs near the aortic bifurcation. It typically begins at the distal aorta or common iliac artery origins and slowly progresses proximally and distally over time.
- arteriosclerosis: the main cause of this syndrome is an atherosclerotic obstruction of aortoiliac arteries 2
An extensive network of collateral parietal and visceral vessels may form to bypass any segment of the aortoiliac arterial system. In abdominal aortoiliac stenosis/occlusion, the commonest collateral pathways to the lower extremities are 5:
- superior mesenteric artery > inferior mesenteric artery > superior rectal artery >
- intercostal, subcostal, and lumbar arteries > superior gluteal and iliolumbar arteries > internal iliac arteries > external iliac arteries.
- intercostal, subcostal, and lumbar arteries > circumflex arteries > external iliac arteries
- subclavian arteries > internal thoracic (mammary) arteries > superior epigastric arteries > inferior epigastric arteries > external iliac arteries (the Winslow Pathway 7)
CT angiography is usually the best modality for assessment. In patients where CT is not possible, contrast-enhanced MR angiography may be a good option 4.
It allows direct anatomical visualisation of the location of the stenosis and occlusion. It also permits the assessment for the presence of a concomitant occlusive disease affecting visceral arteries, the type and extent of collateralization, and the level of the most proximal and distal arterial segments amenable to stent-graft placement.
Treatment and prognosis
Traditional surgical procedures for aortoiliac occlusive disease are 8 :
- aortoiliac endarterectomy (TEA)
- aortobifemoral bypass (AFB)
- axillobifemoral bypass (extra-anatomic technique); used to avoid abdominal surgery
- percutaneous transluminal angioplasty (PTA) and stenting
History and etymology
It is named after French surgeon René Leriche who initially described the findings in 1948 3.
Imaging differential considerations include:
- mid-aortic syndrome: occurs at or above renal artery level with the involvement of a longer segment and usually in much younger patients (usually 10-30 years old)
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- 6. Bean WJ, Rodan BA, Thebaut AL. Leriche syndrome: treatment with streptokinase and angioplasty. AJR Am J Roentgenol. 1985;144 (6): 1285-6. doi:10.2214/ajr.144.6.1285 - Pubmed citation
- 7. Prager RJ, Akin JR, Akin GC, Binder RJ. Winslow's pathway: a rare collateral channel in infrarenal aortic occlusion. AJR Am J Roentgenol. 1977 Mar;128 (3): 485-7. Pubmed citation
- 8. Lee WJ, Cheng YZ, Lin HJ. Leriche syndrome. Int J Emerg Med. 2008;1 (3): 223. doi:10.1007/s12245-008-0039-x - Free text at pubmed - Pubmed citation
- 9. Peripheral vascular interventions. LWW. ISBN:0781786878. Read it at Google Books - Find it at Amazon
- 10. Hardman RL, Lopera JE, Cardan RA, Trimmer CK, Josephs SC. Common and rare collateral pathways in aortoiliac occlusive disease: a pictorial essay. (2011) AJR. American journal of roentgenology. 197 (3): W519-24. doi:10.2214/AJR.10.5896 - Pubmed
- acute aortic syndrome
- thoracic aortic aneurysm
- abdominal aortic aneurysm
- endovascular aneurysm repair (EVAR)
- reporting tips for aortic aneurysms
- aortic coarctation
- aortic pseudocoarctation
- cervical aortic arch
- interrupted aortic arch
- transposition of the great arteries
- variant anatomy of the aortic arch
- traumatic aortic injury