*Piotr Kazmierski, Michal Pajak, Justyna Krus-Hadala, Mateusz Jeckowski
Leriche syndrome – the analysis of 502 cases. Novel or already known issues?
Zespół Leriche’a – analiza 502 przypadków. Nowe czy znane aspekty?
Department of Vascular, General and Oncologic Surgery, Copernicus Memorial Voivodeship Comprehensive Centre for Oncology and Traumatology in Lodz, Poland
Streszczenie
Wstęp. Zespół Leriche’a został opisany w 1923 roku. Dzięki metodom diagnostycznym możliwe jest jego rozpoznanie, a operacje chirurgiczne i wewnątrznaczyniowe pozwalają skutecznie go leczyć. Zaledwie kilku autorów zwróciło uwagę na pewne odmienności kliniczne i epidemiologiczne dotyczące patologii tętnic u pacjentów z zespołem Leriche’a.
Cel pracy. Pierwszorzędowym celem tego badania była ocena częstości występowania i rozległości zmian miażdżycowych w pozaczaszkowych odcinkach tętnic szyjnych u pacjentów z miażdżycą aorty brzusznej i tętnic kończyn dolnych, u których rozpoznano zespół Leriche’a. Dodatkowym celem badania była analiza populacji pacjentów z zespołem Leriche’a pod kątem epidemiologii i czynników ryzyka miażdżycy oraz jej manifestacji klinicznej.
Materiał i metody. Badanie przeprowadzono na grupie 1000 osób leczonych z powodu przewlekłych chorób aorty brzusznej i tętnic kończyn dolnych, wśród których było 502 chorych z zespołem Leriche’a (ZL). U wszystkich pacjentów zbadano pozaczaszkowe odcinki tętnic szyjnych metodą kolorowego Dopplera. Dokonano analizy statystycznej wyników oraz wieku badanych, płci, czynników ryzyka miażdżycy, chorób układu krążenia i przebytych operacji naczyniowych.
Wyniki. Zmiany miażdżycowe w TSZ stwierdzono łącznie u 72,7% pacjentów z ZL. Zwężenia > 50%, > 70% i niedrożności naczyń szyjnych obserwowano w grupie IZL z częstością wynoszącą odpowiednio 9,1; 4,3 i 2,9%, natomiast w grupie WZL: 17,3; 8,1 10,5%. Różnice pomiędzy grupami osiągnęły istotność statystyczną.
Wnioski. Wśród pacjentów z zespołem Leriche’a stwierdzono silną dodatnią zależność pomiędzy stopniem zaawansowania oraz wielopoziomową lokalizacją zmian w tętnicach kończyn dolnych a częstością występowania i stopniem zaawansowania zmian w tętnicach szyjnych. Stwierdzono istotną statystycznie różnicę pod względem wieku, płci, obecności i rozkładu zmian w tętnicach szyjnych oraz zwężeń > 50%, 70% i niedrożności, pomiędzy pacjentami z IZL a pacjentami z WZL. Na podstawie wyników przeprowadzonego badania można przypuszczać, że mamy do czynienia z dwiema populacjami pacjentów z zespołem Leriche’a, a różnice kliniczne pomiędzy nimi są prawdopodobnie spowodowane odmienną patomorfologią tętnic.
Summary
Introduction. Leriche described a specific constellation of symptoms in 1923. Current techniques enable physicians to quickly diagnose patients with this syndrome, while surgical and endovascular techniques. Only few authors noticed that there are some clinical and epidemiological differences in the population of patients with Leriche syndrome (LS).
Aim. The primary aim of this study was to evaluate the incidence and severity of atherosclerotic lesions in extracranial segments of carotid arteries in patients with atherosclerosis of abdominal aorta and arteries of the lower extremities suffering from Leriche syndrome. The additional aim was to analyse a population of patients with Leriche syndrome in terms of epidemiological and risk factors for atherosclerosis and its clinical manifestation.
Material and methods. Study group consisted of 1000 patients treated for chronic diseases of aorta and lower limb arteries and LS was diagnosed in 502 of them. Each patient had an duplex ultrasound of extracranial segments of carotid arteries performed. Statistical analysis of the obtained results was performed with regard to age, sex, atherosclerosis risk factors, cardiovascular diseases and previous vascular surgeries.
Results. Atherosclerotic lesions in carotid arteries were found in 72.7% of LS patients. Stenoses of over 50%, 70% and occlusions were found in 9.1 and 17.3%, 4.3 and 8.1%, 2.9 and 10.5% of patients with isolated form of LS and LS with concomitant arterial lesions, respectively. These differences were statistically significant.
Conclusions. A strong positive correlation between the severity and multi-level localisation of atherosclerotic lesions, and incidence and severity of carotid lesions was observed. Statistically significant differences concerning age, sex, carotid lesion distribution and the presence of > 50%, > 70% stenoses and occlusion was observed between patients with isolated Leriche syndrome and patients with multi-level atherosclerotic lesions in the arteries. The results of the study suggest that there are two different populations of patients with LS. The clinical differences between these two patient populations are probably caused by various arterial pathomorphology.
Introduction
Clinical manifestation of occlusion of aortic bifurcation and/or iliac arteries includes a group of symptoms indication chronic limb ischemia. It was first described by French surgeon Rene Leriche (1-4). Predisposing factors include male sex and other risk factors for atherosclerosis (5, 6). Modern imaging modalities facilitate the diagnosis of Leriche syndrome, and surgical reconstruction methods and endovascular procedures provide effective therapy for such patients (7-10). Many articles concerning Leriche syndrome have been published, yet only few authors observed some discrepancies in the arterial pathology and heterogeneity of patient population, both in terms of clinical and epidemiological factors (4, 11).
Aim
The primary aim of this study was to evaluate the incidence and severity of atherosclerotic lesions in extracranial segments of carotid arteries in patients with atherosclerosis of abdominal aorta and arteries of the lower extremities suffering from Leriche syndrome.
The additional aim was to analyse a population of patients with Leriche syndrome in terms of epidemiological and risk factors for atherosclerosis and its clinical manifestation.
Material and methods
The study was performed in a group of 1000 patients reporting to the Copernicus Memorial Voivodeship Comprehensive Centre for Oncology and Traumatology, Lodz, Poland (Wojewódzkie Wielospecjalistyczne Centrum Onkologii i Traumatologii im. M. Kopernika w Łodzi), who had been treated there due to chronic disease of aorta and lower limb arteries. A total of 502 patients with Leriche syndrome have been identified in this population, 94 of which were women (18.7%) and 408 were men (81.3%) aged 39 to 86 years old (mean age 58.69 ± 9.95). Ultrasound examination of abdominal aorta, arteries of lower limbs and extracranial segments of carotid arteries were performed in Imaging Diagnostic Laboratory by the same, experienced physician (PK) using a PowerVision 6000 SSA-370A device (TOSHIBA) equipped with convex (3-6 MHz) and linear (8-12) transducers.
Each patient had a duplex Doppler ultrasound of abdominal aorta and arteries of lower limbs performed (colour coded ultrasound – CCU) to determine the type, localisation and severity of atherosclerotic lesions and to evaluate the disturbances in arterial blood flow. It was assumed for the analysis, that stenoses of 50% or greater, including vessel occlusion, are hemodynamically significant. The patients with Leriche syndrome were divided into two groups depending on the localisation of the lesions:
Group A – isolated atherosclerotic lesions in aorto-iliac segment: 207 subjects (41.2%), 53 of which were women (25.6%) and 154 were men (74.4%) aged 39 to 78 years (mean age 56.24 ± 8,81 years).
Group B – atherosclerotic lesions in femoro-popliteal segment, concomitant to atherosclerotic lesions in aorto-iliac segment: 295 subjects (58.8%), 41 women (13.9%) and 254 men (86.1%), aged 40 to 86 years (mean age 61.15 ± 9.05 years).
The ultrasound evaluation of atherosclerotic lesions in extracranial segments of carotid arteries was performed based on analysis of flow velocities and its spectrum. The degree of arterial stenosis was based on calculation of percent diameter stenosis, which compared the diameter of the greatest stenosis with the diameter of intact internal carotid artery over the stenosis using NASCET method. The percent diameter stenosis of the carotid arteries calculated by the computer was used to qualify the patients into one of the following six subgroups:
a – no atherosclerotic lesions (0%),
b – low grade stenosis (1-29%),
c – medium-grade stenosis, hemodynamically insignificant (30-49%),
d – medium-grade stenosis, hemodynamically significant (50-69%),
e – high-grade stenosis (70-99%),
f – arterial occlusion (100%).
The analysis of obtained data was based on the data provided by the patient during anamnesis, including their age, sex, atherosclerosis risk factors (smoking – S, diabetes – DM, arterial hypertension – HA, hypercholesterolemia – Chol), atherosclerosis-related diseases (ischemic heart disease – IHD, myocardial infarct), as well as cardiac and vascular surgeries performed due to atherosclerosis.
Statistical analysis
Obtained results were subjected to statistical analysis using both Excel and Statgraphics Plus v. 5.0 software. The structure of patients estimated according to the observed features was described using fractions. Structure indices were used to describe the qualitative features (non-measurable) in the studied group of patients. If the group was small the indices were presented as fractions, not percentages. For measurable (quantitative) features an arithmetic mean was calculated, as an average value, and standard deviation, as the dispersion of the values. Maximal and minimal values were presented as well. To compare the calculated arithmetical means a test for two means was used: a) for large samples (for n1, n2 > 30), b) for small samples (for n1, n2 < 30). The differences between studied parameters (incidences, arithmetical means) were considered statistically significant when the calculated test value was equal or larger from the critical value read from the table of χ2 distribution (normal, Student’s t) for appropriate number of degrees of freedom and probability of bias p < 0.05. Correlation analysis was performed to determine the relationship between the values of the studied features. Regression equations were computed for significant correlations, linear correlation coefficients (Pearson’s r) and regression equations y = ax + b were calculated. Student’s t distribution with N-2 degrees of freedom was used to estimate the correlation significance.
Results
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Piśmiennictwo
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