Acute presentation of atherosclerotic total distal abdominal aorta occlusion

Saurabh Gaba; Monica Gupta; Khushbu Dutta; Gautam Jesrani

doi:10.4103/mjhs.mjhs_151_22

CASE REPORT

Year : 2023 | Volume : 11 | Issue : 3 | Page : 213-215

Acute presentation of atherosclerotic total distal abdominal aorta occlusion

Saurabh Gaba, Monica Gupta, Khushbu Dutta, Gautam Jesrani
Department of General Medicine, Government Medical College and Hospital, Chandigarh, India

Date of Submission	18-Nov-2022
Date of Decision	29-Nov-2022
Date of Acceptance	26-Jan-2023
Date of Web Publication	01-Jun-2023

Correspondence Address:
Monica Gupta
Department of General Medicine, Government Medical College and Hospital, Sector 32, Chandigarh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjhs.mjhs_151_22

Abstract

We are presenting the case of a 49-year-old man, a heavy smoker, who had weakness and wasting of the lower limbs along with neuropathic pain for several months for which no medical care was sought. Presentation to the emergency was prompted by a sudden development of pain in the buttocks and cyanosis of the lower limbs. Investigations revealed total atherosclerotic occlusion of the infrarenal abdominal aorta with collateral circulation that was responsible for the delayed presentation. Anticoagulation with heparin was initiated but the patient refused to undergo any invasive procedure. This case highlights that atherosclerotic disease of the aortoiliac region or distal abdominal aorta can present with long-standing symptoms apparently of a neurologic disorder with muscle weakness and wasting rather than an occlusive vascular disease. The symptoms of lower limb claudication and pain may be ignored until a catastrophic complete occlusion supervenes manifesting as acute ischemia as in our case.

Keywords: Abdominal aorta, aortoiliac, atherosclerosis, Leriche syndrome

How to cite this article:
Gaba S, Gupta M, Dutta K, Jesrani G. Acute presentation of atherosclerotic total distal abdominal aorta occlusion. MRIMS J Health Sci 2023;11:213-5

How to cite this URL:
Gaba S, Gupta M, Dutta K, Jesrani G. Acute presentation of atherosclerotic total distal abdominal aorta occlusion. MRIMS J Health Sci [serial online] 2023 [cited 2023 Oct 3];11:213-5. Available from: http://www.mrimsjournal.com/text.asp?2023/11/3/213/380566

Introduction

Aortoiliac occlusive disease or Leriche syndrome is commonly described as a triad of lower limb claudication, reduced or absent pulses, and impotence.^[1] Anatomically, it is can be type I (localized to the infrarenal abdominal aorta and common iliac arteries), type II (also involving the femoral bifurcation), or type III (also involving the arteries distal to femoral bifurcation). The disease, once established, leads to the development of collateral circulation. This can be in the form of anastomosis between branches of the subclavian artery superiorly with those of external iliac arteries inferiorly, or between the superior mesenteric artery and inferior mesenteric artery.^[2] The presence of virtuous collateral circulation can sometimes mask the symptoms and lead to delayed seeking of medical help until a devastating catastrophe supervenes.^[3] The symptoms also vary depending upon the level of occlusion and may be mistaken for neuropathy or radiculopathy. This is exemplified by the case being presented in this report.

The most characteristic feature of Leriche syndrome is reduced or missing femoral pulses.^[4] However, due to collateral circulation, limb-threatening ischemia may not be obvious.^[5] Certain cases have been published, in which even little blood flow through the collateral circulation was sufficient for the functioning of the limbs under nonstressful conditions or for changing the symptomatology to that of a less perilous disease process.^[6]

Case Report

A 49-year-old laborer presented to the casualty complaining of agonizing pain in his buttocks and bluish discoloration of his legs [Figure 1]. The symptoms appeared out of the blue just hours before the presentation. There was no history of any recent vaccination or COVID-19 infection. On examination, he was distressed, afebrile, and normotensive with a pulse rate of 110/min. His legs were cold, cyanotic, and had reduced muscle bulk. The deep tendon reflexes were hypoactive, and none of the lower limb pulses were palpable (femoral, popliteal, tibial, and dorsalis pedis). He had no past medical and surgical history apart from intermittent tingling and progressive difficulty in carrying load, squatting, and going upstairs due to weakness in his legs which appeared over the preceding few months. He specifically denied the occurrence of claudication, that is, pain exacerbated by exercise and relieved on rest. He was a heavy smoker, amounting to 40 pack-years, and also consumed tobacco and alcohol occasionally. There was no audible carotid or renal bruit.

Figure 1: Reduced muscle bulk and cyanosis of legs

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Investigations revealed normal blood counts, blood sugar, and renal and hepatic functions. The total cholesterol and triglycerides were elevated to 320 mg/dL and 240 mg/dL, respectively. Serum homocysteine levels are normal. Arterial Doppler failed to detect any blood flow below the popliteal artery. An emergent computed tomographic (CT) scan with angiography confirmed the clogging up of the infrarenal abdominal aorta, and the distal regions received sparse blood supply through the collaterals [Figure 2]. The electrocardiogram was normal and echocardiography revealed mild systolic dysfunction with no thrombus or valvular lesion. The hypercoagulability workup (protein C, protein S, antithrombin III, Factor V Leiden mutation, and anticardiolipin antibodies) did not reveal any abnormality. Nerve conduction studies were within normal limits.

Figure 2: CT angiography showing abrupt cutoff of the distal aorta (red arrow) and the collaterals (yellow arrows). CT: Computed tomographic

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He was treated with opioid analgesia, atorvastatin, and an infusion of unfractionated heparin. A bypass surgery was contemplated. Unfortunately, the patient denied any intervention despite a detailed explanation of the condition, impending gangrene, and its grave outcome if left untreated. The family cited personal reasons and took leave against medical advice. He was given a prescription of warfarin, aspirin, and atorvastatin along with advice for smoking cessation.

Discussion

Occlusion of the abdominal aorta can result from atherosclerosis, embolism, thrombosis, or large vessel vasculitis.^[1] Atherosclerosis involves chronic inflammation within the vessel wall with the accumulation of foam cells (macrophages containing low-density lipoproteins), lipids, calcium, proteoglycans, and cellular debris with the proliferation of the smooth cells. It results in steady narrowing of the vascular lumen which can be superimposed with acute thrombosis resulting from endothelial injury, platelet activation, and activation of the coagulation cascade.

The risk factors for atherosclerosis include aging, family history, diabetes, hypertension, smoking, dyslipidemia, and alcohol consumption. Atherosclerosis of aorta is usually associated with similar pathologic changes in other vascular beds such as coronary, cerebral, and mesenteric arteries which may or may not result in clinical disease. Embolism of large blood clots from the heart due to atrial fibrillation (emboli from infective endocarditis or prosthetic valves cannot occlude the entire aorta) or atheromatous emboli from the proximal aorta can cause acute occlusion. In situ thrombosis can occur in hypercoagulable states such as malignancies, myeloproliferative disorders, and thrombophilias. Cases of complete aortic occlusion in Takayasu arteritis have also been reported.^[7]

Patients with peripheral arterial disease may be completely asymptomatic in 10% of cases.^[8],[9] The cardinal clinical feature is intermittent claudication in the buttocks, thighs, and calves.^[1] Exercise leads to the increased metabolic demand of the muscles and an inadequate increase in the blood supply leads to pain in the limbs that ceases after a period of rest. Development of collateral circulation can offset this symptom early in the disease course. Reduced blood flow to genital vessels from the internal iliac arteries leads to impotence. The patient under consideration in this report had a past history which would otherwise be suggestive of a neuropathic or myopathic disorder if had not developed the symptoms which brought him to the hospital. There was a complete absence of claudication despite the advanced disease. The cataclysmic presentation was likely precipitated by acute thrombosis over a preexisting atheromatous plaque.

Kim et al. have reported a similar case with atherosclerotic occlusion of infrarenal aorta and internal iliac arteries that led to lower limb weakness and wasting with lumbosacral plexopathy associated with hyporeflexia and dysesthesias.^[10] Yoon et al. reported the case of a 52-year-old male, whose leg claudication was diagnosed initially as spinal stenosis and then as sciatic neuropathy and finally actually discovering it to be an occlusion of the infrarenal abdominal aorta and distal occlusion on CT angiography since his symptoms were not relieved.^[11]

The diagnostic modality of choice is CT or magnetic resonance angiography. The extent of the disease, adequacy of collateral circulation, and anatomy of the blood vessels help in planning the best treatment modality. Endovascular approach to revascularization involves percutaneous angioplasty with or without placement of sent.^[12] Surgical approach involves thromboendarterectomy and the creation of a bypass from the proximal aorta to femoral arteries. Other aspects of management include the use of anticoagulants during the acute phase, followed by long-term use of antiplatelets such as clopidogrel and aspirin with statins. Control of risk factors is important to prevent or delay recurrence.

Conclusion

This case represents an unusual presentation of a rare and catastrophic disease. Although our patient had an insidious reduction in power and muscle bulk of lower limbs along with paresthesias, he presented only when he had complete occlusion of blood flow through the abdominal aorta. In such a case, where the patient declines any aggressive management, risk factor reduction in the form of quitting smoking, a low-cholesterol diet, and medications including statin and anticoagulants are crucial in curtailing the progression of the disease.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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