Cardiovascular Surgery and Interventions Case Report Open Access Cardiovasc Surg Int 2015;2(2):43-46 http://dx.doi.org/DOI: 10.5606/e-cvsi.2015.373 www.e-cvsi.org ©2015 Turkish Society of Cardiovascular Surgery. All rights reserved. Cardiovascular Surgery and Interventions, an open access journal www.e-cvsi.org Critical lower limb ischemia in Leriche syndrome following acute myocardial infarction: limb salvage with an axillofemoral bypass Hamit Serdar Başbuğ 1 , Macit Bitargil 1 , Ahmet Karakurt 2 , Sefer Usta 3 , Kanat Özışık 1 Received: May 22, 2015 Accepted: June 09, 2015 Published online: August 03, 2015 Departments of 1 Cardiovascular Surgery, 2 Cardiology, Medical Faculty of Kafkas University, Kars, Turkey 3 Department of Cardiovascular Surgery, Ahi Evren Thoracic and Cardiovascular Training Hospital, Trabzon, Turkey Corresponding author: Hamit Serdar Başbuğ, M.D. Kafkas Üniversitesi Tıp Fakültesi Kalp ve Damar Cerrahisi Anabilim Dalı, 36000 Kars, Turkey. Tel: +90 474 - 225 11 90 e-mail: s_basbug@hotmail.com ABSTRACT The aortoiliac occlusive disease, known as Leriche syndrome, primarily merits an aortobifemoral bypass graft which is the standard surgical treatment of critical limb ischemia. However, axillofemoral bypass grafting can be also used as an alternative treatment in high- risk patients. The indications include intraabdominal graft infections, older age, and worsened overall status. In this article, a successful salvage of a limb with an axillofemoral bypass surgery in a critical leg ischemia subsequently developed soon after an acute myocardial infarction was reported. Keywords: Acute myocardial infarction; arterial occlusive disease; axillofemoral bypass grafting; Leriche syndrome; limb salvage. Aortoiliac occlusive disease, also known as Leriche syndrome, is an atherosclerotic obstructive disease involving the distal abdominal aorta prior to the bifurcation into the common iliac arteries. [1] It was first described by Leriche and Morel in 1948. [1] It is a relatively rare condition compared to the infrainguinal arterial obstructions. [2] The primary treatment is surgical revascularization. Aortobifemoral (ABF) bypass is the golden standard with a five-year patency rate of >80%. [3] However, axillofemoral (AXF) bypass was first introduced by Blaisdell and Hall, and Louw at the same time in 1963 as an alternative bypass technique for lower limb inflow revascularization. [3,4] Previously, use of AXF bypass for aortoiliac occlusive disease was limited due to its lower long-term patency rates, compared to ABF grafts. However, it has been, then, widely adopted as an alternative surgical treatment for aortoiliac occlusive disease more frequently with the recent improvements in structure of the prosthetic materials. With the introduction of externally supported grafts, the patency rates of AXF bypass increased up to 70% in five years. [5] Axillofemoral bypass is considered primarily as an alternative revascularization approach in patients with high-risk laparotomy or in whom an aortic approach is troublesome due to the previous abdominal infection or surgery. [6] It is also reserved as a more practical and relatively rapid procedure for elderly with worsened overall status and hemodynamic instability. Coexistence of coronary artery disease and severe aortic occlusive disease is reported as 4 to 15% in different series. [7] In this article, we report a case of critical leg ischemia developed soon after an acute myocardial infarction and its rapid and efficient salvage with an AXF bypass surgery is presented. CASE REPORT A 65-year-old male patient was admitted to the emergency department with chest pain for the last four hours. No significant history was present except intermittent claudication on exertion without resting pain. Blood pressure was 113/76 mmHg. Electrocardiogram revealed tachycardia (116 bpm) without ST elevation. Blood biochemical test results were normal except increased serum troponin-T levels of 0.23 ng/mL (reference range: 0 to 0.02 ng/mL). Non-ST acute myocardial infarction (NSTEMI) was suspected and coronary angiography (CAG) was decided. On physical examination, bilateral femoral artery pulses were non-palpable. Thus, CAG was performed through the right brachial artery. It demonstrated a slow coronary flow in the left anterior descending (LAD) artery and three-vessel disease with a diffuse pattern. Left ventriculography