Leriche syndrome is a disease characterized by thrombotic occlusion in the aorta, frequently in the distal renal artery and classic symptoms of this syndrome include pain in the lower extremities emerging during activity, impalpability of femoral pulses, and impotency in male patients [1, 2]. Due to the chronic course of the disease, the collateral circulation is often well developed and ischemic symptoms are unlikely to appear [4]. In the present case, Leriche syndrome was found incidentally during a preoperative examination.
Two issues need to be considered when performing surgery for rectal cancer complicated by Leriche syndrome: anastomotic leakage due to decreased blood flow to the rectum caused by thrombotic occlusion of the internal iliac artery or IMA, and the risk of ischemia in the lower extremities due to intraoperative manipulations because blood flow to the lower extremities is supplied by collateral blood vessels. We employed the following two methods to treat anastomotic leakage. First, in addition to preserving the LCA, preoperative CT angiography was used to ensure that only the blood vessels feeding the tumor were treated in order to provide continuous blood flow to the rectum [5]. Although our patient had early-stage cancer, we consider that LCA preservation and IMA lymph node dissection should also be performed in advanced cancer cases instead of performing IMA lymph node dissection without preserving the LCA. The second method that we used was to evaluate the blood flow at the anastomotic site using ICG-based fluorescence imaging because such imaging has been reported to be useful for preventing anastomotic leakage [6]. Fluorescence imaging with ICG is also useful for selecting the optimal operative procedure in these cases because it objectively evaluates blood flow. If blood flow decreased in the present case, the procedure would have been converted to Hartmann’s operation. On the other hand, clinical trials that proposed the use of ICG fluorescence to reduce suture failure did not provide supportive evidence [7]. Therefore, mesenteric treatment also needs to be performed with considerations to secure blood flow and assess the color tone of the intestines. To avoid the risk of ischemia in the lower extremities, it is important to identify collateral blood vessels feeding the lower extremities and avoid intraoperative injuries. In patients with Leriche syndrome, the following two collateral pathways to the lower limbs are important: (i) the subclavian artery–internal thoracic artery–superior epigastric artery–inferior epigastric artery pathway and (ii) the subclavian artery–internal thoracic artery–lower intercostal or subcostal arteries–deep circumflex iliac artery pathway [3]. CT angiography may help surgeons to identify vascular variations preoperatively [8]. In the present case, the inferior epigastric artery functioned as a collateral pathway to the lower extremities. To prevent intraoperative injuries, we used magnified views when inserting the trocar, which helped us to avoid the inferior epigastric artery.
We encountered a case of rectal cancer complicated by Leriche syndrome, for which CT angiography was used to safely perform laparoscopic surgery. Since the incidence of arteriosclerosis is increasing, the number of patients with colorectal cancer complicated by Leriche syndrome is also expected to become higher. In these cases, it is important to use preoperative CT angiography to aid surgical planning.