Leriche syndrome, a rare case of intractable hypertension

A 48-year-old Paracelsus Medical University department with treatment-resistant hypertension. She was still symptomatic with systolic blood pressure values up to 250 mmHg even after taking six different antihypertensive drugs. The patient complained about recurrent headache, periorbital edema, and weight gain of about 7 kg during the last 6 months despite any increase in food or fluid intake. Because of the rapidly evolving renal insufficiency, she was admitted to the hospital. Serum creatinine was elevated up to 3.5 mg/dl with an eGFR < 20 ml/min. The 24-h ambulatory blood pressure measurement gave maximum blood pressure values up to 184/117 mmHg without a typical decrease at night (up to 169/107 mmHg) as a sign of insufficient dipping. Examination by use of color Doppler ultrasound revealed the suspicion of Leriche’s syndrome [1] together with an acute decrease in renal function by application of an Angiotensin II antagonist with a creatinine increase up to 5.0 mg/dl. MRI angiography of the descending aorta and renal arteries confirmed the diagnosis and showed a subtotal renal artery stenosis on the right side and a left renal artery occlusion with a small kidney (Fig. 1a). Unexpectedly, our patient did not have symptoms typical for intermittent claudication, such as pain in the legs or neurological impairment of the lower extremities, as usually reported in cases of Leriche’s Syndrome [2]. This was probably due to a sufficient collateral circulation to both femoral arteries. Besides moderate dyslipidemia with an LDL-cholesterol of 150 mg/dl and HDL-cholesterol of 38 mg/dl, no further metabolic disorders could be found in our patient and there were no signs of generalized atherosclerosis such as pronounced carotid plaques or stenotic lesions. Renal artery occlusion is usually the final stage of progressive atherosclerotic renovascular occlusive disease. When high-grade stenosis progresses to occlusion, this may result in aggravation of previously controlled hypertension and elevation of serum creatinine as observed in our patient [3]. Surgical treatment was introduced. An aortic bifurcation prosthesis was implanted, with transosteal right renal artery endarterectomy and a nephrectomy of the left cirrhotic kidney performed (Fig. 1b,2). Further measurements of kidney function showed marked improvement and the antihypertensive medication could be decreased and finally stopped. Six months thereafter, the blood pressure stayed with values around 110/75 mmHg in a normal range and renal function was stable with a serum creatinine of 1.7 mg/dl and an eGFR of 32 ml/min. Normalization of blood pressure in our patient was probably due to the nephrectomy of the left kidney by breaking the in this case pathological renin-angiotensin feedback mechanism and collateral enhancement of the functioning right kidney [4].

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