THE NAME BEHIND THE DISEASE KEYWORDS René Leriche / Leriche syndrome Provenance and Peer review: Commissioned; Peer reviewed; Accepted for publication January 2012.
the Leriche syndrome by Professor Harold Ellis
Correspondence address: Department of Anatomy, University of London, Guy’s Campus, London, SE1 1UL.
It would be reasonable for you to imagine that a complete obstruction of the lower end of the aorta would be lethal. After all, its terminal branches, the iliac arteries, not only supply the whole of both the lower limbs, but also the buttocks, the perineum and the pelvic organs. However, such a lesion, especially if it develops gradually to allow collateral channels to dilate, is compatible with survival. This is because there are a number of collateral channels which anastomose between the aorta above the obstruction and the arteries below. The most important of these communicating channels links the superior and inferior epigastric arteries in the deep layer of the anterior abdominal wall. The superior epigastric artery arises from the internal thoracic artery, which itself is a branch of the subclavian artery in the neck. The inferior epigastric artery arises from the external iliac artery immediately before it enters the upper thigh to become the common femoral artery. Hence this link-up between the subclavian artery at the root of the neck and the femoral artery in the groin! Sir Astley Cooper, of Guy’s Hospital, the leading surgeon of his day, showed in the early 19th century that he could ligate the lower end of the aorta in dogs with survival of the animals. He subsequently demonstrated the rich collateral pathways that develop by means of injection of coloured material into the vessels. You can see one of these beautiful specimens on display in the Gordon Museum in the Hodgkin Building at Guy’s.
You can see the post mortem specimen of the ligated aorta in the same case in the Gordon museum Encouraged by his experiments, Cooper went on to ligate the abdominal aorta in 1817. The patient was a 38 year old porter who was bleeding to death from a leaking aneurysm involving the left iliac arteries. The operation was done at night by candle light and, of course, these were the days before anaesthetics. The normal right limb did indeed remain viable, but the left, where the collateral channels had obviously been damaged, became progressively more ischaemic and the patient died 40 hours after surgery. You can see the post mortem
specimen of the ligated aorta in the same case in the Gordon museum. It was not until 1925 that Rudolph Matas in New Orleans in the USA was able to report a successful aortic ligation, again for an aneurysm. Sadly, the patient died of pulmonary tuberculosis 18 months later. It was René Leriche who described the four classical clinical features of the syndrome which bears his name, obstruction of the aortic bifurcation, (‘le carrefours de l’aorte’ – ‘the cross-roads of the aorta’ in French): 1) The patient has severe claudication of both lower limbs. 2) Not only the legs but the buttocks experience pain on walking. This is due to the involvement of the internal iliac arteries, supplying the buttocks through the gluteal arteries. 3) The lower limbs are icy cold, with pallor and cyanosis. 4) The male patient is impotent; the erectile tissues receive their blood supply from the deep pudendal branches of the internal iliacs. René Leriche was born in Roanne, in Central France, in 1879. His father was a
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lawyer. He received his medical training in Lyons and graduated in 1906; he remained loyal to his medical school throughout his long career. I spent some weeks at L’Hôpital Edouard Heriot in 1957, a couple of years after he had died, and the staff spoke with great affection about ‘le patron’ (‘the boss’). In his early postgraduate years, his surgical interests were wide. His graduation thesis was on resection of the stomach for cancer. In 1909 he published with his senior, Prof. Poncet, a two volume monograph on Surgical Tuberculosis, while during the First World War, as a military surgeon, his main interest was in fractures. At this time he also became involved in the treatment of vascular injuries and vascular disease thereafter remained his principal concern.
At Strasbourg his major work was the study of vascular problems, both in the wards and in the laboratory After the war, in 1924, Leriche was appointed Professor of Surgery at the University of Strasbourg. In his inaugural lecture, entitled ‘Physiological Surgery’, he outlined his surgical philosophy; the patient was to be considered as a whole; 147
THE NAME BEHIND THE DISEASE
René Leriche: the Leriche syndrome Continued
the object of treatment was not simply a matter of surgical technique but had as its target the restoration of function. At Strasbourg his major work was the study of vascular problems, both in the wards and in the laboratory. Unlike many of his colleagues, he made numerous visits to surgical clinics in the rest of Europe and in North and South America, as well as welcoming overseas visitors to his unit. In 1927 he was elected an Honorary Fellow of the Royal College of Surgeons of England and in 1939 awarded its prestigious Lister Medal. Of course, those days were well before the era of reconstructive arterial surgery, whose beginnings corresponded with his last years - much of his operative work was in the various procedures on the sympathetic nerves. Leriche was particularly interested in the operation of peri-arterial stripping, in an effort to produce a local sympathectomy.
In 1937 Leriche was appointed Professeur au Collège de France in Paris. This was the premier academic surgical post in France but carried with it no clinical facilities. He therefore carried out his clinical work in private hospitals, especially the American Hospital at Neuilly.
About the author Professor Harold Ellis CBE, FRCS Emeritus Professor of Surgery, University of London, Department of Anatomy, Guy’s Hospital, London
No competing interests declared
At the outbreak of World War II, Leriche joined a military hospital. On France’s capitulation he transferred to Portugal. Retiring in 1953, he went to live in Cassis on the Mediterranean, where he died in 1955 at the age of 76. How excited he would have been to see today’s reconstructive vascular surgeons at work!
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June 2013 / Volume 23 / Issue 6 / ISSN 1750-4589