Persistent claudication after lumbar spinal surgery may reflect unrecognised peripheral artery disease (PAD) and delayed implementation of secondary cardiovascular prevention. Despite effective guideline-directed therapy, diagnostic and treatment gaps persist in routine practice. Vascular claudication may be under-recognised when exertional lower extremity symptoms are attributed solely to neurogenic causes such as lumbar spinal stenosis. Antiplatelet and statin therapy may be absent even in patients with established PAD, while symptomatic agents such as cilostazol are continued without concurrent secondary prevention. Clinical features supporting vascular rather than neurogenic claudication include reproducible claudication distance, calf-predominant exertional pain, pulse abnormalities, cool extremities and limited posture dependence. Ankle-brachial index (ABI) testing-performed either by Doppler or by validated automated oscillometric devices-provides a practical and guideline-supported first-line diagnostic tool in primary care, with toe-brachial index measurement reserved for patients with non-compressible vessels. This communication provides a primary care reassessment framework integrating symptom-pattern assessment, pulse examination, ABI testing, medication reconciliation and timely vascular referral to reduce diagnostic delay and close secondary prevention gaps in patients with persistent claudication after lumbar spinal surgery. This framework represents a pragmatic clinical approach derived from existing guidelines and observational data; it has not been prospectively validated.

Chronic lower extremity arterial disease (PAD) can be categorized into three subsets: Asymptomatic PAD, Chronic Symptomatic PAD, and Chronic Limb Threatening Ischemia (CLTI). Symptoms, signs and treatment of patients in each category are presented. Ankle Brachial Pressure index and Doppler ultrasound should be measured and individuals with chronic symptomatic PAD and CLTI should undergo computed tomographic angiography (CTA), magnetic resonance angiography (MRA), or contrast peripheral vascular angiography for arterial revascularization evaluation. Medical therapy is initial treatment for asymptomatic and symptomatic chronic PAD and CLTI and should include a statin, antihypertensive medications, antiplatelet and antithrombotic therapy, and management of diabetes. American and European Society of Cardiology guidelines for CLTI with endovascular or surgical arterial revascularization are reviewed. Guidelines provide a Class 1 (strong) recommendation for endovascular therapy for patients with symptomatic claudication with hemodynamically significant aortoiliac or femoral popliteal disease who fail medical therapy and a structured exercise program. A Class 2 recommendation (i.e. reasonable) is given to surgical revascularization if preoperative risk is acceptable, technical factors suggest specific advantages over endovascular procedures, and an autologous saphenous vein is available for grafting. Rivaroxaban + Aspirin or a purinergic receptor P2Y G-protein coupled inhibitor + ASA and an exercise program are recommended for patients with chronic PAD.

Acute paraplegia is a neurological emergency requiring prompt diagnosis to prevent irreversible neurological deficits and permanent disability. Although traumatic causes of acute paraplegia are well-characterized, non-traumatic acute paraplegia poses a diagnostic challenge because of its diverse etiologies. Leriche syndrome, also known as aortoiliac occlusive disease, typically presents with chronic lower-extremity claudication, diminished femoral pulses, and erectile dysfunction; however, it can rarely present with acute paraplegia and mimic a spinal cord emergency. We report the case of a 58-year-old woman with uncontrolled diabetes who presented to the emergency department with sudden-onset, non-traumatic flaccid paraplegia, accompanied by sensory loss below the level of L1 and urinary retention. Physical examination revealed cold bilateral lower extremities with absent bilateral femoral and distal pulses, raising suspicion for an acute vascular etiology. Computed tomography angiography revealed complete occlusion of the abdominal aorta and bilateral common iliac arteries at the L1-L2 level, consistent with acute Leriche syndrome. The patient was treated with intravenous heparin, followed by catheter-directed thrombolysis and aortic stent placement. Her motor function improved from 0/5 at admission to 3/5 at hospital discharge, with substantial neurological recovery during the three-month follow-up while undergoing physiotherapy. This case demonstrates that acute Leriche syndrome may present with acute paraplegia and mimic a spinal cord emergency. It highlights the critical importance of incorporating vascular assessment into the evaluation of non-traumatic acute paraplegia, as timely diagnosis and revascularization may improve neurological outcomes.

Leriche syndrome (LS) is an aortoiliac occlusive disease (AIOD) characterized by claudication, decreased femoral pulses, and erectile dysfunction. We present an LS case with bilateral femoropopliteal occlusive disease (FPOD) considered untreatable with surgery or endovascular therapy alone but successfully revascularized via hybrid intervention (HI). An 84-year-old woman with a history of LS was admitted to our hospital with rest pain in the right leg, and coldness and numbness in the left leg. The ankle-brachial index (ABI) indicated severe bilateral amplitude reduction and pulse elongation. Computed tomography angiography revealed occlusion of the terminal aorta, bilateral common iliac artery to external iliac artery, common femoral artery to superficial femoral artery, and right popliteal artery with poor run-off. We initially decided to perform HI only on the right lower extremity. Easy guidewire passage through the occluded lesion suggested a primarily thrombotic nature. HI using Fogarty arterial thrombectomy was eventually performed for the bilateral lower extremities. Complete revascularization was achieved using covered and self-expanding stents for aortoiliac lesions, and drug-eluting stent deployment and drug-coated balloon angioplasty for FPOD. The post-operative ABI was elevated, and symptoms improved bilaterally. This HI is highly effective for treating AIOD combined with bilateral FPOD involving thrombotic lesions.

Degenerative cervical myelopathy (DCM) is a progressive condition most caused by degenerative changes that lead to spinal canal stenosis and characteristic neurologic deficits involving both upper and lower extremities. We report an atypical presentation of DCM manifesting exclusively as new-onset lower extremity weakness following lumbar decompression surgery, without neck pain or upper extremity symptoms. This case highlights the importance of maintaining a high index of suspicion for cervical myelopathy and performing whole-spine imaging in patients with unexplained postoperative neurologic deficits.

Background and objective Peripheral arterial disease (PAD) is a common manifestation of systemic atherosclerosis and a powerful predictor of coronary and cerebrovascular events, yet it is frequently underdiagnosed, particularly in primary care and resource-limited settings. The ankle-brachial pressure index (ABPI) is an inexpensive, noninvasive, first-line test, whereas arterial duplex ultrasonography provides anatomical and hemodynamic information that can guide revascularization. The objective of this study was to correlate the ABPI and clinical findings with arterial duplex scan findings in the evaluation of lower-limb PAD. Materials and methods This descriptive cross-sectional study enrolled 50 patients with clinically suspected chronic lower-limb arterial occlusive disease admitted to the Department of Surgery, Dhaka Medical College Hospital, between September 2018 and March 2019. All patients underwent history taking, clinical examination, ABPI measurement, and arterial duplex ultrasonography of the affected limb. An ABPI of 0.90 or less, supported by clinical findings, was considered positive for PAD, and stenosis or occlusion on duplex was taken as the imaging finding of interest. Agreement between ABPI plus clinical findings and duplex was assessed, and the corresponding diagnostic performance was calculated. Analyses were performed using IBM SPSS Statistics for Windows, version 20.0 (released 2011; IBM Corp., Armonk, NY, USA), with P < 0.05 considered statistically significant. Results The mean age was 53.4 ± 11.5 years, and 82.0% of patients were male (male-to-female ratio, 4.5:1). Smoking (88.0%) was the most frequent risk factor, followed by diabetes mellitus (64.0%), hypertension (58.0%), and obesity (44.0%). Intermittent claudication and muscle cramping (68.0% each) were the most common symptoms, and all patients had tissue loss (gangrene or ulceration). ABPI indicated moderate disease (0.41-0.70) in 38.0% of patients, mild disease (0.71-0.90) in 28.0%, and severe disease (<0.40) in 16.0%. Duplex demonstrated stenosis or occlusion in 76.0% of patients. ABPI combined with clinical findings showed a sensitivity of 90.2%, specificity of 88.9%, positive predictive value of 97.3%, and overall accuracy of 90.0%, with a statistically significant association with duplex findings (P = 0.0001). Conclusions ABPI combined with clinical assessment correlated strongly with duplex ultrasonography and provided an accurate, accessible approach to the diagnosis of lower-limb PAD. The combined use of physiological and imaging data supports earlier diagnosis and rational treatment planning, an advantage that is especially relevant in resource-limited settings.

Surgical exposure of the paravisceral and supraceliac abdominal aorta through traditional anterior transperitoneal and lateral retroperitoneal approaches are limited by fragmented operative fields and restricted access to right-sided vasculature. We report the technique of a midline transperitoneal infrapancreatic approach to the supraceliac aorta in a 73-year-old man requiring transaortic paravisceral thrombectomy and aortobifemoral bypass grafting for lower-extremity lifestyle-limiting claudication secondary to extensive paravisceral and aortoiliofemoral atherosclerotic disease. Through a midline transperitoneal incision, the pancreas is reflected anterosuperiorly, and dissection is extended cephalad to obtain supraceliac aortic control, thus allowing uninterrupted contiguous exposure of the entire abdominal aorta within a single operative field. This exposure facilitates secure proximal control and complex aortic reconstruction without the need for medial visceral rotation. This technique demonstrates that extension of the infrapancreatic approach to the supraceliac aorta provides continuous aortic exposure while preserving right-sided vascular access and avoiding extensive visceral mobilization, representing a valuable strategy for the management of complex aortic pathology.