A 39-year-old active woman presented with a progressive 6-month history of bilateral lower extremity pain after walking 1 block or ascending a flight of stairs. The pain was aching, relieved with rest, and primarily in her buttocks and thighs bilaterally. The patient denied history of prior abdominal or lower extremity surgery, trauma, or cardiovascular problems. Review of systems and family history revealed nothing remarkable. Physical examination revealed normal sinus rhythm and normal blood pressure. She had no abdominal tenderness and no palpable masses. Femoral pulses were weakly palpable and symmetric, and pedal pulses were not palpable. Laboratory findings were unremarkable except for an elevated erythrocyte sedimentation rate (ESR) (34 mm/h). Blood and urine cultures were negative. Noninvasive arterial flow studies demonstrated an ankle brachial index of 0.60 on the right and 0.62 on the left with biphasic waveforms in the femoral, popliteal, and tibial vessels. Subsequent magnetic resonance angiography (MRA) of the chest, abdomen, and pelvis showed mild stenosis of bilateral subclavian arteries and an abnormal-appearing infrarenal aorta (Figure 1).
Yoon DY, Hoel AW. Progressive Lower Extremity Pain. JAMA Surg. 2016;151(1):81–82. doi:10.1001/jamasurg.2015.1478
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