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A 79-year-old man was referred for evaluation due to severe right calf pain on ambulation for 2 to 3 years and a recent nonhealing ulcer involving the dorsum of the foot with dry gangrene of the fifth toe.

His past medical history was significant for coronary artery ­disease with a myocardial infarction 15 years ago, which was ­managed medically without any further cardiac follow-up. He also suffered from chronic obstructive pulmonary disease (COPD), hypertension, and dyslipidemia and was a current smoker who smoked a pack a day with a 100-pack-year history.

His surgical history was significant for a carotid endarterectomy immediately prior to the myocardial infarction 15 years ago and a prior endovascular stent placed in the right lower extremity, about which details were not available.


Relevant examination revealed a 75-year-old man who appeared older than his stated age. He was not in distress. His heart rate was 92 bpm, blood pressure was 149/82 mm Hg, and oxygen saturation was 90% on room air. He did not have carotid bruit. His cardiac examination revealed first and second heart sounds and a pansystolic murmur. Respiratory sounds were faint with mild expiratory wheeze bilaterally. Vascular examination was significant for pallor with dependent rubor in the right lower extremity but not the left. The left lower extremity had loss of hair and a 1-cm ulcer over the dorsal aspect of the lateral foot and dry gangrene of the fifth toe. Pulse was not manually palpable in the right femoral, popliteal, or pedal positions. A faint monophasic Doppler signal was recorded in the right popliteal and posterior tibial position, but not in the dorsalis pedis position. The left lower extremity had palpable pulses in the femoral and popliteal positions and biphasic Doppler signals in the dorsalis pedis and posterior tibial positions.


Ankle-brachial indices were 0.4 on the right and 0.85 on the left, and segmental pressures and pulse volume recordings showed a significant decrement in right upper thigh pressure and pulse ­volume in comparison to the left, suggestive of right iliac stenosis or occlusions.

Electrocardiography showed anterior Q waves, with subsequent echocardiography revealing a left ventricular ejection fraction of 25% and moderate to severe mitral regurgitation.

Chest x-ray revealed hyperinflated lungs with a narrowed mediastinum and flattened hemidiaphragm. Pulmonary function tests were consistent with severe COPD.

Computed tomography (CT) angiography revealed a long-segment complete occlusion of the right common iliac, external iliac, and common femoral arteries (CFAs) with reconstitution in the right CFA. Faint right-to-left collaterals were noted from the left iliac arteries to the right CFA. The outflow was free of disease with 3-vessel run off below the knee (Figure 34-1).

Figure 34-1

Aortic angiography and iliofemoral runoff.

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