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A 46-year-old woman presented with lifestyle-limiting claudication of the legs. Symptoms had progressed over the previous seven years. She had hypertension, hyperlipidemia, and a smoking history of one pack per day for 30 years. Physical examination revealed nonpalpable femoral, popliteal, dorsalis pedis, and posterior tibial pulses bilaterally. There were no skin changes or ulceration of the legs and feet. Noninvasive vascular tests revealed severe aortoiliac occlusive disease, with monophasic Doppler signals from the groin to the feet on both sides. The ankle–brachial indexes were markedly reduced, at 0.32 on the right and 0.30 on the left. A computed tomographic angiogram showed aortic occlusion just below the origin of the renal arteries (red arrowhead), with refilling of the common femoral arteries through the collateral pathways of the inferior epigastric arteries (large white arrowheads) and the deep iliac circumflex arteries (small white arrowhead). The inferior mesenteric artery (large white arrow) was refilled through Riolan's arch (small white arrow), arising from the superior mesenteric artery (red arrow). The patient was treated with aortobifemoral bypass grafting. She subsequently recovered and has had no further pain in her legs.
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