A 47-year-old woman presented to the outpatient vascular clinic with a 1-year history of left leg pain that began with cramping in the left calf area, progressed up to the thigh, and now is in the buttock and hip region. Even walking a short distance had become significantly uncomfortable, and the pain had progressively gotten worse. She denied any rest pain or nonhealing ulcers. She was an avid runner and was training for a marathon when her symptoms began and now had stopped exercising. She was initially told she had a muscular strain and to limit activities, but she found the discomfort unbearable, even with walking. She was a lifelong nonsmoker and had no significant past medical history.

Physical examination showed a 5-ft, 1-in, 105-lb female with a diminished left femoral pulse with no palpable left pedal pulses and normal contralateral pulses.

Noninvasive Doppler testing showed an ankle-brachial index (ABI) on the right of 1.2, which did not change with exercise. The ABI on the left at rest was 0.7, which indicated moderate disease, and this further dropped to 0.45 with exercise (Figure 40-1). The left femoral waveform was monophasic (Figure 40-2). Duplex ultrasound imaging confirmed a left external iliac occlusion (Figure 40-3).

The options were discussed with her, including conservative management, open surgery, and endovascular methods.

She opted to undergo angiography (Figures 40-4 and 40-5) with concomitant left external iliac stenting. The occlusion required antegrade and retrograde approaches in order to successfully cross the lesion (Figure 40-6) and place a stent (Figure 40-7).

Her postprocedural ABI returned to normal (Figure 40-8).