A Case of Peripheral Arterial Disease

A 34-year old male comes to office complaining of bilateral tingling and pain in his hands, which becomes more intense during exercise. He has also noticed that his fingers turn white and become numb, when exposed to cold. He is an active heavy smoker, drinks occasionally and denies illicit drug use. The patient's medical history is unremarkable apart from recurrent, small and self-limited lower limb ulcerations since his 30s, involving mainly the toes. He denies gross hematuria, bloody stools, cough and shortness of breath. During the clinical examination the hands are found to be cool, mildly edematous and the tips of the fingers have a black discoloration. The Allen test is performed, and it is abnormal for both hands. Lung auscultation shows bilateral fine crackles, while the S1 and S2 heart sounds are normal without any murmurs. Abdominal examination is unremarkable. The blood pressure of the patient is 131/79 mmHg, his heart rate is 68 bpm and he his respiration rate is 14 breaths per minute.

Which of the following is the most likely diagnosis in this patient?

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