An Uncommon Cause of Acute Limb Ischemia

A 55-year-old male presents to the emergency department with acute right lower limb pain that began 2 hours ago. The patient's history includes heavy smoking, dyslipidemia and stable angina that are well controlled with medical treatment. He also reports a femoral fracture 2 years ago that was treated surgically with no further complications. Physical examination reveals a cold and pale right foot. Examination of the left foot is normal. Right femoral pulses are absent, whereas right distal pulses are palpable, but more weakened compared to pulses of the left foot. Neurological examination reveals no sensory or motor deficits in the right lower limb. Ankle-brachial pressure index (ABI) on the right side is 0.65 and on the left is 1.15. The patient undergoes digital subtraction angiography (DSA) that reveals an abnormal continuation of the internal iliac artery with a partially thrombosed aneurysm at the buttock region, and hypoplastic right external iliac and deep femoral arteries. An endovascular repair with stent graft placement is performed for aneurysm exclusion and blood flow restoration.

Which of the following contributed the most to the patient's condition?

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