Exertional Leg Pain and Erectile Dysfunction

A 58-year-old man with a past medical history of hypertension, hyperlipidemia, and poorly controlled diabetes mellitus presents to the cardiology clinic complaining of sexual dysfunction. Patient is a 50 pack-year smoker but denies alcohol and illicit drug use. His family history is significant for a mother with multiple sclerosis and hyperlipidemia. He states he has not been able to produce an erection for a few months and prior to that, his erections were insufficiently rigid. He was seen by his primary care physician 6 months ago complaining of reduced exercise capacity due to pain in his thighs and buttocks. At that time, he was taken off his atorvastatin with little improvement in his symptoms. The patient has no symptoms at rest, but in the office, his pain is reproduced after walking 50 yards on a treadmill and unchanged when increasing the incline. Recent laboratory work demonstrates an elevated creatinine of 1.7 mg/dL (baseline ~1.0), glycohemoglobin 10.7%, hemoglobin 10.2 g/dL, and creatinine kinase 45 U/L. On physical exam, femoral and peripheral pulses are difficult to palpate and did not change during proactive maneuvers, such as dorsiflexion and plantar flexion. Lower extremity reflexes are intact, muscle strength and tone are normal, and straight leg raise is negative bilaterally. Patient endorses mildly diminished sensation to light touch on bottom of his feet. Right and left ankle-brachial index (ABI) values at rest are 0.59 on the right and 0.63 on the left, and with exertion are 0.50 and 0.51, respectively. Pulse volume recording showed a blunted waveform amplitude, and loss of dicrotic notch bilaterally at high thigh, low thigh, calf, and ankle.

What is the most likely diagnosis for this patient?

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