Young Woman with Exertional Leg Pain
A 32-year-old woman with lower extremity claudication, sickle cell trait, depression, and history of intrauterine fetal demise presents to the vascular medicine clinic complaining bilateral lower extremity pain.
The patient states that she has noticed a slow worsening of her bilateral lower extremity claudication for the past 3 years. She was previously able to walk 1-2 blocks with pain in her calves, but now she has pain that has progressed proximally to her thighs and occurs after only ½ block. She is forced to rest for about 10 minutes before the pain subsides; the patient has no pain at rest. She also endorses numbness in her feet at night but improve in a dependent position. The patient is a 12 pack-year smoker but quit 2 years ago. She denies alcohol and illicit drug use. Family history is significant with a mother who died of sudden cardiac death at 54, and a father who died swimming at 23. Her outpatient medications are buspirone 7.5mg twice a day, gabapentin 300mg twice a day, and sertraline 50mg daily.
Laboratory work including C-reactive peptide, erythrocyte sedimentation rate, homocysteine, lipoprotein-a, cardiolipin antibody, and lupus anticoagulant were all within normal limits. Lipid panel demonstrates LDL 69 mg/dL, HDL 41mg/dL, triglycerides 61 mg/dL, and total cholesterol 122 mg/dL. Glycohemoglobin A1c is 4.7%. On physical exam, the patient's lower extremities are warm, but femoral and lower extremity peripheral pulses unable to be palpated. Pulses were monophasic bilaterally via handheld Doppler. Capillary refill is <2 seconds in her bilateral great toes. She has normal muscle strength and tone in her lower extremities. Lower extremity reflexes are intact and straight leg raise is negative bilaterally. Sensation is intact to light touch and vibration bilaterally.
Ankle-brachial index (ABI) values at rest are 0.34 on the right and 0.54 on the left. There are monophasic dorsalis pedis and posterior tibial waveforms bilaterally. Computed tomography angiogram (CTA) abdomen with runoff demonstrates an occluded aorta distally, occluded iliac arteries bilaterally, reconstitution of small common femoral arteries (CFA) bilaterally, with superficial femoral artery and popliteal artery occlusion bilaterally and reconstitution of tibial vessel bilaterally (Figure 1). Bilateral lower extremity duplex ultrasounds show no evidence of deep vein thrombosis and patent great saphenous and superficial saphenous veins bilaterally.
Based on these findings, what is the next best step in the treatment of this patient?