Sudden Onset of Right Leg Pain

A 94-year-old veteran with a past medical history of coronary artery disease, hypothyroidism, hypertension, and hyperlipidemia presents to the emergency room complaining of sudden onset pain, numbness, and cramping in his right lower extremity (RLE).

The patient reports that he had a "charley horse" cramping in his entire RLE starting a few hours ago while he was gardening. He states that the pain subsides marginally when he sits down but is still present at rest.  The veteran is able to move both lower extremities but complains of a "pins and needles" sensation on the right side. He denies any injury or trauma to that area and has no history of claudication symptoms. The patient is a 55 pack-year smoker but quit 5 years ago. He denies alcohol and illicit drug use.

Physical exam of the RLE reveals palpable femoral pulse, but no pulses distally. The patient has decreased sensation and motor strength in the right knee and ankle. His right foot has significant pallor. Examination of the left lower extremity is unremarkable. Bedside ultrasound demonstrates a thrombus in the right common femoral artery. He had monophasic dorsalis pedis signals on the right. Ankle brachial index was 0.4 on the right and 1.06 on the left. Computed tomography angiography (CTA) of the abdomen, pelvis, and bilateral lower extremities was performed, and the images are demonstrated below in Figures 1-4.

Figures 1-4: CTA Images of the Abdomen/Pelvis with Runoff

Figure 1

Figure 2

Figure 3

Figure 4

Based on this patient's presentation and CTA findings, what is the next best step in the management of this patient?

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