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A 44 year old man presented with intermittent claudication of the right lower leg and a history of surgical repair for aortic coarctation at the age of 12 years. Right popliteal and pedal pulses were diminished, and a 3/6 mesosystolic heart murmur was most clearly audible over the posterior part of the thorax. Systolic blood pressure was slightly raised equally in both arms, and a systolic ankle/arm pressure gradient that was higher on the right than on the left side (75 mm Hg and 45 mm Hg, respectively) was found. Ultrasound showed a mass in the right popliteal artery causing severe stenosis. Angiography revealed two structures in the middle and just before the bifurcation of the popliteal artery (far left). Based on these findings, a subacute popliteal artery embolism was suspected. No irregularities were found in the lower aorta and iliac/femoral arteries. Other causes of the embolism, such as atrial fibrillation, endocarditis or patent foramen ovale, were excluded.
Transoesophageal echocardiography showed high grade aortic recoarctation with an extensively protruding and partly mobile sclerotic structure (left) at the site where the patient had undergone corrective surgery with Dacron patch angioplasty 32 years previously. Resection of the restenosed aortic segment with interposition of a synthetic vascular tube graft was performed. The preoperative systolic pressure gradient of 40–50 mm Hg greatly improved, but intermittent claudication remained unchanged. The claudication was resolved only after subsequent balloon angioplasty of the right popliteal artery.