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JAMA Clinical Challenge

Exercise-Induced Leg Pain and High Blood Pressure

Image of selective renal arteriogram of the right renal artery

Jeffrey W. Olin, DO
Daniella Kadian-Dodov, MD

A 52-year-old woman presents with exertional right buttock and thigh pain that resolves within 2 minutes of rest. Exercise tolerance has worsened over the past year and is now limited to several blocks. Previously she was able to run 5 to 6 miles per day. Hypertension was diagnosed several months ago and is controlled with lisinopril (5 mg daily). She has no other cardiovascular risk factors. Her blood pressure is 124/76 mm Hg bilaterally. There is a high-pitched systolic bruit over the right subcostal region and the umbilicus. Peripheral pulses are normal. The ankle brachial index (ABI) at rest is borderline normal (0.91) on the right and normal (1.03) on the left. The remainder of the examination is normal.

After physical therapy and nonsteroidal anti-inflammatory agents failed to improve symptoms, a computed tomography angiogram (CTA) is performed, revealing a “beaded appearance” in the right renal artery and a long-segment stenosis of the right external iliac artery. There is no atherosclerosis. A catheter-based angiogram confirms the CTA findings (Figure).

See the full article for an explanation and discussion.

Author Affiliations: Drs Olin (jeffrey.olin@mountsinai.org) and Kadian-Dodov are affiliated with the Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, New York.