A 62-year-old man presents with buttock pain during evening walks and absent femoral and distal pulses. Likely dx?

• A. Chronic mesenteric ischemia
• B. Leriche syndrome
• C. Renal artery stenosis
• D. Abdominal aortic aneurysm

Answer: (B)

This situation reflects aortoiliac occlusive disease causing buttock claudication and absent pulses in the femoral and distal arteries. When the infrarenal aorta or iliac arteries are chronically occluded, blood flow to the lower extremities drops during exercise, producing pain in the gluteal region with walking. The absence of distal pulses is a key clue that the problem is upstream, at the aorta/iliac level, rather than a more distal leg issue. This classic presentation is Leriche syndrome, resulting from chronic occlusion of the distal aorta and/or iliac arteries, often with diminished or absent femoral pulses and claudication of the buttocks and thighs.

Chronic mesenteric ischemia would cause postprandial abdominal pain and weight loss rather than leg claudication with absent distal pulses. Renal artery stenosis presents with hypertension and renal impairment, not buttock claudication. An abdominal aortic aneurysm can cause abdominal or back pain and a pulsatile abdominal mass, but the specific combination of buttock claudication with absent femoral and distal pulses points toward infrarenal aortic/iliac occlusion rather than an aneurysm presentation.