Endgames Picture Quiz

An unusual case of calf pain

BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c716 (Published 18 February 2010) Cite this as: BMJ 2010;340:c716
  1. Noel Cassar, higher specialist trainee, general surgery,
  2. Branko Dunjic, specialist, general surgery,
  3. Kevin Cassar, consultant vascular surgeon
  1. 1Department of Surgery, Mater Dei Hospital, Tal Qroqq, Msida, MSD 2090, Malta
  1. Correspondence to: N Cassar noel_mt{at}yahoo.com

    A healthy 45 year old man with a passion for rock and roll presented to our vascular outpatients clinic. Over the previous few months he had been unable to continue his dancing sessions because of pain in his right calf, which started a few minutes after he started dancing. He had also noticed that the pain would come on after 200 m of walking.

    On examination he was well, with a blood pressure of 140/80 mm Hg and a pulse of 80 beats/min, which was regular and of good volume. He had normal heart sounds and normal peripheral pulses in the upper limbs and in the left leg but absent pulses distal to the femoral pulse in the right leg. The ankle brachial pressure index was normal on the left but 0.7 on the right. He had smoked 20 cigarettes a day since he was a teenager but was otherwise fit and well. His fasting blood glucose and haemoglobin were normal, as was his preoperative electrocardiography.

    A computed tomography angiogram of his lower limbs had been performed before he was referred to our clinic (fig 1).

    Fig 1 Computed tomography angiogram of the patient’s lower limbs


    • 1 What abnormality is present on the computed tomography angiogram?

    • 2 What is the most likely diagnosis, and what is the differential diagnosis?

    • 3 What further tests can be done to confirm the diagnosis?

    • 4 How should this condition be managed?


    1 What abnormality is present on the computed tomography angiogram?

    Short answer

    Stenosis of the right popliteal artery is present, as shown by the passage of less contrast through this section of the artery. The lumen is compressed so as to resemble a scimitar (“the scimitar sign”) (fig 2).

    Fig 2 …

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