vascular center for evaluation of limiting intermittent claudication. She gave a history of hypertension found to be secondary to renovascular disease that was initially treated with bilateral angioplasty and stenting. The procedure was uncomplicated; however, her renovascular hypertension promptly recurred. One year later, she underwent bilateral aorto-renal artery bypasssurgery. Prior to the operation, she was able to walk for 2/2 miles (4 km) and sometimes further without much limitation. Immediately following her operation, she noted reproducible symmetric bilateral thigh and calf ‘tightness’ limiting her to half a block of ambulation. Review of the preoperative angiogram revealed diffuse aorto-iliac atherosclerosis without stenosis. MR angiography revealed severe focal stenosis of the abdominal aorta superior to patent bilateral aorto-renal bypass grafts (Panel A). The distal aorta, iliac and femoral arteries were of normal caliber without stenosis. The superior mesenteric artery (SMA) is occluded at the origin Vascular Medicine 2006; 11: 173–174