A 42-year-old Japanese man who had undergone amputation of the left leg below the knee because of Buerger disease required emergency thrombectomy 7 months later. He complained of acute abdominal pain after thrombectomy. At aortography the distal superior mesenteric artery and its branches were not well visualized. Emergency laparotomy was performed because of suspected intestinal ischemia, and the terminal ileum and cecum and part of the ascending colon were resected. In total, the patient underwent laparotomy four times. Histopathologic findings revealed that the arteries and veins of the resected small intestine were occluded with organized thrombi. Inflammatory cell infiltration was recognized mainly in the intima. These findings are compatible with Buerger disease.

We performed 167 femoropopliteal bypass surgeries in 151 patients (95 patients underwent above-knee bypass and 56 below-knee bypass) from December 1985 to December 2000 with the use of prosthetic graft or autologous vein graft. We compared primary patency rates between age, sex, graft material, distal anastomotic site and severity of ischemia, considering their survival rates to elucidate the long-term outcome of above-knee and below-knee femoropopliteal bypass. The 10 year patency rate for above-knee bypass was 47.4%, compared to 36.9% for below-knee ( p < 0.01). Better results were found after bypass surgery for claudicants than for critical ischemia ( p < 0.05). With regard to graft material and age categories, there were unexpectedly no statistical differences in either above-knee or below-knee anastomosis. The survival rate at 10 years in claudicants was 51.2%, compared to 15.9% with critical ischemia ( p < 0.01). Mortality was much influenced by ischemic heart disease ( p < 0.002) and the age of patient ( p < 0.05). The results after above-knee bypass had comparable patency, whereas the results after below-knee bypass were disappointing. Below-knee arterial reconstruction for claudicants should be carefully considered and might be recommended only to patients with critical ischemia.

The purpose of this study was to clarify the incidence of limb salvage and patient survival rates among elderly patients with advanced leg ischemia. We reviewed the records of 159 patients treated for advanced ischemia over a 15-year period at Aichi Medical University, 74 of whom were aged over 75 years and 85, between 65 and 74 years. There was a collective total of 186 limbs; 82 in the older group and 104 in the younger group. The older group had a greater proportion of women, and a higher incidence of coronary heart disease, pulmonary dysfunction, and acute onset of advanced ischemia than the younger group. Limb salvage was achieved in 73% of the affected limbs in the older group and in 92% of the limbs in the younger group. The poor limb salvage rate in the older group was mainly related to the high initial amputation rate. Early recognition of the sentinel ischemic signs before the ischemia is essential, especially in the elderly. Timely revascularization should be attempted whenever possible, and it should not be abandoned simply because the patient is deemed too old. The 1-, 3-, and 5-year survival rates in the older group were 59%, 28%, and 23%, respectively, which were markedly poorer than the expected survival rates of the age- and sex-matched Japanese population at 1, 3, and 5 years, which were 93%, 79%, and 65%, respectively. Thus, advanced limb ischemia carries a poor prognosis to the point of being life-threatening, and further continuous systemic management with the collaboration of physicians and surgeons must be provided even after the patient has left the hospital.

We have long advocated the usefulness, accuracy and safety of carbon dioxide angiogrphy for patients with iodine allergy and renal dysfunction. In addition to its utility, no specialized apparatus is necessary for carbon dioxide angiography. Carbon dioxide as a contrast material has been adopted by consensus for use in endovascular revascularization. Here we report 4 cases of endovascular revascularization using carbon dioxide angiography. Two of the four patients had an iodine allergy, one had renal dysfunction, and the remaining one was complicated by diabetes mellitus. All patients exhibited intermittent claudication and were treated for iliac arterial stenotic lesions with percutaneous angioplasty and sequential endovascular stenting using carbon dioxide gas as a negative contrast material. All cases demonstrated improvement of the chief complaint. There were no direct or indirect complications of carbon dioxide angiography and endovascular intervention after the procedures. All 4 patients were discharged without event within 1 week after the endovascular intervention. Carbon dioxide is useful not only as an angiographic contrast material but also for endovascular intervention in patients with iodine allergy or renal dysfunction.

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