Critical limb ischemia (CLI) represents the most severe clinical manifestation of peripheral arterial disease, defined as the presence of chronic ischemic rest pain, ulcers, or gangrene attributable to objectively proven arterial occlusive disease. The dominant pathology underlying CLI is atherosclerosis, distributed at multiple levels along the length of the lower extremity and with a propensity for involvement of the tibial vessels in the leg and the small vessels of the foot. To achieve limb salvage in patients with CLI, revascularization of the affected limb is generally required. In contemporary practice, endovascular techniques are rapidly replacing surgical bypass as the first option for revascularization for CLI based on high technical success rates and low rates of procedure-related morbidity and mortality. Endovascular therapy (EVT) is an emerging new technique for revascularization of lower limb ischemia. EVT is applied in iliac artery primarily but can be used in femoropopliteal artery. Above all, below the knee lesions in patients with CLI is best suited for EVT. We describe the clinical strategy of EVT first approach to revascularization in treating patients with CLI.

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[in Japanese]

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Among CLI (critical limb ischemia) patients, a decline of walking ability after foot amputation is associated with mortality. We have to preserve legs as long as possible, but long duration to treat and additional amputations prevent rehabilitation. Peripheral blood flow is decreased by foot amputation, and so fails stump healing. We have to recognize angiosome concept for foot amputation with peripheral blood flow, which involve arterial-arterial connection, metatarsal artery and digital artery, retained. Minimizing damage to peripheral blood flow is importance for wound healing.

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Recently, end vascular therapies (EVT) has been widely performed for the peripheral artery disease (PAD) patients. In the femoro-popliteal lesions, TASC II guideline recommend to perform bypass surgery for the type C, D complex lesions, because some clinical studies showed that primary patency of EVT for these complex lesions were lower than bypass surgery. Now, EVT for these complex lesions has achieved more than 90% of initial success rate. However, insufficient primary patency rate is still a hurdle. Repeat EVT maintains acceptable secondary patency. EVT is often necessary for high risk patients of operation who have coronary artery disease or cerebral vascular disease, especially when patients have critical limb ischemia. Whenever we perform EVT for these patients, we have to try to get initial success without any complications, and we have to chose effective techniques, for example, bi-directional approach, echo guide wiring and distal protection. In the future, if drug eluting stent will be available in Japan, we can serve less invasive and more effective EVT for PAD patients.

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Revascularization is essential to treat critical ischemic limbs (CLI). Most of patients with CLI have severe below-the-knee (BK) lesions which have to be reconstructed to establish the pulsating reflow to the pedal arteries. Endovascular treatment (EVT) is preferable to bypass surgery because most CLI patients have cardiovascular comorbidities. Most of BK lesions are diffuse, severely calcified and chronic totally occluded (CTO) which are so tough for EVT. However, the development of low profile devices and technical improvement such as echoguidance and bidirectional approach, can improve the initial success rates of EVT to greater than 90%. The limb salvage rates of EVT are also comparable to those of surgery although the primary patency of EVT is poorer than that of surgery. However, the frequent restenosis still remains one of major problems of EVT, which now investigated drug eluting stents and balloons may be able to overcome. EVT for BK lesions is a promising treatment of CLI.

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Subclavian artery disease (SCAD) was not a rare disease in cardiovascular centers because the prevalence of SCAD was achieved in about 3–10% in patients with atherosclerotic disease. However, the indication or strategy of revascularization remains unclear. It has been reported that the primary or secondary patency after primary stenting for symptomatic SCAD was promising for a long time. It should be considered that endovascular procedure for SCAD have a risk of severe complication such as a cerebral infarction. Thus, the indication of revacularization or procedures should be determined cautiously. Based on historical reports or our findings, we reports the indication, procedures, initial success, complications, and long-term outcome.

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[in Japanese]

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【BACKGROUND AND AIMS】 Although SPP is one of the important test for early detection of PAD in dialysis patients, it is unclear about the timing of measurement of SPP; before or during or after dialysis. The aim of study is to compare SPP between before and after dialysis and to examine factors that impact on peripheral circulation. 【METHODS】 We measured SPP before and after dialysis. For 16 patients on hemodialysis (average age 71.4 years, including 11 PAD patients).We examined with ABI, body weight, blood pressure, hANP, calcium, phosphate, PTH. 【RESULTS】 The averages of the SPP before and after hemodialysis were 56.4 mmHg and 53.3 mmHg, respectively, and there was a significant difference between them (p=0.04). Especially, SPP values of patients with PAD, decreased more significantly after dialysis (p=0.04). The difference of SPP values between SPP values before hemodialysis and those after hemodialysis was significantly associated with amount of weight loss, hemodialysis duration, age, pre-and post-systolic blood pressure, and post-diastolic blood pressure. 【CONCLUSION】 SPP values in hemodialysis patients decreased after dialysis, and especially in patients with PAD. The peripheral blood circulation in hemodialysis patients is influenced by blood pressure, circulating plasma volume, dialysis duration, and age.

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