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The most characteristic pathophysiologic change in Buerger's disease or thromboangiitis obliterans (TAO) is considered the breakdown of microcirculation in the extremity, but this has not yet been proven. The purpose of this study is to examine the damage of microcirculation in TAO objectively, by means of intra-arterial injection of two kinds of radioisotope. In 7 TAO and 4 infrainguinal arteriosclerosis obliterans (ASO) patients, thallium 201 chloride (201Tl) and 99mTc macroaggregated human serum albumin (99mTc-MAA) were administered through bilateral common femoral artery injections. In the planar image of the foot, rectangular regions of interest (ROIs) were placed on the foot muscles and toes. Normalized counts of 99mTc-MAA in each ROI were divided by that of 201Tl, and the result was defined as the microcirculation damage index, based on their different kinetics. The damage index of the foot muscle was not different between ASO and TAO, but that of the toe was lower in TAO than ASO patients. Lumbar sympathectomy was performed in 5 TAO patients, but it did not improve the damage index. It is concluded that there is breakdown of the microvascular defense system from the beginning of the disease, and critical ischemia make the regional cell function deteriorate as if a precursor to a trophic lesion. Lumbar sympathectomy did not immediately improve microcirculation.

In the present study, systolic blood pressure in all toes was measured by using a bladder-free cuff in 20 normal limbs and 106 limbs with arterial occlusive disease, and the clinical significance of blood pressure measurement in all toes was studied. In 97 of 106 limbs with arterial occlusion, all 5 toes showed a significantly decreased blood pressure, indicating that any toe can be used for the purpose of diagnosis of arterial occlusions. However, 41% of cases showed the difference in blood pressure of more than 15 mm Hg between any 2 toes. Great variations of blood pressure among 5 toes were observed especially in limbs with gangrene or with other skin ischemic symptoms such as cold sensitivity, numbness, or history of gangrene in the toes. In these cases, evaluation of hemodynamics in each toe is considered to be of use for prognostic study of gangrene, selection and evaluation of treatments, and follow-up study. In limbs with intermittent claudication, however, blood pressure measurement in all toes may have little value in clinical practice because of small variation among blood pressure values of 5 toes. In comparison of blood pressure values in each toe from limbs with gangrene, toes with gangrene showed a significantly lower blood pressure than toes without gangrene. However, even in these toes without gangrene, a significantly lower blood pressure was observed than in toes from limbs without gangrene. These findings indicate that severe damage to digital circulation due to an occlusive process proximal to the toes is a primarily indispensable condition for development of gangrene in arterial occlusive disease.

In the present study the technique and the reliability of indirect blood pressure measurement at the common femoral level was described. The blood pressure was measured by using a long cuff, which encircled the hips at the level of the groin, and determining the flow signals by Doppler technique applied at the ankle. In order to transmit the cuff pressure to the artery, a slender bag with air, which was a blood pressure cuff used in children, was placed over the common femoral artery under the cuff. A 14 cm. wide cuff-bladder was usually used, but in obese subjects with the size of hips more than 90 cm, a 16 cm. wide cuff-bladder was applied. In patients with collateral vessels around the groin due to the iliac disease, the blood pressure could be measured by placing the Doppler flat probe over the common femoral artery or the collateral vessel. In observation of 24 subjects, a close correlation was obtained between the femoral cuff pressures and common femoral intra-arterial pressures. Furthermore, blood pressure values at the common femoral level measured indirectly showed similar reproducibility as those at the ankle and toe levels.

From clinicopathological study, vasculitis of Buerger's disease seemed to start at small branch arteries and veins and progress to the trunk artery with thrombus. Progress of vascular lesions in trunk artery was gradual in general; the pathogenesis was briefly discussed.

This study, using C3a, C4a, and C5a assay and crossed immunoelectrophoresis in vitro and in vivo, was designed to determine whether vascular prostheses activate the complement system. The degree of complement activation and the pathway of activation were also studied. The complement levels (C3, C4, CH50) in different arterial diseases were measured, and the relationship of complement levels to serum lipids in patients with arteriosclerosis obliterans (ASO) was also investigated, in order to clarify a relationship between the complement system and arteriosclerosis or other arterial diseases. Bovine graft, dacron, and PTFE activated the complement system in vitro. In order of the degree of complement activation, bovine graft ranked first, followed by dacron and PTFE. The patient group with acute arterial occlusion showed high C3 and C4 levels. The healthy elderly group showed higher C3 and C4 levels than the healthy persons in their twenties. In ASO patients, C3 levels correlated with serum lipid levels. Judged from the relation of complement activation by vascular prostheses to the progression of arteriosclerotic changes, vascular prostheses should be assessed with regard to complement activation.

The pattern of arterial occlusion in Buerger's disease was analyzed by simultaneous bilateral femoral arteriography in 210 limbs of 105 patients with Buerger's disease. In 55 limbs of 42 patients, the femoropopliteal segment was affected in addition to the infrapopliteal arterial obstructive lesion. The pattern of crural arterial occlusion was similar in about 40% of both the patients with femoropopliteal occlusion and the patients with crural occlusion. Toes were ulcerated in 4 of 58 limbs with continuous arterial flow, and ulceration occurred in 86 of 152 limbs with a discontinuous flow. The rate of occurrence of bilateral trophic lesion in the group with an arteriographically similar occlusion pattern was not significantly higher than that in the group with a different pattern. The pattern of arterial occlusion in Buerger's disease seemed to be fixed mainly within 1 year after the onset of symptoms, and the skip-lesion in the main artery was favorable to proximal progression of the disease.

Seventy-five limbs of 66 patients undergoing arterial reconstruction of the lower extremity were studied. In 41 of 64 limbs that were not involved in early failure, API returned to normal immediately and the increased API was maintained as long as grafts remained patent. The limbs exhibiting a rise in API of 0.1 or more following proximal reconstruction in the cases with combined iliac and femoral arterial occlusion or bypass grafting to an isolated segment obtained marked improvement of symptoms. Postoperative increase in TPI was not so marked as in API, and TPI remained very low in the limbs with arterial obstructive lesions below the ankle after successful reconstruction. Early or late failure could not be predicted on the basis of preoperative or postoperative API, TPI or A-T gradient. In the limbs with no recovery of TPI, blood flow or flow velocity in the foot was of value predicting which limbs would be salvaged.