Midterm Outcome of Directional Atherectomy Combined with Drug-Coated Balloon Angioplasty Versus Drug-Coated Balloon Angioplasty Alone for Femoropopliteal Arteriosclerosis Obliterans.

BACKGROUND: The "leave nothing behind" strategies have been becoming a popular treatment for femoropopliteal arteriosclerosis obliterans. Atherectomy before drug-coated balloon (DCB) angioplasty may have an advantage in improving the efficiency of drug delivery into the blood vessel wall. This study aimed to compare the therapeutic effects of directional atherectomy combined with DCB angioplasty with DCB angioplasty alone in the treatment of femoropopliteal arteriosclerosis obliterans. METHODS: Patients with femoropopliteal arteriosclerosis obliterans who received endovascular therapy from June 2016 to June 2018 in our hospital and presented with life-limiting claudication or severe chronic limb ischemia comprised the study cohort. The patients were randomized to receive directional atherectomy combined with DCB angioplasty (n = 45) or DCB alone (n = 49). Ninety-four patients were enrolled in our study with 72 males, and the mean age was 67 ± 10 years. The mean lesion length was 112 ± 64 mm. RESULTS: There were no significant differences in the baseline characteristics of patients and lesions between the 2 randomized groups (P > 0.05). Flow-limiting dissections occurred more frequently in the DCB group (n = 12; 24.5%) than in the DA-DCB group (n = 2; 4.4%; P = 0.006). The technical success rate in the DA-DCB group was superior to that in the DCB group (95.6% vs. 75.5%, P = 0.006). The mean follow-up duration was 16.7 ± 6.1 months in the DCB group and 15.3 ± 5.8 months in the DA-DCB group. No amputations were performed. The overall mortality in the DCB group was 4.1% (2/49), while all patients survived in the DA-DCB group. The 12-month and 24-month primary patencies in the DA-DCB group were greater than those in the DCB group (80.5% vs. 75.7% and 67.1% vs. 55.1%, respectively); however, using all available patency data, no significant differences over time were observed (P = 0.377). CONCLUSIONS: In this study, directional atherectomy combined with DCB angioplasty can decrease the flow-limiting dissection rate in the treatment of femoropopliteal arteriosclerosis obliterans compared with DCB angioplasty alone. There was no significant difference between the 2 groups in terms of primary patency rate which was needed to be further clarified.

Neutrophil-Lymphocyte Ratio and Platelet-Lymphocyte Ratio Predict Severity and Prognosis of Lower Limb Arteriosclerosis Obliterans.

BACKGROUND: The neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) are 2 markers of inflammation, which are associated with worse cardiovascular disease outcomes. Here, we aimed to determine the association between these ratios and disease severity and evaluate predictive validity of the NLR and PLR in lower limb arteriosclerosis obliterans (ASO). METHODS: We evaluated 211 patients with a diagnosis of ASO from January 2016 to December 2018 at Shanghai Jiaotong University Renji Hospital. The NLR and PLR were accessed from routinely drawn peripheral venous blood at the ward of vascular surgery during hospitalization. The association between the NLR and PLR with baseline characteristics, disease severity, and one-year outcomes were determined, respectively. RESULTS: Both the NLR and PLR showed significant values on predicting disease severity. A higher NLR (P = 0.001) and PLR (P < 0.001) were associated with lower ankle-brachial index and worse clinical presentation. Both the NLR and PLR are positively correlated with one-year readmission rate (P < 0.001, P = 0.001, respectively). Both the NLR and PLR also positively correlated with the tissue loss rate and one-year mortality (P = 0.007, P = 0.034, respectively). CONCLUSIONS: The NLR and PLR show a positive association with the severity of lower extremity peripheral artery disease, both higher ratios correlate with poor prognosis, especially, the risk of one-year readmission. A higher NLR also correlates with one-year mortality.

Evaluation of paramalleolar and inframalleolar bypasses in dialysis- and nondialysis-dependent patients with critical limb ischemia.

OBJECTIVE: The aim of this study was to elucidate the efficacy of paramalleolar or inframalleolar bypass (PIMB) in hemodialysis-dependent (HD) patients with critical limb ischemia (CLI) and nonhemodialysis-dependent (NHD) patients in terms of clinical outcomes. METHODS: Between January 2000 and December 2013, there were 333 consecutive arteriosclerosis obliterans patients with CLI who underwent 401 PIMB procedures for limb salvage (LS). Of the 333 patients, 188 (56.5%) were HD patients. Vein grafts were exclusively used, and 172 paramalleolar and 229 inframalleolar bypasses were performed. Five-year primary and secondary cumulative graft patency, LS, and amputation-free survival (AFS) rates were compared between the two groups, and the independent determinants of these outcomes were identified in each group. RESULTS: The 5-year primary and secondary cumulative graft patency rates were 53% and 82% in HD patients and 69% and 92% in NHD patients (primary cumulative graft patency, P < .05; secondary cumulative graft patency, nonsignificant), respectively. The LS rates were 87% and 99% (P < .01) in HD patients and NHD patients, respectively. Overall, 48% and 70% of HD and NHD patients were ambulatory before PIMB (P < .01), and 73% and 85% of HD and NHD patients were ambulatory 12 months after PIMB (including 1-year survivors; nonsignificant), respectively, demonstrating drastic post-PIMB improvement in HD patients. The 5-year AFS rates in the HD and NHD groups were 27% and 69% (P < .01), respectively, demonstrating very poor AFS rates in HD patients. In HD patients, factors negatively associated with AFS were female gender (hazard ratio [HR], 2.102; 95% confidence interval [CI], 1.254-3.524), history of congestive heart failure (HR, 2.075; 95% CI, 1.395-3.085), and preoperative nonambulatory status (HR, 1.974; 95% CI, 1.305-2.986), whereas older age (HR, 2.601; 95% CI, 1.372-4.931) and history of congestive heart failure (HR, 2.928; 95% CI, 1.496-5.731) were identified as independent factors negatively associated with AFS in NHD patients. CONCLUSIONS: The use of PIMB for CLI was associated with excellent LS rates in both HD and NHD patients with low operative mortality and complications. However, the AFS rate observed in HD patients was significantly lower than that observed in NHD patients, indicating the necessity of a specific management program to improve AFS after LS in HD patients.

[A FOLLOW-UP STUDY ON AUTOLOGOUS BONE MARROW MONONUCLEAR CELLS TRANSPLANTATION FOR CRITICAL LOWER ARTERIOSCLEROSIS OBLITERANS IN DIABETIC PATIENTS].

OBJECTIVE: To assess the long-term effectiveness and safety of autologous bone marrow mononuclear cells (BM-MNC) transplantation in the treatment of critical diabetic lower arteriosclerosis obliterans (ASO). METHODS: Between January 2007 and January 2010, 61 patients with critical diabetic lower ASO were treated with standard medical therapies in 29 cases (control group) or with standard medical therapies and autologous BM-MNC transplantation in 32 cases (treatment group). There was no significant difference in gender, age, disease duration, Fontatine stage, glucose (GLU), triglyceride (TG), total cholesterol (CHOL), low-density lipoprotein-cholesterol (LDL-C), hemoglobin Alc (HbA1c), systolic blood pressure (SBP), and diastolic blood pressure (DBP) between 2 groups (P > 0.05). The endpoints were overall survival (OS) and amputation-free survival (AFS). The risk indexes for ASO were observed and compared between 2 groups before and after treatments. RESULTS: The patients were followed up 2-36 months, and no malignant tumor occurred. The OS rate, OS time, AFS rate, and AFS time were 82.76% (24/29), (32.31 ± 9.08) months, 37.50% (9/24), and (21.28 ± 13.35) months in the control group and were 78.13% (25/32), (32.47 ± 6.96) months, 68.00% (17/25), and (28.38 ± 9.48) months in the treatment group; all indexes showed no significant differences (P > 0.05). OS rate, OS time, AFS rate, and AFS time showed no significant differences between 2 groups at the other time (P > 0.05) except AFS time at 1 year, which was significantly short in the control group than the treatment group (t = 2.806, P = 0.007). At the endpoint of follow-up, the indexes of GLU, TG, CHOL, LDL-C, HbAlc, SBP, and DBP showed no significant differences between before and after treatments and between 2 groups (P > 0.05) in 49 survival patients (24 in control group and 25 in treatment group). CONCLUSION: Autologous BM-MNC transplantation is safe and effective in the treatment of critical diabetic lower ASO, which can significantly improve AFS rate and prolong AFS time with no risks.

Bone marrow mononuclear cells versus G-CSF-mobilized peripheral blood mononuclear cells for treatment of lower limb ASO: pooled analysis for long-term prognosis.

In this study, we report the comparative result of long-term clinical prognoses for patients with no-option critical limb ischemia (CLI) caused by arteriosclerosis obliterans, who are implanted with autologous bone marrow mononuclear cells (BMMNC; n=74) or G-CSF-mobilized (M)-PBMNC (n=111), as no information is available on how the two treatments compare in terms of long-term prognosis, such as survival or amputation. We performed pooled analysis using data from two previous cohort studies. All patients had disease of Fontaine classification III or IV. The endpoints were OS and amputation-free survival (AFS). After adjustment for history of dialysis and Fontaine classification, there was no significant difference between the two treatments with respect to OS (hazard ratio (HR)=1.49; 95% confidence interval (CI)=0.74-3.03, P=0.26) or AFS (HR=0.96; 95% CI=0.61-1.51, P=0.87). The negative prognostic factors affecting OS or AFS were the small number of CD34-positive cells collected, history of dialysis, Fontaine classification, male sex and older age. These results suggest that there was no significant difference in long-term prognosis between patients treated with BMMNC and those treated with M-PBMNC. The number of CD34-positive cells collected was an important prognostic factor for amputation and death.

Characteristics of revascularization treatment for arteriosclerosis obliterans in patients with and without hemodialysis.

BACKGROUND: Limb ischemia is a major complication in patients who are receiving hemodialysis (HD). In this study, distinctive features and factors affecting the outcome of HD patients with limb ischemia are identified. METHODS AND RESULTS: One hundred and eighty consecutive symptomatic limb ischemic patients who were or were not receiving HD and who successfully underwent surgical bypass grafting (bypass, n=75) or endovascular angioplasty (percutaneous transluminal angioplasty (PTA), n=105) were retrospectively compared at our hospital. The endpoint of this study was amputation of the ischemic leg or death. Median follow up was 2.25 years. The amputation-free survival of HD patients was significantly lower than that of non-HD patients (P<0.0001). In the bypass group, the amputation-free survival of HD patients was significantly lower than that of non-HD patients (P=0.0002), even if the graft was patented or not (P=0.77). In contrast, in the PTA group, the amputation-free survival of HD patients was lower than that of non-HD patients (P=0.03), and with a significantly lower patency rate (P=0.0004). Predictors of amputation-free survival differed between HD and non-HD patients; predictors were diabetes mellitus and gender in HD patients, while they were Fontaine classification and hyperlipidemia in non-HD patients. The infectious death rate was higher in HD patients than in non-HD patients (53% vs 22%, P<0.05). CONCLUSIONS: This study clearly showed a poorer prognosis in HD patients than in non-HD patients especially after bypass surgery, even if the the graft was patented or not.

Long-term clinical outcomes for patients with lower limb ischemia implanted with G-CSF-mobilized autologous peripheral blood mononuclear cells.

BACKGROUND: Many studies have described the clinical effects of treating critical limb ischemia with granulocyte colony-stimulating factor-mobilized autologous peripheral blood mononuclear cells (M-PBMNC); however, there are no long-term data available on survival, limb salvage, or prognostic factors. METHODS: To investigate the long-term clinical outcomes of M-PBMNC implantation, we reviewed data for 162 consecutive patients with limb ischemia who were treated with M-PBMNC implantation at 6 hospitals between 2001 and 2006. A subset of 123 patients with homogenous clinical profiles was selected for prognostic factor analysis. RESULTS: Of the 162 patients, 50 died during the follow-up period. The median follow-up time for surviving patients was 26.4 months. The 2-year survival rate was 65% for the 140 patients with arteriosclerosis obliterans (ASO), and 100% for the 11, 4 and 7 patients with thromboangiitis obliterans (TAO), diabetic gangrene (DG) and connective tissue disease (CTD), respectively. The 1-year amputation-free rates for ASO, TAO, DG and CTD were 70%, 79%, 75% and 83%, respectively. Common serious adverse events included heart failure (15 cases), myocardial infarction (15 cases), serious infection (13 cases), stroke (10 cases), and malignant tumor (9 cases). Significant negative prognostic factors associated with overall survival were ischemic heart disease and collection of a small number of CD34-positive cells. Factors associated with time-to-amputation and amputation-free survival were a combination of Fontaine classification and lower limb gangrene, and history of dialysis. CONCLUSIONS: Collection of a small number of CD34-positive cells and ischemic heart disease were associated with a reduction in overall survival.

Comparative study of the management of diabetic versus nondiabetic patients with atherosclerosis obliterans of the lower extremities.

The aim of this study was to identify the influence of diabetes mellitus on patients with atherosclerosis obliterans (ASO) of the lower extremities. A prospective study was designed to compare differences between ASO patients with and without diabetes mellitus in regard to clinical characteristics and outcomes of management. Two hundred fifty-three consecutive (61.1%) diabetic and 161 (38.9%) nondiabetic patients were included in this study. Crural artery occlusion occurred more frequently in diabetic patients (tibioperoneal segment 26.5% vs 14.3%; p = .003). Diabetic patients had higher comorbidities, such as ischemic heart disease, disabling stroke, and renal failure. Infection requiring urgent surgical intervention was higher in diabetic patients (39.1% vs 24.2%; p = .001). This required primary major amputation in limb-threatening ischemia superimposed with infection (27.6% vs 17.7%; p = .037). The feasibility (67.2% vs 69.8%; p = .651) and success (74.4% vs 79.0%; p = .481) of revascularization between the two groups were comparable. Diabetic patients often needed more distal revascularization for limb salvage (34.4% vs 18.5%; p = .019). The mortality rate after revascularization was higher in diabetic patients (13.3% vs 2.5%; p = .009). Diabetes mellitus per se has no direct impact on limb salvageability in limb-threatening ischemia. The parity of feasibility and success in revascularization between the two groups should encourage attempts at limb salvage revascularization in diabetic patients.

Percutaneous transluminal angioplasty against arteriosclerosis obliterans in dialysis patients.

The incidence of peripheral arteriosclerosis is on the increase in chronic hemodialysis patients. Recently, the intervention (IV) treatment is conducted to deal with this problem. IV was performed in 4 dialysis patients against the complication of arteriosclerosis obliterans (ASO) but the result was unsuccessful in 3 of them. These 3 failure cases were investigated to find the problems associated with percutaneous transluminal angioplasty (PTA). Cases 1, 2 and 3 had intermittent claudication while case 4 had gangrenous toes as the major complaint. The symptoms in these cases were attributable to 90-100% stenosis and occlusion of superficial femoral artery, bilateral iliac arteries, bilateral superficial femoral-popliteal artery, branch of right iliac artery and left iliac artery region, respectively. IV was successful in case 1 but failed in cases 2 and 4 because the catheter itself did not go through due to the severe stenosis of vessel or the procedure of forcefully dilating the vessel caused dispersion of minute thrombi. In case 3, acute myocardial infarction occurred at 10 h after successful IV, resulting in sudden death. In view of the extent of invasion, IV is a treatment method selected against ASO in dialysis patients. However, the method has a high risk of causing thrombus formation, vessel rupture and organ failure. In this regard, it is advisable to evaluate the systemic condition and conduct IV if the extent of stenosis is mild.

[Chronic pancreatitis combined with obliterative arterial disease]. / Chronicus pancreatitis és obliteratív veróérbetegég együttes elófordulása.

We performed a prospective study at the 1st Surgical Department, Semmelweis University Budapest between 1996 and 2000, in which we examined the common occurrence of chronic pancreatitis and obstructive vascular disease in patients admitted to our department because of either of these illnesses. There were 37 patients suffering from both diseases, all are included in our trial. Control groups were set up of 50 consecutive chronic pancreatitis patients and 50 consecutive vascular patients. In all patients with two disease chronic pancreatitis developed earlier than vascular disease. Occurrence of vascular disease is twice as common among patients with chronic pancreatitis as in normal population. Risk factors like smoking, coffee-abuse and alcohol, which might trigger both diseases, didn't vary in the three groups. This combination of diseases usually starts in the young, and causes severe and progressive deterioration in the quality of life. In four patients after operations performed because of chronic pancreatitis, peripheral arterial operation was also necessary. Operative mortality rate in the chronic pancreatitis group was 2%, in vascular patients 4% and in the group with both diseases it was 16%. We found in our study that there is relation between chronic pancreatitis and peripheral obstructive vascular disease. Further examinations are necessary to examine the etiology. In patients with chronic pancreatitis we must always think of the possibility of later obstructive vascular disease.

Is arterial surgery advisable for patients over 80 years of age?

BACKGROUND: Recently life expectancy has become longer and longer. The purpose of this study was to analyse whether arterial surgery for patients over 80 years of age is advisable. METHODS: During the last 14 years, 527 patients, 50 of whom were over 80 and 477 of whom were under 80 years of age, received graft replacement or bypass surgery. They suffered from ruptured abdominal aortic aneurysm (R-AAA, n=21), non-ruptured abdominal aortic aneurysm (N-R AAA, n=133) or arteriosclerosis obliterans (ASO, n=373). Complications such as cerebrovascular disease, ischemic heart disease, respiratory and kidney dysfunction, and risk factors for ASO were also checked. RESULTS: All of the patients over 80 with R-AAA (n=3/3) and 50% of the patients under 80 with R-AAA (n=9/18) died during their stay in the hospital. However, none of the N-R AAA patients over 80 (n=0/7) and only one of the 126 N-R AAA patients (0.8%) under 80 died. For the patients over 80 with ASO, the graft patency rate was better than the patients survival rate. There were no age-specific factors that should condemn arterial surgery for patients over 80 years of age. CONCLUSIONS: Arterial surgery should not be ruled out on the basis of age alone.

[Transposition of the omentum to the thigh, for the vascular salvage of a limb. Apropos of 17 cases]. / Transposition de l'épiploon à la cuisse, pour le sauvetage vasculaire d'un membre. A propos de 17 cas.

A new procedure to supply effective anastomotic blood supply via the omentum transpositioned to the hip in cases of impaired lower limb vascularization was proposed in 16 cases of stage III and stage IV obliterative artherosclerosis including one case of massive venous thrombosis. The results demonstrated that under rigorously controlled fundamental conditions, circulation can be established and the limb can be saved. 1--good omentum vascularization is essential: the two gastroepiploic arteries must have a large caliber and form a complete anastomotic circle. 2--After disconnecting the omentum from the stomach, while carefully protecting the gastro-epiploic arcade, one pedicle is sectioned and the other is saved depending upon the side the omentum is transpositioned. It is best to save the right pedicle which has a stronger flow even for the left limb. If the omentum is ample enough, the anatomic situation does not require a lengthening plasy. 3--If the omentum is insufficiently long, it is lengthened by a second counter-section between the two gastro-epiploic and epiploic arcades. The ends of the arcades can thus be placed in direct contact forming a unique continuous arcade. This plasty is only possible if the anastomotic circle of the gastro-epiploic arcade is complete. 4--Transposition to the hip is made by including the omentum between the rectus and its posterior sheath through a newly formed channel widening the crural canal. The omentum is thus incorporated as a bridge forming a major circulatory route between the subclavian artery and the pelvic and lower limb arteries. 5--We recommend transpositioning the omentum after lumbar sympathectomy to favour strong vasodilatation and lower flow resistance helping create favourable conditions for the new anastomotic circulation. 6--Based on these specific conditions, we have had excellent results in 80% of the cases for the entire life-span of the patients who underwent the operation. The two cases with poor results occurred after a major technical error due to a lengthening plasty on an omentum without a complete gastro-epiploic arcade.

[Prognostic evaluation of patients with arteriosclerosis obliterans]. / Prognosztikai vizsgálatok arteriosclerosis obliteransos betegekben.

The natural course of 365 random patients with peripheral arterial obliterative disease was followed up on an average 8 years. In 36% of the patients worsening of angiological condition has been shown. The state of the other patients was unchanged (55%) or improved (9%). During the observation period 87 angiological surgeries and amputation of 41 lower limbs were performed, most of them in 1-2 years after onset of the disease. At follow up in 151 cases myocardial infarction and in 72 cases stroke occurred; the incidence of both diseases was characterized by a cluster like accumulation in 1-3 years before or after onset of the disease. The deterioration of the angiological condition of the patients was related to smoking (mainly heavy smoking), diabetes mellitus and-even more markedly--to the combinations of different risk factors including smoking. The pathological levels of haemorheological factors also showed significant connection with the severity of the disease. In the prospective 6 year period of the study 147 patients (40%) died. This mortality was twice that of the general population matched for age and sex. Information about the cause of death could be collected in 128 cases (87%), among them 51 (40%) died of vascular diseases (peripheral arterial obliterative disease, myocardial infarction, stroke).

Aterosclerosis obliterante y mortalidad / Atherosclerosis obliterans and mortality

Se analizó la mortalidad en pacientes no diabéticos fallecidos, que presentaron aterosclerosis obliterante en el Instituto de Angiología y Cirugía Vascular durante un período de 12,5 años. El promedio de edad fue de 71,4 +- 1,6 años, el 66 por ciento correspondió al sexo masculino, el 71 por ciento motivó un ingreso de urgencia el 89 por ciento del total se encontraba en un estadio avanzado de la enferemedad; el 66,7 por ciento requirió una amputación mayor. Al 69 por ciento de los fallecidos se les realizó necropsia y las causas principales de muerte directa fueron el tromboembolismo pulmonar, la bronconeumonía y el infarto del miocardio en el 34,6 el 26,9 y el 24,7 por ciento respectivamente. Se analizan dichas causas y los factores de riesgo asociados con la enfermedad

Aterosclerosis obliterante y mortalidad / Atherosclerosis obliterans and mortality

Se analizó la mortalidad en pacientes no diabéticos fallecidos, que presentaron aterosclerosis obliterante en el Instituto de Angiología y Cirugía Vascular durante un período de 12,5 años. El promedio de edad fue de 71,4 +- 1,6 años, el 66 por ciento correspondió al sexo masculino, el 71 por ciento motivó un ingreso de urgencia el 89 por ciento del total se encontraba en un estadio avanzado de la enferemedad; el 66,7 por ciento requirió una amputación mayor. Al 69 por ciento de los fallecidos se les realizó necropsia y las causas principales de muerte directa fueron el tromboembolismo pulmonar, la bronconeumonía y el infarto del miocardio en el 34,6 el 26,9 y el 24,7 por ciento respectivamente. Se analizan dichas causas y los factores de riesgo asociados con la enfermedad (AU)

Arterial reconstruction in elderly patients.

The surgical results of primary peripheral arterial reconstruction for arteriosclerosis obliterans during a 16-year period were examined as a function of age. Data in group 1 were of 121 procedures performed on 95 patients aged > or = 70 years and those in group 2 of 215 procedures performed on 148 patients aged < or = 69 years. There was no significant difference between the operative mortality rate of 4% (four of 95) in group 1 and 3.4% (five of 148) in group 2. The long-term mortality rate was 33% (31 of 95) in group 1, significantly higher (P < 0.05) than 18.9% (28 of 148) in group 2. The most common cause of death in both groups was cardiac failure. Cumulative 5-year survival rates in groups 1 and 2 were 56.3 and 78.3% respectively (P < 0.0001). The cumulative primary 5-year patency rates of suprainguinal bypass grafts in the two groups were 94.2 and 90.4%, respectively, while those of infrainguinal reconstruction were 67.7 and 55.0% respectively. The 5-year cumulative limb salvage rate was 93.1% in group 1 and 92.7% in group 2. None of these differences was significant. The results support an active approach to surgery in elderly patients with peripheral arterial obstruction caused by arteriosclerosis obliterans.

[The late results in the surgical treatment of patients with arteriosclerosis obliterans of the arteries of the lower extremities]. / Otdalennye rezul'taty operativnogo lecheniia bol'nykh obliteriruiushchim aterosklerozom arterii nizhnikh konechnostei.

Long-term outcomes of surgical treatment were examined in 157 patients with atherosclerosis obliterans of lower extremity arteries. Complications of an atherosclerotic process are a basic cause of death in the patients in the long-term postoperative period. More than half (53.7%) the deaths were due to coronary heart disease. In a group of patients in whom coronary heart disease was not diagnosed prior to surgery, death from myocardial infarction was observed in 20.4% of cases during 5 years. Hypokinetic hemodynamics is a poor predictor of survival of patients with lower extremity artery atherosclerotic occlusions.

[The fate of patients with intermittent claudication-comparison of surgical and non-surgical treatment].

The purpose of this study was to determine the operative indication for patients with intermittent claudication because of arteriosclerosis obliterans, and to compare the late result of the surgical treatment group (182 cases, 250 limbs) with that of the non-surgical treatment group (35 cases, 43 limbs). There were 3 operative deaths and 34 late deaths in the surgical group, and 14 late deaths in the non-surgical group. The number one cause of death was heart failure, including ischemic heart disease, in both groups. The 4-year cumulative patency rates were 91% in the aorto-iliac, 71% in the femoro-distal and 79% in the aorto-femoro-distal arterial reconstructions. Long term symptom free rates of the surgical group and the non-surgical group, except fatal case, were 83% and 44% in the aorto-iliac, 79% and 27% in the femoro-distal, 87% and 33% in the aorto-femoro-distal arterial regions, respectively. Late result of intermittent claudication in the surgical group was better than that in the non-surgical group. We concluded that intermittent claudication should be considered to be the indication for surgery, except for the cases with high risk diseases or malignant diseases.