Endovascular therapy for limb salvage in a case of critical lower limb ischemia resulting from fibromuscular dysplasia Osamu Iida, MD, Shinsuke Nanto,

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Endovascular therapy for limb salvage in a case of critical lower limb ischemia resulting from fibromuscular dysplasia Osamu Iida, MD, Shinsuke Nanto, MD, PhD, Masaaki Uematsu, MD, PhD, Takakazu Morozumi, MD, Hirokuni Akahori, MD, Seiki Nagata, MD, PhD Journal of Vascular Surgery Volume 46, Issue 4, Pages 803-807 (October 2007) DOI: 10.1016/j.jvs.2007.05.037 Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig 1 Conditions of ulcer and measurements of skin perfusion pressure (SPP) before and after the endovascular therapy. Nonhealing ulcer with intractable rest pain presented in the left foot before the procedure (a). SPP stood at 27 mm Hg in the dorsal region (b) and 19 mm Hg in the plantar region (c). These indicated the flow was not sufficient for the ulcer to be healed. The ulcer was completely healed 2 weeks after the endovascular therapy (d). Amputation was unnecessary. SPP significantly improved to 56 mm Hg in the dorsal region (e) and to 55 mm Hg in the plantar region (f), which were sufficient (>45 mm Hg) for the ulcer to be healed. Journal of Vascular Surgery 2007 46, 803-807DOI: (10.1016/j.jvs.2007.05.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig 2 CT angiogram of the aorta-iliac-femoro-popliteal arteries (a), the angiogram (b) and the pathology of the mesenteric artery (c and d). The aortoiliac, femoral, and popliteal arteries (above the knee) were all normal by CT angiogram without any embolic sources (a). Angiogram of the superior mesenteric artery revealed “string of beads” pattern, which is typical to FMD (b). In the mesenteric arteries of the small intestine, walls were irregularly thickened without any inflammatory changes. Accumulation of subendothelial mesenchymal cells was noted in the fibrous connective tissue. This fibrous connective tissue was sometimes loose, and at times, myxoid change was observed (c) (hematoxylin-eosin stain, 20×). Elastic lamina, highlighted by Verhoeff-van Gieson stain (d) (20×), was occasionally dissociated. Journal of Vascular Surgery 2007 46, 803-807DOI: (10.1016/j.jvs.2007.05.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig 3 Angiographic findings of the tibial arteries before and after the endovascular therapy. Angiogram of the contralateral tibial arteries in the right leg also demonstrated “string of beads” (a). Baseline angiogram of the left tibial arteries revealed a subtotal occlusion in the distal anterior tibial artery (ATA) and a total occlusion in tibioperoneal artery with collaterals (b). These lesions showed “strings of beads” pattern, which is typical of fibromuscular dysplasia. After balloon angioplasty (c and d), sufficient blood flow was restored from the ATA to the dorsalis pedis artery (e). Journal of Vascular Surgery 2007 46, 803-807DOI: (10.1016/j.jvs.2007.05.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions