a 36-year - old man visited the emergency department of inje university haeundae paik hospital with severe pain in both lower limbs for 1 day . a physical examination revealed pale , pulseless , and cold lower limbs . one year ago , he had been diagnosed with kimura disease ( kd ) after excision of a right upper limb mass ( fig . the initial laboratory findings were as follows : leukocyte count of 45.510/l with 74% eosinophils , elevated serum fibrinogen degradation product ( fdp ) level ( 18.7 g / ml ) , elevated d - dimer level ( 5.1 g / ml ) , and extremely elevated serum immunoglobulin ( ig ) e ( > 2,500 iu / dl ) . a computed tomography ( ct ) angiogram showed total occlusion of both popliteal arteries ( pas ) ( fig . under the presumptive diagnosis of acute limb ischemia ( ali ) , the patient underwent an emergency thrombectomy of both femoral arteries using a fogarty catheter ( edwards laboratories , santa ana , ca , usa ) . after the operation , the pain and color changes resolved , but the right foot drop remained . to prevent thromboembolic events , immunochemical tests for autoimmune diseases , including lupus anticoagulant , anticardiolipin igg and igm antibodies , anti - beta2-glycoprotein igg and igm , and anti - phospholipid antibodies , were negative . protein s activity was low , but the levels of the total and free protein s antigen were normal , suggesting a type - ii protein s deficiency . an echocardiogram was performed ; it revealed no evidence of a cardiac thrombus or decreased systolic function of the left ventricle ( ejection fraction=47% ) . under the presumptive diagnosis of kd - related ali , the patient was administered steroid therapy . a follow - up ct angiogram on postoperative day ( pod ) brachial index ( abi ) was 0.87 on the right side and 0.62 on the left . coronary angiography ( cag ) on pod 5 showed triple - vessel disease with chronic total occlusion of the left anterior descending artery ( lad ) , left circumflex artery ( lcx ) , proximal obtuse marginal artery , and posterior descending artery ( fig . stent insertion for the coronary artery was delayed because we needed to observe the kd activity and plan the second operation for the left pa . we performed the second operation on pod 17 because of the low abi of the left lower limb . a thrombus and a hypertrophic , injured intimal layer were observed after the longitudinal arteriotomy ( fig . after the removal of the thrombus and the injured intimal layer , a patch angioplasty using bovine pericardium ( vascu - guard biovascular inc . , st . 2e ) : ( 1 ) thrombosis occluding the vessel lumen and intimal thickening with fibroblastic proliferation ( the intima showed reactive changes with fibroblastic proliferation ) were observed . ( 2 ) the thrombotic material contained a prominent number of eosinophils , and mixed inflammatory cell infiltration composed of eosinophils and lymphocytes was observed in the vessel wall . two months after the first discharge , the patient returned to the emergency department with right lower extremity pain and a color change that had developed the day before . a ct angiogram showed total occlusion from the right superficial femoral artery to the distal pa ( fig . we performed an emergency thrombectomy , partial endarterectomy , and patch angioplasty on the right side . the operative findings on the right side were the same as the findings on the left side . a coronary stent was inserted into the lad , and the lcx was balloon dilated ( fig . the patient was then treated with aspirin , clopidogrel , and cilostazol for preventing in - stent thrombosis and prednisolone for kd . kd is characterized by marked eosinophilia , an elevated ige level , and recurrent subcutaneous nodules around the head and neck . however , the increased serum ige level and eosinophilia suggest an allergic disease [ 14 ] . despite an unclear mechanism , hypereosinophilia can lead to a hypercoagulable condition and vasculitis according to some published reports [ 57 ] . a possible mechanism is that the cytokines secreted by eosinophils , including eosinophil cationic protein , eosinophil peroxidase , and major basic protein , activate platelet aggregation . some researchers have demonstrated that human eosinophils contain various amounts of the tissue factor ( tf ) and have concluded that relatively high tf expression in patients with hypereosinophilia may contribute to an increased thrombotic risk . in this case however , kd has been treated with local mass excision , steroids for systemic inflammation , revascularization , and anticoagulation for organ ischemia . some researchers have reported that radiotherapy was a successful treatment for kd . in our patient , furthermore , we performed a partial endarterectomy and patch angioplasty for revascularization . additionally , the patient was administered prednisolone to control the activity of kd . his serum leukocyte and eosinophil counts and fdp and serum ige levels normalized . many revascularization methods are available for ali , including thrombectomy , stent insertion , patch angioplasty , and extra - anatomic bypass with a synthetic or saphenous vein graft . patch angioplasty is more effective for removing a thrombus and widening the lumen than a stent and is easier than a bypass . cag to evaluate other forms of vasculitis revealed coronary artery obstructive disease ( caod ) , and we inserted a coronary stent instead of performing a bypass . because of the patient s young age , coronary artery bypass grafting was the treatment of choice for caod . the mechanism of caod in our patient was different from that of caod in other cases . however , antiplatelet therapy was needed , and the patient required long - term follow - up . in conclusion , kd is a systemic disease that affects many organs and presents with thromboembolism and vasculitis . in a patient with kd , physicians should evaluate the vascular system , including the coronary arteries .