Background: Thromboangiitis obliterans (Buerger���s disease) is a segmental occlusive inflammatory disorder of the small and medium sized arteries and superficial veins of unknown cause, occurring predominantly in young male smokers. In Buerger���s disease, many patients have critical limb ischemia with long occlusions in distal arteries, and intraluminal angioplasty or bypass surgery is not feasible in most cases. We report our early experiences of subintimal angioplasty for below-knee occlusions in Buerger's disease. Methods: Eight patients with Buerger's disease underwent subintimal angioplasty for limb threatening ischemia caused by below knee arterial occlusion from January 2003 to December 2004. There were three popliteal, two popliteal-tibial, seven tibial, and five peroneal artery lesions. Via antegrade common femoral artery puncture (n =8), a subintimal dissection plane was created across the occlusion with a 0.035 inch hydrophilic wire and a 5F multipurpose catheter. The arterial lumen was reentered distal to the occlusion, and in the recanalized segment, the created extraluminal channel was dilated with a 3.0 ~ 3.5 mm coronary balloon. Results: All patients were smoking males. Mean age was 39 짹 8 years (at the time of diagnosis: 34 짹 8 years) and mean duration of critical limb ischemia was 2 짹 1 months. Mean follow up duration was 12.3 months (range 4-24 months). The subintimal angioplasty was technically successful in 7 of the 8 patients (87.5%). The distributions of lesions treated were three popliteal arteries, three tibial arteries, and two peroneal arteries. Of the 7 technically successful cases, 6 cases (85.7%) showed improved healing in the gangrenous wound and avoided major amputations. There were no distal embolic events, or other significant complications requiring surgical interventions. Conclusions: Subintimal angioplasty is feasible with relatively favorable success and complication rates even in Buerger's disease with below knee critical limb ischemia, although the long-term patency of recanalized vessels needs to be explored. Therefore, it may be an appropriate method for acute rescue from major amputation.