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Objectives To present a clinical case of two patients with resistant thromboangiitis obliterans, as a manifestation of antiphospholipid syndrome (APS), successfully treated with rituximab.Methods Two patients (men, aged 44 and 40, one of whom had been a long-time smoker) with high triple aPL positivity, occlusive artery disease and ischemia of the distal lower extremities received anticoagulants, aspirin, hydroxychloroquine, statins and a prostaglandin E1 analog (alprostadil). A 44-year-old man had a history of heart attack that had been treated with thrombolysis. The patients met the diagnostic criteria for APS. They underwent balloon angioplasty of the lower extremities, which was performed to treat peripheral arterial disease. Blood flow was restored above the level of the feet, but remained reduced in the foot area. Rituximab was prescribed to patients with good efficacy and tolerability because the previous treatment had not worked.Results One of the patients had dry gangrene of the terminal phalanx of the second toe of the right foot. The finger was amputated and the wound healed without complications. In addition to rituximab, antibiotics and intravenous immunoglobulin of 100 mg per kg of body weight were added to the therapy. The second patient had no recurrence of ischemia after rituximab therapy. Figure 1 shows the results of computed tomography angiography of the lower extremities of one of the patients before balloon angioplasty, with uneven stenosis of the celiac trunk (figure 1a) and occlusion of peripheral arteries (figure 1b) and the second toe of the right foot before (figure 1c) and after amputation (figure 1d) due to dry gangrene.Abstract PO:01:015 Figure 1Conclusions Patients with definite high triple positive antiphospholipid syndrome may have an inflammatory component that is resistant to standard anticoagulant therapy and requires treatment with rituximab with good effect.