Thromboangiitis obliterans (Buerger's disease) in visceral vessels confirmed by angiographic and histological findings

Isolated visceral manifestation of Buerger's disease presenting as intestinal obstruction: a case report

Introduction and importance

Buerger's disease is an uncommon segmental nonatherosclerotic vasculitis essentially affecting small to medium-sized arteries and veins of upper and lower extremities and can lead to limb amputation. Visceral vessel involvement is quite rare accounting for 2% of cases presenting with acute abdomen due to mesenteric ischemia. Moreover, isolated visceral involvement is even rare.

Case presentation

A 42-year-old gentleman, a chronic smoker, presented with abdominal pain associated with nausea and vomiting and loose stool of 2 months duration. Magnetic resonance enterography revealed segmental circumferential wall thickening with stricture in the mid part of the jejunum with lymphadenopathy features of possible inflammatory bowel disease (Crohn's disease). Furthermore, intraoperative surgical findings were also suggestive of Crohn's disease. However, histologic findings were consistent with thromboangiitis obliterans.

Discussion

Thromboangiitis obliterans can present with inflammatory vascular lesions without necrosis in the early stage to varying degrees of recanalisation, gangrene, and amputation in the late stage. It rarely involves the brain, heart, and abdominal viscera. The visceral involvement may be in the form of intestinal obstruction or mesenteric ischemia or can mimic Crohn's in a background of smoking.

Conclusion

This case report will help to learn more about the rarer intestinal presentation of intestinal Buerger's disease. It can present with features of bowel ischemia, obstruction or Crohn's. So, histology would play a pivotal role in differentiating the diagnostic dilemma.

Intestinal manifestation of Buerger's disease in a middle-age female with subsequent transverse colon perforation: A case report and review of literature

Thromboangiitis obliterans, or Buerger's disease, is a relatively rare nonatherosclerotic, segmental inflammatory and obliterative vascular disease that affects the small- and medium-sized arteries, veins, and nerves. In the acute phase, the lesion presents as an inflammatory, nonsuppurative panarteritis or panphlebitis with vascular thrombosis without necrosis. In the late stage of the disease, the thrombus becomes organized leading to varying degrees of recanalization and subsequent gangrene and amputation. There have been rare reports of thromboangiitis obliterans with involvement of the gastrointestinal trace and even more unusual is the occurrence of this manifestation of disease in women. Here, we report a case of a 45-year-old female patient with a history of thromboangiitis obliterans who presented with ischemic colitis.

Visceral bed involvement in thromboangiitis obliterans: a systematic review

One of the challenges of thromboangiitis obliterans (TAO) management is in the patients whose other vascular beds are involved and it remains a challenge to know whether to pursue invasive procedures or to continue medical treatment for such TAO patients. The aim of this review was to investigate reports of the involvement of the visceral vessels in TAO and the related clinical manifestations, management approaches and outcomes. According to our systematic review, the frequency of published articles, the organs most commonly involved were the gastrointestinal tract, the heart, the central nervous system, the eye, the kidneys, the urogenital system, the mucocutaneous zones, joints, lymphohematopoietic system and the ear. Notably, reports of the involvement of almost all organs have been made in relation to TAO. There were several reports of TAO presentation in other organs before disease diagnosis, in which the involvement of the extremities presented after visceral involvement. The characteristics of the visceral arteries looked like the arteries of the extremities according to angiography or aortography. Also, in autopsies of TAO patients, the vascular involvement of multiple organs has been noted. Moreover, systemic medical treatment could lead to the recovery of the patient from the onset of visceral TAO. This study reveals that TAO may be a systemic disease and patients should be aware of the possible involvement of other organs along with the attendant warning signs. Also, early systemic medical treatment of such patients may lead to better outcomes and reduce the overall mortality rate.

Intestinal Ischemia as a Single Manifestation of Thromboangiitis Obliterans

Thromboangiitis obliterans (TAO) is an inflammatory, nonocclusive, and nonatherosclerotic vascular disease. It commonly affects arteries, veins, and surrounding neural elements and is directly related to smoking. Although distal vessels of lower and upper extremities are the most commonly involved, other vessels such as intestinal arteries can be rarely affected. The authors describe a 41-year-old white male smoker who presented with abdominal pain for 3 months and developed an acute bowel ischemia. He underwent urgent surgery, and segmental enterectomy was performed. Histopathologic findings were suggestive of TAO, showing typical involvement of small-sized veins and arteries with intact internal elastic lamina, preserved media, a local nonspecific inflammatory reaction, with new and older arterial and venous thromboses associated. Although mesenteric arteries are seldom injured by TAO, this diagnosis must be considered when the usual causes of intestinal ischemia are ruled out. In this case, even without any other clinical symptoms of TAO, this rare diagnosis could be made.

Buerger disease (thromboangiitis obliterans)

Buerger disease is a nonatherosclerotic vasculitis that is triggered by substantial exposure to tobacco. This disease usually affects small- and medium-sized arteries in the upper and lower extremities. All clinicians who take care of patients with peripheral arterial disease should know the clinical features and diagnostic evaluation of Buerger disease. In this article, we review the clinical presentation and diagnostic criteria for Buerger disease. We describe the diagnostic work-up of patients suspected of having Buerger disease and discuss the typical findings on noninvasive arterial studies and angiography. Lastly, we review the management of these patients, including medical therapy, with an emphasis on smoking cessation, as well as the potential role of revascularization, both surgical and endovascular.

Clinical outcome after extended endovascular recanalization in Buerger's disease in 20 consecutive cases

BACKGROUND

To present our experience of extended endovascular management for thromboangiitis obliterans (Buerger's disease) patients with critical limb ischemia (CLI).

METHODS

Between January 2005 and July 2010, a consecutive series of 17 Buerger's disease patients with CLI in 20 limbs were admitted and the diagnosis confirmed. The mean age of the patients was 41.5 years (standard error: ±1.7). All patients presented with history of smoking, one patient presented with hypertension, and eight patients presented with dyslipidemia. According to Rutherford classification, all patients were found to be between grades 3 and 5. Ultrasonography first, and angiography examination later, confirmed a severe arterial disease involving almost exclusively below-the-knee and foot arteries in all cases. A new approach for revascularization, defined as extended angioplasty of each tibial and foot artery obstruction, was performed to achieve direct perfusion of at least one foot artery.

RESULTS

An extensive endovascular treatment was intended in all patients with success in 19 of 20 limbs, achieving a technical success in 95%. No mortality or complication related to the procedure was observed. During a mean follow-up of 23 months (standard error: ±4.05), amputation-free survival with no need of major amputation in any case and sustained clinical improvement was achieved in 16 of the 19 limbs (84.2%) successfully treated, resulting in a 100% limb salvage rate (19/19).

CONCLUSION

In this first experience, in patients with thromboangiitis obliterans, extended endovascular intervention was a feasible and effective revascularization procedure in case of CLI. High technical success, amputation-free survival, and sustained clinical improvement rates were achieved at midterm follow-up was achieved.

Colon Ischemia Associated with Buerger's Disease: Case Report and Review of the Literature

Buerger's disease, or thromboangiitis obliterans, is a nonatherosclerotic inflammatory disease affecting the small- and medium-sized arteries and veins of the extremities (arms, hands, legs, and feet). It is most common in the Orient, Southeast Asia, India, and the Middle East, and usually affects men aged between 20 and 40 years, although it is becoming more common in women. It is well established that most such patients smoke heavily and experience an improvement in symptoms following smoking cessation. Mesenteric involvement in Buerger's disease is extremely rare; however, we describe herein two cases of colon ischemia in patients who were previously diagnosed with lower-extremity Buerger's disease. In one case, the patient developed colonic obstruction, and surgical resection was performed. Histopathologic findings were compatible with the chronic stage of Buerger's disease. In the other case, angiography revealed abrupt occlusion of the inferior mesenteric artery with numerous collateral vessels, just like the corkscrew appearance found in the extremities. If patients with established Buerger's disease of the extremities complain of gastrointestinal symptoms, early interventional diagnosis should be performed to prevent intestinal obstruction and gangrene.

Buerger disease in an elderly man

Buerger disease is characterized by progressive distal extremity ischemia in persons with recent tobacco consumption. Typically, affected persons are young men. There have been case reports of Buerger disease in older men. Almost all of the reported cases were characterized with progressive, severe disease requiring amputation. We report a case of an older man with features of Buerger disease without significant proximal progression despite active smoking. Arteriographic and pathologic studies confirmed the diagnosis.

[Buerger's disease or thromboangiitis obliterans]

The Buerger's disease or thromboangiitis obliterants (TAO) is a non atheromatous inflammatory disease which alters medium and small-sized arteries and veins. It can be found world-wide, but it is more frequent in Eastern Europe, Middle East, Asia and Southeast Asia. Young men and smokers are the most affected. The incidence of this disease is increasing among women. The cause of this disease is unknown yet. The most striking fact is the relationship between TAO and tobacco. The diagnostic is most often late in front of a digital leg ischemia. Complementary exams help to its diagnostic and management but none of them are specific out of the pathology. The affection is evolving towards distal gangrene with amputation in 5 to 10% of cases. Prostacyclin demonstrated its efficiency. Revascularization surgery is difficult but sometimes possible. Sympathectomy, medular stimulation must be suggested. The patient survival is not at stake and the prognosis is above all functional. The most important element in the treatment is stop smoking definitively.