Endovascular Treatment of Critical Limb Ischemia in Buerger Disease (Thromboangiitis Obliterans) With Midterm Follow-Up: A Viable Option When Bypass Surgery Is Not Feasible

OBJECTIVE. Thromboangiitis obliterans (TAO) is an occlusive inflammatory disease affecting small- and medium-sized vessels that causes decrease in life quality and eventually limb loss. The only proven treatment method is smoking cessation, but it may be insufficient for limb salvage in patients with critical limb ischemia. In this single-center retrospective study, the feasibility and efficiency of endovascular treatment in TAO were evaluated. MATERIALS AND METHODS. After approval of the local institutional review board, 41 patients who underwent endovascular treatment of TAO between January 2014 and June 2019 were evaluated retrospectively. Technical success and procedure-related complications were recorded. Decrease in Rutherford classification score, relief of pain, and wound healing were evaluated to determine clinical success. Primary patency, limb salvage rate, and amputation-free survival were also evaluated. RESULTS. A total of 45 limbs were treated during the study period. Technical success was achieved in 82.2% of procedures. Mean follow-up was 29.8 months. Clinical improvement was achieved in 35 limbs. Three patients underwent major amputation and 12 patients underwent minor amputation. Amputation-free survival and limb salvage were both 93.3% at both 1 and 2 years. Reintervention was performed in 14 patients because of occlusion and clinical relapsing of the symptoms. CONCLUSION. Endovascular treatment of TAO is feasible, has a potential to prevent limb amputation in patients with critical limb ischemia, and has acceptable technical success and limb salvage rates. Because there is no consensus in treatment of TAO, prospective comparative studies are needed to determine the effectiveness of an endovascular approach.

Case report of two pregnancies and deliveries by a woman with Buerger disease

Buerger disease is a chronic inflammatory disease that involves blood clot formation in the medium and small arteries, resulting in thrombophlebitis. It is usually observed in middle-aged men who smoke and is very rare in young women. Previous reports have indicated that Buerger disease worsens during pregnancy due to hypercoagulability associated with pregnancy, and newborns' birth weights were often lower than normal. This report describes a young woman with Buerger disease who experienced two pregnancies and deliveries. During the 1st pregnancy, d-dimer and soluble fibrin levels slightly increased, but no treatment was needed. However, during the 2nd pregnancy, d-dimer and soluble fibrin levels abruptly increased at 20 weeks of pregnancy, and heparin was administered subcutaneously. Four days after heparin administration, d-dimer and soluble fibrin levels decreased to normal pregnancy levels. d-dimer and soluble fibrin measurements were useful for evaluating the coagulation tendencies of this pregnant woman with Buerger disease.

Three cases of dorsal metatarsal artery bypass in patients with Buerger disease

Buerger disease is a rare peripheral vascular disease that most frequently affects young men and is strongly correlated with tobacco use. Although several options have been suggested, no consensus exists on the management of patients with Buerger disease except for smoking cessation. Revascularization is sometimes required to salvage ischemic limbs; however, it is often not feasible because of a lack of distal target vessels. Herein, we present the cases of three patients with tissue loss and gangrene due to Buerger disease. These patients underwent dorsal metatarsal artery bypass and avoided amputation.

Endothelial dysfunction in patients with Buerger disease

We evaluated the endothelial function of patients with Buerger disease using peripheral arterial tonometry test, and examined the factors that are significantly correlated with the endothelial dysfunction in these patients. We performed the peripheral arterial tonometry test in 22 patients with Buerger disease. We recorded the patients' characteristics, including ankle brachial pressure index and reactive hyperemia index, which reflect the endothelial dysfunction. We divided the patients with Buerger disease into the conservative treatment and lumbar sympathectomy group. While the reactive hyperemia index was not significantly different between these two groups, the ankle brachial pressure index was significantly different (1.12 versus 0.83, P=0.003). Furthermore, the reactive hyperemia index was significantly correlated with the ankle brachial pressure index value in the patients in the lumbar sympathectomy group (ρ=0.848, P=0.005). Given that patients with Buerger disease show impairment of the sympathetic nervous system, we should consider the after-effects of such an impaired system on the condition of these patients. The patients treated with lumbar sympathectomy might be more appropriate to evaluate their endothelial function by a peripheral arterial tonometry test.

Investigation of the Etiology of Anemia in Thromboangiitis Obliterans

During a review of patients admitted with thromboangiitis obliterans (TAO), there was evidence of normochromic normocytic anemia and abrupt changes in hemoglobin (Hgb) levels in patients with several hospital admissions. Therefore, the evidence of hemolytic anemia was evaluated based on 37 banked plasma samples taken from Caucasian male TAO patients during disease exacerbation between 2012 and 2014. The patients' hospital records, including clinical manifestations and complete blood count, were evaluated. The following tests were performed on all samples: indirect antiglobulin test (IAT), C-reactive protein (CRP), high-sensitivity CRP (hsCRP), lactate dehydrogenase (LDH), haptoglobin, indirect bilirubin, d-aspartate aminotransferase (AST), and d-alanine aminotransferase (ALT). The mean age of the patients was 40 ± 7 years. Two patients underwent below-knee amputation. The mean hospital-documented Hgb of the patients was 12.9 ± 2.6 g/dL. CRP and IAT were positive in 75.6 and 70.2% of the samples, respectively. The tests and corresponding results were as follows: hsCRP, 14.07 ± 2.37 µg/mL; LDH, 2,552 ± 315 u/L; haptoglobin, 2.27 ± 1.1 g/L; indirect bilirubin, 0.09 ± 0.04 mg/dL; AST, 67 ± 7 u/L; and ALT, 26 ± 3 u/L. There was a significant inverse correlation between hsCRP and hospital-documented Hgb level (p = 0.03). Anemia with the positive IAT in most of the samples, high LDH and AST, and normal ALT are suggestive of hemolytic anemia. Normal indirect bilirubin is consistent with intravascular hemolysis. The positive CRP and elevated haptoglobin levels could be due to systemic inflammation in TAO. However, it is not known if an autoantigen or an infectious antigen is responsible for TAO systemic inflammation and induction hemolytic anemia. As such, the underlying mechanism of anemia in TAO could be part of the footprint of its main etiology.

Thromboangiitis obliterans (Buerger disease)

Thromboangiitis obliterans (Buerger disease) is an occlusive, nonatherosclerotic, inflammatory vasculitis that causes ischemia in small and medium vessels. Most commonly, Buerger disease is diagnosed in 40- to 45-year-old men with a heavy smoking history. Our case exemplifies the most common presentation, diagnosis, and treatment in a 53-year-old male smoker who presents with arm pain and dusky cool fingers. A Buerger diagnosis requires exclusion of autoimmune, diabetic, and embolic causes. The only recognized treatment for this disease is smoking cessation.

Connective tissue disorders associated with vasculitis and vaso-occlusive disease of the hand

Hand ischemia caused by vasculitis is a secondary finding in many autoimmune processes. Many of these autoimmune diseases are managed primarily with medications that can prevent the development of occlusive disease, tissue ischemia, and tissue loss. Unfortunately several disease conditions can be recalcitrant to medical management and can result in ischemic changes within the hand, which may require operative intervention. This article briefly reviews the major connective tissue disorders associated with vasculitis and vaso-occlusive disease of the hand, including scleroderma, lupus, and Buerger disease, and their surgical treatment.

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.

[Severe mesenteric infarction by superior mesenteric artery occlusion in a patient suffering from Buerger's disease]

La thromboangéite oblitérant ou maladie de Buerger, est une artérite inflammatoire non-artériosclérotique touchant classiquement les réseaux vasculaires périphériques des membres. Elle atteint principalement les hommes jeunes tabagiques et sans autres facteurs de risques cardiovasculaires. Les atteintes des artères digestives sont très rares et souvent fatales si elles ne sont pas évoquées et prises en charge précocement. Nous rapportons l'observation d'un jeune patient tabagique chronique qui s’était présenté aux urgences dans un tableau de péritonite aigue négligée due a un infarctus entero-mésentérique massif. L'origine était une ischémie mésentérique due à une thrombose de l'artère mésentérique supérieure. L’étude anatomopathologique avait objectivée une atteinte des artères digestive due à la maladie de Buerger.

Current status of patients with buerger disease in Japan

THE PREVALENCE AND CLINICAL CHARACTERISTICS OF JAPANESE PATIENTS WITH BUERGER DISEASE (THROMBOANGIITIS OBLITERANS: TAO) were analyzed based on the Ministry of Health, Labour and Welfare (MHLW) database in 2009. A total of 129 new patients and 3639 patients in follow-up were selected according to the clinical criteria of TAO. The current number of patients with TAO in Japan is estimated at about 4000. The clinical course is relatively favorable, and the rates of limb morbidity and mortality were not completely discouraging.

Buerger disease, smoking, and periodontitis

Weak oral bacteria such as periodontal bacteria or Chlamydia pneumoniae have been observed in various arterial and venous lesions with epidemiological data reported prior to the discovery of bacterial invasion into vessels. Rich lymph vessels easily bring the bacteria from the mouth to the neck and the venous angle, which is directly open to the blood vessels. Periodontal bacteria travel within platelets and Chlamydia pneumoniae can be carried by monocytes. The transportation system of other weak oral bacteria have not been determined. Periodontal bacteria, especially P. gingivalis aggregate platelets and form thrombi. At the same time, secretions such as serotonin, various cytokines, and adhesion factors also appear in the blood. The characteristics of arterial lesions are dependent on the age of the patient and the condition of the endothelial cells. In young patients, infectious incidents occur due to embolic mechanisms in Buerger disease or adhesion to the superficial veins valves in varicose veins. In older patients, incidents result in adhesion in the proximal aorta, coronary arteries, or large arteries. The hypothesis here unifies the evidence on vessel lesion development and explains the possible discrepancy between vascular diseases.