Demographic Traits, Clinical Status, and Comorbidities of Patients With Thromboangiitis Obliterans in Japan.

BACKGROUND: The latest demographics, clinical and living conditions, and comorbidities of patients with thromboangiitis obliterans (TAO) in Japan are unknown.Methods and Results: We conducted a retrospective cross-sectional survey using the annual database of the Japanese Ministry of Health, Labour and Welfare medical support system for patients with TAO between April 2013 and March 2014. This study included 3,220 patients (87.6% male), with current age ≥60 years in 2,155 patients (66.9%), including 306 (9.5%) patients aged ≥80 years. Overall, 546 (17.0%) had undergone extremity amputation. The median interval from onset to amputation was 3 years. Compared with never smokers (n=400), 2,715 patients with a smoking history had a higher amputation rate (17.7% vs. 13.0%, P=0.02, odds ratio [OR]=1.437, 95% confidence interval [CI]=1.058-1.953). A lower proportion of workers and students was seen among patients after amputation than among amputation-free patients (37.9% vs. 53.0%, P<0.0001, OR=0.542, 95% CI=0.449-0.654). Comorbidities, including arteriosclerosis-related diseases, were found even in patients in their 20-30 s. CONCLUSIONS: This large survey confirmed that TAO is not a life-threatening but an extremity-threatening disease that threatens patients' professional lives. Smoking history worsens patients' condition and extremity prognosis. Long-term total health support is required, including care of extremities and arteriosclerosis-related diseases, social life support, and smoking cessation.

Efficacy of Transpedal Retrograde Approach in Endovascular Treatment of Patients With Buerger's Disease.

BACKGROUND: Endovascular treatment of Buerger's disease is challenging, which usually impedes antegrade revascularization options. We aimed to evaluate the effectiveness of transpedal retrograde approach in patients with Buerger's disease with ambiguous proximal caps and/or previously failed endovascular intervention via antegrade approach. METHODS: Eighteen patients with the diagnosis of Buerger's disease who had previously failed antegrade endovascular interventions and/or ambiguous proximal caps were enrolled. Baseline demographic characteristics, severity of critical limb-threatening ischemia, wound scores, postprocedural pedal loop scores, and recovery or amputation rates were recorded. RESULTS: The patients presented with ischemic rest pain (n = 5, Rutherford stage 4), ischemic ulcers with minor tissue loss (n = 8, Rutherford stage 5), and severe ischemic ulcers or gangrene with major tissue loss (n = 5, Rutherford stage 6). Preprocedural wound score according to Saint Elian Wound Score System (SEWSS) was 15.72 ± 5.05. Retrograde transpedal puncture was achieved with an 89% success rate. Postintervention angiographic success rate was 100%. Postintervention Rutherford stage improved compared with preprocedural Rutherford stages (P<.01). In addition, the average SEWSS score decreased significantly after the interventions (P<.001). Postprocedural pedal loop score was found to be associated with SEWSS scores and amputation rates. CONCLUSIONS: Transpedal retrograde approach is a technically feasible and potentially effective treatment modality for Buerger's disease and may be considered as a first-line treatment option in the treatment of limb salvage, especially when proximal caps of target vessels are ambiguous or antegrade approach is unsuccessful.

Clinical outcomes in patients with infrapopliteal arterial occlusive disease treated by lower extremity bypass surgery: a comparison of atherosclerosis and thromboangiitis obliterans.

OBJECTIVE: Surgical bypasses are commonly utilized for the treatment of infrapopliteal arterial occlusive disease resulting from atherosclerosis (ASO) and thromboangiitis obliterans (TAO), especially when endovascular procedures fail. The aim of this study is to compare the in-hospital and follow-up outcomes of ASO and TAO patients treated with infrapopliteal bypass surgery. PATIENTS AND METHODS: A total of 32 infrapopliteal bypasses were analyzed in 18 TAO patients and 14 ASO patients. Preoperative and postoperative arterial Doppler ultrasonography was performed in all patients. The ankle-brachial index (ABI) was calculated preoperatively and postoperatively in all cases. All patients were followed-up for at least one year and clinical outcomes were recorded. RESULTS: Within 1-7 days postoperatively, 4 grafts in TAO patients occluded; nevertheless, 1 graft occlusion occurred in ASO patients. Patency rates at in-hospital were 77.8% and 92.9% in TAO and ASO patients, respectively. In 27 patients with successful infrapopliteal bypass, ABIs and crural peak arterial flow velocities significantly increased at 1-7 days postoperatively. During the period of follow-up, 6 graft occlusions occurred in TAO patients, and one ASO patient died of myocardial infarction. Patency rates at follow-up were 44.5% and 85.7% in TAO and ASO patients. For TAO patients with graft failure, ABIs at follow-up did not statistically differ from those postoperatively; however, they were significantly higher than those preoperatively. CONCLUSIONS: Infrapopliteal bypass surgery is a feasible and effective procedure for ASO and TAO patients. Patency rates are lower in TAO than those in ASO during the in-hospital and follow-up period. However, TAO patients had the ischemic symptom relief and the improvement in ABI despite graft occlusion one year postoperatively.

Long-term outcomes of large artery thromboangiitis obliterans and comparison with small artery thromboangiitis obliterans.

ABSTRACT: Although the distribution of arterial involvement is still the subject of controversy for defining the diagnostic criteria for thromboangiitis obliterans (TAO), several reports have described TAO involving the more proximal arterial segment. This study aimed to investigate the clinical characteristics and outcomes of large artery TAO in comparison with those of small artery TAO.Between January 2007 and July 2019, 83 consecutive symptomatic patients with a diagnosis of lower extremity TAO were stratified according to the most proximal arterial involvement, with the cutoff level of the adductor canal as a reference (large artery TAO versus small artery TAO), and analyzed retrospectively. The study outcomes included any amputations and major amputations.The large artery TAO group consisted of 30 patients (36.1%), and the small artery TAO group consisted of 53 patients (63.9%). In terms of clinical symptoms and signs, the proportion of major tissue loss (Rutherford class 6) was significantly higher among patients with large artery TAO than among those with small artery TAO (13.3% versus 0%, P = .02). Any amputation rate was similar between the large and small artery TAO groups during the median follow-up period of 148 months (range, 0-376 months) (43.3% versus 28.3%, P = .16). However, the major amputation rate was significantly higher among patients with large artery TAO (13.3% versus 0%, P = .02). On Kaplan-Meier survival analysis of the cumulative event-free rates, although there was a similar 10-year amputation-free survival rate (P = .24) between the 2 groups, the large artery TAO group had a significantly lower 10-year major amputation-free survival rate (P < .01) than the small artery TAO group.Large artery TAO is a limb-threatening condition and had a worse prognosis than small artery TAO.

The Preliminary Outcome of Laser-Assisted Angioplasty Combined with Endovascular Radiofrequency Ablation for Thromboangiitis Obliterans.

INTRODUCTION: Endovascular therapies have not yet had an ideal effect on thromboangiitis obliterans (TAO) and no data have been published about laser-assisted angioplasty (LA) combined with radiofrequency ablation (RFA) for TAO. This study aimed to investigate the outcome of LA combined with RFA for TAO. METHODS: Sixteen consecutive patients underwent LA and RFA procedures between June 2018 and March 2019 in this prospective pilot study. The clinical outcomes and complications were assessed at 6, 12, and 18 months after the procedure. The primary endpoint was defined as the limb salvage rate and freedom of target-lesion revascularization (f-TLR) of the limb, and the effect on the outcome was assessed by the ankle brachial index (ABI), numerical rating scores (NRSs), and the EuroQol Group 5-Dimension Self-Report Questionnaire (EQ-5D). RESULTS: Men accounted for 87.5% of the patients. All patients underwent LA, and following the RFA procedure, two patients received bailout stenting (12.50%). The technique success rate was 100%, and no severe complications occurred. The ABI was significantly higher at the 18-month follow-up than at baseline (P < 0.001). The primary and secondary patency rates were 71.82% and 79.80%, respectively, and the f-TLR and limb salvage rates were 90% and 92.86% based on Kaplan-Meier analysis. The EQ-5D value was higher after the procedure than at baseline (P < 0.001), and the NRS value was lower after the procedure than at baseline (P < 0.001). CONCLUSIONS: Our results confirmed that LA combined with RFA was a feasible procedure that resulted in acceptable limb salvage and f-TLR rates.

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.

Patterns of arterial involvement and feasibility of revascularization in thromboangiitis obliterans: a tertiary care centre experience.

BACKGROUND: Arterial revascularization is seldom considered as a treatment option in thromboangiitis obliterans (TAO) due to diffuse segmental involvement of medium- and small-sized extremity vessels. Although typical angiographic features include bilaterally symmetrical involvement of infrapopliteal vessels, larger vessels too can be affected. Similarly, there could be distal target vessels feasible for revascularization. This study was conducted to describe the patterns of arterial involvement in TAO and assess the feasibility of revascularization. METHODS: The study was approved by the Institutional Review Board and research ethics committee of Christian Medical College, Vellore (IRB no: 12034). A retrospective study was conducted in the Department of Vascular Surgery, Christian Medical College, Vellore, India, between January 2009 and December 2018. There were 329 patients who fulfilled the clinical criteria for TAO of whom 83 had an angiogram done. These 83 patients formed the study cohort. RESULTS: Large vessel involvement was seen in 56.6% of patients and 79.5% of patients had at least one or more distal target artery feasible for revascularization. The anterior tibial artery and peroneal artery were the most common target vessels that were patent for revascularization. Of the 22 patients who underwent revascularization (16 bypasses and six angioplasties), the patency rate was 64.8% and the limb salvage rate was 80.9% at the end of 6 months. CONCLUSION: The study shows that one-third of our patients with TAO have a distal target artery feasible for revascularization. As most of the affected patients are in the economically productive age group, every attempt should be made to salvage the limb with revascularization for which the use of angiography should be more liberal.

[Early outcomes of therapy and indirect revascularization surgery in patients with critical ischemia of lower extremities]. / Blizhaishie rezul'taty konservativnogo lecheniya i operatsii nepryamoi revaskulyarizatsii u bol'nykh s kriticheskoi ishemiei nizhnikh konechnostei na fone distal'noi okklyuzii arterii.

OBJECTIVE: To study the immediate results of therapy and indirect revascularization in patients with critical ischemia of the lower limbs. MATERIAL AND METHODS: The results of medication and surgical treatment were analyzed in 210 patients with critical ischemia of the lower limbs. Atherosclerosis obliterans was diagnosed in 142 patients, thromboangiitis obliterans - in 68 patients. Lesion of femoropopliteal segment was observed in 32 (15.2%) cases, popliteal-tibial segment - 68 (32.8%) patients, tibial and foot segment - 62 (29.5%) cases, foot - 31 (14.8%) cases, multiple-level lesion - 17 (8.1%) cases. Survey consisted of Doppler ultrasound, CT angiography, rheovasography with analysis of rheographic index (RI) and pulse oximetry. Circulatory parameters were compared with identical values in 48 almost healthy persons ("reference group"). The results of medication and surgical treatment were evaluated by using of the scale of Rutherford R.B. et al. (1997). RESULTS: Conservative treatment was performed in 48 patients (control group). The following types of indirect revascularization operations were performed to stimulate regional circulation: bone trepanation in 42 patients, lumbar sympathectomy in 51 patients, bone trepanation + lumbar sympathectomy in 38 patients, bone trepanation with intraosseous irradiation in 31 cases. CONCLUSION: Indirect revascularization improves early postoperative outcomes, ensures maintaining support function of the limb and active lifestyle in patients with critical ischemia of the lower limbs. Technical simplicity of these procedures facilitates widespread introduction of indirect revascularization in multi-field hospitals.

The Efficacy of Percutaneous Transluminal Angioplasty on the Limb Salvage and Recovery of Symptoms in Patients With Buerger's Disease With Critical Limb Ischemia.

INTRODUCTION: Buerger's disease, or thromboangiitis obliterans, is associated with limb-threatening chronic arterial lesions. In this study, we sought to investigate the efficacy of the percutaneous transluminal angioplasty method for the treatment of critical limb ischemia (CLI) in patients with Buerger's disease in our modest cohort. METHODS: Patients diagnosed with CLI secondary to Buerger's disease who underwent percutaneous transluminal angioplasty between May 2014 and June 2017 were retrospectively investigated. Patient demographics, presentations, procedural details, responses to percutaneous treatment, complications, limb salvage, wound healing, reinterventions, and early follow-up data were recorded. RESULTS: The cohort included 24 patients with Buerger's disease presenting with CLI observed in 46 limbs. Presentations were gangrene in 12 patients, ulcer formation in 7 patients, and rest pain in the remaining 5 patients. All patients received percutaneous balloon angioplasty, with limb salvage in 21 patients (87.5%). Revascularization was achieved in 87.5% of the destination arteries at the primary intervention and overall technical success rate including reinterventions reached 95.8%. Following the procedures, a total of 22 patients had clinical response with at least ≥1 Rutherford category and mean Rutherford category significantly improved from 5.2 ± 0.74 to 1.6 ± 0.7 (P<.001). Limb salvage rate was 87.5%. Complete wound healing was achieved in all patients with ischemic ulcers at 3.9 ± 2.6 months (range 1-13 months) post revascularization. Mean follow-up duration was 16.07 ± 3.4 months and 6 patients (who were especially subjected to cigarette smoke) required reinterventions. CONCLUSION: Percutaneous treatment of arterial occlusions in patients with Buerger's disease seems feasible in the current era of improving devices and angioplasty materials. Procedures may be safely performed with good technical and clinical success rates, and without mortality or complications as experience increases.

Pharmacological treatment for Buerger's disease.

BACKGROUND: Buerger's disease (thromboangiitis obliterans) is a non-atherosclerotic, segmental inflammatory pathology that most commonly affects the small and medium sized arteries, veins, and nerves in the upper and lower extremities. The aetiology is unknown, but involves hereditary susceptibility, tobacco exposure, immune and coagulation responses. In many cases, there is no possibility of revascularisation to improve the condition. Pharmacological treatment is an option for patients with severe complications, such as ischaemic ulcers or rest pain.This is an update of the review first published in 2016. OBJECTIVES: To assess the effectiveness of any pharmacological agent (intravenous or oral) compared with placebo or any other pharmacological agent in patients with Buerger's disease. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, AMED, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 15 October 2019. The review authors searched LILACS, ISRCTN, Australian New Zealand Clinical Trials Registry, EU Clinical Trials Register, clincialtrials.gov and the OpenGrey Database to 5 January 2020. SELECTION CRITERIA: We included randomised controlled trials (RCTs) involving pharmacological agents used in the treatment of Buerger's disease. DATA COLLECTION AND ANALYSIS: Two review authors, independently assessed the studies, extracted data and performed data analysis. MAIN RESULTS: No new studies were identified for this update. Five randomised controlled trials (total 602 participants) compared prostacyclin analogue with placebo, aspirin, or a prostaglandin analogue, and folic acid with placebo. No studies assessed other pharmacological agents such as cilostazol, clopidogrel and pentoxifylline or compared oral versus intravenous prostanoid. Compared with aspirin, intravenous prostacyclin analogue iloprost improved ulcer healing (risk ratio (RR) 2.65; 95% confidence interval (CI) 1.15 to 6.11; 98 participants; 1 study; moderate-certainty evidence), and helped to eradicate rest pain after 28 days (RR 2.28; 95% CI 1.48 to 3.52; 133 participants; 1 study; moderate-certainty evidence), although amputation rates were similar six months after treatment (RR 0.32; 95% CI 0.09 to 1.15; 95 participants; 1 study; moderate-certainty evidence). When comparing prostacyclin (iloprost and clinprost) with prostaglandin (alprostadil) analogues, ulcer healing was similar (RR 1.13; 95% CI 0.76 to 1.69; 89 participants; 2 studies; I² = 0%; very low-certainty evidence), as was the eradication of rest pain after 28 days (RR 1.57; 95% CI 0.72 to 3.44; 38 participants; 1 study; low-certainty evidence), while amputation rates were not measured. Compared with placebo, the effects of oral prostacyclin analogue iloprost were similar for: healing ischaemic ulcers (iloprost 200 mcg: RR 1.11; 95% CI 0.54 to 2.29; 133 participants; 1 study; moderate-certainty evidence, and iloprost 400 mcg: RR 0.90; 95% CI 0.42 to 1.93; 135 participants; 1 study; moderate-certainty evidence), eradication of rest pain after eight weeks (iloprost 200 mcg: RR 1.14; 95% CI 0.79 to 1.63; 207 participants; 1 study; moderate-certainty evidence, and iloprost 400 mcg: RR 1.11; 95% CI 0.77 to 1.59; 201 participants; 1 study; moderate-certainty evidence), and amputation rates after six months (iloprost 200 mcg: RR 0.54; 95% CI 0.19 to 1.56; 209 participants; 1 study, and iloprost 400 mcg: RR 0.42; 95% CI 0.13 to 1.31; 213 participants; 1 study). When comparing folic acid with placebo in patients with Buerger's disease and hyperhomocysteinaemia, pain scores were similar, there were no new cases of amputation in either group, and ulcer healing was not assessed (very low-certainty evidence). Treatment side effects such as headaches, flushing or nausea were not associated with treatment interruptions or more serious consequences. Outcomes such as amputation-free survival, walking distance or pain-free walking distance, and ankle brachial index were not assessed by any study. Overall, the certainty of the evidence was very low to moderate, with few studies, small numbers of participants, variation in severity of disease of participants between studies and missing information (for example regarding baseline tobacco exposure). AUTHORS' CONCLUSIONS: Moderate-certainty evidence suggests that intravenous iloprost (prostacyclin analogue) is more effective than aspirin for eradicating rest pain and healing ischaemic ulcers in Buerger's disease, but oral iloprost is not more effective than placebo. Very low and low-certainty evidence suggests there is no clear difference between prostacyclin (iloprost and clinprost) and the prostaglandin analogue alprostadil for healing ulcers and relieving pain respectively in severe Buerger's disease. Very low-certainty evidence suggests there is no clear difference in pain scores and amputation rates between folic acid and placebo, in people with Buerger's disease and hyperhomocysteinaemia. Further well designed RCTs assessing the effectiveness of pharmacological agents (intravenous or oral) in people with Buerger's disease are needed.

Did the Clinical Spectrum of Thromboangiitis Obliterans Change in the Past 40 Years?

Thromboangiitis obliterans (TAO) is an inflammatory disease that usually affects small and medium-sized arteries in the upper and lower limbs of young smokers. Previous studies showed that the spectrum TAO has changed in the 80s: the male-to-female ratio decreased, older patients were diagnosed, and upper limb involvement was more common. The aim of our study was to assess the changing clinical spectrum of TAO in France during the past 40 years. All consecutive patients fulfilling TAO's criteria between January 1967 and January 2016 were retrospectively included in 3 departments of internal medicine. We compared TAO features in patients diagnosed before and after 2002; 141 (77.5%) men and 41 (22.5%) women were included. Patients diagnosed after 2002 were older (37 [31-39] vs 34 [29-35] years P = .03), had a more frequent isolated upper limb involvement (34.3% vs 7.8% P = .001), and less frequent isolated lower limb involvement (55.7% vs 74.5%, P < .001). The clinical spectrum of TAO has changed in France since the beginning of the 21st century.

Long-Term Clinical Outcomes of Autologous Bone Marrow Mononuclear Cell Implantation in Patients With Severe Thromboangiitis Obliterans.

BACKGROUND: Patients with severe Buerger disease, also known as thromboangiitis obliterans (TAO), are at risk of major limb amputation. It has been shown that autologous bone marrow mononuclear cell (BM-MNC) implantation improves the condition of critical limb ischemia in TAO patients. This study was conducted to further clarify the long-term (>10 years) results of autologous BM-MNC implantation in patients with TAO.Methods and Results:An observational study was conducted of the long-term results of BM-MNC implantation in 47 lower limbs of 27 patients with TAO. The mean (±SD) follow-up period was 12.0±8.6 years. There was no major amputation event up to 10 years of follow-up in patients treated with BM-MNC implantation. The overall amputation-free survival rates were significantly higher in patients who underwent BM-MNC implantation than in internal controls and historical controls. There was no significant difference in amputation-free survival rates between the historical and internal controls. There was also no significant difference in overall survival between patients who underwent BM-MNC implantation and the historical controls. CONCLUSIONS: BM-MNC transplantation successfully prevented major limb amputation over a period of >10 years in patients with severe TAO who had no other therapeutic options.

A Non-smoking Woman with Anti-phospholipid Antibodies Proved to Have Thromboangiitis Obliterans.

A 48-year-old woman with severe pain and numbness of her right leg and foot was admitted to our hospital. She had never smoked and had little exposure to passive smoking. Initially, polyarteritis nodosa with anti-phospholipid antibodies was considered. Combination therapy with methylprednisolone pulse therapy, intravenous cyclophosphamide pulse therapy, vasodilators, antiplatelet agents, and anticoagulants was not effective. Vasculopathy was progressive, and she presented with gangrene of the toes. She required amputation of her right leg. The pathological findings of the amputated leg revealed thromboangiitis obliterans (TAO). TAO should be considered even in non-smoking women. Non-response to immunosuppressant and anticoagulant therapies may be a clue to the diagnosis of TAO.

Successful Fat Grafting in a Patient With Thromboangiitis Obliterans.

Thromboangiitis obliterans, or Buerger disease, is a rare nonatherosclerotic segmental inflammatory vasculitis that generally affects young tobacco smokers. Although no surgical treatment is available, the most effective way to halt the disease's progress is smoking cessation. In this case report, a 29-year-old smoker showed up to emergency department with gangrene of his fifth left toe and extensive plantar ulceration. After investigative angiography, he was diagnosed with Buerger disease. On November 2017, he underwent fifth left toe amputation and hyperbaric therapy. Five months after amputation, the patient was rehospitalized because of surgical wound dehiscence, wide ulceration, and pain. He was treated with lipofilling using the Coleman technique. Two weeks after the fat grafting procedure, the patient suspended pain control medication, and after 2 months, the surgical wound was almost healed. Fat grafting (lipofilling) is mostly used in plastic surgery; it offers regenerative effects, with minimal discomfort for the patient. This case report demonstrates a successful alternative use of lipofilling for this unique condition and opens up new options for use of this technique in other fields.

Coronary Artery Dissection in a Patient with Buerger's Disease.

Buerger's disease, vasculitis of small and medium-sized blood vessels, is a non-atherosclerotic and progressive occlusive condition which frequently involves the distal part of the limbs. The occlusion of coronary arteries in Buerger's disease is a rare condition; however, coronary artery dissection has not been reported previously. Therefore, this paper presents a 45-year-old man who developed coronary artery dissection associated with Buerger's disease. The patient was treated successfully with coronary artery bypass grafting with the left internal mammary artery to the left anterior descending artery, and saphenous vein graft to the right coronary artery.

Coronary artery dissection in a patient with Buerger's Disease

Abstract Buerger's disease, vasculitis of small and medium-sized blood vessels, is a non-atherosclerotic and progressive occlusive condition which frequently involves the distal part of the limbs. The occlusion of coronary arteries in Buerger's disease is a rare condition; however, coronary artery dissection has not been reported previously. Therefore, this paper presents a 45-year-old man who developed coronary artery dissection associated with Buerger's disease. The patient was treated successfully with coronary artery bypass grafting with the left internal mammary artery to the left anterior descending artery, and saphenous vein graft to the right coronary artery.

Outcomes of endovascular treatment versus bypass surgery for critical limb ischemia in patients with thromboangiitis obliterans.

We aimed to compare the clinical outcomes between endovascular treatment and inframalleolar bypass surgery for critical limb ischemia (CLI) in patients with thromboangiitis obliterans (TAO) and to assess the role of bypass surgery in the era of innovative endovascular treatment. Between January 2007 and December 2017, a total of 33 consecutive patients with the diagnosis of TAO presenting with CLI who underwent endovascular treatment (endovascular group, n = 22) or bypass surgery to the pedal or plantar vessels (bypass group, n = 11) were included and analyzed retrospectively. The primary endpoint was defined as a major amputation of the index limb, and the secondary endpoint was defined as graft occlusion, regardless of the number of subsequent procedures. In the bypass group, six patients (55%) had undergone previous failed endovascular procedures and/or arterial bypass surgery to the index limb before inframalleolar bypass, and two patients (18%) received microvascular flap reconstruction after bypass surgery. During the median follow-up period of 32 months (range 1-115 months), there were no significant differences in primary and secondary endpoints between the two groups although the bypass group had a higher Rutherford class than the endovascular group. Kaplan-Meier survival analysis showed that there were similar limb salvage (P = 0.95) and graft patency rates (P = 0.39). In conclusion, endovascular treatment is a valid strategy leading to an acceptable limb salvage rate for TAO patients, and surgical bypass to distal target vessels could play a vital role in cases of previous failed endovascular treatment or extensive soft tissue loss of the foot.

How to Treat a Patient with Thromboangiitis Obliterans: A Systematic Review.

To date, there is still no treatment protocol for patients with thromboangiitis obliterans (TAO) who are also afflicted with critical limb ischemia (CLI). Smoking cessation on its own cannot be considered a treatment for the purposes of salvaging a limb of a TAO patient with CLI. The aim of this review was to evaluate different studies of various treatment protocols for avoiding amputation in TAO patients. A systematic search for relevant studies dating from 1990 to the end of 2016 was performed on the PubMed, SCOPUS, and Science Direct databases. Only 24 studies fulfilled the inclusion criteria, of which only one was a randomized controlled trial (RCT). The remaining studies were quasi-experimental with various treatments and follow-up durations. Therefore, meta-analysis was not performed. Judging from the major amputation rates after the suggested treatments were performed, no treatment was particularly effective. This review demonstrated that more standard RCTs are needed to resolve this treatment issue involved in TAO. In addition, because health insurance coverage for TAO patients differs by country, regional cost-benefit and cost-efficacy studies of the suggested treatments for TAO are highly recommended.

Immediate and late outcomes of endovascular therapy for lower extremity arteries in Buerger disease.

OBJECTIVE: Buerger disease is a rare inflammatory vasculopathy presenting with severe claudication or critical limb ischemia. In this study, we sought to evaluate the feasibility and clinical outcomes of endovascular therapy for Buerger disease involving arteries in the lower extremities. METHODS: Between January 2006 and May 2016, there were 44 Buerger disease patients (43 men; mean age, 40.4 ± 9.6 years) with 50 target limbs treated by endovascular therapy at the Severance Cardiovascular Hospital. Baseline characteristics as well as both immediate and late clinical outcomes were retrospectively analyzed. RESULTS: The majority (86.4%) of patients presented with critical limb ischemia. A total of 88 target lesions in 50 limbs were treated with endovascular procedures. All limbs showed infrapopliteal artery occlusions, and multilevel diseases involving the iliac or femoropopliteal artery were found in 31 patients (62%). Technical success was achieved in 80% of subjects. We found that a lower serum level of C-reactive protein, specifically the log C-reactive protein value (odds ratio, 0.03; 95% confidence interval [CI], 0.00-0.71; P = .030), was an independent predictor of technical failure. The median follow-up duration was 29 months. Major adverse limb event-free survival and reintervention- and amputation-free survival were 83.3% and 67.9% at 3 years, respectively. In a multivariate Cox proportional hazards analysis, previous endovascular treatment (hazard ratio, 3.70; 95% CI, 1.20-11.31; P = .022) and previous amputation (hazard ratio, 4.68; 95% CI, 1.37-15.96; P = .014) were identified as independent risk factors for reintervention- and amputation-free survival. CONCLUSIONS: In patients with Buerger disease, endovascular treatment achieved technical success in the majority of the cases and was associated with favorable immediate and late clinical outcomes. These findings indicate that endovascular therapy may be considered a first-line treatment option for severe symptomatic patients with Buerger disease.