Efficacy of Endovascular Radiofrequency Ablation for Thromboangiitis Obliterans (Buerger's Disease)

Endovascular Denervation for the Improvement of Limb Ischemia in Patients with Peripheral Artery Disease: A Randomized Clinical Trial

BACKGROUND

To evaluate the safety and efficacy of endovascular denervation (EDN) as an adjunct to percutaneous vascular intervention (PVI) for peripheral artery disease (PAD).

METHODS

From August 2019 to April 2021, 38 eligible patients with PAD enrolled in this study were randomly and equally assigned into 2 groups: the PVI group and the PVI + EDN group treated with EDN at the iliac and femoral arteries before PVI. The primary endpoint was the improvement in the ankle brachial index at 6 months after the procedure. The secondary endpoints were transcutaneous oxygen pressure (TcPO2), Rutherford category, numerical rating scale score, and safety.

RESULTS

The technical success rates of PVI and EDN were 100%, and no device-related or procedure-related major adverse events occurred in either group. Compared with PVI alone, PVI + EDN demonstrated a significant improvement in limb hemodynamics at 6 months (Δ ankle brachial index 0.44 ± 0.31 vs. 0.24 ± 0.15, P = 0.018). Microcirculatory perfusion of PAD was significantly better at 6 months in the PVI + EDN group (ΔTcPO2, 15.68 ± 16.72 vs. 4.95 ± 13.43, P = 0.036). The Rutherford category was significantly improved in the PVI + EDN group in comparison with the PVI group at the 3-month follow-up (100.00% vs. 68.42%, P = 0.02). The decrease in the numerical rating scale score in the PVI + EDN group was greater than that in the PVI group at 1 week following the procedure (3 [2-5] vs. 4 [4-6], P = 0.022).

CONCLUSIONS

In this single-center pilot analysis of a heterogeneous cohort of patients with PAD, PVI with EDN demonstrated a significant improvement in limb ischemia at 6 months compared with PVI alone.

Endovascular treatment for thromboangiitis obliterans (Buerger’s disease)

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To assess the effectiveness and safety of endovascular treatment for thromboangiitis obliterans (Buerger’s disease).

Outcomes of Anticoagulant Therapy with Low-Molecular-Weight Heparin (LMWH) and Warfarin for Thromboangiitis Obliterans (TAO)

BACKGROUND

Thromboangiitis obliterans (TAO) is a chronic, non-atherosclerotic, progressive inflammatory vascular disease affecting the small- and medium-size arteries and veins of the extremities.

OBJECTIVE

To evaluate whether long-term anticoagulation with low-molecular-weight heparin (LMWH) and warfarin is beneficial for treating the inflammation and symptoms associated with TAO.

METHODS

Patients with TAO who underwent anticoagulation as the mainstay of treatment were included in this prospective study. Rest pain relief and healing of trophic lesions (as the primary and secondary endpoint) were investigated at Day 14 and after 6 months of follow-up. High sensitivity C-reactive protein (hsCRP), monocyte count, and ankle-brachial index (ABI) were recorded, and the difference was compared before and after 2-week anticoagulation. The Chi-square test was used to compare the difference between anticoagulant and aspirin groups (based on the literature).

RESULTS

From 2014 to 2019, 18 patients were included. Only 1 patient with wet gangrene received endo-therapy for a failing stent at the start of treatment. After ~14 days, 12 of 13 (92%) patients showed complete ulcer healing, and 17 of 18 (94%) patients showed complete relief from rest pain. Monocyte-counts and hsCRP levels decreased significantly (p<0.001) after a 2-week period of anticoagulation with LMWH. The mean follow-up was 2.6 years (range 0.5-5 years). At 6 months, all patients showed relief of rest pain and complete healing of trophic lesions. All endpoints were significantly improved compared with the aspirin group (p<0.01), and no rest pain or ulcer/gangrene recurred during follow-up.

CONCLUSION

Anticoagulant therapy may alleviate the inflammation and symptoms of 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.

Integration of traditional Chinese medicine and nibble debridement and dressing method reduces thrombosis and inflammatory response in the treatment of thromboangiitis obliterans

Background

Thromboangiitis obliterans (TAO), also known as Buerger's disease, is an occlusive arterial disease; however, the pathogenesis of TAO is still unclear. Research has shown that traditional Chinese medicine (TCM) has significant advantages in the treatment of TAO. Our purpose was to explore the underlying roles of TCM in combination with nibble debridement and dressing method (NDDM) in a TAO rat model.

Methods

We administered rats with 10 mg/mL sodium laurate to establish a TAO model, and then the TAO model rats were treated with notoginseng powder (NP), maifusheng (MFS), or the combination of NP or MFS and NDDM. Gangrene classification and blood rheology were evaluated; the pathological characteristics of rat limbs were examined by hematoxylin and eosin (H&E) staining and Masson staining; and cluster of differentiation 3+ (CD3+) and cluster of differentiation 20+ (CD20+) levels were measured by immunohistochemistry (IHC) and flow cytometry. In addition, inflammation-associated cytokines were analyzed by quantitative reverse transcription polymerase chain reaction (RT-qPCR), western blot, and enzyme-linked immunosorbent assay (ELISA).

Results

Integration of NP or MFS and NDDM dramatically reduced the gangrene classification and affected blood rheology parameters of TAO model rats compared with NP and MFS alone. Meanwhile, NP or MFS in combination with NDDM decreased CD3+CD20+ T cells, reduced thrombosis and inflammatory cell infiltration, and dramatically decreased the levels of inflammation-associated cytokines.

Conclusions

Our results suggested that integration of NP or MFS and NDDM could relieve the symptoms of TAO model rats induced by sodium laurate, which might provide a new management strategy for TAO.

Risk Factors, Mechanisms and Treatments of Thromboangiitis Obliterans: An Overview of Recent Research

BACKGROUND

Thromboangiitis obliterans (TAO) is a nonatherosclerotic thromboticocclusive vasculitis that affects the vessels of the small and medium-sized extremities. No explicit etiology or pathogenesis of TAO has been proven, and more effective treatments are needed.

OBJECTIVE

The study aimed to summarize and present an overview of recent advances regarding the risk factors, mechanisms and treatments of TAO and to organize the related information in figures to provide a comparatively complete reference.

METHODS

We searched PubMed for English-language literature about TAO without article type limits, including articles about the risk factors, pathological mechanisms and treatments of TAO in the last 10 years with essential supplements (references over ranges and English abstracts of Russian literature).

RESULTS

After screening content of works of literature, 99 references were evaluated. We found that risk factors of TAO include smoking, gene factors and periodontal diseases. The underlying mechanism of TAO involves oxidative stress, immunity, hemodynamic changes, inflammation and so on. Moreover, similarities in genetic factors and cigarette relevance existed between periodontal diseases and TAO, so further study of relationship was required. For TAO treatment, medicine, endovascular intervention and revascularization surgery, autologous cell therapy and novel therapies were also mentioned. Besides, a hypothesis that infection triggers autoimmunity in TAO could be speculated, in which TLR4 plays a key role.

CONCLUSION

1. A hypothesis is put forward that infections can trigger autoimmunity in TAO development, in which TLR4, as a key agent, can activate immune signaling pathways and induce autoimmune cytokines expression. 2. It is suggested to reconsider the association between periodontal diseases and TAO, as they share the same high-risk population. Controlling periodontal disease severity in TAO studies may provide new clues. 3. For TAO treatment, endovascular intervention and autologous cell therapy both showed promising long-term therapeutic effectiveness, in which autologous cell therapy is becoming more popular, although more clinical comparisons are needed.

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.

Thromboangiitis obliterans: Aggressive angioplasty provides a potential solution (randomized pilot study)

Background

Thromboangiitis obliterans is an inflammatory disease affecting both medium- and small-sized vessels. Vasodilators, antiplatelets were proposed for treatment but the effect was minimal.

Objective

This study was conducted to investigate the effect of balloon angioplasty on patients with Buerger's disease compared to medical treatment.

Methods

Between January 2006 and December 2016, 82 patients with Buerger's disease were enrolled in the study, of whom 52 were randomized to the aggressive endovascular intervention and 30 were randomized medically by cilostazol and aspirin as a control group. In all, 23% of the patients presented with severe claudication, 50% with ischemic rest pain and 27% with ischemic ulcers. Randomization was done using the opaque envelope method. Allocation concealment was maintained to ensure no selection bias. Patient groups were compared for the duration of ulcer healing, ankle-brachial index, peak systolic velocity changes and transcutaneous oximetry (TcPO2) level for 30 months.

Results

No major procedural complications occurred in the endovascular group. Angiographic success was achieved in 100% of supragenicular lesions but in 90% of infrapopliteal lesions. The endovascular group showed a statistically significant improvement in the ulcer healing size and duration at 6 months after the procedure with a mean time of 3 ± 0.9 months compared to 5.8 ± 1.69 months for the medical treatment group (p < 0.001), the mean TcPO2 from 27.23 ± 16.75 mm Hg (range: 0-56 mm Hg) before the procedure to 71.32 ± 12.94 mm Hg (range: 52-92 mm Hg) following revascularization (p < 0.01). The mean ankle-brachial index significantly improved from 0.54 ± 0.14 preoperatively to 0.82 ± 0.08 at final follow-up (p < 0.01).

Conclusion

The endovascular therapy should be considered as an effective, safe, minimally invasive method in the light of the promising results after a modification of the standard technique.

Endovascular Treatment of Thromboangiitis Obliterans (Buerger’s Disease)

Purpose:

When critical limb ischemia (CLI) occurs in patients with thromboangiitis obliterans (TAO) or Buerger’s disease, smoking cessation alone may be insufficient to relieve rest pain and promote wound healing. Accordingly, adjunctive measures are warranted to restore adequate blood flow required for limb salvage. This study aimed to evaluate the feasibility and efficacy of percutaneous transluminal angioplasty (PTA) for the treatment of patients with TAO and CLI. In addition, a review of the literature on endovascular management of TAO is included.

Methods:

Between April 2012 and June 2017, all patients with TAO and CLI who underwent PTA were studied retrospectively. Patient demographics, presentation, procedural details, and clinical response were recorded. Patients were monitored at 1 week, 1, 2, 3, and 6 months after revascularization and at least every 6 months thereafter.

Results:

Thirteen patients with TAO and CLI, who presented with rest pain only (n = 1), ischemic ulcer (n = 4), or gangrene (n = 8) underwent endovascular interventions with primary and assisted primary technical success of 85% and 92%, respectively. A below-knee amputation was eventually done in the only patient with technical failure (limb salvage rate: 92%). Following the procedures, 11 patients had clinical response, one of whom also received intra-arterial vasodilator to achieve complete symptom relief. The other patient who failed PTA underwent a successful lumbar sympathectomy. In addition, all ulcers healed and eight minor amputations were performed due to already established gangrene. During follow-up (mean: 19.4 months), four patients needed reintervention. Patients who continued to smoke experienced more severe ischemia ( P = .017) and were more likely to require reintervention ( P = .009).

Conclusion:

Percutaneous transluminal angioplasty can be considered as a technically feasible and potentially effective treatment for patients with TAO and CLI, as well as a last resort for limb salvage when other options have failed. However, reintervention may be required, especially in patients who continue smoking.