Outcomes of endovascular recanalization versus autogenous venous bypass for thromboangiitis obliterans patients with critical limb ischemia due to tibioperoneal arterial occlusion

Short-term efficacy of endovascular procedures for lower extremity thromboangiitis obliterans (Buerger's disease)

PURPOSE

Although thrombolysis obliterans (TAO) has been recognized for more than a century, there is no optimal treatment for this disease. The aim of this report was to compare the short-term efficacies of catheter-directed thrombolysis (CDT), percutaneous transluminal angioplasty (PTA) and CDT+PTA in treating TAO disease.

METHOD

Consecutive patients with TAO treated at Ganzhou People's Hospital between 2012 and 2022 were included in this retrospective study. According to the information provided in the medical records, endovascular procedures included CDT, PTA or CDT+PTA. One-year follow-up outcomes of the patients with TAO who underwent endovascular procedures were compared. The primary outcome was major adverse limb event (MALE) and the secondary outcomes were the technical success, complications, ABI at 1 week after surgery and minor amputation.

RESULTS

Sixty-nine patients with TAO were assessed for inclusion in our single-center study from 2012 to 2022 and received endovascular procedures. Among them, 22 patients underwent CDT, 21 patients underwent PTA, and 26 patients underwent PTA+CDT. The one-year follow-up revealed significant differences in the MALE-free survival rates among the three groups, particularly between the CDT group and the PTA+CDT group (the hazard ratio (HR) for MALE-free survival was 0.173, 95% CI [0.050-0.599], p = 0.006). The technical success rates of the three groups were 63.6%, 90.5%, and 92.3%, respectively. There were differences in the ABI at one week after surgery among the three groups.

CONCLUSIONS

Endovascular procedures are effective for TAO in the short term. The effectiveness of CDT alone is suboptimal; combining CDT with PTA achieves the most favorable endovascular treatment outcome; while the effectiveness of PTA falls in between these two procedures.

Assessment of atherectomy treatment for Thromboangiitis Obliterans: A single center experience

BACKGROUND AND AIMS

Endovascular recanalizaiton (ER) has been proven to be a feasible method for Thromboangiitis Obliterans (TAO). The aims of this study were to evaluate the effectiveness and safety of atherectomy for TAO compared to nonatherectomy ER in our center.

METHODS

Patients diagnosed as TAO were reviewed from January 2016 to June 2021 in our center. Basic characteristics of patients before ER and perioperative data were collected and compared between the atherectomy and nonatherectomy groups. The vascular event-free survival and limb salvage were calculated to evaluate the prognosis of TAO patients after ERs. Logistic Regression and Cox Regression were used to identify the risk factors for technical failure and prognosis, respectively.

RESULTS

Seventy-two TAO patients with 79 lower limbs who met the criteria were included in this report. Compared with the nonatherectomy group, no significant improvement was identified in ER technical success, vascular event-free survival, or limb salvage in the atherectomy group. The total technical success rate was 91.1% (atherectomy group, 95.2%; nonatherectomy group, 89.7%), and the multiple limb involvement (p = 0.005; odds ratio [OR], 28.16; confidence interval [CI], 3.28-241.55) was the independent risk factor for technical failure. The total vascular event-free survival proportion was 66.05% and 58.40% at 1 and 3 years, respectively. Technical failure (OR, 5.61; 95% CI, 1.57-20.04; p = 0.008), and runoff grade 0 (OR, 3.28; 95% CI, 1.09-9.85; p = 0.034) were independent risk factors for vascular events. The total limb salvage proportion at 1 and 3 years was 95.84% and 92.53%, respectively. Technical failure (OR, 8.54; 95% CI, 1.71-40.73; p = 0.02) was identified as an independent risk factor for above ankle amputation.

CONCLUSIONS

No significant difference in prognosis was found between the atherectomy group and the nonatherectomy group during a midterm follow-up. The technical success of ER was crucial for TAO prognosis.

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).

A SYSTEMATIC REVIEW AND META-ANALYSIS OF EARLY AND LATE OUTCOMES AFTER ENDOVASCULAR ANGIOPLASTY AMONG PATIENTS WITH THROMBOANGIITIS OBLITERANS AND CHRONIC LIMB ISCHEMIA

INTRODUCTION

There is still no consensus on optimal treatment among patients with Thromboangiitis obliterans (TO) and chronic limb ischemia. The present study aims to summarize results on endovascular treatment of such patients.

METHODS

This is a meta-analysis. The following databases were utilized: Pubmed, Scopus and Cochrane Library. Eligible studies were published up to December 2021 and they evaluated endovascular angioplasty among patients with TO and chronic limb ischemia. Early (mortality and technical success) and late (primary/secondary patency and limb salvage) outcomes were evaluated. StatsDirect® was used for statistical analysis.

RESULTS

Overall, 15 eligible studies were included (11 studies only endovascular, 4 studies both endovascular and open repair). Among 601 patients, 402 endovascular procedures (416 limbs) were recorded (angioplasty plus stenting in 7.2% of cases and plus thrombolysis in 3.7% of cases). Regarding clinical presentation, 7.9% of patients had intermittent claudication (stages II/III) and 92.1% critical ischemia (stages IV-VI). The majority of cases had lesions below the knee, whereas there were 5 cases with upper extremity lesions. Pooled technical success was 86% (81.1-90.3) and in-hospital mortality null. Other complications included: 1.9% perforations, 2.2% wound complications, 0.2% distal embolism. Primary patency reached 65.7% (52.7-77.6) at 12 months and 50.7% (23.3-77.9) at 36 months. Secondary patency reached 76.2% (57.5-90.8) at 12 months and 64.5% (32.3-90.6) at 36 months. Limb salvage reached 94.1% (90.7-96.7) at 12 months and 89.1% (80.6-95.4) at 36 months.

CONCLUSIONS

Endovascular angioplasty in patients with TO and chronic limb ischemia is associated with optimal safety and low complication rates. Technical success and late outcomes are acceptable.

Endovascular Excimer Laser-Assisted Balloon Angioplasty for Infrapopliteal Arteries in Thromboangiitis Obliterans: A Treatment for Acute-Phase TAO

Background

Thromboangiitis obliterans (TAO, Buerger's disease) is an inflammatory and obstructive vasculopathy, which leads to limb ischemic rest pain and ulcerations in the acute stage.

Objectives

This study aimed to assess the feasibility of excimer laser-assisted balloon angioplasty (BA) for patients with acute infrapopliteal TAO.

Method

This was a single-center retrospective cohort study. In this study, 220 patients with 210 target limbs between January 2012 and September 2021 were involved. Among them, 52 target limbs have received endovascular excimer laser-assisted balloon angioplasty from January 2017. The ankle brachial index (ABI), rest pain score, ulcer, Rutherford classification, and TASC II classification were assessed. The follow-up time was 6 months.

Results

The technical success rate of laser + BA and BA groups was 71.15 and 65.82% (p = 0.5021), respectively. After intervention, the ABI of two groups were 0.85 ± 0.20 and 0.77 ± 0.20 (p = 0.0419), and the rest pain score was 1.00 ± 1.43 and 1.71 ± 2.25 (p = 0.0449). During the 6 months follow-up, the ABI of two groups was 0.76 ± 0.17 and 0.75 ± 0.23 (p = 0.8539), the rest pain score was 1.43 ± 1.82 and 2.24 ± 2.06 (p = 0.0783), and the ulcer rate was 23.68 and 40.98% (p = 0.0867), respectively. The proportion of patients who were assessed as TASC II C/D or Rutherford 4–6 in laser +BA group was significantly lower than that in BA group, indicating that the former had better efficacy. The rate of critical limb ischemia and restenosis in the laser +BA group was lower than that in the BA group (47.36 vs. 67.22%; 21.05 vs. 34.43%) during follow-up. In the laser + BA group, the reintervention rate was lower than that in the BA group (2.70 vs. 8.20%, p = 0.0425). No serious adverse events (AEs) occurred.

Conclusion

Excimer laser debulking-assisted angioplasty is a feasible, effective, and safe method to treat acute infrapopliteal TAO.

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

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.

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.

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.

Predictive value of serum VEGF, IL-1 and TNF-α in the treatment of thromboangiitis obliterans by revascularization

Effect of revascularization in the treatment of thromboangiitis obliterans (TAO) and the predictive value of serum vascular endothelial growth factor (VEGF), interleukin-1 (IL-1) and tumor necrosis factor-α (TNF-α) of risk factors of amputation were investigated. From April 2012 to August 2015, a total of 117 patients with TAO admitted to the First Hospital of Lanzhou University were selected. Patients treated with revascularization combined with prostaglandin sodium and cilostazol were enrolled in group A (67 patients), and patients treated with sodium and cilostazol were enrolled in group B (50 patients). The clinical efficacy was evaluated by calculating the intermittent claudication distance and the ankle brachial index (ABI) of patients. The occurrence probability of nausea and vomiting, skin pruritus, abdominal pain, coagulation abnormalities and amputation were recorded. The concentration of serum VEGF, IL-1 and TNF-α were measured using enzyme-linked immunosorbent assay (ELISA). After treatment, the intermittent claudication distance, ABI and efficiency of group A was markedly higher than that of group B (P<0.05). After treatment, serum VEGF concentration in group A was clearly higher than that in group B (P<0.05), and IL-1 and TNF-α levels were much lower than those in group B (P<0.05). The amputation rate in group A was significantly lower than that in group B (P<0.05). Patients with amputation in both groups were enrolled in the study group (24 cases), and those without amputation were included in the control group (93 cases). The serum VEGF concentration in the study group before treatment was significantly lower than that in the control group (P<0.05), while IL-1 and TNF-α levels were significantly higher than those of the control group (P<0.05). In conclusion, pretreatment serum VEGF, IL-1 and TNF-α had a positive diagnostic value for poor prognosis of patients with amputation, and low concentration of VEGF and higher concentration of IL-1 and TNF-α are the risk factors for amputations in patients with TAO.

Thromboangiitis Obliterans: 110 Years Old and Little Progress Made

See Article by Le Joncour et al .

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.

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.

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.