Thromboangiitis Obliterans (Buerger's Disease)-Current Practices

Trends in prevalence and complications for smokers who underwent total hip arthroplasty from 2011 to 2019: an analysis of 243,163 patients

BACKGROUND

Smoking is an established risk factor for postoperative complications after total hip arthroplasty (THA). It is unknown if the decreasing prevalence of adult smoking in the United States is reflected in the elective THA patient population. We aimed to investigate recent trends in: (1) the prevalence of smoking pre-THA, stratified by patient demographics; and (2) rates of 30-day complications and increased healthcare utilisation post-THA in smokers versus non-smokers.

METHODS

Patients who underwent primary elective THA (2011-2019) were identified using the National Surgical Quality Improvement Program database. A total of 243,163 cases (Smokers: n = 30,536; Non-smokers: n = 212,627) were included. Trends analyses were performed for smoking prevalence across the study period. Smokers were propensity score-matched (1:1) to a cohort of non-smokers (n = 29,628, each), and rates of 30-day complications, readmission, and non-home discharge were compared.

RESULTS

The rate of preoperative smoking significantly decreased from 14.0% in 2011 to 11.6% in 2019 (p-trend = 0.0286). When stratified, a significant decreasing trend in smoking was found for males and all races; within races, American-Indian/Alaska-Native race had the sharpest decline (2011:36.3% vs. 2019:23.2%). No significant change in 30-day complication rates among smokers or non-smokers was observed (p-trend > 0.05), but non-home discharge significantly decreased for both smokers (p-trend = 0.001) and non-smokers (p-trend < 0.001). After matching, higher rates of superficial surgical site infections (SSI) (0.9% vs. 0.5%; p < 0.001), deep SSI (0.5% vs. 0.3%; p < 0.001), wound disruption (0.2% vs. 0.1%; p = 0.006), and readmission (4.2% vs. 3.1%; p = <0.001) were found in smokers versus non-smokers.

CONCLUSIONS

The present study is encouraging that national efforts to reduce the prevalence of smoking may be successful within the THA population, but there is a persistently elevated risk of postoperative complications in smokers after THA.

The Safety and Effectiveness of Interval Stellate Ganglion Neurolysis in a Patient with Bilateral Digital Ischemia of Hands Due to Buerger's Disease: A Case Report

Introduction

Thromboangiitis obliterans (TAO) or Buerger's disease (BD) is a small and medium-sized arteriovenous segmental occlusive inflammatory disease frequently occurring in men as compared to women. Although a common etiological agent is smoking or tobacco consumption, it has also been reported infrequently in non-smokers. Except for smoking other etiological agents, HLA, autoimmune diseases like systemic lupus erythematosus, and periodontitis have also been suggested. Minimally invasive pain and spine intervention (MIPSI) like stellate ganglion neurolysis with 8% phenol, 10 days apart in patients suffering from bilateral digital ischemia of both hands is a safe and effective treatment.

Case Report

Fifty-five-year-old female with chief complaints of burning pain, swelling, and blackening of all five fingers of the right and four fingers of the left hands excluding the thumb for the past 3 months. On examination, pulse was almost absent at the wrist in both hands. There was no history of smoking. Under aseptic precautions, fluoroscopy and radiocontrast guidance stellate ganglion neurolysis with a 22G spinal needle, 2 ml of 8% phenol, 2 ml of 0.25% bupivacaine and 4 mg of dexamethasone were given at C7 vertebral level 10 days apart on both sides. After 3-4 months of stellate ganglion phenol chemical neurolysis, involved fingers were saved except the gangrenous part which was autoamputated itself in due course of time.

Conclusion

Bilateral interval (10 days apart) chemical neurolysis of stellate ganglion in Buerger's disease involving both hands is a safe and effective technique in terms of control of disease progression, pain, cardiac complications, and recurrent laryngeal nerve-related complications.

[Is this iatrogenic pathology or rare disease?]

The article is devoted to the problem of diagnosis and treatment strategy of Buerger's disease rarely found in the expert and clinical practice, that is inflammatory disease of unknown etiology, affecting mainly small and medium arteries and veins of limbs. Vascular surgeons around the world have been solving this problem for many years, both in terms of timely diagnosis of this disease and its proper pathogenic treatment. The authors of the article described an expert case of Buerger's disease larvated course in 15-years-old girl, which primarily was mistakenly assessed by specialists as iatrogenic pathology of right forearm vessels in injecting aminazin solution that, according to the clinicians' opinion, led to dry gangrene formation of right wrist and its subsequent amputation. The results of the forensic histological study and retrospective analysis of all child's medical documents allowed to correctly diagnose this rare pathology but only on the stage of commission forensic medical examination in the framework of the initiated criminal proceeding against several leading medical organizations in Saint-Petersburg with a pediatric profile. The authors noted the role of routine medical manipulation in manifestation of larvated pathologic process in a teenage girl in addition to full health and well-being. The objective of present article is devoted to understanding this problem.

Management of Buerger's disease during pregnancy

Buerger's disease (BD), also known as thromboangiitis obliterans, is a non-atherosclerotic inflammatory disorder of unknown aetiology that affects small-sized and medium-sized vessels of the extremities. It is usually observed in middle-aged adults, especially those who smoke or use tobacco products. This condition is more frequently observed in men, although recent findings indicate an increasing prevalence among women, potentially due to increased cigarette use. The association between pregnancy and BD is rare, with only a few published cases. Previous reports have indicated that BD may worsen during gestation due to the characteristic hypercoagulable state of pregnancy. In addition, it seems to be associated with intrauterine growth restriction secondary to infarction of placental vessels. Careful obstetric management of maternal and fetal status is mandatory in pregnancies complicated with BD. We report a successful case of a pregnancy in a patient with BD treated with low-molecular-weight heparin.

Decreasing tobacco use promotes ulcer healing in a patient with Buerger's disease

Tobacco cessation remains the mainstay treatment for Buerger's Disease; however, limited research exists examining the effect of decreased tobacco use rather than cessation in improving symptoms. We describe a case of a patient with Buerger's disease who experienced ulcer healing and pain improvement through reduced tobacco use.

Psychiatric sequelae of thromboangiitis obliterans: a case report and review of the literature

BACKGROUND

Peripheral manifestations secondary to progressive vascular occlusions are characteristic of the rare condition termed thromboangiitis obliternas (TAO) or Buerger's disease. The central manifestations of this disease are however poorly characterized, particularly those of psychiatric nature, and their prevalence is largely unknown. Speculations have been made around the polymorphic nature and triggers of observed psychopathology in TAO; much however remains to be unraveled in this area.

CASE PRESENTATION

We present the case of a 33-year-old Caucasian male who developed first episode of psychosis at the age of 29 years. There was no history of previous mental illness either in the patient, or in any of his family members. He had been a long- term heavy smoker and was experiencing progressive lower limb claudication since the age of 22 years; however, all inflammatory, autoimmune and atherosclerotic markers were negative. His psychosis was characterized by retention of a warm affect, and despite some amelioration, was generally resistant to a fair trial of several anti-psychotic medications including Clozapine.

CONCLUSION

The pathophysiology of psychosis secondary to Buerger's is not yet well characterized which adds to the complexity of managing these cases. Recognizing that cerebral manifestations of this disease may evolve several years after the onset of peripheral thromboangiitic features is important for following the natural history and considering measures that may reduce the burden of illness.

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).

Buerger’s disease with cerebral involvement in a middle-aged woman with diabetes mellitus. A case report

Introduction: Buerger’s disease (BD) generally affects men, young people, and smokers, but it can also affect women. Its incidence is rare in Latin America. Case report: A 40-year-old Colombian woman, active smoker and user of psychoactive substances, attended the emergency department of a tertiary care center due to symptoms of 3 days consisting of retraction of the corner of the mouth, drooling, and involuntary tongue movements. The patient, who had a history of uncontrolled diabetes and recent acute ischemia of the right upper limb due to acute thrombosis, required surgical management and subsequent use of oral anticoagulation. She later developed necrotic changes in the distal phalanges of the right hand that required ablative therapy. Since age, sex and limb involvement were not typical for BD, collagenosis, vasculitis or thrombophilia were ruled out, but after excluding these disorders, BD with atypical features was considered. The patient was discharged with oral anticoagulation, aspirin, combined analgesia, physiotherapy, and recommendation for smoking cessation. Conclusions: Age, sex, smoking and comorbidities such as diabetes are risk factors for BD. Imaging and histopathology are the gold standard for the definitive diagnosis of this entity. Multidisciplinary management, lifestyle changes, smoking cessation, pain control, good wound healing and social support are key aspects for better clinical outcomes in patients with BD.

An improved bone transport surgical method for treating chronic ischemic ulcers (thromboangiitis obliterans)

Introduction

The chronic ischemic injury of the upper/lower limbs caused by thromboangiitis obliterans (TAO, Buerger's disease) is difficult to heal, leading to high morbidity and amputation risk, seriously lowering the quality of life of patients. So far, the pathogenesis of this disease is still not clear, and there are still no effective therapeutic approaches. Here, we first use an improved bone transport technique to treat TAO-related foot ulcers and achieve good therapeutic effects.

Materials and Methods

In this report, 22 patients met the inclusion criteria, and we provide an improved bone transport technique to repair TAO-related chronic lower limb wounds, which have a minimally surgical incision and a satisfying surgical field.

Results

The improved bone transport technique resulted in TAO-related chronic lower extremity wound healing in most patients (18, M:F 16:2) within the first treatment cycle. All wounds healed completely after two treatment cycles. After these cycles, the cold sensation in the patients’ feet was significantly relieved, and the rest pain in the lower extremities was significantly relieved (Visual Analog Scale, P < 0.0001). Furthermore, the Laser Doppler flowmeter showed that the blood perfusion and percutaneous oxygen pressure of the affected foot were higher than in preoperation (P < 0.0001). To conclude, bone transport technology is available for the refractory wounds of the extremity, which may promote healing by increasing blood circulation and tissue oxygen supply.

Conclusions

In summary, the improved surgical method of the bone transport technique is worth considering in the treatment of thromboangiitis obliterans–related foot ulcers.

Autologous Stem Cells Transplantation for No-Option Angiitis-Induced Critical Limb Ischemia: Recurrence and New Lesion

Although satisfying outcomes have been demonstrated in terms of autologous stem cell transplantation in the treatment of angiitis-induced critical limb ischemia (AICLI), few studies have systematically reported the recurrence conditions. In the current study, we aimed to investigate recurrence conditions of a relatively large AICLI cohort in our center during a long-term follow-up period. From May 2009 to August 2020, 181 patients with AICLI received peripheral blood mononuclear cells (PBMNCs) or purified CD34+ cells (PCCs) transplantation. The main outcomes included recurrence and new lesions. Patient demographic data, ischemic limb characteristics, interventional characteristics, etc., were identified and analyzed. A logistic multivariable regression was performed to identify the independent risk factors for recurrence by a stepwise selection of variables. One hundred forty-eight patients were enrolled in this study. The mean follow-up period was 62.3 ± 37.4 months (range 12-144 months). The 5- and 10-year recurrence-free rates were 88.5% (95% confidence interval [CI] 3.1%-82.6%) and 71.7% (95% CI 7.6%-58.2%), respectively. The 5- and 10-year new lesion-free rates were 93.2% (95% CI 2.2%-89.0%) and 91.7% (95% CI 2.7%-86.6%), respectively. The finding of multiple limbs involved (OR 1.322 95% CI 1.123-12.549, P = .036) and ischemia relief period ≥5 months (OR 3.367 95% CI 1.112-10.192, P = .032) were demonstrated to be independent risk factors for recurrence in patients with AICLI who underwent cell transplantation. For patients with AICLI who responded to cell transplantation, the durability of this therapy was satisfactory, with 5- and 10-year recurrence-free rates of 88.5% and 71.7%, respectively. Multiple limbs involved at admission and ischemia relief period ≥5 months were demonstrated to be independent risk factors for recurrence after transplantation.

A Rare Case of Thromboangiitis Obliterans of Bilateral Upper Extremities in an Adult Male

Thromboangiitis obliterans (TAO) also known as Buerger’s disease is a nonatherosclerotic vasculitis that is more common in adult male smokers. TAO predominantly affects lower extremities, however, cases with bilateral upper extremities involvement are a rare entity and difficult to manage. Symptoms of the disease mostly mimic that of acute ischemia of the limb. Diagnosis is mostly made clinically, however, radiographic vascular evaluation can strengthen the diagnosis. Herein we present a case of a 41-years-old male with a history of chronic smoking whose signs and symptoms were suggestive of TAO in bilateral upper extremities, however, the patient did not respond to smoking cessation and pharmacotherapy for a long time owing to which he underwent amputation after taking proper informed consent.

Coxiella burnetii Infection Associated With Thromboangiitis Obliterans-like Phenomena With Digital Autoamputation: A Case Report and Review of Q Fever-Associated Autoimmunity

We present a case of a patient with chronic Q fever who presented with digital necrosis, autoamputations, and positive anticentromere antibody, mimicking a scleroderma vasculopathy or thromboangiitis obliterans. Coxiella burnetii infection has long been associated with the presence of autoantibodies and autoimmune phenomena including vasculitis. Clinicians should consider Q fever testing in patients with new-onset autoimmune diseases or autoantibodies and appropriate exposure histories.

Recent Updates and Advances in Winiwarter-Buerger Disease (Thromboangiitis Obliterans): Biomolecular Mechanisms, Diagnostics and Clinical Consequences

Thromboangiitis obliterans (TAO) or Buerger’s disease is a segmental inflammatory, thrombotic occlusive peripheral vascular disease with unknown aetiology that usually involves the medium and small-sized vessels of young male smokers. Due to its unknown aetiology and similarities with atherosclerosis and vasculitis, TAO diagnosis is still challenging. We aimed to review the status of biomolecular and laboratory para-clinical markers in TAO compared to atherosclerosis and vasculitis. We reported that, although some biomarkers might be common in TAO, atherosclerosis, and vasculitis, each disease occurs through a different pathway and, to our knowledge, there is no specific and definitive marker for differentiating TAO from atherosclerosis or vasculitis. Our review highlighted that pro-inflammatory and cell-mediated immunity cytokines, IL-33, HMGB1, neopterin, MMPs, ICAM1, complement components, fibrinogen, oxidative stress, NO levels, eNOS polymorphism, adrenalin and noradrenalin, lead, cadmium, and homocysteine are common markers. Nitric oxide, MPV, TLRs, MDA, ox-LDL, sST2, antioxidant system, autoantibodies, and type of infection are differential markers, whereas platelet and leukocyte count, haemoglobin, lipid profile, CRP, ESR, FBS, creatinine, d-dimer, hypercoagulation activity, as well as protein C and S are controversial markers. Finally, our study proposed diagnostic panels for laboratory differential diagnosis to be considered at first and in more advanced stages.

Milestones in thromboangiitis obliterans. A position paper of the VAS-European Independent Foundation in Angiology/Vascular Medicine

BACKGROUND

Unfortunately, even today Thromboangiitis Obliterans has disease features that remain misunderstood or underappreciated. The epidemiology, etiology and pathophysiology of the disease are still unclear. Biomarkers and disease activity markers are lacking, thus clinical assessment is difficult. We are still struggling to establish unique diagnostic, staging and treatment criteria. This is an academic-collaborative effort to describe the pathophysiology, the clinical manifestations, the diagnostic approach, and the challenges of management of patients with TAO.

METHODS

A systematic search for relevant studies dating from 1900 to the end of 2020 was performed on the PubMed, SCOPUS, and Science Direct databases.

RESULTS

Given the intriguing nature of presentation of TAO, its management, to some extent is not only different in different regions of the world but also varies within the same region. Following this project, we discovered ambiguity, overlap and lack of clear-cut criteria for management of TAO.

CONCLUSIONS AND RELEVANCE

An international group of experts however came to one conclusion. They all agree that management of TAO is in need of a call for action for a renewed global look with multi-center studies, to update the geographical distribution of the disease and to establish a unique set of diagnostic criteria and a consensus-based guideline for best treatment based on current evidence.

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.

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.

Stem Cell Therapy for Thromboangiitis Obliterans (Buerger’s Disease)

Buerger’s disease or Thromboangiitis Obliterans (TAO) is a nonatherosclerotic segmental vascular disease which affects small and medium arteries and veins in the upper and lower extremities. Based on pathological findings, TAO can be considered as a distinct form of vasculitis that is most prevalent in young male smokers. There is no definitive cure for this disease as therapeutic modalities are limited in number and efficacy. Surgical bypass has limited utility and 24% of patients will ultimately require amputation. Recently, studies have shown that therapeutic angiogenesis and immunomodulatory approaches through the delivery of stem cells to target tissues are potential options for ischemic lesion treatment. In this review, we summarize the current knowledge of TAO treatment and provide an overview of stem cell-based treatment modalities.

Autologous peripheral blood-derived stem cells transplantation for treatment of no-option angiitis-induced critical limb ischemia: 10-year management experience

Background

Previous studies have demonstrated that no-option angiitis-induced critical limb ischemia (NO-AICLI) could be significantly improved by transplantation of peripheral blood-derived stem cells (PBDSCs). Additionally, a randomized controlled trial (RCT) recently conducted by us suggested that peripheral blood-derived purified CD34+ cells (PCCs) were not inferior to non-purified peripheral blood mononuclear cells (PBMNCs) at limb salvage in treatment of NO-AICLI. However, most of these clinical trials whether RCT or single-arm studies were characterized with a small sample size and absence of long-term outcomes.

Methods

To analyze long-term clinical outcomes of PBDSCs transplantation for NO-AICLI, we reviewed clinical data of patients with NO-AICLI receiving PBDSCs transplantation at our center during the past decade. Meanwhile, we first compared the long-term safety and efficacy of intramuscular transplantation of PCCs versus PBMNCs in a sizable number of patients with NO-AICLI.

Results

From May 2009 to December 2019, a total of 160 patients with NO-AICLI patients were treated by PBDSCs transplantation (82 with PCCs, 78 with PBMNCs) at our center. Baseline characteristics between two groups were similar. Up to June 2020, the mean follow-up period was 46.6 ± 35.3 months. No critical adverse events were observed in either group. There was one death during the follow-up period. A total of eight major amputations occurred. The cumulative major amputation-free survival (MAFS) rate at 5 years after PBDSCs transplantation was 94.4%, without difference between two groups (P = .855). Wound healing, rest pain, pain-free walking time, ankle-brachial index, transcutaneous oxygen pressure, and quality of life (QoL) also significantly improved after PBDSCs transplantation.

Conclusions

Autologous PBDSCs intramuscular transplantation could significantly decrease the major amputation rates and improve the QoL in patients with NO-AICLI. Long-term observation of a large sample of patients confirmed that the clinical benefits of PBDSCs transplantation were durable, without difference between the PCCs and PBMNCs groups.

Human leukocyte antigen class I (A, B) and class II (DRB1) allele and haplotype frequencies in Iranian patients with Buerger's disease

OBJECTIVE

The aim of this study was to investigate the human leukocyte antigen (HLA) class I (HLA-A and HLA-B) and II (HLA-DRB1) allele and haplotype frequencies in a group of Iranian patients with Buerger's disease (BD) in comparison with a normal healthy control group.

METHODS

A total of 70 unrelated male patients and 100 healthy controls from Sina Hospital, Tehran, Iran, belonging to the same ethnic background, were enrolled in this case-control study. HLA-A, B, and DRB1 typing were performed by polymerase chain reaction with sequence-specific primers (PCR-SSP).

RESULTS

The results of this case-control study showed that the frequency of the HLA-A*03:01 (odds ratio (OR) = 2.88, P value (Pv) = .002), HLA-A*29:01 (OR = 15.31, Pv < .001), HLA-DRB1*04:02 (OR = 3.41, Pv < .001), and HLA-DRB1*16:01 (OR = 8.16, Pv < .001) was significantly higher in BD patients compared with healthy controls, whereas the frequency of the HLA-DRB1*01:01 (OR = 0.03, Pv < .001) was significantly lower in BD patients. The most frequent extended haplotypes in our patients were HLA-A*02:01-B*55:01-DRB1*04:03.

CONCLUSION

This study is the first study evaluating an association between the HLA pattern and BD in the patients with BD from North West and North Iran.

Ischemic Colitis in Buerger's Disease: Case Presentation and Review

Buerger's disease is a type of vasculitis that predominantly affects small to medium arteries and the veins of the upper and lower extremities. Intestinal vessels are rarely involved. This is a case report of a 38-year-old male, smoker, with known Buerger's disease who was found to have ischemic colitis of the sigmoid colon on biopsy and inferior mesenteric artery occlusion on computed tomography (CT) angiography. Intestinal ischemia is a rare complication in Buerger's disease. Patients may present with vague abdominal symptoms. Given the very low incidence of intestinal involvement, social history and clinical correlation are of chief importance for early detection. Smoking cessation is paramount, as it is the mainstay treatment of the underlying disease.

Practical approach to vasculitides in adults: an overview of clinical conditions that can mimic vasculitides closely

Primary systemic vasculitides are rare diseases affecting blood vessel walls. The type and patterns of distribution of the organs affected usually reflect the size of the vessels predominantly involved, and the patterns of clinical manifestations are generally useful to reach a specific diagnosis. However, presenting symptoms may lack adequate specificity for a prompt diagnosis, leading to a diagnostic (and therapeutic) delay, often causing irreversible damage to the affected organs. Due to their rarity and variable clinical presentation, the diagnosis of primary vasculitides could be challenging for physicians. Vasculitis mimickers, i.e. the clinical conditions that could be likely mistaken for vasculitides, need to be carefully ruled out, especially before starting the immunosuppressive therapy. We present here a practical approach to the diagnosis of primary systemic vasculitides involving large, medium and small size vessels, and reviewed most of the conditions that could mimic primary systemic vasculitides.

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.

Purified CD34+ cells versus peripheral blood mononuclear cells in the treatment of angiitis-induced no-option critical limb ischaemia: 12-Month results of a prospective randomised single-blinded non-inferiority trial

BACKGROUND

Peripheral blood mononuclear cells (PBMNCs) and purified CD34+ cells (PCCs) are increasingly being used at treating no-option critical limb ischaemia (NO-CLI). We aimed to compare the efficacies and uncover the advantages associated with each treatment approach.

METHODS

A randomised single-blinded non-inferiority trial (Number: NCT 02089828) was performed. NO-CLI patients were 1:1 randomised to the PBMNCs and PCCs groups, and compared in relation to safety and efficacy outcomes. The primary efficacy outcomes included major amputation and total amputation over 12 months. The major amputation-free survival (MAFS) and total amputation-free survival (TAFS) rates were calculated.

FINDINGS

Fifty patients (25 per group, 47 with thromboangiitis obliterans and 3 with other angiitis) were enrolled, with a median follow-up period of 24.5 months (interquartile range: 17-34 months). One patient in the PCCs group was lost at 2 months and one major amputation occurred in the PBMNCs group at 3 months post-transplantation. The total amputation rates at 6 months post-transplantation were 28.0% in the PCCs group and 16.0% in the PBMNCs group (p = 0.343), and remained unchanged at 12 months. The groups did not differ regarding the MAFS and TAFS (Breslow-Wilcoxon test: p = 0.3014 and p = 0.3414). The PCCs group had a significantly higher probability of rest pain relief than the PBMNCs group (Breslow-Wilcoxon test: p = 0.0454).

INTERPRETATION

PCCs was not inferior to PBMNCs at limb salvage in the treatment of angiitis-induced NO-CLI and appeared to induce earlier ischaemia relief. Each cell type had specific advantages. These outcomes require verification from longer-term trials involving larger numbers of patients. FUND: Training program for outstanding academic leaders of Shanghai health and family planning system (Hundred Talent Program，Grant No. 2018BR40); China National Natural Science Funds (Grant No. 30801122); The excellent core member training programme at Zhongshan Hospital, Fudan University, China (Grant No. 2015ZSYXGG02); and Zhongshan Funds for the Institute of Vascular Surgery, Fudan University, China.

CLINICAL TRIAL REGISTRATION

This study is registered with ClinicalTrials.gov (NCT 02089828).

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.

Peripheral sympathetic block with therapeutic local anesthesia for the manage-ment of upper limb digital ischemia

BACKGROUND

Thromboangiitis obliterans (TAO) is a non-arteriosclerotic segmental inflammatory occlusive vasculitis typically in the upper and lower extremities affecting small- and medium-sized arteries and veins. We present the treatment protocol for TAO involving the use of peripheral sympathetic block through an axillary catheter.

CASE REPORT

An unconscious 56-year-old female patient was transferred to the emergency service, intubated, and mechanically ventilated. The patient was provisionally diagnosed with hypertensive intracranial hematoma and admitted to the intensive care unit. Invasive arterial pressure monitoring was performed through the left radial artery cannula. Four days later, upon the observation of symptoms of a circulatory disorder in the fingers distal of the left and right hands, the cannula was removed from the left radial artery, and another was placed in the left dorsalis pedis artery. At the same time, an 18 Gauge catheter was placed in the axillary perineural sheath bilaterally, and a total of 10 ml lidocaine 0.5 % (5 ml for each side) was injected six times a day. During each injection, the temperature was measured using a surface probe on the distal of the fingers with poor perfusion and another area of the same hand with good perfusion. Lidocaine treatment protocol through the axillary perineural catheter was applied for 15 days for the right hand and 18 days for the left hand. As the treatment proceeded, a significant increase was observed in the results of the temperature measurements on the fingers with poor perfusion.  Conclusion: We believe that a peripheral sympathetic block as we report herein could be considered as an alternative in the treatment of TAO. HIPPOKRATIA 2018, 22(3): 141-144.

Could Buerger's disease cause nonarteritic anterior ischemic optic neuropathy?: a rare case report

We present an interesting case with nonarteritic anterior ischemic optic neuropathy (NAION) accompanied by Buerger's disease. A 43-year-old man was referred to our neuro-ophthalmology clinic with a complaint of visual deterioration in the left eye that started 5 days ago. He suffered from Buerger's disease, and he had acute pain in the right lower limb below the knee. His best corrected visual acuity was 10/10 in the right eye and 2/10 in the left eye by Snellen chart. There was a relative afferent pupil defect in the left eye. The right optic disc was normal on fundus examination, and blurring, hemorrhagic swelling was found at the left optic disc. Inferior altitudinal visual field defect was observed in the left eye. Neurological examination was normal. Computed tomography angiography scan revealed occlusion in the right posterior tibial artery. Brain imaging and laboratory tests such as blood analyses, genetic screening, coagulation, and lipid panels were unremarkable. NAION may occur in patients with Buerger's disease, but it is extremely rare. Therefore, clinicians should be aware of this rare association.

Plasma nitric oxide level is correlated with microvascular functions in the peripheral arterial disease

At present there is no widely accepted biomarker for monitoring of vascular functions. The purpose of this prospective study was to investigate the association of some blood biomarkers with vascular reactivity in patients with peripheral arterial diseases (PAD). A prospective evaluation was made of 3 groups comprising a control group of healthy individuals, and patients with PAD caused by either atherosclerosis or Buerger's disease. Microvascular perfusion was examined using laser Doppler imaging of cutaneous erythrocyte flux after iontophoresis of acetylcholine (ACh) and sodium nitroprusside (SNP). The correlation of microvascular reactivity with endothelium-related biomarkers was assessed. ACh-induced and SNP-induced vasodilations were significantly diminished in the PAD groups. The plasma nitric oxide (NO) levels of PAD patients were significantly higher than those of the control group, but asymmetric dimethylarginine, total antioxidant capacity and hydrogen sulphide levels were similar. Plasma NO level was negatively correlated with ACh and SNP-stimulated microvascular flow increase, whereas a positive correlation was detected with blood glucose and glycated hemoglobin (HbA1c) levels in all groups. These results indicate that a high plasma level of NO in PAD patients is associated with diminished endothelium-dependent and independent flow increase in the microvascular bed. An excessive amount of NO-induced nitrosative stress in an inflammatory condition that might be a reason for vascular dysfunction should be taken into consideration in the diagnostic and therapeutic approaches to PAD.

Therapeutic strategies for cell-based neovascularization in critical limb ischemia

Critical limb ischemia (CLI) causes severe ischemic rest pain, ulcer, and gangrene in the lower limbs. In spite of angioplasty and surgery, CLI patients without suitable artery inflow or enough vascular bed in the lesions are often forced to undergo amputation of a major limb. Cell-based therapeutic angiogenesis has the potential to treat ischemic lesions by promoting the formation of collateral vessel networks and the vascular bed. Peripheral blood mononuclear cells and bone marrow-derived mononuclear cells are the most frequently employed cell types in CLI clinical trials. However, the clinical outcomes of cell-based therapeutic angiogenesis using these cells have not provided the promised benefits for CLI patients, reinforcing the need for novel cell-based therapeutic angiogenesis strategies to cure untreatable CLI patients. Recent studies have demonstrated the possible enhancement of therapeutic efficacy in ischemic diseases by preconditioned graft cells. Moreover, judging from past clinical trials, the identification of adequate transplant timing and responders to cell-based therapy is important for improving therapeutic outcomes in CLI patients in clinical settings. Thus, to establish cell-based therapeutic angiogenesis as one of the most promising therapeutic strategies for CLI patients, its advantages and limitations should be taken into account.

Efficacy of bosentan in patients with refractory thromboangiitis obliterans (Buerger disease): A case series and review of the literature

The cornerstone of therapy in thromboangiitis obliterans (TAO) is complete abstinence from tobacco. In addition to discontinuation of cigarette smoking, very few pharmacological and surgical options of controversial efficacy are available to date. New therapeutic options with greater efficacy are clearly needed to properly manage these patients.In this preliminary study, we assessed the effectiveness and safety of bosentan in a case series of 8 adults with TAO and severe ischemic ulceronecrotic lesions who were treated with bosentan after inadequate response to platelet inhibitors, vasodilators, and intravenous alprostadil. Additionally, we reviewed 18 well-documented patients with refractory TAO treated with bosentan, which was previously reported (PubMed 1965-2015). These 26 patients formed the basis of our present analysis. All were current smokers.The median duration of bosentan treatment (SD) was 4.5 ± 4 months (range 3-16). Eleven patients (42%) were unable to completely abstain from smoking during their follow-up. With bosentan treatment, no new ischemic lesions were observed in the target extremities. A complete therapeutic response was achieved in 80% of patients, whereas a partial response was observed in 12%. Two patients (8%) ultimately required amputation despite treatment.After discontinuation of bosentan, patients were followed for a median of 20 ± 14 months (range 3-60). Two patients whose trophic lesions had healed relapsed.When comparing patients who gave up smoking with those who were unable to completely abstain from smoking during follow-up, no significant differences were found in efficacy outcomes. Four patients (15%) developed adverse events, requiring bosentan discontinuation in 1 case.These preliminary data suggest that bosentan may be considered a therapeutic option for treatment of cases of severe TAO refractory to conventional treatment, and merit further evaluation in larger controlled, randomized clinical studies.

Administration of Adult Human Bone Marrow-Derived, Cultured, Pooled, Allogeneic Mesenchymal Stromal Cells in Critical Limb Ischemia Due to Buerger's Disease: Phase II Study Report Suggests Clinical Efficacy

Critical limb ischemia (CLI) due to Buerger’s disease is a major unmet medical need with a high incidence of morbidity. This phase II, prospective, nonrandomized, open‐label, multicentric, dose‐ranging study was conducted to assess the efficacy and safety of i.m. injection of adult human bone marrow‐derived, cultured, pooled, allogeneic mesenchymal stromal cells (BMMSC) in CLI due to Buerger’s disease. Patients were allocated to three groups: 1 and 2 million cells/kg body weight (36 patients each) and standard of care (SOC) (18 patients). BMMSCs were administered as 40–60 injections in the calf muscle and locally, around the ulcer. Most patients were young (age range, 38–42 years) and ex‐smokers, and all patients had at least one ulcer. Both the primary endpoints—reduction in rest pain (0.3 units per month [SE, 0.13]) and healing of ulcers (11% decrease in size per month [SE, 0.05])—were significantly better in the group receiving 2 million cells/kg body weight than in the SOC arm. Improvement in secondary endpoints, such as ankle brachial pressure index (0.03 [SE, 0.01] unit increase per month) and total walking distance (1.03 [SE, 0.02] times higher per month), were also significant in the group receiving 2 million cells/kg as compared with the SOC arm. Adverse events reported were remotely related or unrelated to BMMSCs. In conclusion, i.m. administration of BMMSC at a dose of 2 million cells/kg showed clinical benefit and may be the best regimen in patients with CLI due to Buerger’s disease. However, further randomized controlled trials are required to confirm the most appropriate dose. Stem Cells Translational Medicine2017;6:689–699

A Prospective, Nonrandomized, no Placebo-Controlled, Phase I/II Clinical Trial Assessing the Safety and Efficacy of Intramuscular Injection of Autologous Adipose Tissue-Derived Mesenchymal Stem Cells in Patients With Severe Buerger's Disease

Buerger's disease is a rare and severe disease affecting the blood vessels of the limbs. Adipose tissue-derived mesenchymal stem cells (ADSCs) have the potential to cure Buerger's disease when developed as a stem cell drug. In the present study, we conducted a prospective, nonrandomized, no placebo-controlled, phase I/II clinical trial with a 2-year follow-up questionnaire survey. A total of 17 patients were intramuscularly administered autologous ADSCs at a dose of 5 million cells/kg. The incidence of adverse events (AEs), adverse drug reaction (ADR), and serious adverse events (SAEs) was monitored. No ADRs and SAEs related to stem cell treatment occurred during the 6-month follow-up. In terms of efficacy, the primary endpoint was increase in total walking distance (TWD). The secondary endpoint was improvement in rest pain, increase in pain-free walking distance (PFWD), toe-brachial pressure index (TBPI), transcutaneous oxygen pressure (TcPO₂), and arterial brachial pressure index (ABPI). ADSCs demonstrated significant functional improvement results including increased TWD, PFWD, and rest pain reduction. No amputations were reported during the 6-month clinical trial period and in the follow-up questionnaire survey more than 2 years after the ADSC injection. In conclusion, intramuscular injection of ADSCs is very safe and is shown to prompt functional improvement in patients with severe Buerger's disease at a dosage of 300 million cells per 60 kg of body weight. However, the confirmatory therapeutic efficacy and angiogenesis need further study.

Safety and efficacy of cell-based therapy on critical limb ischemia: A meta-analysis

BACKGROUND AIMS

Critical limb ischemia (CLI) is a major health problem worldwide, affecting approximately 500-1000 people per million per annum. Cell-based therapy has given new hope for the treatment of limb ischemia. This study assessed the safety and efficacy of cellular therapy CLI treatment.

METHODS

We searched the PubMed, Embase and Cochrane databases through October 20, 2015, and selected the controlled trials with cell-based therapy for CLI treatment compared with cell-free treatment. We assessed the results by meta-analysis using a variety of outcome measures, as well as the association of mononuclear cell dosage with treatment effect by dose-response meta-analysis.

RESULTS

Twenty-five trials were included. For the primary evaluation index, cell-based therapy significantly reduced the rate of major amputation (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.32-0.60, P = 0.000) and significantly increased the rate of amputation-free survival (OR 2.80, 95% CI 1.70-4.61, P = 0.000). Trial sequence analysis indicated that optimal sample size (n = 3374) is needed to detect a plausible treatment effect in all-cause mortality. Cell-based therapy significantly improves ankle brachial index, increases the rate of ulcer healing, increases the transcutaneous pressure of oxygen, reduces limb pain and improves movement ability. Subgroup analysis indicated heterogeneity is caused by type of control, design bias and transplant route. In the dose-response analysis, there was no significant correlation between cell dosage and the therapeutic effect.

CONCLUSIONS

Cell-based therapy has a significant therapeutic effect on CLI, but randomized double-blind placebo-controlled trials are needed to improve the credibility of this conclusion. Assessment of all-cause mortality also requires a larger sample size to arrive at a strong conclusion. In dose-response analysis, increasing the dosage of cell injections does not significantly improve the therapeutic effects of cell-based therapy.

Severe gangrene at the glans penis requiring penectomy as the first major complication of Buerger's disease

We report an interesting case of Buerger's disease that manifested at the glans penis in a 56 year-old former smoker. Penile involvement in Buerger's disease is rare. Our patient had no prior extremity or digit amputations in his 4-year history of Buerger's disease. However, our patient did suffer from recurrent penile ulcers over an 8-week timeframe that ultimately progressed to a gangrenous, unsalvageable glans penis. He underwent a partial penectomy and urethral reconstruction with excellent post-operative results.

[The results of combined surgical treatment of thromboangiitis obliterans and critical lower limb ischemia using prolonged epidural analgesia and autohemotherapy with ozone]

AIM

to evaluate the results of combined treatment of thromboangiitis obliterans with severe lower limb ischemia using prolonged epidural anaesthesia and autohemotherapy with ozone.

MATERIAL AND METHODS

It was analyzed treatment of 125 patients with thromboangiitis obliterans and severe lower limb ischemia. Patients were divided into 2 groups. Control group consisted of 60 patients who underwent conventional perioperative therapy with anticoagulants, antiplatelet agents, dextrans, metabolic drugs, glucocorticoids, angioprotectors, narcotic and non-narcotic analgesics. Study group included 65 patients in whom prolonged epidural anaesthesia and autohemotherapy with ozone was applied additionally.

RESULTS

In early postoperative period (up to 30 days) the incidence of secondary lower leg amputation was 10% and 1.5% in both groups respectively (p<0.05). Primary healing after limited foot amputation was achieved in 63.6% and 83.3% in control and stugy groups respectively (p<0.05). Ulcerative defect recovery was observed in 62.2% and 76.2% in both groups respectively (p<0.01). Satisfactory result of treatment was obtained in 61.7% and 80.0% of patients.

CONCLUSION

Restoration of magistral and collateral blood flow combined with prolonged epidural anaesthesia and autohemotherapy with ozone improves surgical outcomes and rehabilitation of patients with thromboangiitis obliterans and severe lower limb ischemia.

End stage renal disease caused by thromboangiitis obliterans: a case report

INTRODUCTION

Thromboangiitis obliterans or Buerger's disease is a nonatherosclerotic, segmental, inflammatory vasculitis that is strongly associated with tobacco products and commonly affects the small- and medium-sized arteries of the upper and lower extremities. However, the disease can, rarely, involve large central or visceral arteries. We report here the case of end stage renal disease due to renal artery thrombosis caused by thromboangiitis obliterans.

CASE PRESENTATION

A 51-year-old Korean man who had previously required amputation of both great toes due to thromboangiitis obliterans presented with left flank pain and oliguria. Both his renal arteries were occluded on contrast-enhanced abdominal computed tomography and abdominal angiography. He also had abdominal angina. He had no risk factor of thromboembolism from cardiac origin, atherosclerosis except for tobacco abuse, collagen diseases or hypercoagulable disorders. Renal failure and mesenteric ischemia associated with thromboangiitis obliterans progression was diagnosed.

CONCLUSIONS

Renal failure due to renal artery thrombosis and mesenteric ischemia represents an unusual manifestation of thromboangiitis obliterans. But once it occurs, it can be life-threatening. When we care for a patient with thromboangiitis obliterans, we should pay attention to this rare disease course, and encourage cessation of the smoking of tobacco products.

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.

Shenfu injection protects human ECV304 cells from hydrogen peroxide via its anti-apoptosis way

ETHNOPHARMACOLOGICAL RELEVANCE

The pathogenesis of thromboangiitis obliterans (TAO) has not been fully elucidated until now. Shenfu injection (SFI), a traditional Chinese formula has been widely used clinically for the treatment of cardiovascular diseases for more than two decade. Our previous results first suggested that SFI can cause a significant therapeutic effect on experimental TAO model rats. This experiment was designed to further investigate the protective effect of SFI on VEC damaged by hydrogen peroxide (H2O2) oxidative stress in vitro.

METERIALS AND METHODS

The cell viability was evaluated by the MTT assay, the activities of SOD and GSH-PX and the content of MDA in the supernatants of the cultured ECV304 cells were evaluated by a colorimetry method, cell apoptosis was detected by flow cytometry and an AO/EB double staining method. The protein expressions of Bcl2, Bax and caspase-3 were examined by Western blotting.

RESULTS

When compared with control group, lower survival rate of ECV304 cells was observed in H2O2 group (p<0.01) ; 20μl/ml, 30μl/ml and 40μl/ml SFI increased the survival rate of ECV304 cells under H2O2 oxidative stress (p<0.05 and p<0.01). The activities of SOD and GSH-PX were higher and MDA level was lower in H2O2 group than those in control group. These effects of H2O2 on SOD, GSH-PX activities and MDA content were reversed by SFI in concentration-dependent way (p<0.05 and p<0.01). Flow cytometry and AO-EB double staining discovered that SFI pretreatment inhibited the ECV304 cells apoptosis. The protein expression of caspase3 in 30μl/ml and 40μl/ml SFI groups significantly decreased whereas Bcl2 protein expressions in 20μl/ml, 30μl/ml and 40μl/ml SFI groups were higher than H2O2 group, with Bax protein expression much lower than H2O2 group (p<0.05 and p<0.01).

CONCLUSIONS

Our findings suggest that SFI could prevent the ECV304 cells against H2O2 oxidative-stress by enhancing antioxidant enzyme activities, reducing the membrane lipid peroxidation, as well as upregulating antiapoptotic and downregulating apoptosis protein expressions.

A young adult male with peripheral artery disease

A 19-year-old man was admitted with severe symptoms suggestive for bilateral occlusive disease of his lower extremities. Clinical, laboratory, and radiological evaluation established the diagnosis of Buerger's disease. Buerger's disease often poses a diagnostic challenge and requires a high degree of suspicion. Although rare for this patient's young age, it is important that a correct diagnosis is being made, because the disease process can be stopped if the patient stops smoking.

''The association of normal tension glaucoma with Buerger's disease: a case report''

BACKGROUND

To report a case of a 48-year-old man with Buerger's disease who presented with bilateral normal-tension glaucoma (NTG).

CASE PRESENTATION

A 48-year-old man who had been diagnosed with Buerger's disease 12 years ago, and received bilateral below-the-knee amputations for ischemic ulcers of the lower limbs, presented at our clinic due to a sudden loss of visual acuity in the left eye. A fundus exam revealed a cup-to-disc ratio of 0.5 for the right eye and 0.8 for the left eye, arteriolar constriction in both eyes, retinal edema in the inferopapillary area, and splinter hemorrhages and soft exudate in the left eye. We diagnosed the patient as having acute nasal branch retinal artery occlusion in the left eye and bilateral NTG, as a result of the ophthalmologic examination and the other findings.

CONCLUSION

Although the pathomechanism of NTG is still unknown, previous studies have suggested that patients with NTG show a higher prevalence of vasospastic disorders. We present the second report of NTG associated with Buerger's disease to be described in the literature.