Diagnostic Criteria and Treatment of Buerger’s Disease: A Review

Screening for Lung Cancer by Chest Computed Tomography During Thromboangiitis Obliterans

Buerger's disease or thromboangiitis obliterans (TAO) is a non-atherosclerotic inflammatory arteritis strongly associated with smoking exposure. This tobacco use would expose patients to lung cancer. The French-speaking thoracic cancer intergroup recommends screening for lung cancer with a chest computed tomography (CT). Our study aims to evaluate lung cancer screening using chest CT during TAO. Ninety-seven TAO patients were included. The mean age of onset of TAO symptoms was 36.5 ± 10 years, and 73 (75%) were male. The mean follow-up was 8.5 ± 14 years. Overall, at least one chest CT was performed during follow-up in 32 (33%) patients. Twenty-three of the thirty-four (68%) patients who were over 50 at follow-up did not have a CT. An abnormality was found in 15 of the 32 (47%) patients who had a CT: lung nodules 6/15, lung mass 1/15, emphysema 6/15, and others 2. Two cases of lung adenocarcinoma were diagnosed. None died during 2 years follow-up. In conclusion, two-third of the TAO patients over 50 years of age did not receive the routine screening recommended in the general smoking population. Two cases of lung cancer have been diagnosed. Improving screening practices for lung cancer in this high-risk population is crucial.

Cannabis arteritis presenting with Raynaud's and digital ulcerations: a case-based review of a controversial thromboangiitis obliterans-like condition

Thromboangiitis obliterans (TAO), or Buerger's disease, is a non-atherosclerotic inflammatory disease of the small and medium-sized arteries, veins, and nerves of the legs and arms, strongly associated with the use of tobacco products in young adults. Cannabis arteritis (CA), an entity with similar clinical and pathological features, has been described in marijuana users as a subtype of TAO. Distinction between TAO and CA is challenging, given that most patients use tobacco and marijuana products concomitantly. Herein, we report the case of a male in his late forties who was referred to rheumatology with a 2-month history of hand swelling and bilateral painful digital ulcers with blue discoloration on his fingers and toes. The patient reported daily use of marijuana in blunt wraps and denied tobacco use. His laboratory work-up was negative for scleroderma and other connective tissue diseases. His angiogram confirmed the diagnosis of thromboangiitis obliterans, which was attributed to cannabis arteritis. The patient was started on aspirin and nifedipine daily and discontinued marijuana use. His symptoms resolved within 6 months and have not recurred for more than a year with continued avoidance of marijuana. Our case is one of the few that features primarily marijuana-driven CA and highlights the importance of not only considering marijuana use but also blunt wrap use in patients presenting with Raynaud's phenomenon and ulcerations as cannabis use rises globally.

The Reliability and Quality of YouTube Videos as a Source of Information on Buerger's Disease: A Cross-Sectional Study

BACKGROUND

Patients are increasingly referring to the internet after a diagnosis of vascular disease. This study was performed to quantitatively define the accuracy and reliability of information on YouTube regarding Buerger's Disease (BD).

METHODS

A systematic search of YouTube was conducted using BD and thromboangiitis obliterans keywords. The default YouTube search setting of "relevance" was used to replicate an average search attempt, and the first 50 results from each keyword search were reviewed and analyzed by 2 independent reviewers. Descriptive characteristics, Journal of the American Medical Association Score (JAMAS), modified DISCERN score, Global Quality Score (GQS) were used to record data.

RESULTS

A total of 50 videos were reviewed for the study. The mean JAMAS, modified DISCERN, and GQS values among the videos were 2.06/4.00 (standard deviation [SD], 0.91), 2.36/5.00 (SD, 1.39), and 2.6/5.00 (SD, 1.16) respectively. When the videos were analyzed according to the user types uploading them, the modified DISCERN score was found to be significantly higher (3.57/5.00 SD, 0.97) in the videos uploaded by vascular surgeons (P = 0.029). High-quality videos were determined as more recent (P = 0.048). It was observed that the modified DISCERN and JAMA scores increased as the video quality increased.

CONCLUSIONS

While variable in source and content, the completeness and reliability of the information presented on YouTube about BD is poor. We believe that these videos should be uploaded more up-to-date and comprehensively by medical professionals, especially medical doctors.

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.

SMOKING AND BUERGER’S DISEASE: FROM HYPOTHESES TO EVIDENCE SYNTHESIS

Early after the definition of thromboangiitis obliterans (TAO), it was noticed that TAO patients are almost always tobacco smokers. Later on, the relationship between continued smoking and TAO prognosis was documented. Consequently, smoking came to be considered as the main cause of TAO. However, it is still unknown why, amongst millions of smokers, only a small number develop TAO. It also remains unknown why, of the TAO patients who continue smoking, only half of them show aggravation and undergo amputations. The aims of this review are to investigate evidence in support of or against the relationship between TAO and smoking, according to the TAO-related literature published from 1908 to January 2022, and to discover the possible role of smoking in TAO pathophysiology. Taken together, it appears that smoking predisposes TAO patients toward the potential harmful effects of the main aetiology and helps the main aetiology to develop vascular lesions. Therefore, smoking cessation would almost always be helpful for improving the prognosis of TAO patients and reducing disease manifestation. However, concluding that smoking is not the main aetiology of TAO would open a new door to finding the true main aetiology of TAO and to discovering the appropriate treatment and medical management of patients who fail to stop smoking.

Therapeutic angiogenesis in Buerger's disease: reviewing the treatment landscape

Thromboangiitis obliterans, also known as Buerger's disease, is a rare inflammatory vasculitis that predominantly develops in smokers and characteristically affects the small- and medium-sized peripheral arteries and veins. Patients typically present with extremity claudication, but symptoms may progress to rest pain and tissue loss, especially in those unable to abstain from tobacco use. Unfortunately, traditional medical treatments are largely ineffective and due to the small caliber of affected vessels and lack of suitable distal targets or venous conduits, endovascular and open surgical approaches are often not possible. Eventually, a significant number of patients require major amputation. For these reasons, much research effort has been made in developing techniques of therapeutic angiogenesis to improve limb perfusion, both for atherosclerotic peripheral arterial disease and the smaller subset of patients with critical limb ischemia due to Buerger's disease. Neovascularization in response to ischemia relies on a complex interplay between the local tissue microenvironment and circulating stem and progenitor cells. To date, studies of therapeutic angiogenesis have therefore focused on exploiting known angiogenic factors and stem cells to induce neovascularization in ischemic tissues. This review summarizes the available clinical data regarding the safety and efficacy of various angiogenic therapies, notably injection of naked DNA plasmids, viral gene constructs, and cell-based preparations, and describes techniques for potentiating in vivo efficacy of gene- and cell-based therapies as well as ongoing developments in exosome-based cell-free approaches for therapeutic angiogenesis.

Plain Language Title and Summary

A review of available and emerging treatments for improving blood flow and wound healing in patients with Buerger's disease, a rare disorder of blood vessels Buerger's disease is a rare disorder of the small- and medium-sized blood vessels in the arms and legs that almost exclusively develops in young smokers. Buerger's disease causes inflammation in arteries and veins, which leads to blockage of these vessels and reduces blood flow to and from the extremities. Decreased blood flow to the arms and legs can lead to development of nonhealing wounds and infection for which some patients may eventually require amputation. Unfortunately, traditional medical and surgical treatments are not effective in Buerger's disease, so other methods for improving blood flow are needed for these patients. There are several different ways to stimulate new blood vessel formation, both in humans and animal models. The most common treatments involve injection of DNA or viruses that express genes related to blood vessel formation or, alternatively, stem cell-based treatments that help regenerate blood vessels and repair wound tissue. This review explores how safe and effective these various treatments are and describes recent research developments that may lead to better therapies for patients with Buerger's disease and other vascular disorders.

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.

Current Trends in Epidemiology and Clinical Features of Thromboangiitis Obliterans in Japan - A Nationwide Survey Using the Medical Support System Database

BACKGROUND

The epidemiology and clinical features of thromboangiitis obliterans (TAO) in Japan have not been updated extensively.

METHODS AND RESULTS

This retrospective study used the Japanese Ministry of Health, Labour and Welfare (JMHLW) medical support system database and associated health insurance data. The number of medical financial support recipients registered as TAO patients and estimated prevalence of TAO decreased from fiscal year (FY) 2000 (10,089 and 7.95 [95% confidence interval, CI: 7.79-8.10] per 100,000 population) to FY 2010 (7,147 and 5.58 [95% Cl: 5.45-5.71] per 100,000) and leveled off until 2014. The prevalence of TAO among patients with peripheral arterial occlusive diseases declined from 7.15% (95% Cl: 7.00-7.31) in FY 2008 to 6.12% (95% Cl: 5.98-6.26) in FY 2014. Clinicodemographic features were obtained from 89 new recipients in FY 2013 and 2014: 12 (13%) women, 36 (40%) aged ≥50 years, 26 (29%) had probable onset age ≥50 years, 7 (8%) were non-smokers, and 12 (13%) had arteriosclerosis-related comorbidities. The symptoms were similar regardless of registration age, smoking history, or sex. Although 40 (45%) had digit ulcers, only 12 (13%) fulfilled Shionoya's criteria. They rarely had infrapopliteal lesions combined with upper extremity involvement or phlebitis.

CONCLUSIONS

The prevalence of TAO has decreased in Japan. In the current diagnosis of TAO, various clinical characteristics including late onset, arteriosclerotic factors, non-smoking, or mild symptoms should be considered.

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

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

The Imbalance among Oxidative Biomarkers and Antioxidant Defense Systems in Thromboangiitis Obliterans (Winiwarter-Buerger Disease)

(1) Background: Thromboangiitis obliterans or Winiwarter-Buerger disease (WBD), is an inflammatory, thrombotic occlusive, peripheral vascular disease, usually occurring in young smokers. The pathophysiological mechanisms underlying the disease are not clearly understood. The aim of this study is to investigate the imbalance between oxidants and antioxidants occurring in these patients. (2) Patients and Methods: In this cross-sectional study, 22 male patients with WBD and 20 healthy male smoking habit matched control group were included. To evaluate the possible sources of oxidative stress, the antioxidant biomarkers, and the markers of lipid peroxidation and protein oxidation, serum samples were analyzed for total oxidative status (TOS), total antioxidant capacity (TAC), myeloperoxidase (MPO), coenzyme Q10 (CoQ10), superoxide dismutase (SOD), glutathione reductase (GR), malondialdehyde (MDA), and protein carbonyl (PC) activity and/or content. (3) Results: The circulating levels of TOS, TAC, and CoQ10 were significantly higher in WBD patients, with respect to healthy smokers as controls. No significant difference was found among the serum level of PC, total cholesterol, MPO, and GR activity in WBD patients and healthy smoker controls. The activity of SOD and the mean serum level of MDA were significantly lower in WBD patients, with respect to healthy smoker controls. (4) Conclusion: Considerably high levels of oxidative stress were detected in WBD patients, which were greater than the antioxidant capacity. The low level of MDA may be associated with the enzymatic degradation of lipid peroxidation products. High levels of CoQ10 and low levels of SOD may be related to a harmful oxidative cooperation, leading to the vasoconstriction of WBD, representing a promising tool to discern possible different clinical risks of this poorly understood peripheral occlusive disease.

Fibrinogen, Neutrophil-to-Lymphocyte Rate and Platelet-to-Neutrophil Rate as Novel Acute Phase Indicators in Patients with Thromboangiitis Obliterans

BACKGROUND/OBJECTIVES

The acute exacerbations and progressive deterioration seen in thromboangiitis obliterans (TAO) have been related to poor clinical outcomes. Here, we have studied the association of laboratory biomarkers with the acute phase of TAO (AP-TAO).

METHODS/RESULTS

We conducted a retrospective case-control study on 112 patients with TAO and 98 healthy controls; comparing the neutrophil-to-lymphocyte rate (NLR), lymphocyte-to-monocyte rate (LMR), platelet-to-neutrophil rate (PNR), fibrinogen (FIB), and apolipoprotein A-I (ApoA-I). Significantly higher NLR level, as well as lower LMR, PNR, and ApoA-I levels were observed in patients with TAO, particularly the acute phase. Significantly increased FIB was only observed in AP-TAO. A positive correlation was found between NLR and with C-reactive protein (CRP) in the acute phase (r = 0.817, P < 0.001). Moreover, NLR, PNR, and FIB levels of 3.38, 45.12, and 3.69 were shown to be the predictive cut-off values for the AP-TAO (sensitivity 72.5, 82,4, and 66,7%, specificity 92.2, 78.4, and 96.1%; area under the curve [AUC] 0.875, 0.855, and 0.872), respectively. The FIB level was independently associated with the AP-TAO (OR = 11.420, P = 0.007).

CONCLUSIONS

NLR, PNR, and FIB may be useful markers for the identification of inflammation and the AP-TAO. FIB may be an independent risk factor for the acute phase.

Never Underestimate a Concomitant Repairable Inflow Lesion in Buerger's Disease!

A case of Buerger's disease is presented where percutaneous endovascular treatment of a concomitant focal stenosis in the superficial femoral artery led to immediate remission of symptoms and aided wound healing. The existence of such lesions should never be underestimated.

Treatment of Critical Limb Ischemia by pIRES/VEGF165/HGF Administration

BACKGROUND

Prognosis of peripheral artery disease (PAD), especially critical limb ischemia (CLI), is very poor despite the development of endovascular therapy and bypass surgery. Many patients result in having leg amputation. We decided to investigate the safety and efficacy of plasmid of internal ribosome entry site/vascular endothelial growth factor (VEGF) 165/hepatocyte growth factor (HGF) gene therapy (GT) in patients suffered from CLI.

METHODS

Administration of plasmid of internal ribosome entry site/VEGF165/HGF was performed in 12 limbs of 12 patients with rest pain and ischemic ulcers due to CLI. Plasmid was injected into the muscles of the ischemic limbs. The levels of VEGF in serum and the ankle-brachial index (ABI) were measured before and after treatment.

RESULTS

Mean (±SD) plasma levels of VEGF increased nonsignificantly from 258 ± 81 pg/L to 489 ± 96 pg/L (P > 0.05) 2 weeks after therapy, and the ABI improved significantly from 0.27 ± 0.20 to 0.50 ± 0.22 (P < 0.001) 3 months after therapy. Ischemic ulcers healed in 9 limbs. Amputation was performed in 3 patients because of advanced necrosis and wound infection. However, the level of amputations was lowered below knee in these cases. Complications were limited to transient leg edema in 3 patients and fever in 2 patients.

CONCLUSIONS

Intramuscular administration of plasmid of internal ribosome entry site/VEGF165/HGF is safe, feasible, and effective for patients with critical leg ischemia.

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.

Thromboangitis Obliterans involving Bilateral Upper limb Extremities - A Rare Case Report from Malaysia

Thromboangitis Obliterans (TAO) or Buerger's disease is a non-atherosclerotic, occlusive, progressive and highly inflammatory disorder of distal arteries seen predominantly affecting the lower limb in smokers. TAO presenting itself in upper limb or bilaterally involving the upper limb is a very rare entity. We report on a rare case of TAO in a 46-year-old gentleman who presented with bilateral upper extremity digital gangrene with 18 pack-years of smoking. Brachial and radial pulses were palpable bilaterally and were of good volume but right ulnar pulse was faintly felt, while on the left side it was not appreciated due to malunion. Further Computed Tomography (CT)- angiography showed occlusion of distal right ulnar artery, stenosis of distal left ulnar artery with bilateral poor opacification of palmar and digital arteries. This case reports on the unusual and rare presentation of TAO in upper extremity involving both limbs. The case is reported for the first time from Malaysia.

Hyperbaric Oxygen Therapy in the Treatment of Fontaine Stage IV Thromboangiitis Obliterans

Ischemic wounds unresponsive to standard treatment in thromboangiitis obliterans are associated with amputation, morbidity, and mortality. In this study, hyperbaric oxygen therapy was added to standard treatment of 36 patients with thromboangiitis obliterans with ischemic ulcerated wounds in the extremities. Full recovery was observed in 52.7% of cases (25% at discharge, 27.7% during follow-up). Resting pain after treatment decreased significantly compared to pretreatment levels based on visual analog scale scores (7.1 ± 1.7 vs 2.2 ± 3.0, P = .0001). Mean wound area also decreased significantly after treatment (22.6 ± 17.5 vs 13.02 ± 16.5, P = .0001). The number of patients requiring no assistance during routine daily activities increased significantly (25% vs 55.5%, P = .001). All patients were at Fontaine stage IV before hyperbaric oxygen therapy. The number of patients at stage IIB increased significantly after treatment, while that of patients at stage IV decreased significantly (0% vs 47.2%, P = .0001, and 100% vs 47.2%, P = .0001, respectively). None of our patients was able to walk without pain before treatment; however, walking distance was significantly extended in 16 patients who were capable of walking (0 vs 190.6 ± 129.4 meters, P = .0001). In addition, 11.1% of patients underwent major amputation during follow-up.

CFD simulation of blood flow inside the corkscrew collaterals of the Buerger's disease

Introduction: Buerger’s disease is an occlusive arterial disease that occurs mainly in medium and small vessels. This disease is associated with Tobacco usage. The existence of corkscrew collateral is one of the established characteristics of the Buerger’s disease.

Methods: In this study, the computational fluid dynamics (CFD) simulation of blood flow within the corkscrew artery of the Buerger’s disease is conducted. The geometry of the artery is constructed based on the actual corkscrew artery of a patient diagnosed with the Buerger’s disease. The blood properties are the same as the actual blood properties of the patient. The blood flow rate is taken from the available experimental data in the literature.

Results: The local velocity patterns, pressure and kinematic viscosity distributions in different segments of the corkscrew collateral artery was demonstrated and discussed for the first time for this kind of artery. The effects of non-Newtonian consideration for the blood viscosity behavior were investigated in different segments of the artery. Moreover, the variations of the blood flow patterns along the artery were investigated in details for each segment.

Conclusion: It was found that the flow patterns were affected by the complex geometry of this artery in such a way that it could lead to the presence of sites that were prone to the accumulation of the flowing particles in blood like nicotine. Furthermore, due to the existence of many successive bends in this artery, the variations of kinematic viscosity along this artery were significant, therefore the non-Newtonian behavior of the blood viscosity must be considered.

Politics, culture, and the legitimacy of disease: the case of Buerger's disease

Thromboangiitis obliterans (TAO) or Buerger's disease is a rare form of vasculitis with distinctive clinical and pathological features that carries significant morbidity, often leading to amputation, and is strongly associated with tobacco smoking. Despite its distinctive clinicopathological characteristics, the existence of TAO as an entity sui generis was challenged for many years as it languished in relative obscurity. Then, as societal attitudes towards smoking changed, TAO not only became accepted as a disease entity, it quite literally became a poster child to illustrate the ills of smoking. Herein, we examine the history of TAO to illustrate the power of societal attitudes and politics in shaping medicine.

Effectiveness of Intravenous Ilomedin Infusion and Smoking Cessation in the Treatment of Acutely Symptomatic Buerger Disease

We assessed the effectiveness of iloprost treatment in the management of symptomatic Buerger disease (BD) and assessed smoking cessation compliance, based on a single-center experience. Thirteen patients with BD were treated with sessions of intravenous (IV) Ilomedin infusion. At 1-year follow-up, pain status alteration, number of analgesics required, ankle–brachial index (ABI) change, compliance with supervised smoking cessation, and amputation-free rate were recorded. The pain status improved considerably according to a visual analog scale, the number of analgesics required was significantly reduced, and all patients improved their pain-free walking distance, the ABI, and their self-reported quality of life. Only 2 patients required minor amputations. Combination of IV Ilomedin infusion, supervised smoking cessation, and a specific follow-up protocol may lead to improvement in pain-free walking distance, pain status, quality of life, and substantial reduction in amputation risk.

Noninvasive Transcutaneous Monitoring in Long-Term Follow-Up of Patients With Thromboangiitis Obliterans Treated With Intravenous Iloprost

We evaluated the effectiveness of intravenous iloprost (IVI) in outpatients with thromboangiitis obliterans (TAO) and lower limb noninvasive transcutaneous monitoring (TCM) at follow-up (FU). Ten consecutive patients with TAO underwent IVI therapy. Transcutaneous oxygen (TcPo2) and carbon dioxide (TcPco2) determination and laser Doppler flowmetry (LDF) were performed before and after IVI at 3, 6, and 12 months of FU. Clinical response was positive in 7 patients, whereas 3 nonresponders underwent a second IVI cycle with 1 showing a late positive clinical response. After 12 months of FU, all patients were alive without amputations. Supine and dependent TcP2 levels significantly improved ( P < .005). Hallux LDF values showed significant change with the maximal hyperemic test at 44°C ( P < .005). Forefoot maximal hyperemic test at 44°C LDF ( P < .005) and improved venous arterial reflex ( P < .05) showed statistically significant time evolution. We demonstrated some degree of IVI effectiveness and evaluated TCM in patients with TAO.

Cerebral vasculitis

The noninfectious, inflammatory vasculitides include giant cell arteritis, Takayasu disease, Churg-Strauss angiitis, Wegener disease, polyarteritis nodosa, microscopic polyangiitis, Buerger disease, amyloid-β-related angiitis, and isolated vasculitis of the central nervous system. While these disorders are relatively uncommon, they produce a variety of neurologic diseases including muscle disease, mononeuropathy multiplex, polyneuropathy, cranial nerve palsies, visual loss, seizures, an encephalopathy, venous thrombosis, ischemic stroke, and intracranial hemorrhage. The multisystem vasculitides often have stereotypical clinical findings that reflect disease of the kidney, sinuses, lungs, skin, joints, or cardiovascular system. These disorders also usually have abnormalities found on serologic testing. Isolated vasculitis of the central nervous system is more difficult to diagnose because the clinical and brain imaging findings are relatively nonspecific. Examination of the cerebrospinal fluid will demonstrate changes consistent with an inflammatory process. Arteriography often shows areas of segmental narrowing affecting multiple intracranial vessels and brain/meningeal biopsy may be required to establish the diagnosis. Management of patients with a multisystem vasculitis or isolated vasculitis of the central nervous system is centered on the administration of immunosuppressive agents. In many cases, corticosteroids remain the mainstay of medical treatment.

CT angiography of the upper extremity arterial system: Part 2- Clinical applications beyond trauma patients

OBJECTIVE

CT angiography using modern MDCT scanners has evolved into a highly accurate noninvasive diagnostic tool for the evaluation of patients with pathologic abnormalities of the upper extremity arterial system.

CONCLUSION

Here we focus on the use of this modality in patients with nontraumatic vascular pathologic abnormalities.

Thromboangiitis Obliterans (Buerger's Disease)-Current Practices

Thromboangiitis obliterans (TAO) is a nonatherosclerotic, segmental inflammatory disease that most commonly affects the small and medium-sized arteries and veins in the upper and lower extremities. Cigarette smoking has been implicated as the main etiology of the disease. In eastern parts of the world TAO forms 40-60% of peripheral vascular diseases. Clinical features and angiographic finding are the basis of early diagnosis of TAO. Abstinence from smoking is the only definitive treatment to prevent disease progression. Medical management in form of aspirin, pentoxyfylline, cilostazol, and verapamil increase pain-free walking distance in intermittent claudication, but long term usage fails to prevent disease progression in patients who continue to smoke. Surgical treatment in form of revascularization, lumbar sympathectomy, omentopexy, and Ilizarov techniques help reduce pain and promote healing of trophic changes. Newer treatment modalities like spinal cord stimulation, prostacyclin, bosentan, VEGF, and stem cell therapy have shown promising results. Latest treatment options include peripheral mononuclear stem cell, and adipose tissue derived mononuclear stem cells have been shown to be effective in preventing disease progression, decrease major amputation rates, and improving quality of life.

Subintimal angioplasty of lengthy femorotibial total occlusion in Buerger's disease

PURPOSE

To report successful subintimal angioplasty of a lengthy femorotibial occlusion in a patient with Buerger's disease, with wound healing and limb salvage.

CASE REPORT

A 38-year-old female heavy smoker was referred to our hospital for treatment of extensive infectious tissue loss, with severe foot pain 1 month after early failure of a distal bypass graft. Angiography revealed total occlusion in the femoropopliteal and infrapopliteal arteries. Endovascular recanalization was attempted in order to establish "straight-line flow" to the foot on the verge of limb loss. The subintimal angioplasty technique with a 0.014-inch hydrophilic guidewire facilitated successful crossing of the occlusive femoropopliteal and posterior tibial arteries. The lesions were serially dilated (standard and cutting balloons). Angiography demonstrated antegrade flow to the foot without flow-limiting dissection, and the serious pain dramatically disappeared. Complete wound healing was observed 5 months after initial revascularization with the assistance of repeat angioplasty for restenosis.

CONCLUSION

Contemporary endovascular therapy using the subintimal angioplasty technique could represent a viable option for Buerger's disease.

Activation of cytokines corroborate with development of inflammation and autoimmunity in thromboangiitis obliterans patients

Thromboangiitis obliterans (TAO) is a segmental inflammatory occlusive disorder that affects the arm and leg arteries of young smokers. The immune system seems to play a critical role in the aetiology of TAO; however, knowledge of the aspects involved in the progression of vascular tissue inflammation and, consequently, the evolution of this disease is still limited. This study was carried out to investigate the cytokine levels of tumour necrosis factor (TNF)-α, interleukin (IL)-1β, IL-4, IL-17 and IL-23 in the plasma of TAO patients presenting with acute clinical manifestations. The study included 20 TAO patients (n = 10 women; n = 10 men) aged 38-59 years under clinical follow-up, classified into two groups: (i) TAO former smokers (n = 11) and (ii) TAO active smokers (n = 9); the control groups included normal volunteer non-smokers (n = 10, active smokers (n = 10) and former smokers (n = 10). Patients' plasma samples were measured using the sandwich enzyme-linked immunosorbent assay. Statistical analyses were performed using the non-parametric Mann-Whitney U-test, with parameters significant at P < 0·05. The activities of all cytokines were different in groups of TAO patients when compared with normal controls, and decreased for control smokers. Increased levels of TNF-α, IL-1β, IL-4, IL-17 and IL-23 were significant in patients with TAO when compared to the controls (P < 0·005, all parameters). The results presented here indicate an increased production of cytokines in TAO, possibly contributing to the inflammatory response observed in the patients' vascular levels. In addition, the increased levels of IL-17 and IL-23 suggest that the disturbance of TAO is involved with mechanisms of autoimmunity. Thus, the discovery of IL-17 and its association with inflammation and autoimmune pathology has reshaped our viewpoint regarding the pathogenesis of TAO, which was based previously on the T helper type 1 (Th1)-Th2 paradigm.

Imaging appearances of Buerger's disease complications in the upper and lower limbs

Thromboangiitis obliterans (Buerger's disease) is a rare, non-atherosclerotic, segmental, inflammatory vasculitis that most commonly involves small and medium-sized arteries, veins and nerves of the extremities and affects tobacco smokers between the ages of 25 and 45 years. The manifestations of Buerger's disease can be extremely variable and, therefore, awareness of the condition is important for both general and musculoskeletal radiologists. This paper presents the radiological appearance of the sequelae of Buerger's disease involving the upper and lower limbs.

Paraneoplastic Raynaud's phenomenon manifesting before the diagnosis of lung cancer

This description pertains to a previously healthy gentleman aged 54 years who developed symptoms coherent with Raynaud's phenomenon. The patient never had any prior episodes of peripheral cyanosis. The patient's first presentation was in summer and the paroxysms of peripheral cyanosis were not associated with any specific aggravating factor. The paroxysms went on to become more severe and painful across a span of 6 months, when he also developed non-radiating pain in the right lateral chest-wall, which would aggravate after episodes of cough. A chest roentgenogram then demonstrated the presence of a mass lesion in the right lung and a fine-needle-aspiration cytology confirmed malignancy- an adenocarcinoma. There was a dramatic relief in pain and a reduction in the intensity and duration of paroxysms of peripheral cyanosis within 2-weeks of initiation of chemotherapy for lung cancer.

Paraneoplastic Raynaud's phenomenon manifesting before the diagnosis of lung cancer

This description pertains to a previously healthy gentleman aged 54 years who developed symptoms coherent with Raynaud's phenomenon. The patient never had any prior episodes of peripheral cyanosis. The patient's first presentation was in summer and the paroxysms of peripheral cyanosis were not associated with any specific aggravating factor. The paroxysms went on to become more severe and painful across a span of 6 months, when he also developed non-radiating pain in the right lateral chest-wall, which would aggravate after episodes of cough. A chest roentgenogram then demonstrated the presence of a mass lesion in the right lung and a fine-needle-aspiration cytology confirmed malignancy- an adenocarcinoma. There was a dramatic relief in pain and a reduction in the intensity and duration of paroxysms of peripheral cyanosis within 2-weeks of initiation of chemotherapy for lung cancer.

Endovascular treatment is a hope for patient with Buerger's disease and foot ulcer: case report

Scarce information exists regarding the usefulness of the endovascular approach in patients with thromboangiitis obliterans and critical ischemia. A 41-old-man diagnosed with Buerger's disease had rest pain and a severe ulceration on the big toe. He had been scheduled for a big toe amputation. Typical findings of Buerger's disease were found in the angiogram including below-the-knee involvement and corkscrew collateral arteries. Stenoses of the posterior tibial artery were angioplastied and the plantar artery was recanalized and angioplastied. Healing was achieved and the patient remains asymptomatic 21 months after the procedure. The outcome achieved in this case and recent series should encourage doctors dealing with this problem to attempt limb salvage by means of the endovascular approach.

Circulating angiogenic factors in patients with thromboangiitis obliterans

Background

Thromboangiitis obliterans (TAO, also known as Buerger's disease) is a non-atherosclerotic inflammatory vascular disease that primarily affects arteries in the extremities of young adult smokers. Since the etiology of TAO is still unknown, therapeutic options are limited. Recent attempts in therapeutic angiogenesis have been promising. Therefore, the aim of our study was to evaluate angiogenic processes and factors including circulating progenitor cells in TAO.

Methodology/Principal Findings

TAO patients with critical limb ischemia and age- and gender-matched nonsmokers and smokers without cardiovascular disease (n = 12 in each group) were enrolled in the study. Flow cytometric analysis of peripheral blood showed significantly decreased levels of circulating CD45^dimCD34⁺ progenitor cells in TAO patients and in smokers compared to nonsmokers. In contrast to both control groups, the proportion of CD45^dimCD34⁺ progenitor cells co-expressing VEGF receptor-2 (VEGFR2) was significantly elevated in TAO patients. Enzyme-linked immunosorbent assay (ELISA) of common angiogenic factors (such as VEGF) did not clearly point to pro- or antiangiogenic conditions in serum or plasma of TAO patients. Serum of TAO patients and controls was evaluated in proliferation, migration (scratch assay) and spheroid sprouting assays using human umbilical vein endothelial cells (HUVECs). Serum of TAO patients exhibited a diminished sprouting capacity of HUVECs compared to both control groups. Proliferation and migration of endothelial cells were impaired after treatment with serum of TAO patients.

Conclusion

Levels of circulating progenitor cells were altered in TAO patients compared to healthy nonsmokers and smokers. Furthermore, serum of TAO patients exhibited an antiangiogenic activity (impaired endothelial cell sprouting, migration and proliferation) on endothelial cells, which may contribute to vascular pathology in this patient population.

Imbalanced matrix metalloproteinase-9 and tissue inhibitor of metalloproteinase-1 activities in patients with thromboangiitis obliterans

The pathogenic mechanisms of thromboangiitis obliterans (TAO) are not entirely known and the imbalance of matrix metalloproteinases (MMPs) plays a role in vascular diseases. We evaluated the MMP-2 and MMP-9 circulating levels and their endogenous tissue inhibitors of metalloproteinases (TIMP-1 and TIMP-2) in TAO patients with clinical manifestations. The study included 20 TAO patients (n = 10 female, n = 10 male) aged 38-59 years under clinical follow-up. The patients were classified into two groups: (1) TAO former smokers (n = 11) and (2) TAO active smokers (n = 9); the control group included normal volunteer non-smokers (n = 10) and active smokers without peripheral artery disease (n = 10). Patient plasma samples were used to analyze MMP-2 and MMP-9 levels using zymography, and TIMP-1 and TIMP-2 concentrations were determined by enzyme-linked immunosorbent assays. The analysis of MMP-2/TIMP-2 and MMP-9/TIMP-1 ratios (which were used as indices of net MMP-2 and MMP-9 activity, respectively) showed significantly higher MMP-9/TIMP-1 ratios in TAO patients (p < 0.05). We found no significant differences in MMP-2/TIMP-2 ratios (p > 0.05). We found higher MMP-9 levels and decreased levels of TIMP-1 in the TAO groups (active smokers and former smokers), especially in active smokers compared with the other groups (all p < 0.05). MMP-2 and TIMP-2 were not significantly different in patients with TAO as compared to the control group (p > 0.05). In conclusion, our results showed increased MMP-9 and reduced TIMP-1 activity in TAO patients, especially in active smokers compared with non-TAO patients. These data suggest that smoke compounds could activate MMP-9 production or inhibit TIMP-1 activity.

Natural history definition and a suggested clinical approach to Buerger's disease: a case-control study with survival analysis

The aim of this study was first to describe the natural history of Buerger's disease (BD) and then to discuss a clinical approach to this disease based on multivariate analysis. One hundred eight patients who corresponded with Shionoya's criteria were selected from 2000 to 2007 for this study. Major amputation was considered the ultimate adverse event. Survival analyses were performed by Kaplan-Meier curves. Independent variables including gender, duration of smoking, number of cigarettes smoked per day, minor amputation events and type of treatments, were determined by multivariate Cox regression analysis. The recorded data demonstrated that BD may present in four forms, including relapsing-remitting (75%), secondary progressive (4.6%), primary progressive (14.2%) and benign BD (6.2%). Most of the amputations occurred due to relapses within the six years after diagnosis of BD. In multivariate analysis, duration of smoking of more than 20 years had a significant relationship with further major amputation among patients with BD. Smoking cessation programs with experienced psychotherapists are strongly recommended for those areas in which Buerger's disease is common. Patients who have smoked for more than 20 years should be encouraged to quit smoking, but should also be recommended for more advanced treatment for limb salvage.

Buerger's disease (thromboangiitis obliterans): clinical features and assessment by colour duplex ultrasound

Buerger's disease is a progressive, nonatherosclerotic, segmental inflammatory vasoocclusive disease of unknown aetiology^1-9, affecting the small and medium sized arteries, veins and nerves and is often bilateral^5-7. The normal structure of the vessel wall is usually preserved, including the internal elastic lamina and media. Buerger's disease predominantly affects male cigarette smokers^1-3,8 with 11%-23% of disease distribution in females^6-7. Buerger's disease remains largely a clinicopathologic entity highlighting the importance of the sonographer's role to obtain a comprehensive clinical history and clinical examination. The combination of clinical assessment and the distinctive appearance of vessels affected by Bueger's disease on colour duplex ultrasound provide a useful tool for correct diagnosis.

Buerger's Disease (Thromboangiitis Obliterans)- Management by Ilizarov's Technique of Horizontal Distraction. A Retrospective Study of 60 Cases

In Buerger's disease conservative treatment is questionable. Arterial reconstructive surgery is not feasible and sympathectomy has limited role. Progression of the disease invariably leads to amputation. Ilizarov's method increases the vascularity of the ischaemic limb. Retrospective analysis of Ilizarov's technique in 60 patients was done. Immediate results took into account rest pain, colour of skin, venous return, temperature, pulse oxymeter measured oxygen saturation and ulcer/amputation stump wound healing. Early and late results took into account rest pain, healing of ulcers/amputation stump with or without plastic coverage, claudication distance, resumption of previous occupation and domestic ambulation. The mean follow up of patients was 63 months. Immediate results were promising except two amputations. Early result were excellent to good in 56 and late results were excellent to good in 48 patients. Deterioration had significant correlation with smoking. Ilizarov's method is an excellent and cheap procedure in treatment of Buerger's disease.

Regions of arterial stenosis and clinical factors determining transcutaneous oxygen tension in patients with peripheral arterial disease

AIMS

Despite the clinical usefulness of transcutaneous oxygen tension (TcPO(2)) to assess the severity of limb ischemia, the factors determining TcPO(2) in patients with peripheral arterial disease (PAD) have not been fully clarified. We therefore examined the regions of arterial stenosis and clinical factors affecting lower-extremity TcPO(2).

METHODS

Resting TcPO(2) (REST-TcPO(2)) and postexercise TcPO(2) (Ex-TcPO(2)) in the calf region and the dorsalis pedis were measured simultaneously in 66 patients (132 limbs) with clinically suspected PAD, in whom angiography was also performed.

RESULTS

The peripheral arteries of the lower extremities were divided into five segments, and the impact of significant stenosis in each segment on ipsilateral TcPO(2) was evaluated by multiple regression analysis. In the calf region, significant stenosis of the proximal arteries (common-external iliac artery) revealed stronger involvement determining Ex-TcPO(2) than the peripheral segment (posterior tibial artery). In the dorsalis pedis, the peripheral segment (anterior tibial artery) more strongly determined Ex-TcPO(2) and REST-TcPO(2) than proximal segments. Age, creatinine, and diabetes were associated with REST-TcPO(2) of the calf region independent of arterial stenoses, while those of the dorsalis pedis were independently associated with age, and creatinine. In contrast, Ex-TcPO(2) in both regions was not independently associated with clinical factors, except for stenosis of the perfusing arteries.

CONCLUSION

The vascular lesions affecting TcPO(2) differ between the calf region (proximal > peripheral) and the dorsalis pedis (proximal < peripheral). In addition postexercise TcPO(2) is solely determined by stenosis of the perfusing arteries, while TcPO(2) at rest is affected by multiple clinical factors.

Determination of kininogens levels and kallikrein/kininase II activities in patients with thromboangiitis obliterans

Some components of the kinin system such as plasma kallikrein levels, the activities of tissue kallikrein (including saliva) and kininase II and the concentrations of kininogen fractions (low-molecular weight/LKg and high-molecular weight/HKg) were evaluated in the plasma of patients with thromboangiitis obliterans (TAO) presenting clinical symptoms of the condition. Twenty TAO were diagnosed by means of the traditional Shionoya and Olin criteria and later classified into non-smokers (n = 11) and active smokers (n = 9). Fifty-three normal, non-smoking/smoking individuals (control) were also studied. Kininogen levels were determined by ELISA; the activities of kallikreins and kininase II were determined using selective substrates. The levels of enzymes (kallikreins and kininase II) and protein (kininogens) were significantly higher in patients with TAO who were active smokers compared to the control groups (no matter whether control individuals were active smokers or non-smokers, P < 0.001 for all comparisons). Interestingly, regardless of the time of disease onset, a significant increase in the levels of these components of the kinin system was also observed in patients when TAO active smokers were compared with TAO ex-smokers (P < 0.01 for all analysed parameters). Activation of the kinin system in patients with TAO may indicate the involvement of vasodilatation in an attempt to control vascular changes, thereby favouring the deposition of immune complexes at the vascular level because of nicotine stimulation. Moreover, our results corroborate the idea that TAO can be an autoimmune disorder with specific mechanisms.

Colon Ischemia Associated with Buerger's Disease: Case Report and Review of the Literature

Buerger's disease, or thromboangiitis obliterans, is a nonatherosclerotic inflammatory disease affecting the small- and medium-sized arteries and veins of the extremities (arms, hands, legs, and feet). It is most common in the Orient, Southeast Asia, India, and the Middle East, and usually affects men aged between 20 and 40 years, although it is becoming more common in women. It is well established that most such patients smoke heavily and experience an improvement in symptoms following smoking cessation. Mesenteric involvement in Buerger's disease is extremely rare; however, we describe herein two cases of colon ischemia in patients who were previously diagnosed with lower-extremity Buerger's disease. In one case, the patient developed colonic obstruction, and surgical resection was performed. Histopathologic findings were compatible with the chronic stage of Buerger's disease. In the other case, angiography revealed abrupt occlusion of the inferior mesenteric artery with numerous collateral vessels, just like the corkscrew appearance found in the extremities. If patients with established Buerger's disease of the extremities complain of gastrointestinal symptoms, early interventional diagnosis should be performed to prevent intestinal obstruction and gangrene.

Safety and Biodistribution Profile of Placental-derived Mesenchymal Stromal Cells (PLX-PAD) Following Intramuscular Delivery

The administration of mesenchymal stromal cells (MSCs) provides an exciting emerging therapeutic modality for the treatment of peripheral arterial disease, a condition that is associated with critical limb ischemia as its end stage. Placental-derived MSCs, termed PLX-PAD cells, are stable adhesive stromal cells isolated from full-term human placentae, cultured on carriers, and expanded in a bioreactor called the PluriX. These cells can be expanded in vitro without phenotypic or karyotypic changes. We studied the safety and biodistribution properties of PLX-PAD cells following intramuscular administration in NOD/SCID mice. No significant clinical signs, hematological and biochemical parameters, or major pathological changes were found in PLX-PAD-treated animals in comparison to vehicle controls. Several animals in the control and PLX-PAD-treated groups developed thymic malignant lymphoma, first seen after one month, as expected in this mouse strain. In addition, both groups developed spontaneous mesenteric vessel inflammation. Real-time quantitative polymerase chain reaction (RT-qPCR) demonstrated that distribution of PLX-PAD cells was confined to the injection site. Placental-derived MSCs remained in this site with gradual decrease in concentration during a three-month period. In view of these data, we conclude that the administration of PLX-PAD cells is not associated with any adverse effects in NOD/SCID mice.

Thromboangiitis obliterans in the 21st century--a new face of disease

Thromboangiitis obliterans (TAO) is a relatively rare disease of peripheral blood vessels, affecting small and medium sized arteries and veins. Although the first description of the disease was given by Winiwarter almost 130 years ago, etiology of TAO remains not elucidated. Smoking is considered as a precipitating factor of the disease. We emphasised some particular features of the new face of TAO - significant decrease in incidences, increased disease prevalence among women and coexistence of other than smoking atherosclerotic risk factors (especially disturbances of glucose metabolism). Contemporary methods of treatment were also discussed.

Penile and scrotal involvement in Buerger's disease

Buerger's disease (thromboangiitis obliterans) is a recurrent inflammatory, nonatherosclerotic vasoocclusive disease, which typically affects small and medium-sized arteries, veins and nerves of the upper and lower extremities. Although the exact underlying causes of Buerger's disease are still unknown, the disease is strongly associated with tobacco smoking. Affected patients are mostly young male smokers who develop ulcers and gangrene of the toes and fingers as a result of vascular ischaemia. We report a 47-year-old man with scrotal and penile necrosis. Partial penectomy, scrotal debridement and urethra-cutaneous anastomosis were performed.