Critical Limb Ischemia Due to Suspected Buerger's Disease in an Adolescent Patient: A Case Report

Buerger's disease is a segmental and inflammatory syndrome affecting relatively young individuals primarily and occurs with occlusion of small to medium-sized vessels in their extremities. The typical age for symptoms to appear is between 35 and 50 years in smoking patients. The disease is not manifested in children or the elderly. The only recognized successful treatment for it is immediate termination of smoking. In this report, we describe the case of a 16-year-old male suffering from this condition and referred from the pediatric department to our clinic, followed by a literature review of Buerger's disease reported in adolescent patients.

Comparative Analysis of Transcriptome Profiles in Patients with Thromboangiitis Obliterans

BACKGROUND

Thromboangiitis obliterans (TAO) causes vascular insufficiency due to chronic inflammation and abrupt thrombosis of the medium and small arteries of the extremities. In our study, we aimed to determine biomarkers for the diagnosis of TAO by evaluating 15 male TAO patients with Shinoya diagnostic criteria and 5 healthy controls who did not have TAO-related symptoms in their family histories.

METHODS

The Clariom D Affymetrix platform was used to conduct microarray analysis on total RNA extracted from whole blood. A total of 477 genes (FC ≤ 5 or >5) common to the fifteen patient and five control samples were selected using comparative microarray analysis; among them, 79 genes were upregulated and 398 genes were downregulated.

RESULTS

According to FC ≤ 10 or >10, in the same TAO patient and control group, 13 genes out of 28 were upregulated, whereas 15 genes were downregulated. The 11 key genes identified according to their mean log2FC values were PLP2, RPL27A, CCL4, FMNL1, EGR1, EIF4A1, RPL9, LAMP2, RNF149, EIF4G2, and DGKZ. The genes were ranked according to their relative expression as follows: FMNL1 > RNF149 > RPL27A > EIF4G2 > EIF4A1 > LAMP2 > EGR1 > PLP2 > DGKZ > RPL9 > CCL4. Using protein-protein interaction network analysis, RPL9, RPL27A, and RPL32 were found to be closely related to EIF4G2 and EIF4A1. The Reactome pathway found pathways linked to 28 genes. These pathways included the immune system, cellular responses to stress, cytokine signaling in the immune system, and signaling by ROBO receptors.

CONCLUSIONS

By figuring out the protein expression levels of the genes that have been found to explain how TAO disease works at the molecular level, it will be possible to figure out how well these chosen transcripts can diagnose and predict the disease.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Endovascular Treatment of Critical Limb Ischemia in Buerger Disease (Thromboangiitis Obliterans) With Midterm Follow-Up: A Viable Option When Bypass Surgery Is Not Feasible

OBJECTIVE. Thromboangiitis obliterans (TAO) is an occlusive inflammatory disease affecting small- and medium-sized vessels that causes decrease in life quality and eventually limb loss. The only proven treatment method is smoking cessation, but it may be insufficient for limb salvage in patients with critical limb ischemia. In this single-center retrospective study, the feasibility and efficiency of endovascular treatment in TAO were evaluated. MATERIALS AND METHODS. After approval of the local institutional review board, 41 patients who underwent endovascular treatment of TAO between January 2014 and June 2019 were evaluated retrospectively. Technical success and procedure-related complications were recorded. Decrease in Rutherford classification score, relief of pain, and wound healing were evaluated to determine clinical success. Primary patency, limb salvage rate, and amputation-free survival were also evaluated. RESULTS. A total of 45 limbs were treated during the study period. Technical success was achieved in 82.2% of procedures. Mean follow-up was 29.8 months. Clinical improvement was achieved in 35 limbs. Three patients underwent major amputation and 12 patients underwent minor amputation. Amputation-free survival and limb salvage were both 93.3% at both 1 and 2 years. Reintervention was performed in 14 patients because of occlusion and clinical relapsing of the symptoms. CONCLUSION. Endovascular treatment of TAO is feasible, has a potential to prevent limb amputation in patients with critical limb ischemia, and has acceptable technical success and limb salvage rates. Because there is no consensus in treatment of TAO, prospective comparative studies are needed to determine the effectiveness of an endovascular approach.

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.