CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 5, September/October 2022 254 AFRICA Endovascular treatment of Buerger’s disease in patients with critical limb ischaemia Deniz Serefli, Onur Saydam Abstract Objectives: Thromboangitis obliteransis (TAO) is a nonatherosclerotic, inflammatory, occlusive arteritis that affects small and medium-sized arteries, veins and nerves. A large proportion of patients with TAO suffer from claudication, and the ultimate condition is gangrene and limb loss if there is no treatment or the cessation of smoking. Endovascular revascularisations are performed frequently and provide acceptable results in patients who are not suitable for surgery. In this study, we aimed to show our clinical experience in patients with TAO who were treated with endovascular revascularisation. Methods: Between January 2014 and March 2020, 18 patients with lower-extremity critical limb ischaemia (CLI) underwent endovascular treatment (ET). Technical details and clinical success at follow up were documented. Results: This study included 18 patients with lower-extremity TAO who presented with CLI and were treated with ET. The mean age of the patients was 38.8 ± 7.3 years. Fifty per cent of patients had pain at rest, 33.7% had minor tissue loss and non-healing ulcers, and 16.7% had major tissue loss on admission. The majority of lesions were located in the peroneal and tibial arteries (n = 13, 72.2%). Two (11.1%) patients had distal superficial femoral artery occlusion concomitant with popliteal artery (PA) lesions, and three (16.7%) had PA occlusion concomitant with peroneal and tibial artery lesions. Re-establishment of antegrade flow in at least one vessel was achieved in 15 (83.3%) patients. Balloon angioplasty was performed in all patients. Plain old balloon angioplasty (POBA) was used in nine (60%) patients and drug-eluting balloon (DEB) angioplasty in six (40%). The mean duration of follow up in 15 patient who had undergone successful ET was 21.5 ± 8.1 months. The primary CLI-free rate at 12 and 24 months was 80% (66.7% in all patients). Secondary CLI-free rates at six, 12 and 24 months were 100, 93.3 and 53.3%, respectively. Patients who were active smokers during their follow up had a higher frequency of out-patient clinic consultations (p = 0.03). Conclusion: Controversy has continued on the role of ET in the treatment of TAO. This study shows that ET of TAO had promising primary and secondary patency rates with high technical success and limb-salvage rates. Keywords: peripheral arterial disease, Buerger’s disease, endovascular procedures Submitted 18/7/21, accepted 1/4/22 Published online 30/6/22 Cardiovasc J Afr 2022; 33: 254–259 www.cvja.co.za DOI: 10.5830/CVJA-2022-018 Thromboangitis obliterans (TAO), also known as Buerger’s disease, is a non-atherosclerotic, inflammatory occlusive arteritis that effects small and medium-sized arteries, veins and nerves.1 TAO occurs episodically and the use of tobacco and its products can trigger the process.2,3 Although genetic factors such as human leukocyte antigen (HLA)-related factors and genetic polymorphism have been emphasised due to their regional distribution, the aetiology of TAO is unknown.4,5 Initial symptoms of TAO commonly include coldness, pallor, cyanosis, burning pain, sensory findings and/or phlebitis of the affected limb. These symptoms can easily be confused with atherosclerotic peripheral artery disease. Therefore, the diagnosis of TAO has been based on clinical signs and imaging methods. In two studies that have often been quoted, the criteria include a history of smoking, onset before the age of 50 years, belowknee arterial occlusions, either upper-extremity involvement or superficial phlebitis migrans, the absence of atherosclerotic risk factors except for smoking, the presence of ischaemia (resting pain, minor or major tissue loss), and consistent arteriographic findings in the clinically involved and non-involved limbs.6,7 One must also rule out autoimmune diseases, hypercoagulability syndromes, diabetes mellitus, and a proximal source of emboli using echocardiography and arteriography. A large proportion of patients with TAO suffer from claudication, and the ultimate condition is gangrene and limb loss if there is no treatment or the cessation of smoking.6 Cessation of smoking is the most effective option and without this, other treatment options may be insufficient. Medical treatment with prostanoid therapy, antiplatelets, anticoagulant drugs, vasodilators and surgical treatment with sympathectomy, omentum transfer and revascularisation are the treatment options. Revascularisation can be performed either surgically or endovascularly.4 Surgical revascularisation has acceptable results in appropriate patients, however the absence of suitable venous conduits and distal run-off vessels results in surgery being performed in a more limited population. Wound healing can also be a challenging situation after surgical revascularisation. In the light of all these difficulties, alternative methods, such as endovascular revascularisation, are performed more frequently and provide acceptable results in patients who are not suitable for surgery.8-10 In this study, we aimed to demonstrate our clinical experience in patients with TAO who were treated with endovascular revascularisation. Department of Cardiovascular Surgery, Tepecik Training and Research Hospital, Izmir, Turkey Deniz Serefli, MD, dseref@gmail.com Onur Saydam, MD
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