CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 5, September/October 2022 258 AFRICA months. Two patients had undergone re-intervention with ET. One patient had successful recanalisation with DEB and was discharged without CLI symptoms. Lumbar sympathetic blockage was performed on the patient who had unsuccessful ET and another seven patients who had not undergone ET due to unsuitable vascular lesions. Prostaglandin infusion was administered to all patients regardless of intervention type. None of the patient underwent amputation during their re-admission. Seven out of nine patients who underwent re-intervention were active smokers during the follow-up period. There were significant differences in terms of re-intervention between patients who quit smoking and active smokers (p = 0.02). Although no significant difference was found between treatment modalities, all three patients who had undergone ET with a combination of atherectomy and DEB angioplasty had 100% primary CLI-free rate at 24 months (p = 0.052). Although DEB angioplasty had better primary CLI-free rates at 12 (83 vs 78%) and 24 (67 vs 44%) months compared with POBA, no significant differences were found (p = 0.48). After re-intervention, three patients underwent unplanned amputation during their follow-up period. One patient had unsuccessful re-intervention and underwent lumbar sympathetic blockage 10 months before the unplanned amputation. The other two patients were also admitted and directly underwent lumbar sympathetic blockage due to unsuitable vascular lesions for ET, two and five months before the amputation. All three patients were active, heavy smokers during their follow up. Limb salvage rate was 80%. Secondary CLI-free rates at six, 12 and 24 months were 100, 93.3 and 53.3%, respectively. No mortality was observed during the follow up. The median frequency of attendance at the out-patient clinic was seven (2–15) visits per year. Patients who were active smokers during their follow up had a higher frequency of out-patient clinic attendance (p = 0.03). Discussion The improvement and mid-term outcomes of 18 patients with TAO who were treated with ET were promising. It was demonstrated in previous studies that the incidence of TAO has decreased over the past few decades, and this has been associated with reduced smoking habits and improved socio-economic conditions.2,7 Since there is less diagnosis and treatment of TAO patients, difficulties may arise in both diagnosis and treatment. It is not surprising that this disease is observed in the working class due to their low social status.2 Our hospital receives patients from a region where the working class generally attend and where low socio-economic conditions are observed. Our patients were therefore in a low socio-economic class and all had a history of smoking. The condition experienced by this class may be related to problems such as a protein-poor diet, frequent infections, dental problems and neglect of diseases. In terms of aetiological factors, many studies have investigated HLA-related factors and genetic polymorphism but no clear results have been obtained.5 It was also emphasised that this may be due to low sample size of the studies.4 Pathologically, different processes were revealed at different stages of the TAO lesions, such as endothelial activation and proliferation, immunocompetent cell accumulation, immunoglobulin and complement deposition, micro-abse formation, cytokine activation and the emergence of various antibodies.12,13 However, these findings are not pathognomonic and do not cause TAO.4 On the other hand, there is no other disease that has such a close relationship with smoking.14 In our study, all patients were current smokers at the time of diagnosis. Smoking cessation is unfortunately a difficult process and its success rate is low.15,16 Moreover, in the character analysis of these patients, it was revealed that they were indifferent to the disease and adopted a self-destructive lifestyle.17 With all these unfavourable conditions, treatment of the disease may be more difficult. Due to these factors, in our study there were significant differences in terms of re-intervention between patients who quitted smoking and active smokers. Although quitting smoking is the fundamental step in treatment and recovery, most of the time, other treatment methods will be required after CLI has developed.7,18 In addition to conventional treatment methods (prostanoids, anticoagulant and anti-aggregant drugs, vasodilators, surgery and endovascular revascularisation, sympathectomy/sympathetic blockade), relatively new treatment options (progenitor cell therapy) and regionally applied treatment methods such as omental transfer are used in TAO patients.4 However, with recent experience and the development of new methods and devices, the most promising of these methods may be ET.9,19-22 We applied ET in 15 of our 18 patients with 83.8% primary success rate. This coincides with the success rates of 66 to 96% in the literature.9,10,19,22 There may be several reasons why the lesions could not be crossed in the other three patients. First is diffuse involvement of the disease in the artery and the simultaneous occurrence of acute thrombosis to chronic sclerosis.4 Therefore, in this challenging situation, it may be necessary to intervene with various advanced techniques to cross the lesion. In parallel, several studies using advanced ET as a combination have revealed high technical success rates.9,20 A second reason for treatment failure may be related to the fact that the disease retains small vascular structures with a relatively thick muscular layer (Rutherford arterial wall), and may be susceptible to vasospasm. In addition, catheter-induced vasospasm can cause angiographically unsuccessful results, even if the lesion is passed. In particular, patients whose do not have pain relief after the procedure may experience vasospasm. Accordingly, two of the patients who underwent successful revascularisation did not have any relief from their possible vasospasm symptoms and they were treated with intra-arterial vasodilators. The primary CLI-free rate of the 15 patients successfully treated was 67% at 24 months. This rate was relatively low compared to the literature.9,20,22 However, clinical improvement was considered rather than patency. As emphasised above, smoking may be the most critical factor in exacerbation of the disease, and the rate of smoking increased significantly in nine patients who underwent intervention (p = 0.02). Clinical recovery was re-attempted in these patients with at least one intervention, including ET. However, the secondary CLI-free rate at 24 months was only 53%. One-year results were however better at 93%. Therefore, good results may be obtained with different treatment combinations with close clinical follow up in the early period, but CLI seems inevitable for these patients in the mid to long term.
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