buerger s disease · buerger’s disease new endovascular approach louay altarazi, m.d damascus,...

Buerger’s Disease New endovascular approach

Louay Altarazi, M.D Damascus, Syria

"Oriental" countries are well known for certain life style and

history, they also share certain characteristic vascular

pathologies and social reactions to disease and treatment.

Buerger’s disease “TAO” may be the most typical entity due

to its high prevalence in our region and rarity in occidental

population, the difficulties to deal with the characteristic

psychic background of those young patients and the increase

of young smokers in oriental societies.

In Syria this pathology presents 6 -15% of all

foots critical ischemia cases and

More than 70% of male young's foot necrosis

How to treat ? (literature)

Conservative treatment+(tobacco cessation) ?: 19% minor amputations; 19% major amputations and 6% upper limb amputations !!

By-Pass surgery ?: less than 10% suitable for surgical revascularization, variable results. SYMPATHECTOMY efficient, may relieve symptoms !!

Novel therapies ?: stem cells implantation and gene transfer ?

Endovascular therapy ?: very rare previous experiences of published !!

Conservative treatment+(prostaglandines) good confirmed results;

IV adminstration daily for one to tow months associated with tobacco cessation

Ultrasonic diagnostic

corkscrew appearance, bidirectional flow

Inclusion Criteria

Olin’s Diagnostic criteria

• Age under 45 years

•Current or recent history of tobacco use

• Presence of distal-extremity ischemia indicated by claudication, pain at rest, ischemic ulcers or gangrenes and documented by non-invasive vascular testing

• Exclusion : autoimmune diseases, hypercoagulability states, Diabetes, presence of arterial calcifications

• Exclusion: proximal source of emboli by echocardiography or arteriography

• Exclusion: non cooperation, smoking continuation, follow-up difficulties

The procedure (in brief)

before during after

Before during after

The procedure (in brief)

Before during after

The procedure (in brief)

Before during after

The procedure (in brief)

Angiosomal concept

A T PER P T

Anatomic Consideration

BTK endovascular procedures

characteristics

AtherosclerosisDiabetic arteriopathy

Buerger’sdisease

Pain during procedure

slightly painful specially during inflating balloons

painless Can be very Painful

Recoil after PTA Possible leading toVascular reoclusion

Very rare Frequent but often transitory

Wire & cath-balloon passage

Relatively easy somehow difficult Difficult needs hard pushability

Subintimal way Almost possible Sometimes feasible impossible

Incomplete recanalization

Rarely useful ineffective Can be effective du to intense vasavasoriumdevelopment

Peri-procedure care

tobacco cessation test for at least 15 days +- psychic consultation

Peri-op Aspirin or Clopidogrel

Anticoagulation during procedure and 5 days post-op

Peri-op 48h corticosteroids +- Nitroglycerin +- diltiazem

Prostaglandins (prostavasine I.V 3amp/d) 3 days pre-0p for 10 days

Associated intrarterial thrombolysis if evidence of fresh thrombus or recent rapid ischemia progression

33 procedures in 28 male patients (out of 78 candidate)

CLI, foot necrosis or sever rest pain

7 passage failure, 5 associated thrombolysis

26 procedure achieved; 17 complete recanalization of at least on artery to foot, 9 partial recanalization.

2 cases needed redu intervention

average age 28 (21-44) years

Average procedure time 72 minutes

From January 2006 to July 2011

Clinical Improvement

(21 patients followed for 6-30 months)

One major and three minor amputation

Before after

Clinical case

Before after

Clinical case

Before after

Clinical case

Before after

Clinical case

Before after

Clinical case

Before after

Clinical case

Clinical limit case

Conclusion

Endovascular procedures are feasible and can be effective for the treatment of Büerger´s (TAO)

disease.

Associated with an excellent medium term results and extremely low complications , this approach deserves to be encouraged and to be subject to

further trails and evaluation.

It’s role as first line treatment for patients with TAO presenting CLI has to be supported in future

studies