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)
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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
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Before after
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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