Very distal vein bypass in patients with thromboangiitis obliterans

Abstract

Summary:Background: Surgical revascularization for chronic critical limb ischaemia in patients with thromboangiitis obliterans (TAO) still remains controversial. Generally, besides cessation of smoking, conservative treatment supported by intravenous administration of vasoactive agents is regarded as the treatment of choice, in combination with local wound therapy or minor amputation. Patients and methods: In four male patients (42-47 years) surgical revascularization was chosen as therapy for established gangrene or non-healing ulceration after unsuccessful conservative treatment and cessation of smoking. Angiography was able to identify a suitable distal arterial segment for the bypass which was revascularized by means of an autologous vein graft. Grafts were followed with repetitive duplex ultrasound. Revision of the bypass graft was initiated if indicated by pathological duplex fi ndings. Results: In all cases a bypass could be constructed with either the ipsilateral greater saphenous vein or arm veins. A distal origin confi guration was possible in three cases with popliteo-pedal or cruro-pedal bypasses. In the fourth case the distal superfi cial femoral artery was used for infl ow. Two early graft thromboses underwent successful revision. During follow-up, duplex ultrasound identifi ed graft stenoses in three bypasses which were successfully treated with endovascular techniques. All grafts are patent with complete resolution of ischaemic symptoms after 46, 42, 32, and 29 months. The patients remained non-smokers and returned to a professional life. Conclusions: Surgical therapy with distal vein bypass for persistent ischaemic symptoms after defi nitive cessation of smoking seems feasible in selected cases with TAO and a suitable distal artery. Close follow-ups of the patients with duplex ultrasound are necessary to identify developing vein graft stenoses. Angioplasty seems to be an important part of the long-term therapeutic concept.Keywords: Thromboangiitis obliterans, bypass, limb salvage, human, vascular patency ease frequently involves the small distal arteries of the calf and the foot with complete obliteration of the vessel lumen and absence of a suitable distal artery for bypass. The angiographic pattern of TAO is characterized by occlusions of the tibial and pedal arteries and the presence of typical corkscrew collaterals with normal proximal arteries [2,3]. Surgical revascularization with autologous vein bypass is rarely regarded as feasible due to the absence of healthy distal arterial segments or because of the small calibre of patent arteries and recent advances in conservative treatment. Superfi cial veins may become aff ected by the disease in form of phlebitis migrans with consecutive infl ammatory changes [4]. Hence previous infl ammation of the superfi cial veins often limits their availability as bypass grafts. However surgical vein bypass was recommended by Asian groups and a few European groups as an eff ective therapy for critical ischaemia [5][6][7][8][9]. The results of a contemporar...

Outcomes of endovascular treatment versus bypass surgery for critical limb ischemia in patients with thromboangiitis obliterans

“…TAO is regarded as a chronic inflammation of the small and medium-sized arteries and veins of both the lower and upper extremities with unknown etiology affecting younger smokers followed by a thrombotic occlusion [ 2 , 3 ]. Although medical treatment and smoking cessation are sometimes sufficient to induce a remission of the ischemic symptoms, resulting in relatively favorable outcomes for the affected limbs in contrast to patients with ASO, the resulting ischemia may lead to severe chronic symptoms such as non-healing ulceration and gangrene, and even major amputation [ 2 , 3 ].…”

“…TAO is regarded as a chronic inflammation of the small and medium-sized arteries and veins of both the lower and upper extremities with unknown etiology affecting younger smokers followed by a thrombotic occlusion [ 2 , 3 ]. Although medical treatment and smoking cessation are sometimes sufficient to induce a remission of the ischemic symptoms, resulting in relatively favorable outcomes for the affected limbs in contrast to patients with ASO, the resulting ischemia may lead to severe chronic symptoms such as non-healing ulceration and gangrene, and even major amputation [ 2 , 3 ]. In patients with TAO in jeopardy of losing a foot or leg, a more aggressive therapeutic option, either endovascular or surgical procedure, is required to not only avoid major amputation (allowing a return to ambulation) but also to stabilize the socioeconomic situation (allowing a return to work) of these relatively young patients [ 14 ].…”

Integration of traditional Chinese medicine and nibble debridement and dressing method reduces thrombosis and inflammatory response in the treatment of thromboangiitis obliterans

“…Thromboangiitis obliterans (TAO) is a chronic occlusive disease characterized by segmental, non-suppurative inflammation, and intravascular thrombus formation (1). It mainly invades the limbs, especially the small and medium arteries and veins of the lower limbs, and then causes ischemic changes in the distal side of the affected limb (2).…”

Predictive value of serum VEGF, IL‑1 and TNF‑α in the treatment of thromboangiitis obliterans by revascularization

“…In recent years, it has been shown that the prevalence of TAO in women has also increased, reaching 11-23% ( 2 ). Early TAO manifests as ischemic symptoms, and in the advanced stage, symptoms such as limb ulcers and gangrene appear ( 3 ). Although there is a detailed understanding of the occurrence and development of TAO, TAO has the characteristics of being difficult to cure clinically.…”