Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 231-237

A prospective study of surgical revascularization in patients of buerger's disease from North India


1 Department of Cardiothoracic Surgery, Jawahar Lal Nehru Medical College and Hospital, AMU, Aligarh, Uttar Pradesh, India
2 Department of Cardiothoracic and Vascular Surgery, PGIMER RML Hospital, New Delhi, India
3 Department of General Surgery, Jawahar Lal Nehru Medical College and Hospital, AMU, Aligarh, Uttar Pradesh, India
4 Department of Cardiothoracic Surgery, GB Pant Hospital, New Delhi, India
5 Department of Cardiothoracic and Vascular Surgery, VMMC and Safdarjung Hospital, New Delhi, India
6 Department of General Surgery, FH Medical College, Tundla, Uttar Pradesh, India

Date of Submission12-Aug-2020
Date of Decision19-Aug-2020
Date of Acceptance05-Sep-2020
Date of Web Publication6-Jul-2021

Correspondence Address:
Mayank Yadav
Department of Cardiothoracic Surgery, Jawahar Lal Nehru Medical College and Hospital, AMU, Aligarh, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_114_20

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  Abstract 


Introduction: Buerger's disease, also known as thromboangiitis obliterans (TAO), is vasculitis of small- and medium-sized arteries and veins, which may involve both upper and lower extremities. It is strongly related to smoking and fairly common in the Indian subcontinent. Diagnosis is based on history, clinical examination, and angiography. The single most important modality of treatment is smoking cessation. As only few patients have suitable anatomy for surgical revascularization, the aim of this study is to evaluate the feasibility and outcome of surgical revascularization in TAO patients of North India. Methods: This is a prospective observational study involving 50 patients of TAO diagnosed by modified Shionoya criteria who underwent surgical revascularization. Computed tomographic angiography was done in all patients to see their suitability for surgical revascularization. Graft patency at 6 months postsurgery, pre- and post-operative ankle–brachial pressure index (ABPI), and visual analog scale (VAS) score for pain were calculated and compared. Results: All patients were male bidi smokers, with a mean age of 29.8 ± 9.5 years. Intermittent claudication was present in 42%, rest pain in 58%, and ulcer in 40%. Most common area of blockage was tibioperoneal trunk (62%) and tibial arteries (52%). The most frequent bypass procedure was popliteotibial done in 32 (64%) patients, followed by femoropopliteal bypass in 8 (16%) patients. Majority of our patients were symptom free at 6 months postsurgery. The mean VAS score for pain at the time of presentation was 6.08 ± 1.77, which decreased to 1.62 ± 1.23 at the end of 6 months. The mean preoperative ABPI was 0.45 ± 0.12 which improved to 0.73 ± 0.09 at 6 months postsurgery. A total of 46 (92%) limbs were salvaged while overall our graft patency rate was 70% at 6 months. Conclusion: We conclude that surgical revascularization is feasible in properly selected patients of TAO with acceptable results.

Keywords: Buerger's disease, critical limb ischemia, surgical revascularization, thromboangiitis obliterans


How to cite this article:
Haseen MA, Ghazanfar M, Aslam M, Yadav M, Singh SP, Naqvi SE, Gupta M, Beg MH. A prospective study of surgical revascularization in patients of buerger's disease from North India. Indian J Vasc Endovasc Surg 2021;8:231-7

How to cite this URL:
Haseen MA, Ghazanfar M, Aslam M, Yadav M, Singh SP, Naqvi SE, Gupta M, Beg MH. A prospective study of surgical revascularization in patients of buerger's disease from North India. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Jul 26];8:231-7. Available from: https://www.indjvascsurg.org/text.asp?2021/8/3/231/320611




  Introduction Top


Thromboangiitis obliterans (TAO) is an inflammatory, segmental, nonatherosclerotic, occlusive disease of small- and medium-sized arteries and veins that involve distal vessels of the extremities. Felix von Winiwarter was the first to describe TAO; it was revisited by Leo Buerger in 1908, after which TAO became commonly referred to as Buerger's disease.[1] Leo Buerger proposed a multifactorial etiology of the disease, with smoking being an important determinant.[2]

Genetic factors with geographical distribution also play a role as Buerger's disease does not afflict all heavy smokers and is more common in India, Korea, and Japan as compared to Western Europe.[3],[4] Earlier studies showed that Buerger's disease primarily affected young male smokers; however, recently, with changing habit of smoking in females, they are constituting up to 20% of diagnosed patients.[5],[6] Presence of autoantibodies such as anti-endothelial antibodies and anticardiolipin antibodies point toward its autoimmune origin.[7],[8]

Early symptoms may include episodic pain and coldness in fingers, and late findings may present as intermittent claudication, skin ulcers, or gangrene requiring eventual amputation.[9] Diagnosis is usually based on clinical and angiomorphologic criteria published by Olin et al. and Shionoya.[10],[11]

Abstinence from smoking is the only definitive treatment to prevent disease progression. Medical management in the form of aspirin, pentoxifylline, cilostazol, and calcium channel blockers increases pain-free walking distance in intermittent claudication.[12] Surgical treatment in the form of revascularization, lumbar sympathectomy, omentopexy, and Ilizarov techniques help reduce pain and promote healing of trophic changes.[12] Several studies have shown that surgical revascularization is possible in properly selected subgroup of patients and it yields good results.[13]

We planned this study to see the feasibility and outcomes of surgical revascularization in Buerger's disease. Since ours is a tertiary care center of Western Uttar Pradesh, we see a lot of patients being referred to us for the management of TAO.


  Methods Top


This single-center prospective nonrandomized observational study was conducted between September 2015 and March 2019, with follow-up through February 2020. During this period, 187 patients of Buerger's disease of the lower limb were seen, out of which 73 patients needed surgical revascularization, but only 50 patients had suitable vascular anatomy. Baseline demographic and clinical data were collected, and each patient was categorized using the Rutherford classification.[14]

To be included in the study, the patients had to fulfill the modified Shionoya criteria:

  1. Onset of distal ischemic symptoms in one extremity before the age of 50 years
  2. Smoker or history of smoking
  3. Distal ischemia of the extremity confirmed by a noninvasive test (ankle–brachial pressure index [ABPI], color Doppler)
  4. Absence of thrombophilia, autoimmune disease, diabetes mellitus, hyperlipidemia, trauma, or a proximal source of embolism
  5. Diseased arterial segment should be distal to superficial femoral artery.


Clinical management

All the patients were evaluated with detailed history and thorough clinical examination. ABPI, blood sugar levels, HbA1C levels, serum lipid profile, and computed tomographic (CT) angiography were done. Management was done according to the presenting ABPI. ABPI was done by a hand-held ultrasound Doppler (Company: Bistos Co. Ltd., Model: BT-200). Patients having ABPI ≤0.5 were categorized as critical limb ischemia (CLI) and were taken for surgical revascularization if their anatomy permitted. The patients with ABPI >0.5 were categorized as chronic limb ischemia and they were given a trial of drugs for 2 weeks along with cessation of smoking. The drugs used were aspirin 75 mg daily and cilostazol 5 mg/kg daily in divided doses along with pain killers and antibiotics (if needed). The patients were re-evaluated after 2 weeks for distal pulses, ABPI, pain relief, ulcer healing, sensations, and skin changes. If the patients showing signs of improvement, they were continued on medical management; otherwise, they were considered for surgical intervention. All these patients underwent CT angiography by Siemens Somatom Emotion 16 slice machine using Rezohex dye (1.2–1.5 ml/kg). Patients with suitable anatomy were taken for surgical revascularization (n = 50), while patients who did not have suitable anatomy were referred for chemical sympathectomy (n = 23).

Adequate length of great saphenous vein was harvested from the opposite limb after giving continuous incision over the skin. Injection heparin 100 IU/kg stat was given intravenously before applying arterial clamp over donor artery. Graft was tunneled in subcutaneous plane, and anastomosis was done in end-to-side fashion at both ends using 7-0 prolene. After surgery, flow in graft and distal vessels was confirmed with the hand-held Doppler. The surgical procedure was done in accordance with anatomy of patient. All the patients undergoing surgical revascularization were given postoperative anticoagulation, i.e., injection heparin 20 IU/kg/h for 72 h. Aspirin tablet 75 mg was started on the 1st postoperative day and continued for 12 weeks in all patients.

End points

  • Primary end points: To study the feasibility and outcomes of surgical revascularization in patients of Buerger's disease presenting at our hospital. Outcome will be assessed by limb salvage rate (LSR), healing of ulcer, and relief of claudication
  • Secondary end point: To study the graft patency at 1, 3, and 6 months.


Follow-up

Patients were followed in the outpatient department and evaluated for ABPI, pain relief, distal pulses, sensations, skin color changes, and ulcer status at 1, 3, and 6 months.

Pain assessment

Pain was assessed by visual analog scale (VAS).[15] It was recorded preoperatively and postoperatively at 1, 3, and 6 months. It was recorded on the scale ranging from 0 (no pain) to 10 (worst unbearable pain).

Statistical analysis

All the data were tabulated using MS Excel 2013® and subjected to statistical analysis using statistical software IBM SPSS version 23.0 (IBM CORP. Armonk, N.Y.,USA) Data were expressed as mean ± standard deviation (SD).


  Results Top


The mean age of the patients was 29.8 ± 9.5 years and the range was 18–46 years. Maximum number of the patients was in the age group of 20–30 years (40%, n = 20), while overall 80% of the patients were below 40 years of age [Table 1]. All the patients who underwent revascularization were adult males; no female patient was found suitable candidate for revascularization.
Table 1: Age distribution of patients with Buerger's disease

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All our patients were either current or past bidi smokers (a form of nonfilter cigarette containing around 6% of nicotine). Each bidi packet contains 20–25 sticks. The majority of the patients were in the <5 pack-years group (20 patients, 40%). The mean pack-years of smoking were 8.28 ± 5.69 and the range was 1.25–20.0 pack-years [Table 2].
Table 2: Smoking habits of study subjects in terms of pack-years

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Presenting complaints of the patients in our study was intermittent claudication (42%), rest pain (64%), ulcer (40%), and ischemic gangrene (14%) [Table 3].
Table 3: Presenting complaints of the patients preoperatively and 6-month postoperatively

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The mean score of VAS score of pain at the time of presentation was 6.08 ± 1.7 ranging from 3 to 9. Postoperatively, the VAS score at the end of 1 week was 5.44 ± 1.26 and it continued to decrease, and by the end of 6 months, it was 1.62 ± 1.23, making the difference statistically significant (P < 0.0001) [Table 4].
Table 4: Pain in preoperative and postoperative period on visual analog score scale

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The mean preoperative ABPI of the study population was 0.45 ± 0.12 ranging from 0.27 to 0.68. The ABPI after 1 week of surgery was 0.90 ± 0.17; however, it decreased gradually over the next 6 months to 0.73 ± 0.09 but still making it statistically significant with P < 0.0001 [Table 5].
Table 5: Preoperative and postoperative ankle–brachial pressure index

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All patients who underwent revascularization had infrainguinal involvement of the arteries [Table 6]. Most common area of blockage was tibioperoneal trunk (62%), popliteal artery (46%), tibial arteries (52%), and distal superficial femoral artery (16%); however, few patients had blocks at multiple levels. All the 50 patients who were planned for surgery got revascularized. None of the cases were deferred, and all the procedures were completed as planned. None of the patients suffered any notable intraoperative complications. Thus, 100% feasibility was observed after appropriate selection of the patients. The mean operating duration was 162.6 ± 19.9 min.
Table 6: Level of block on computed tomographic angiography

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The vascular bypasses were done depending upon the level of the block. The most frequent bypass procedure was popliteotibial done in 32 (64%) patients, followed by femoropopliteal bypass in 8 (16%) patients, patch plasty with endarterectomy in 4 (8%), femorotibial bypass in 1 (2%), popliteocrural in 3 (6%), and tibiocrural in 2 (4%) patients [Table 7].
Table 7: Type of surgery done and their patency rate at the end of 6 months

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Majority of our patients were symptom-free at 6 months postsurgery. 6 (12%) patients had intermittent claudication, two patients had rest pain, while only one patient had nonhealing ulcer. There was no appearance of fresh gangrene in any patient [Table 3].

Our LSR was 92% and only 4 (8%) patients needed major amputation in the postoperative period (all of them had below knee amputations). Nine minor amputations (forefoot amputation) were also done in patients who had pre-existent dry gangrene before revascularization. In these patients, amputation was not done with the main operation to prevent surgical site infection and decide level of amputation in a more accurate manner (after revascularization).

Overall, our graft patency rate at 6 months was 70% with femoropopliteal and popliteotibial bypass, having the best patency rates of 87.5% and 75%, respectively [Table 7]. Endarterectomy with patch plasty had 50% patency rate at 6 months. The crural bypass procedures had poor 6-month patency rates ranging from 33% to 50%.

Some preoperative images of CT angiogram are shown in [Figure 1]a and [Figure 1]b, operative picture of the popliteotibial bypass using reversed saphenous venous graft is shown in [Figure 2]a and [Figure 2]b, and postoperative healed scar mark of the popliteocrural bypass is shown in [Figure 3].
Figure 1: (a) Computed tomographic angiogram anteroposterior view showing popliteal artery block with refilling of tibioperoneal trunk with collaterals. (b) Lateral view of computed tomographic angiogram showing popliteal block

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Figure 2: (a) Operative picture of the popliteotibial bypass using reversed saphenous venous graft. (b) Close-up operative view of anastomosis of reversed saphenous venous graft with tibioperoneal trunk

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Figure 3: Postoperative image of healed scar of popliteocrural bypass

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  Discussion Top


Age distribution

Buerger's disease is a disease of the young and affects the economically most productive age group. In our study, the mean age of the patients was 29.8 ± 9.5 years. Maximum number of the patients was in the age group of 20–30 years (40%, n = 20), while overall 80% of the patients were below 40 years of age. These data were comparable to other studies[5],[16] in which majority of patients of Buerger's disease fell in the range of 25–35 years.

Smoking

All the patients of this study were heavy bidi smokers. The mean pack-years of smoking were 8.28 ± 5.69. The relation of smoking with Buerger's disease is well documented by numerous studies.[17]

Presenting complaints

Almost half of the patients had intermittent claudication (n = 21, 42%), majority of the patients had rest pain (n = 29, 58%) and ulcer (n = 20, 40%), while 7 (14%) had ischemic gangrene. The presenting features in our study were similar to other studies.[10],[18] Of noteworthy is that rest pain was present in more patients as intermittent claudication, this could be explained by late presentation of the patients to our center.

Pain and ankle–brachial pressure index

The mean of the preoperative pain on VAS was 6.08 ± 1.77 (SD) and the mean of the preoperative ABPI was 0.45 ± 0.12 (SD). This was in concordance with the study done by Durdu et al., which reported similar trend among patients of Buerger's disease with VAS of 8.2 ± 1.2 (SD) and ABPI of 0.52 ± 0.09 (SD) at the time of presentation.[19] The mean VAS came down from 6.08 ± 1.77 at the end of 6 months to 1.62 ± 1.23, which was statistically significant (P < 0.05). Similarly, the mean ABPI improved from its preoperative value of 0.45 ± 0.12–0.73 ± 0.09 at the end of 6 months, which was also significant. As shown by the ABPI figures [Table 2] which reached near-normal at 1 month after surgery, they continue to fall after surgery, thereby indicating that gradually, grafts are blocking over time which is expected as Buerger's disease has recurring and relapsing course and a strong correlation to smoking. Other studies have also shown similar fall in graft patency rates postsurgery from 75% at 1 month to 51% at 6 months in patients of Buerger's disease.[20]

Level of block

The Buerger's disease affects primarily infrapopliteal arteries although other arteries may get involved. Few of our patients had blocks at several levels, which made revascularization challenging. Majority of our patients had blockage of the popliteal artery and tibioperoneal trunk (>90%). These findings are comparable with the studies which reported 90%–100% infrapopliteal involvement and 12%–40% femoropopliteal involvement.[10],[21]

Feasibility of surgery

We saw 187 patients of TAO over a period of 4 years; however, only 50 patients had suitable anatomy to undergo revascularization. We were able to revascularize all our selected patients, so feasibility of surgical revascularization in our study group is 100%. Since our hospital is a tertiary care referral center, we got more patients who actually needed surgery, as those who responded to medical management were managed at other centers and hospitals. Hence, a higher percentage (26.7%) of patients undergoing revascularization could be due to referral bias.

Due to the distal localization of arterial occlusions and the absence of recipient vessels, endovascular or surgical revascularization is impossible to perform in majority of cases. Nevertheless, especially in the older literature, a series of peripheral bypass procedures in Buerger's disease have been published with acceptable results in highly selected patients (revascularization rate: 4.6%–17.7%) and highly specialized centers, reporting up to 48.8% and 62.5% at 5 years and 43.0% and 56.3% at 10 years, respectively.[22]

Outcome measures

After 6 months of surgery, the prevalence of intermittent claudication decreased from 42% to 12%. The ulcer was present in 20 (40%) patients at the time of presentation; however, at the end of 6 months, only 1 (2%) patient was left with nonhealing ulcer. In CLI, an underlying principle of treatment is that it takes more oxygenated blood to heal a wound than to maintain tissue integrity. Urgent restoration of perfusion to the ischemic territory is the primary treatment goal, rather than long-term patency.[23]

The rest pain was present in 29 (58%) patients at the time of presentation; however, after 6 months of surgery, only 2 (4%) patients had rest pain. However, when we did proper neurological examination, we found out that most of these patients had neuralgic pain (because of healed ulcer) and paresthesia which they confused with pain. Few of our patients had persistent symptoms which could be explained by blocked grafts in the postoperative period.

Graft patency

All patients underwent color Doppler to assess their graft patency. Overall graft was patent in 35 (70%) patients at the end of 6 months. In rest of the 15 (30%) patients, the grafts got blocked at 6 months of which 4 (8%) patients had to undergo major amputation. The remaining 11 (22%) patients with blocked grafts did not need amputation as they had developed sufficient collaterals. Similar to our study, others have also reported a graft patency of 64% for infrainguinal bypasses.[24],[25] Our patency rates of crural bypass is poor (40% at 6 months) because of very few grafts done (only 5 out of 50 patients) as compared to other series, with comparatively large number of patients, and due to habit of continued smoking in our patients in the postoperative period.[26] A point to be noted is that even if the bypass grafts are patent over a short period of time, they are sufficient to allow healing of ulcers in patients with Buerger's disease.[27]

Limb salvage

LSR was 92% in our study, which is in concordance with other studies.[13] Only 4 (8%) patients had to undergo major amputation even after surgery, while in 9 patients, minor amputations were carried out for gangrene of digits and fore foot which existed before surgical revascularization was done.

Many studies point out that amputation after surgery is strongly related to continued tobacco use. However, in advanced stages of the disease and despite cessation of smoking, recurrent episodes of ischemia or tissue loss can occur.[28]

Effect of smoking on postoperative results

In our study group, 16 patients (32%) continued to smoke in the postoperative period, which could explain the reason for recurrent symptoms in few patients.[13] Patients with TAO should be prevented not only from active smoking but also from alternative consumption mode and passive exposure to prevent progression of disease process.[29] However, contrary to our finding, there are studies which state that there is no advantageous effect of smoking cessation on the long-term remission in patients with Buerger's disease.[26]

Medical management in Buerger's Disease

A recently published Cochrane review emphasized low-quality evidence concerning medical therapy in Buerger's disease and stated that high-quality trials assessing the effectiveness of pharmacological agents in people with Buerger's disease are urgently needed.[12] Although widely used, there is no proven evidence for platelet function inhibitors such as aspirin or clopidogrel in TAO, the same is true for oral anticoagulants.[4]

In patients with acute ischemia, there is need to increase the blood supply immediately which can be achieved by surgical revascularization; however, in patients with bad surgical anatomy, sympathectomy and prostacyclin analogs offer good results provided there is complete abstinence from smoking.[13],[30]

As only limited subset of patients are appropriate candidates for surgical or endovascular revascularization while others have to be managed with medical management, sympathectomies, and other newer modalities of management such as prostacyclin analogs, stem cell therapy, and immunoadsorption techniques.[31]


  Conclusion Top


We conclude that surgical revascularization is feasible in properly selected patients of Buerger's disease with acceptable results, if patient abstains from smoking. Since it involves predominantly infrapopliteal vessels, bypass grafting is difficult and the surgeon has to be innovative and flexible with the surgical procedure. Even if the graft is patent for short period of time, it leads to healing of ulcer and stops progression of gangrene. Since Buerger's disease has a recurring and relapsing course, so the ultimate treatment is cessation of smoking and lifestyle modification.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Ates A, Yekeler I, Ceviz M, Erkut B, Pac M, Basoglu A, et al. One of the most frequent vascular diseases in northeastern of Turkey: Thromboangiitis obliterans or Buerger's disease (experience with 344 cases). Int J Cardiol 2006;111:147-53.  Back to cited text no. 16
    
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Sugimoto M, Miyachi H, Morimae H, Kodama A, Narita H, Banno H, et al. Fate of ischemic limbs in patients with Buerger's disease based on our 30-year experience: Does smoking have a definitive impact on the late loss of limbs? Surg Today 2015;45:466-70.  Back to cited text no. 26
    
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Sayin A, Bozkurt AK, Tüzün H, Vural FS, Erdog G, Ozer M. Surgical treatment of Buerger's disease: Experience with 216 patients. Cardiovasc Surg 1993;1:377-80.  Back to cited text no. 31
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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