Thromboangiitis Obliterans

Brenner Dixon, MD 11/15/2010 Vascular conference

History
Disease first described by Felix von Winiwarter in 1879 Accurate Pathologic Description in 1908 by Leo Buerger
Pre-Senile Spontaneous Gangrene 11 amputations

Presentation
Claudicationhands, feet, legs, arms Raynauds phenomenon Painful open sores of fingers and toes 2/3 may have severe periodontal disease Superficial Thrombophlebitis may predate the onset of ischemic symptoms Generally Infra-popliteal or infra-brachial

Basics
Described as a non-atherosclerotic segmental inflammatory disease of medium and small arteries. Occurrence Rate: 12-13 per 100,000
Worse in Indian and middle eastern ethnicities

Progresses distil to proximal In addition to Extremities can involve cerebral, coronary, renal, mesenteric or pulmonary arteries.

Pathophysiology
Characterized by highly cellular inflammatory thrombus with relative sparing of the vessel wall. Patients often have increased immunity to Type1 and Type III collagen Three Phases:
AcuteHighly cellular inflammatory thrombus
PMNs, Giant Cell

Chronic- organized thrombus and fibrosis Sub-acute

Key: Preservation of internal elastic lamina

TOA

Atherosclerosis

Risk Factors
SMOKING!!! Can be through Chewing Tobacco Also reported after Marijuana Use Case reports of TOA in non-smokers

Work-Up
Start with history!!
20-40s, smoker, male
(though increasing rates of occurrence in women)

ExamDistil ischemia
Positive Allen test (non-specific)

Labs: CBC, BMP, LFT, ESR, CRP, Cold Agglutinins and Cryoglobulins ABIs, PVR etc.

Corkscrew Vessels

Proposed Criteria (Olins)

Age <45 Recent History of Tobacco use Distil Extremity ischemia Exclusion of Auto-immune diseases Exclusion of proximal embolic source

Prognosis
Amputation: (smokers)
5 Years 25%--------11% major 10 years 38%-------21% major 20 years 46%-------23% major

Recurrence: 5-7 Years (average) Significantly improved in non-smokers

Minimal Amputations!!

Treatment
Smoking Cessation
Nicotine replacement does not help

Bypass
Because of distil involvement, usually not feasible

Vasodilators
IloprostImproves symptoms; not outcomes

Epidural Spinal Cord Stimulation/Denervation Streptokinase: Sparse reports; improves up to 58%

New Treatments
Antagonists of Cannabinoid or endothelin receptors Prostaglandin E1 Debated:
Sympathetic Denervation: likely temporary though may help to heal lesions

Literature Cited
Piazza, G. Creager, MA. Thromobangiitis Obliterans. Circulation, 2010, April; 121 (16): 1858-61. Malecki, R. Zdrojowy, K. Adamiec, R. Thromboangiitis Obliterans in the 21st Centurya new face of disease. Atherosclerosis. 2009 Oct;206(2):328-34. Olin, JW. Thromboangiitis obliterans (Buergers Disease). N Engl J Med. 2000 Sep 21;343 (12):864-9.