Buerger's disease surgery: Difference between revisions

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==Overview=
==Overview==
 
Surgery is usually not feasible in Buerger's disease since the integrity of the distal vessels usually does not allow for [[revascularization]], nevertheless, surgical intervention may be considered in order to maintain peripheral blood flow as much possible. Surgical intervention may also be carried out in order to provide [[Pain management|pain relief]], heal [[Ulcer|ulcers]] and decrease the chances of future [[Amputation|amputations]], such as [[sympathectomy]].  
Surgery is usually not feasible in Buerger's disease since the integrity of the distal vessels usually does not allow for revascularization, nevertheless, surgical intervention may be considered in order to maintain peripheral flow as much possible.
 
==Indications==
 
*Surgical intervention is not recommended for the management of [disease name].
OR
*Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either:
**[Indication 1]
**[Indication 2]
**[Indication 3]
*The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either:
**[Indication 1]  
**[Indication 2]
**[Indication 3]
 
==Surgery==
 
*The feasibility of surgery depends on the stage of [malignancy] at diagnosis.
OR
*Surgery is the mainstay of treatment for [disease or malignancy].
 
==Contraindications==
 


==Surgery==
==Surgery==
*[[Vascular surgery]] can sometimes be helpful in treating limbs with poor perfusion secondary to this disease.
Surgery is usually not feasible in Buerger's disease since the integrity of the distal vessels usually does not allow for [[revascularization]], nevertheless, surgical intervention may be considered in order to maintain peripheral blood flow as much possible. Surgical intervention may also be carried out in order to provide [[Pain management|pain relief]], heal [[Ulcer|ulcers]] and decrease the chances of future [[Amputation|amputations]], such as [[sympathectomy]].  
*[[Surgery]]: Cutting the nerves in the affected area may help control [[pain]].
*[[Amputation]]: This treatment is used when [[infection]] or [[gangrene]] occurs.
 
 
Revascularization — Surgical revascularization is usually not indicated due to the distal nature of occlusive disease and because most patients do well with smoking cessation. It has been our experience that surgery is rarely needed if the patient is able to stop smoking. (See "Treatment of chronic limb-threatening ischemia".)
 
Bypass surgery may be considered in select patients with severe ischemia and suitable distal target vessels. Surgical bypass with autologous vein [92-94] or even omental graft may allow limb salvage [95,96].Although the long-term vein graft patency is less than that seen with peripheral artery disease, limb salvage rates are reasonable and generally greater than 90 percent [7,97]. A possible explanation is that patent grafts, even over a short period of time, are sufficient to allow healing of ulcers in patients with thromboangiitis obliterans. Ulcers are not likely to develop or recur provided the patient is compliant with smoking cessation.
 
●In a retrospective review of 71 bypasses performed on patients with thromboangiitis obliterans, primary and secondary patency rates were 50 and 63 percent at 5 years, and 43 and 56 percent at 10 years, respectively [94]. The 10-year patency rates of the postoperative non-smoking group were significantly higher than that of the smoking group (67 versus 35 percent).
 
●In another study, revascularization was performed in 19 patients and the cumulative secondary patency rate was 58 percent at a mean of 5.4 years follow up [93]. The limb salvage rate was 96 percent with seven major and 36 minor amputations performed. These authors noted that, although the long-term patency of the bypass grafts was low, short-term patency was sufficient to allow healing of ischemic lesion.
 
●Similarly, in another study of 27 patients with thromboangiitis obliterans who underwent revascularization, patency rates at 12, 24, and 36 months were 59, 48, and 33 percent, respectively [7]. The limb salvage rate, however, was 93 percent.


●In a consecutive series of 17 patients with thromboangiitis and critical limb ischemia in 20 limbs were revascularized using endovascular means. Technical success was achieved in 95 percent. During a mean follow-up of two years, amputation-free survival was 84.2 percent [98].
===Revascularization===
*The mainstay of treatment for Buerger's disease is [[smoking cessation]].<ref name="pmid21944922">{{cite journal |vauthors=Lee T, Ra HD, Park YJ, Park HS, Kim SJ |title=New routing alternative for proximal anterior tibial artery bypass in patients with Buerger disease |journal=J. Vasc. Surg. |volume=54 |issue=6 |pages=1839–41 |date=December 2011 |pmid=21944922 |doi=10.1016/j.jvs.2011.06.111 |url=}}</ref><ref name="pmid8076063">{{cite journal |vauthors=Sayin A, Bozkurt AK, Tüzün H, Vural FS, Erdog G, Ozer M |title=Surgical treatment of Buerger's disease: experience with 216 patients |journal=Cardiovasc Surg |volume=1 |issue=4 |pages=377–80 |date=August 1993 |pmid=8076063 |doi= |url=}}</ref><ref name="pmid9091153">{{cite journal |vauthors=Sasajima T, Kubo Y, Inaba M, Goh K, Azuma N |title=Role of infrainguinal bypass in Buerger's disease: an eighteen-year experience |journal=Eur J Vasc Endovasc Surg |volume=13 |issue=2 |pages=186–92 |date=February 1997 |pmid=9091153 |doi= |url=}}</ref>
*[[Bypass surgery]] may be an appropriate intervention in those with severe [[ischemia]] and target vessels.
*An autologous [[vein]] or an omental graft is often used to save compromised limbs.
*[[Medical grafting|Grafts]] may also be used to treat non-healing [[Ulcer|ulcers]] in those who have abstained from [[smoking]].


Endovascular intervention including thrombolytic therapy or angioplasty has undergone limited investigation in patients with thromboangiitis obliterans [98,99]. In one study of 11 patients with longstanding disease who had gangrene or pregangrenous lesions of the toes or feet, treatment with low-dose intraarterial streptokinase resulted in avoidance or alteration in the level of amputation in 58 percent of patients [99]. However, further study is required before the precise role of thrombolytic therapy can be defined. In our experience, thrombolytic therapy is rarely used because of its limited benefit.
===Endovascular intervention===
* [[Thrombolytic therapy]] with low dose intra-arterial [[streptokinase]] has been found to improve the chances of limb salvage in [[Gangrene|gangrenous]] or [[Gangrene|pre-gangrenous]] limbs.<ref name="pmid22285343">{{cite journal |vauthors=Graziani L, Morelli L, Parini F, Franceschini L, Spano P, Calza S, Sigala S |title=Clinical outcome after extended endovascular recanalization in Buerger's disease in 20 consecutive cases |journal=Ann Vasc Surg |volume=26 |issue=3 |pages=387–95 |date=April 2012 |pmid=22285343 |doi=10.1016/j.avsg.2011.08.014 |url=}}</ref><ref name="pmid8473086">{{cite journal |vauthors=Hussein EA, el Dorri A |title=Intra-arterial streptokinase as adjuvant therapy for complicated Buerger's disease: early trials |journal=Int Surg |volume=78 |issue=1 |pages=54–8 |date=1993 |pmid=8473086 |doi= |url=}}</ref>


Sympathectomy — Lumbar or thoracic sympathectomy improves pain control in other vascular occlusive diseases, but its role in the treatment of patients with thromboangiitis remains unclear. There have been several reports demonstrating that sympathectomy can be safely and effectively used in these patients [15,100]. Laparoscopic sympathectomy in the lower [101,102] and upper extremities [103] has been performed. Although sympathectomy anecdotally benefits some individuals, there are no data to guide patient choice. (See "Medical thoracoscopy (pleuroscopy): Diagnostic and therapeutic applications".)
===Sympathectomy and spinal cord stimulation===
* Lumbar and thoracic [[Endoscopic thoracic sympathectomy|sympathectomy]], and [[spinal cord stimulation]] may be performed to  heal [[ulcers]] and control pain symptoms.<ref name="pmid9152156">{{cite journal |vauthors=Lau H, Cheng SW |title=Buerger's disease in Hong Kong: a review of 89 cases |journal=Aust N Z J Surg |volume=67 |issue=5 |pages=264–9 |date=May 1997 |pmid=9152156 |doi= |url=}}</ref><ref name="pmid10231644">{{cite journal |vauthors=Swigris JJ, Olin JW, Mekhail NA |title=Implantable spinal cord stimulator to treat the ischemic manifestations of thromboangiitis obliterans (Buerger's disease) |journal=J. Vasc. Surg. |volume=29 |issue=5 |pages=928–35 |date=May 1999 |pmid=10231644 |doi= |url=}}</ref><ref name="pmid12429549">{{cite journal |vauthors=Pace AV, Saratzis N, Karokis D, Dalainas D, Kitas GD |title=Spinal cord stimulation in Buerger's disease |journal=Ann. Rheum. Dis. |volume=61 |issue=12 |pages=1114 |date=December 2002 |pmid=12429549 |pmc=1753958 |doi= |url=}}</ref>


Other interventions — As with other forms of chronic critical limb ischemia, spinal cord stimulation has been used to manage pain in patients with thromboangiitis obliterans [104-107]. (See "Treatment of chronic limb-threatening ischemia", section on 'Spinal cord stimulation'.)
==References==
==References==
{{reflist|2}}
{{reflist|2}}

Latest revision as of 19:40, 1 May 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]

Overview

Surgery is usually not feasible in Buerger's disease since the integrity of the distal vessels usually does not allow for revascularization, nevertheless, surgical intervention may be considered in order to maintain peripheral blood flow as much possible. Surgical intervention may also be carried out in order to provide pain relief, heal ulcers and decrease the chances of future amputations, such as sympathectomy.

Surgery

Surgery is usually not feasible in Buerger's disease since the integrity of the distal vessels usually does not allow for revascularization, nevertheless, surgical intervention may be considered in order to maintain peripheral blood flow as much possible. Surgical intervention may also be carried out in order to provide pain relief, heal ulcers and decrease the chances of future amputations, such as sympathectomy.

Revascularization

Endovascular intervention

Sympathectomy and spinal cord stimulation

References

  1. ↑ Lee T, Ra HD, Park YJ, Park HS, Kim SJ (December 2011). "New routing alternative for proximal anterior tibial artery bypass in patients with Buerger disease". J. Vasc. Surg. 54 (6): 1839–41. doi:10.1016/j.jvs.2011.06.111. PMID 21944922.
  2. ↑ Sayin A, Bozkurt AK, Tüzün H, Vural FS, Erdog G, Ozer M (August 1993). "Surgical treatment of Buerger's disease: experience with 216 patients". Cardiovasc Surg. 1 (4): 377–80. PMID 8076063.
  3. ↑ Sasajima T, Kubo Y, Inaba M, Goh K, Azuma N (February 1997). "Role of infrainguinal bypass in Buerger's disease: an eighteen-year experience". Eur J Vasc Endovasc Surg. 13 (2): 186–92. PMID 9091153.
  4. ↑ Graziani L, Morelli L, Parini F, Franceschini L, Spano P, Calza S, Sigala S (April 2012). "Clinical outcome after extended endovascular recanalization in Buerger's disease in 20 consecutive cases". Ann Vasc Surg. 26 (3): 387–95. doi:10.1016/j.avsg.2011.08.014. PMID 22285343.
  5. ↑ Hussein EA, el Dorri A (1993). "Intra-arterial streptokinase as adjuvant therapy for complicated Buerger's disease: early trials". Int Surg. 78 (1): 54–8. PMID 8473086.
  6. ↑ Lau H, Cheng SW (May 1997). "Buerger's disease in Hong Kong: a review of 89 cases". Aust N Z J Surg. 67 (5): 264–9. PMID 9152156.
  7. ↑ Swigris JJ, Olin JW, Mekhail NA (May 1999). "Implantable spinal cord stimulator to treat the ischemic manifestations of thromboangiitis obliterans (Buerger's disease)". J. Vasc. Surg. 29 (5): 928–35. PMID 10231644.
  8. ↑ Pace AV, Saratzis N, Karokis D, Dalainas D, Kitas GD (December 2002). "Spinal cord stimulation in Buerger's disease". Ann. Rheum. Dis. 61 (12): 1114. PMC 1753958. PMID 12429549.

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