Buerger's disease surgery
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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 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
- Vascular surgery can sometimes be helpful in treating limbs with poor perfusion secondary to this disease.
- 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].
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.
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".)
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'.)