Humoral and cellular immune response to Buerger's disease.

OBJECTIVE: Thromboangiitis obliterans is a nonatherosclerotic occlusive disease, affecting small to moderate sized arteries of the upper and lower extremities, leading to progressive inflammation and clot formation. However, the role of humoral and cell-mediated immunity in the development of this disease has not been clearly identified. The present study was intended to investigate the humoral and cellular immune response in patients with Buerger's disease with different disease severity. METHODS: In an observational study, 80 male patients with Buerger's disease were included and categorized into three groups (mild, moderate, and severe) based on clinical manifestations. After blood sampling, cellular phenotypes were determined, and erythrocyte sedimentation rate, immunoglobulins (Ig) A, M, G, and E, as well as C3 and C4 components of the complement system and complement hemolytic activity (CH50) were measured. RESULTS: The mean age of the patient was 42.85 ± 8.39 years. Pulse abnormality, cold intolerance, and claudication were the most common symptoms. Eleven (13.75%), 46 (57.50%), and 23 (28.75%) patients had mild, moderate, and severe symptoms. Regression analyses showed that the presence of severe symptoms was significantly associated with elevated erythrocyte sedimentation rate and C4 levels (p < 0.05). CONCLUSION: Buerger's disease in severe cases was associated with increased erythrocyte sedimentation rate and abnormal C4 levels. The alterations in these inflammatory biomarkers might be due to a secondary inflammatory response to the presence of ulcer or gangrene and the inflammatory process in patients with severe symptoms.

Endovascular Treatment of Thromboangiitis Obliterans (Buerger's Disease).

PURPOSE: When critical limb ischemia (CLI) occurs in patients with thromboangiitis obliterans (TAO) or Buerger's disease, smoking cessation alone may be insufficient to relieve rest pain and promote wound healing. Accordingly, adjunctive measures are warranted to restore adequate blood flow required for limb salvage. This study aimed to evaluate the feasibility and efficacy of percutaneous transluminal angioplasty (PTA) for the treatment of patients with TAO and CLI. In addition, a review of the literature on endovascular management of TAO is included. METHODS: Between April 2012 and June 2017, all patients with TAO and CLI who underwent PTA were studied retrospectively. Patient demographics, presentation, procedural details, and clinical response were recorded. Patients were monitored at 1 week, 1, 2, 3, and 6 months after revascularization and at least every 6 months thereafter. RESULTS: Thirteen patients with TAO and CLI, who presented with rest pain only (n = 1), ischemic ulcer (n = 4), or gangrene (n = 8) underwent endovascular interventions with primary and assisted primary technical success of 85% and 92%, respectively. A below-knee amputation was eventually done in the only patient with technical failure (limb salvage rate: 92%). Following the procedures, 11 patients had clinical response, one of whom also received intra-arterial vasodilator to achieve complete symptom relief. The other patient who failed PTA underwent a successful lumbar sympathectomy. In addition, all ulcers healed and eight minor amputations were performed due to already established gangrene. During follow-up (mean: 19.4 months), four patients needed reintervention. Patients who continued to smoke experienced more severe ischemia ( P = .017) and were more likely to require reintervention ( P = .009). CONCLUSION: Percutaneous transluminal angioplasty can be considered as a technically feasible and potentially effective treatment for patients with TAO and CLI, as well as a last resort for limb salvage when other options have failed. However, reintervention may be required, especially in patients who continue smoking.

Digital pressure and oxygen saturation measurements in the diagnosis of chronic hemodialysis access-induced distal ischemia.

OBJECTIVE: Hemodialysis access-induced distal ischemia (HAIDI) can be classified as acute (on the first postoperative day), subacute (≤1 month), or chronic (>1 month), based on the time of onset after access creation. The diagnosis is mainly clinical. However, performing additional tests is beneficial in further assessment of patients. The purpose of this study was to evaluate the use of finger pressure and oxygen saturation measurements for the diagnosis of chronic HAIDI. METHODS: A total of 20 patients with chronic HAIDI (cases) and 40 asymptomatic hemodialysis patients (controls) were matched for age, sex, etiology of end-stage renal disease, and type of arteriovenous access. Basal digital pressure (BDP), digital pressure during manual compression of access, digital brachial index (DBI), change in digital pressure with access compression (CDP), digital pressure of the contralateral side, and bilateral oxygen saturation (O2 Sat) were measured in all patients. RESULTS: In the case group, compression of the arteriovenous fistula (AVF) increased mean BDP from 61 ± 26 to 118 ± 28 mm Hg (P < .001), which failed to reach the non-AVF side mean digital pressure of 151 ± 25 mm Hg (P < .001). In addition, O2 Sat of the AVF side was significantly lower than the contralateral side (92.9% ± 2.1% vs 95.6% ± 1.4%; P = .001). Among the controls, manual AVF compression raised the mean BDP from 114 ± 36 mm Hg to 133 ± 29 mm Hg (P < .001), which was still significantly lower than the contralateral side mean digital pressure of 141 ± 30 mm Hg (P = .002). In addition, O2 Sat values of the two sides were different (96.7% ± 2.1% vs 97.1% ± 1.9%; P = .01). Comparing the cases and controls, the mean BDP (61 ± 26 mm Hg vs 114 ± 36 mm Hg; P < .001), DBI (0.44 ± 0.16 vs 0.82 ± 0.19; P < .001), and O2 Sat (92.9% ± 2.1% vs 96.7% ± 2.1%; P < .001) were significantly lower and CDP (57 ± 24 mm Hg vs 19 ± 17 mm Hg; P < .001) was significantly higher in the cases than in the controls. The optimal discriminatory thresholds of 80 mm Hg for BDP, 0.7 for DBI, 40 mm Hg for CDP, and 94% for O2 Sat were determined. CONCLUSIONS: Digital pressure and O2 Sat measurements are useful additional methods to assist in the clinical evaluation of hemodialysis patients with access-related hand ischemia. BDP <80 mm Hg, DBI <0.7, CDP >40 mm Hg, and O2 Sat <94% are associated with chronic HAIDI.