Chapter 138 - Thromboangiitis obliterans

Question 1

Thromboangiitis obliterans define

Answer 1

1) Buerger disease 2) von Winiwarter-Buerger syndrome 3) inflammatory affecting infrapopliteal and infrabrachial medium small arteries and veins 4) age < 50 5) smoking related 6) male > female (5-10x more in men) 7) middle east, asia, mediterranean, eastern europe

Question 2

Treatment for Buerger disease

Answer 2

1) smoking cessation 2) iloprost 3) endothelin receptor antagonist 4) immunoadsorption 5) growth factors 6) gene and stem therapy 7) bone fenestration to mobilize bone marrow

Question 3

First full description of thromboangiitis obliterans

Answer 3

Buerger 1924 - the circulatory disturbances of the extremities

Question 4

Risk factors for Buerger disease

Answer 4

1) smoking 2) low SES 3) poor oral hygiene 4) nutritional deficit 5) fungal/viral infection 6) cold injury 7) sympathomimetic drug abuse 8) arsenic intoxication

Question 5

Possible pathways of immune-mediated injury in thromboangiitis obliterans

Answer 5

1) active smoking (urinary cotinine) 2) increased cellular sensitivity to collagen type I, III, IV 3) circulating immune complex 4) TNFalpha, IL1beta, IL5, IL6, IL12, IL17, IL23 increase 5) reduced IL10 6) Increased HMGB1, MMP9, ICAM1

Question 6

Autoantibodies associated with TAO

Answer 6

1) antiphospholipid syndrome 2) anticardiolipin 3) antineutrophil cytoplasmic antibodies (ANCA) (controversial) 4) anti-endothelial cell antibodies

Question 7

Genes associated with TAO

Answer 7

1) England: HLA-A9 and HLA-B5 2) Israel: HLA-DR4 and low HLA-DRW6 3) India: HLA-DRB1*1501

Question 8

Hypercoagulable states in TAO

Answer 8

controversial 1) lower levels of urokinase-plasminogen activator 2) lower levels of plasminogen activator inhibitor 1 3) elevated platelet contractile force

Question 9

Associated infectious cause of TAO

Answer 9

1) Treponema denticola 2) porphyromonas gingivalis 3) actinobacillus actinomycetemcomitans

Question 10

Pathogenesis of TAO

Answer 10

1) endothelial cell damage 2) activation of APC 3) cellular and humoral inflammation 4) thrombotic occlusion

Question 11

Which layer is affected in TAO

Answer 11

restricted to intima = endarteritis

Question 12

Differentiating TAO from atherosclerosis in histology

Answer 12

Internal elastic lamina and architecture of vascular wall preserved in TAO

Question 13

Three stages of TAO

Answer 13

1) acute phase: inflammation of small-medium (1-5mm) artery/vein - occlusive - cellular arterial thrombus - polymorphonuclear cell infiltrate - leukocytoclasis - giant cells - microabscess - inflammation of entire vessel wall - neurovascular bundle 2) intermediate/subacute phase: organization of occlusive thrombus - disappearance of microabscesses - CD3 pan, CD4 T cells, CD20 panB cells against internal elastic lamina - CD68 macrophage and S100 dendritic cells in intima - IgG, IgM, IgA, complement 3d 4c on internal elastic lamina 3) Chronic phase/end-stage: thrombus organization and recanalization - prominent vascularization of media - perivascular fibrosis

Question 14

Phlebitis saltans define

Answer 14

Migrating phlebitis in 40-65% of TAO patients

Question 15

How often are venous involvements in TAO

Answer 15

60% mostly superficial, DVT unusual

Question 16

Symptoms of TAO and rate

Answer 16

TABLE 138.2

Question 17

Late signs of TAO

Answer 17

1) trophic nail changes 2) ischemic ulcerations 3) digital gangrene 4) superinfections 5) joint manifestations 6) splinter hemorrhages 7) psych conditions

Question 18

TAO rate of 2, 3, 4 limb involvement

Answer 18

2 limb - 16% 3 limbs 41% 4 limbs 43%

Question 19

TAO rate of UE vs LE involvement

Answer 19

LE only 75% UE only 5% both 20%

Question 20

Distribution of TAO in LE named vessels

Answer 20

AT 41% PT 40% DP 21% peroneal 18% pop 18% digital 11% plantar 9%

Question 21

Distribution of TAO in UE named vessels

Answer 21

Ulnar 11.5% digital 8% radial 7% palmar arch 4.5% brachial 0.8%

Question 22

Shionoya 5 major criteria for TAO

Answer 22

No criteria is universally accepted 1) smoking history 2) onset < 50 years age 3) infrapopliteal arterial occlusive lesion 4) UE involvement or phlebitis migrans 5) absence of atherosclerotic risk factors (besides smoking)

Question 23

Olin’s criteria on TAO

Answer 23

1) age < 45 2) recent smoking 3) distal extremity ischemia on imaging 4) exclusion of autoimmune, hypercoabulable, DM 5) exclusion of proximal emboli 6) consistent arteriographic findings

Question 24

Martorell sign

Answer 24

snake or dot sign Monophasic waveform pattern within corkscrew shaped collaterals

Question 25

ESR and CRP in TAO

Answer 25

normal or slightly elevated

Question 26

Percentage of TAO with corkscrew collaterals

Answer 26

27%

Question 27

Corkkscrew collaterals in other disease besides TAO

Answer 27

1) Scleroderma 2) CREST 3) SLE 4) rheumatoid vasculitis 5) antiphospholipid-antibody syndrome

Question 28

CREST syndrome define

Answer 28

1) calcinosis 2) Raynaud phenomenon 3) esophageal disease 4) sclerodactyly 5) telangiectasia

Question 29

Arteriographic findings in TAO

Answer 29

1) small and medium arteries 2) segmental occlusive lesion 3) more severe distally 4) tapering or abrupt cutoff with corkscrew 5) normal proximal artery

Question 30

Types of corkscrew

Answer 30

Type 1: artery > 2mm, large hlical sign Type 2: 1.5-2mm, medium helical sign Type 3: 1-1.5 mm, small helical sign Type 4: <1 mm, tiny helical sign

Question 31

TAO mean life expectancy

Answer 31

52.2 +/- 8.9 years

Question 32

TAO risk of amputation any

Answer 32

25% 5 years 38% 10 years 46% 20 years

Question 33

TAO risk of major amputation

Answer 33

11% at 5 years 21% at 10 years 23% at 20 years

Question 34

TAO survival long term

Answer 34

97% 5 years 94.4% 10 years 92.4% 20 years 83.8% 25 years

Question 35

Length of smoking cessation in TAO to eliminate risk of amputation

Answer 35

8 years

Question 36

Regular exercise regimen for TAO

Answer 36

30 min 3-5x/week

Question 37

Improvement in claudication in TAO with exercise

Answer 37

180% pain-free walking time 120% max walking time

Question 38

Pharmacological treatment of TAO

Answer 38

1) calcium channel blocker - help vasospasm 2) iloprost - vasodilator and antiplatelet, antiproliferation, anti-chemotaxis 3) cilastazol (PDE3 inhibitor) 4) PDE5 inhibitor (sildenafil, tadalafil) - offlabel use 5) Bosentan - dual endothelin 1 receptor antagonist 6) thrombolytics 7) folate supplement 8) statins 9) analgesia no clear evidence

Question 39

Nerve treatment of TAO

Answer 39

1) regional sympathetic blockade 2) spinal cord stimulation 3) lumbar/thoracic sympathectomy no clear evidence helps with neurogenic but not somatic

Question 40

Surgical treatment of TAO

Answer 40

1) bypass 2) pedicled omental graft 3) distal venous arterialization 4) hyperbaric oxygen therapy

Question 41

Immunoadsorption in TAO key points

Answer 41

1) selective removal of circulating immunoglobulin and antibodies 2) treat pain, improve walking distance and improve tissue perfusion