Thromboangiitis obliterans is a non-atherosclerotic inflammatory disease that affects small and medium-sized arteries. It predominantly affects young male smokers. The presentation is with pain in the lower extremities due to arterial insufficiency. Diagnosis involves excluding other causes through testing and showing features of segmental stenosis and occlusions on angiography. Treatment involves complete smoking cessation, medications to improve blood flow, and surgery in severe cases. Prognosis depends on patient adherence to avoiding tobacco.

1. Welcome
To the presentation……….

2. Sheikh Mohammad Ullah
Resident(Phase-A),CVTS
NICVD.
Thromboangiitis Obliterans

3. Referance book

4.  Buerger’s disease
 Von Winiwarter-Buerger syndrome
Synonyms

5. Thromboangiitis Obliterans is an inflammatory obliterative
nonatheromatous vascular disease that affects the small and
medium-sized arteries, veins, and nerves.
Definition

6. While it is only associated with mild
inflammatory changes, the presence of
inflammation means that this disease is
considered to be a vasculitis.
Is it vasculitis?

7. Thromboangiitis Obliterans is predominantly a disease of young men, most
commonly affecting individuals between the ages of 18 and 50 years; and
men are more commonly affected than women. The disease is also more
common in the Middleand Far East than in North America and Western
Europe.
There is a strong association with tobacco exposure, although thromboangiitis
obliterans has been reported even in individuals who only smoke small
amounts, and it has also been seen in pipe smokers,marijuana users, and
tobacco chewers.
Epidemiology

8. Epidemiology

9. The only risk factor consistently reported is smoking.
Cigar and pipe smoking;
Habitual home-made cigarette “bidi” smoking in India, Bangladesh.
“kawung” smoking in Indonesia;
Chewed “miang” (steamed tea leaves) or “khiyo” (the home-made raw
t tobacco in handrolled banana leaves) smoking in Thailand,
Smokeless tobacco and marijuana.
Lower socioeconomic status, poor oral hygiene, nutritional deficits, history
o of viral or fungal infection, cold injury, abuse of sympathomimetic drugs,
Arsenic intoxication are reported as other possible risk factors.
Cocaine, amphetamines, and cannabis addiction.
Risk factors

10.  The etiology of Thromboangiitis Obliterans is unknown;
 Closly associated with
1. Use of tobacco in any form is beyond any debate.
2. Genetic predisposition,
3. Immunemediated mechanisms,
4. Hypercoagulable states,
5. Endothelial dysfunction,
6. Oral infection-inflammatory pathway
Etiology

11. The specific pathologic mechanisms in
TAO are still unknown.
BD is characterized by segmental
inflammatory cellinfiltration of the vessel
wall and arterial or venous thrombotic
occlusions.
Hypercellularthrombus formation and
preserved architecture of vessel wallsis
wellestablished in TAO
Pathology
Typical subacute
thrombotic occlusion
of the right digital
artery

12.  The initial manifestation of TO is lower extremity claudication.
sometimes progresses to digital ischemia.
 Pedal, instep claudication is also a very specific symptom.
 Gangrene,ulceration, or rest pain is the presenting complaint in
one-third of patients;
 Nail trimming or pressure from tight shoes.
 Superficial thrombophlebitis and Raynaud’s syndrome are also
described
Clinical Presentation

13. TO is a diagnosis of exclusion
Prothrombotic states, diabetes, and other autoimmune diseases; especially scleroderma
should be excluded before attributingdigital gangrene to TO.
Echocardiogram to rule out infectious endocarditis .
Arteriogram to rule out atherosclerosis.
Arteriographic features
1.Bilateral focal segmental stenosis
2.Occlusion with relatively normal interveningvessels.
3.Collateral developmentaround areas of occlusion lead to the appearance of
“ “tree-root,” “spiders web,” or “corkscrew”collaterals.
4.The most importantfinding is that proximal arteries are normal without evidence of
a atherosclerosis or emboli
Diagnostic Testing

14. (1) Smoking history
(2) Onset before age 50,
(3) Infrapopliteal arterial occlusive lesions,
(4) Upper limb involvement or phlebitis migrans,
(5) An absence of atherosclerotic risk factors other than smoking.
Shionoya’s
major criteria
Dx contd..

15. 1. Age less than 45 years;
2. Current (or recent) history of tobacco use;
3. The presence of distal-extremity ischemia(indicated by
claudication, pain at rest, ischemic ulcers, or gangrene)
documented by noninvasive vasculartesting;
4. Exclusion of autoimmune diseases, Hypercoagulable states, and
diabetesmellitusby laboratory tests;
5. Exclusion of a proximal source of emboli by echocardiography and
arteriography;
6. Consistent arteriographic findings in the clinically involved and
noninvolvedlimbs
Dx contd..
Olin’s criteria

16.  Decreased vascular resistance may develop as a result of
increased collateral blood visualize and functionally evaluate the
corkscrew shaped collaterals.
 Using continuous wave Doppler ultrasound monophasic waveform
pattern within the corkscrew shaped collaterals is also known as
Martorellsign (“snake” or“dot”sign) flow and low-resistance
cutaneous arteries
Noninvasive
testing
Color-flow Doppler studies demonstrating triphasic flow within the right (A) and left (B) anterior tibialarteries, monophasic
flow within the left dorsalis pedis artery (C), and the “dot” sign because of continuousflow within corkscrew collateralsat the
toe level (D and E).

17. (A and B) Abrupt right tibialvessel occlusion with
corkscrew collaterals(arrows) in a 34-year-old
man detected with 64-slice multidetectorcomputed
tomographicangiography
Invasive testing
Digitalsubtraction angiographyreveals left poplitealand tibial
vessel occlusions with corkscrew collaterals(arrows) proximally(A)
and distally(B) and right radialand ulnar artery involvement(C) in a
32-year-old man with a nonhealingleft toe ulceration.

18. • Involvement of small and medium-sized arteries
Digital arteries of fingers and toes
Palmar, plantar, tibial, peroneal, radial, and ulnar arteries
• Segmental occlusive lesions: diseased arterial segments interspersed with
normal-appearing segments
• More severe disease distally
• Tapering or abrupt arterial occlusions with collateralization around areas of
occlusion: described as “corkscrew collaterals,”
“spider leg” or “tree root appearance” (not pathognomonic)
• Normal proximal arteries free of atherosclerosis, aneurysms, or other sources of
emboli
Angiographic Findings in Thromboangiitis obliterans

20. Some pictorial examples

21. Lifestyle changes
1. Complete and permanent discontinuation of
smoking in any form including passive smoking
2. Exercise Training
3. Foot, Hand, and Dental Care
Treatment

22.  Pharmacologic Treatment
1. Antiplatelet agents including oral anticoagulants, clopidogrel, dextran,
pentoxifylline, phenylbutazone, pyridinolcarbamate, inositol niacinate,
nonsteroidal antiinflammatory agents, and immunosuppressive drugs including
cyclophosphamide254 and corticosteroids.
2. Calcium Channel Blockers
3. Prostacyclin Analogs(both infusion & oral)
4. Prostaglandin E1 Analogs
5. Phosphodiesterase Inhibitors (Phosphodiesterase 3 Inhibitors-Cilastazol,
Phosphodiesterase 5 Inhibitors (Sildenafil, Tadalafil)
6. Endothelin Receptor Antagonists
7. Thrombolytics
Treatment contd..

23. 8. Folate Supplementation
9. Statins
10. Analgesia-Regional Sympathetic Blockade,Spinal Cord Stimulation
 Surgery
1. Lumbar or Thoracic Sympathectomy
2. Distal Surgical Revascularization
3. PedicledOmental Graft
4. Distal Venous Arterialization
5. Local Wound Care
6. Endovascular Treatment
Treatment contd..

24.  Other Interventional Procedures
1. Immunoadsorption
2. Growth Factors
3. Stem Cell-BasedTherapeutic Angiogenesis
Treatment contd..
Limb salvage after autologousbone marrow–derived mononuclearcell therapy

25. Thank you