Teaching Case

A 54 years old heavy smoker woman with a 5 year history of bilateral lower limb ischemia, presented with a 10 day history of left forearm and hand pain, numbness, coldness and absence of pulses. Pulses were also diminished in the contralateral upper limb.

This heavy smoker woman with a 5 year history of Buerger's disease affecting the lower limb arteries bilaterally, presented with a 10 day history of left forearm and hand pain, numbness, coldness and absence of pulses. Pulses were also diminished in the contralateral upper limb. History for predisposing factors and workup for hypercoagulable states was negative. Color doppler U/S of left upper limb showed absence of flow in the middle brachial artery (Fig 1a) with reconstitution through collaterals of its distal portion, where a damped doppler waveform with decreased peak systolic velocity was obtained (Fig 1b). Transfemoral bilateral selective brachial arteriogram showed a 7 cm long left mid brachial artery tight irregular stenosis with evidence of intraluminal thrombus (Fig 2). Moreover, bilateral 3-5 cm long radial and ulnar arterial occlusions together with corkscrew type collaterals were observed (Fig 3a and 3b). The thrombus was transversed with a 0,035" hydrophilic guidewire (Terumo, Tokyo, Japan) and a 5F Mewissen infusion catheter with 10 side-holes was embedded into it. Three boluses of 5mg rtPA each were given at intervals of 5 min. followed by continuous infusion of 2mg/h. Heparin (5000 IU) was given intraarterially as soon as the thrombus was transversed with the guidewire and was continued throughout lysis as IV infusion of 500IU/h in order to prevent thrombus formation around the catheter. Post-lysis heparin was infused at a dose of 500 IU/h IV for 24 h. After a cumulative dose of 20 mg rtPA, recanalization of the obstructed brachial artery was achieved and the completion angiogram showed an underlying normal arterial segment with some residual thrombus causing no flow obstruction (Fig 5).There was clinical improvement and restoration of pulses in the left hand immediately after thrombolysis and at 1-month follow-up. Post-thrombolysis color doppler U/S showed unobstructed flow in the left brachial artery with a triphasic waveform and normal peak systolic velocity (Fig 6).

Thrombangiitis obliterans or Buerger's disease is an inflammatory obliterative vasculitis of unknown cause involving small and medium size arteries and veins. The disease more commonly affects the lower extremities than the upper and is often associated with thrombophlebitis. Although it typically occurs in 20-50 years old men who are heavy smokers, women also may be affected. The diagnosis is best made histologically by punch biopsy. However this is rarely used because biopsy itself may initiate ulceration. It may be difficult to distinguish from atherosclerosis angiographically. Features that favor Buerger's rather than atherosclerosis include distal rather than proximal predilection of occlusions, absence of atherosclerotic changes in the larger more proximal arteries , normal vascular segments between areas of disease and typically corkscrew collaterals bridging the areas of occlusion. Arterial thrombosis in proximal clinically non-involved vessels is rare. Catheter-directed thrombolysis with urokinase and subsequent small vessel angioplasty has been used successfully in the treatment of hand ischaemia in Buerger's disease. Recombinant tissue plasminogen activator (rtPA) tends to induce more rapid lysis during the first hours compared to urokinase ; for this reason it is our agent of preference. An initial high-dose transthrombus bolus of the lytic drug followed by continuous infusion, significantly shortens the duration of lysis without compromising outcome.