There are various therapeutic options for TAO which are pharmacotherapy with diverse medications (prostacyclin analog (iloprost and clinprost), aspirin, prostaglandin analog, folic acid cilostazol, clopidogrel, pentoxifylline )(5)
autologous bone marrow mononuclear cell (BM-MNC) implantation, implantation of spinal cord stimulators, Gene therapy with vascular endothelial growth factor, and surgical interventions, that include surgical sympathectomy, bypass surgery, and amputation of the involved limb in refractory TAO.
The study aimed to compare sympathectomy surgery outcomes in patients with TAO with bypass surgery and drug therapy outcomes.
Quit consumption of cigarettes and tobacco in any form is the only fundamental treatment for Buerger disease, and all the other surgical and medical treatments are palliatives. Many studies showed that there was no need for amputation surgery in patients with TAO that abstained from tobacco and cigarette as long as the organ was not ischemic or gangrenous.
Thus the results of the studies strongly prove the correlation between tobacco use and exacerbation of the disease leading to non-healing ulcers and limb amputation.(1, 6)
However, it seems that discontinuing smoking on its own is not enough for treatment of the patients with critical limb ischemia and other therapeutic interventions are needed as well.(7)
Pharmacotherapy with different medications may help patients reduce ischemic ulcers and rest pain but have no effects on preventing the disease progression.
Surgical sympathectomy reduces spasms of arteries in patients with TAO, but it is still unclear how the surgery improves the symptoms.
It seems that surgical sympathectomy is helpful in patients with persistent pain and non-healing ischemic lesions that have abstained from consumption of tobacco.(8)
In our study, Among 70 patients, 28 of them underwent lumbar sympathectomy, and 9 of them underwent thoracic sympathectomy. one day after surgery, around 60% of patients had improvements of claudication of calf, paresthesia, and rest pain.
In 3-month post-operative follow-ups ,50–60% of patients mentioned improvements and remissions in symptoms, and in 6-moth post-op follow-ups the patients mentioned 50–60% remission in symptoms (detailed reports are in Table 2 )
The efficacy of sympathectomy in short-term follow-ups was evaluated in a study done by N.Nakajima, and results were as follows: 60% of all patients showed marked improvements in symptoms. 25% of them improved in symptoms and only 1/5% had aggravation in symptoms .The study also confirmed that advanced symptoms such as rest pain and ulcers were improved after sympathectomy too.
remission in symptoms in long-term follow-ups were recorded in 83% of patients in which the effectiveness of the surgery lasted in 50% of them after 5 years and just 10% of the patients had no change in symptoms.(9)
Although surgical sympathectomy improves severe symptoms in patients, complete remission only occurs if they stop smoking. Stop smoking can heal ischemic lesions and reduce the risk of amputation.(6)
The correlation between recovery rate in people who quit smoking and continue smoking after sympathectomy is detailed in Table 3.
Among 70 patients, 15 of them underwent bypass surgery. In 6-month follow-ups, no treatment failure was reported. Moreover, improvements of symptoms in one-day,3-month, and 6-month follow-ups were significant.
Improvements and remission of the symptoms were around 70 to 80%.
The results were much better than outcomes in patients who underwent sympathectomy surgery and pharmacotherapy.
A study done by Dilege and colleagues on 27 patients who underwent bypass surgery confirmed successful bypasses with a 92.5% salvage rate in follow-ups in 3 years. Also, 31 patients underwent bypass surgery in a study done by Ohta and the post-op results of the study showed an 85.4% salvage rate in 10-year follow-ups.
However, bypass surgery seems to be a beneficial surgical treatment with a high amputation-free survival rate, this procedure is most of the time difficult and unavailable due to lack of possible, sufficient vessel and diffuse segmental pattern of thrombus in distal vessels.
Surgical sympathectomy usually is performed when bypass surgery is impossible.(10)
Among 70 patients, 12 of them underwent pharmacotherapy and received Iloprost, a. Detailed report of post-ups follow ups mentioned in Table 2.
To clarify which performed therapeutic intervention, is the most appropriate treatment, we compared the sympathectomy surgery, bypass surgery and pharmacotherapy based on the rate of improvements of claudication of calf, ulcer
, rest pain, plantar claudication in post-op follow-ups and P-value was calculated. (Table 4, Table 5)
According to the results of comparison between sympathectomy and bypass, it seems that patients benefited significantly more from bypass surgery than sympathectom; However, there was no meaningful results of comparison between sympathectomy and pharmacotherapy.
However, a randomized controlled study that compared sympathectomy with ILOPROST showed that ILOPROST is more effective in healing of ulcers and rest pain in patients with TAO.(11)