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血栓闭塞性脉管炎(Buerger病)

Author
Jeffrey W Olin, DO
Section Editors
John F Eidt, MD
Joseph L Mills, Sr, MD
Emile R Mohler III, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS
Translators
邵江, 主治医师

引言

血栓闭塞性脉管炎又称Buerger病，是一种非动脉粥样硬化性节段性炎性疾病，最常累及肢体的静脉和中小动脉[1-3]。血栓闭塞性脉管炎的特征为出现细胞富集的炎性闭塞性血栓，而血管壁相对正常[4]。患者通常是表现为远端肢体缺血、指/趾缺血性溃疡或指/趾坏疽的年轻吸烟者[5]。本病与使用烟草产品有很强的相关性，因此戒烟对降低截肢风险很重要。本文将总结血栓闭塞性脉管炎的流行病学、临床表现、诊断和治疗。

流行病学

血栓闭塞性脉管炎更常见于大量使用烟草的国家，尤其是使用原烟自制香烟的人群[6]。因此，该病在地中海、中东和亚洲最为普遍[7,8]。北美在过去的30年因吸烟减少，该病的患病率已有所下降[8,9]。在世界其他地区，该病在动脉闭塞性疾病患者中的患病率差别较大，西欧为0.5%-5.6%，而印度则高达45%-63%[10]。

男性较女性更常受累，发病年龄通常为40-45岁。诊断为血栓闭塞性脉管炎的患者中，70%-91%为男性，11%-30%为女性[11]。不过有研究报道女性的患病率有所增加，这可能是因为女性烟草使用增加[5,9,11-17]。

危险因素

烟草的使用对于血栓闭塞性脉管炎的发生和发展都很关键[18-20]。大部分患者为大量吸烟者。一项研究发现，诊断为血栓闭塞性脉管炎的患者平均烟龄为23年[20]。在雪茄、大麻(大麻诱发动脉炎)及无烟烟草(如嚼烟和鼻烟)使用者中也有该病报道[4,5,21-25]。

慢性厌氧菌牙周感染也可能在血栓闭塞性脉管炎的发生中起一定作用[26,27]。几乎2/3的血栓闭塞性脉管炎患者有严重的牙周疾病。一项研究在血栓闭塞性脉管炎患者的动脉病变和口腔中均发现了与厌氧菌相关的DNA片段[26]。然而，在不患血栓闭塞性脉管炎的吸烟者中，牙周疾病的患病率同样高，因而两者之间的联系可能并不明确。

                     

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Literature review current through: 2017-06 . | This topic last updated: 2017-05-18.
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References
Top
  1. Buerger L. Landmark publication from the American Journal of the Medical Sciences, 'Thrombo-angiitis obliterans: a study of the vascular lesions leading to presenile spontaneous gangrene'. 1908. Am J Med Sci 2009; 337:274.
  2. Piazza G, Creager MA. Thromboangiitis obliterans. Circulation 2010; 121:1858.
  3. Dargon PT, Landry GJ. Buerger's disease. Ann Vasc Surg 2012; 26:871.
  4. Olin JW. Thromboangiitis obliterans (Buerger's disease). N Engl J Med 2000; 343:864.
  5. Mills JL, Porter JM. Buerger's disease: a review and update. Semin Vasc Surg 1993; 6:14.
  6. Grove WJ, Stansby GP. Buerger's disease and cigarette smoking in Bangladesh. Ann R Coll Surg Engl 1992; 74:115.
  7. Dilege S, Aksoy M, Kayabali M, et al. Vascular reconstruction in Buerger's disease: is it feasible? Surg Today 2002; 32:1042.
  8. Lie JT. The rise and fall and resurgence of thromboangiitis obliterans (Buerger's disease). Acta Pathol Jpn 1989; 39:153.
  9. Lie JT. Thromboangiitis obliterans (Buerger's disease) in women. Medicine (Baltimore) 1987; 66:65.
  10. Arkkila PE. Thromboangiitis obliterans (Buerger's disease). Orphanet J Rare Dis 2006; 1:14.
  11. Mills JL, Taylor LM Jr, Porter JM. Buerger's disease in the modern era. Am J Surg 1987; 154:123.
  12. Olin JW, Young JR, Graor RA, et al. The changing clinical spectrum of thromboangiitis obliterans (Buerger's disease). Circulation 1990; 82:IV3.
  13. Cooper LT, Tse TS, Mikhail MA, et al. Long-term survival and amputation risk in thromboangiitis obliterans (Buerger's disease). J Am Coll Cardiol 2004; 44:2410.
  14. Ehrenfeld M, Adar R. Rheumatic manifestations in patients with thromboangiitis obliterans (Buerger's disease). J Rheumatol 2000; 27:1818.
  15. Lau H, Cheng SW. Buerger's disease in Hong Kong: a review of 89 cases. Aust N Z J Surg 1997; 67:264.
  16. Shionoya S, Ban I, Nakata Y, et al. Involvement of the iliac artery in Buerger's disease (pathogenesis and arterial reconstruction). J Cardiovasc Surg (Torino) 1978; 19:69.
  17. Sasaki S, Sakuma M, Yasuda K. Current status of thromboangiitis obliterans (Buerger's disease) in Japan. Int J Cardiol 2000; 75 Suppl 1:S175.
  18. Mills JL, Porter JM. Buerger's disease (thromboangiitis obliterans). Ann Vasc Surg 1991; 5:570.
  19. Papa M, Bass A, Adar R, et al. Autoimmune mechanisms in thromboangiitis obliterans (Buerger's disease): the role of tobacco antigen and the major histocompatibility complex. Surgery 1992; 111:527.
  20. Tavakoli H, Rezaii J, Esfandiari K, et al. Buerger's disease: a 10-year experience in Tehran, Iran. Clin Rheumatol 2008; 27:369.
  21. Martin-Blondel G, Koskas F, Cacoub P, Sène D. Is thromboangiitis obliterans presentation influenced by cannabis addiction? Ann Vasc Surg 2011; 25:469.
  22. Lie JT. Thromboangiitis obliterans (Buerger's disease) and smokeless tobacco. Arthritis Rheum 1988; 31:812.
  23. Combemale P, Consort T, Denis-Thelis L, et al. Cannabis arteritis. Br J Dermatol 2005; 152:166.
  24. Disdier P, Granel B, Serratrice J, et al. Cannabis arteritis revisited--ten new case reports. Angiology 2001; 52:1.
  25. Cottencin O, Karila L, Lambert M, et al. Cannabis arteritis: review of the literature. J Addict Med 2010; 4:191.
  26. Iwai T, Inoue Y, Umeda M, et al. Oral bacteria in the occluded arteries of patients with Buerger disease. J Vasc Surg 2005; 42:107.
  27. Chen YW, Nagasawa T, Wara-Aswapati N, et al. Association between periodontitis and anti-cardiolipin antibodies in Buerger disease. J Clin Periodontol 2009; 36:830.
  28. Lie JT. Diagnostic histopathology of major systemic and pulmonary vasculitic syndromes. Rheum Dis Clin North Am 1990; 16:269.
  29. Małecki R, Zdrojowy K, Adamiec R. Thromboangiitis obliterans in the 21st century--a new face of disease. Atherosclerosis 2009; 206:328.
  30. Leu HJ. Early inflammatory changes in thromboangiitis obliterans. Pathol Microbiol (Basel) 1975; 43:151.
  31. Lie JT. Thromboangiitis obliterans (Buerger's disease) revisited. Pathol Annu 1988; 23 Pt 2:257.
  32. Adar R, Papa MZ, Halpern Z, et al. Cellular sensitivity to collagen in thromboangiitis obliterans. N Engl J Med 1983; 308:1113.
  33. Lee T, Seo JW, Sumpio BE, Kim SJ. Immunobiologic analysis of arterial tissue in Buerger's disease. Eur J Vasc Endovasc Surg 2003; 25:451.
  34. Kobayashi M, Ito M, Nakagawa A, et al. Immunohistochemical analysis of arterial wall cellular infiltration in Buerger's disease (endarteritis obliterans). J Vasc Surg 1999; 29:451.
  35. Guzel E, Topal E, Yildirim A, et al. Targeting novel antigens in the arterial wall in thromboangiitis obliterans. Folia Histochem Cytobiol 2010; 48:134.
  36. Edo N, Miyai K, Ogata S, et al. Thromboangiitis obliterans with multiple large vessel involvement: case report and analysis of immunophenotypes. Cardiovasc Pathol 2010; 19:59.
  37. Dellalibera-Joviliano R, Joviliano EE, Silva JS, Evora PR. Activation of cytokines corroborate with development of inflammation and autoimmunity in thromboangiitis obliterans patients. Clin Exp Immunol 2012; 170:28.
  38. Tamai H, Kobayashi M, Takeshita K, et al. Possible involvement of Notch signaling in the pathogenesis of Buerger's disease. Surg Today 2014; 44:307.
  39. Eichhorn J, Sima D, Lindschau C, et al. Antiendothelial cell antibodies in thromboangiitis obliterans. Am J Med Sci 1998; 315:17.
  40. Azizi M, Boutouyrie P, Bura-Rivière A, et al. Thromboangiitis obliterans and endothelial function. Eur J Clin Invest 2010; 40:518.
  41. Joras M, Poredos P, Fras Z. Endothelial dysfunction in Buerger's disease and its relation to markers of inflammation. Eur J Clin Invest 2006; 36:376.
  42. Makita S, Nakamura M, Murakami H, et al. Impaired endothelium-dependent vasorelaxation in peripheral vasculature of patients with thromboangiitis obliterans (Buerger's disease). Circulation 1996; 94:II211.
  43. Maslowski L, McBane R, Alexewicz P, Wysokinski WE. Antiphospholipid antibodies in thromboangiitis obliterans. Vasc Med 2002; 7:259.
  44. Hus I, Sokolowska B, Walter-Croneck A, et al. Assessment of plasma prothrombotic factors in patients with Buerger's disease. Blood Coagul Fibrinolysis 2013; 24:133.
  45. Puéchal X, Fiessinger JN. Thromboangiitis obliterans or Buerger's disease: challenges for the rheumatologist. Rheumatology (Oxford) 2007; 46:192.
  46. Olin JW, Shih A. Thromboangiitis obliterans (Buerger's disease). Curr Opin Rheumatol 2006; 18:18.
  47. Hartmann P, Mohokum M, Schlattmann P. The association of Raynaud syndrome with thromboangiitis obliterans--a meta-analysis. Angiology 2012; 63:315.
  48. Donatelli F, Triggiani M, Nascimbene S, et al. Thromboangiitis obliterans of coronary and internal thoracic arteries in a young woman. J Thorac Cardiovasc Surg 1997; 113:800.
  49. Lie JT. Visceral intestinal Buerger's disease. Int J Cardiol 1998; 66 Suppl 1:S249.
  50. Kurata A, Nonaka T, Arimura Y, et al. Multiple ulcers with perforation of the small intestine in buerger's disease: a case report. Gastroenterology 2003; 125:911.
  51. Cakmak A, Gyedu A, Akyol C, et al. Occlusion of the celiac trunk, the inferior mesenteric artery and stenosis of the superior mesenteric artery in peripheral thrombangiitis obliterans. Vasa 2009; 38:394.
  52. Michail PO, Filis KA, Delladetsima JK, et al. Thromboangiitis obliterans (Buerger's disease) in visceral vessels confirmed by angiographic and histological findings. Eur J Vasc Endovasc Surg 1998; 16:445.
  53. Fujii Y, Soga J, Hidaka T, et al. Color doppler flows of corkscrew collaterals in Thromboangiitis obliterans (Buerger's disease) using color duplex ultrasonography. J Am Coll Cardiol 2011; 57:2539.
  54. Pereira de Godoy JM, Braile DM. Buerger's disease and anticardiolipin antibodies. J Cardiovasc Med (Hagerstown) 2009; 10:792.
  55. Shionoya S. Diagnostic criteria of Buerger's disease. Int J Cardiol 1998; 66 Suppl 1:S243.
  56. Shionoya S. What is Buerger's disease? World J Surg 1983; 7:544.
  57. Dimmick SJ, Goh AC, Cauzza E, et al. Imaging appearances of Buerger's disease complications in the upper and lower limbs. Clin Radiol 2012; 67:1207.
  58. Lambeth JT, Yong NK. Arteriographic findings in thromboangiitis obliterans with emphasis on femoropopliteal involvement. Am J Roentgenol Radium Ther Nucl Med 1970; 109:553.
  59. Yoshimuta T, Akutsu K, Okajima T, et al. Corkscrew collaterals in Buerger's disease. Can J Cardiol 2009; 25:365.
  60. Marder VJ, Mellinghoff IK. Cocaine and Buerger disease: is there a pathogenetic association? Arch Intern Med 2000; 160:2057.
  61. Noël B. Cocaine and arsenic-induced Raynaud's phenomenon. Clin Rheumatol 2002; 21:343.
  62. Papa MZ, Rabi I, Adar R. A point scoring system for the clinical diagnosis of Buerger's disease. Eur J Vasc Endovasc Surg 1996; 11:335.
  63. Lazarides MK, Georgiadis GS, Papas TT, Nikolopoulos ES. Diagnostic criteria and treatment of Buerger's disease: a review. Int J Low Extrem Wounds 2006; 5:89.
  64. Canter HI, Isci E, Erk Y. Vacuum-assisted wound closure for the management of a foot ulcer due to Buerger's disease. J Plast Reconstr Aesthet Surg 2009; 62:250.
  65. Hurt RD, Hays JT. Urinary tobacco alkaloid measurement in patients having thromboangiitis obliterans. Mayo Clin Proc 2008; 83:1187.
  66. Ohta T, Ishioashi H, Hosaka M, Sugimoto I. Clinical and social consequences of Buerger disease. J Vasc Surg 2004; 39:176.
  67. Hooten WM, Bruns HK, Hays JT. Inpatient treatment of severe nicotine dependence in a patient with thromboangiitis obliterans (Buerger's disease). Mayo Clin Proc 1998; 73:529.
  68. Oral iloprost in the treatment of thromboangiitis obliterans (Buerger's disease): a double-blind, randomised, placebo-controlled trial. The European TAO Study Group. Eur J Vasc Endovasc Surg 1998; 15:300.
  69. Fiessinger JN, Schäfer M. Trial of iloprost versus aspirin treatment for critical limb ischaemia of thromboangiitis obliterans. The TAO Study. Lancet 1990; 335:555.
  70. Bozkurt AK, Köksal C, Demirbas MY, et al. A randomized trial of intravenous iloprost (a stable prostacyclin analogue) versus lumbar sympathectomy in the management of Buerger's disease. Int Angiol 2006; 25:162.
  71. Bozkurt AK, Cengiz K, Arslan C, et al. A stable prostacyclin analogue (iloprost) in the treatment of Buerger's disease: a prospective analysis of 150 patients. Ann Thorac Cardiovasc Surg 2013; 19:120.
  72. Labropoulos N, Watson WC, Mansour MA, et al. Acute effects of intermittent pneumatic compression on popliteal artery blood flow. Arch Surg 1998; 133:1072.
  73. Montori VM, Kavros SJ, Walsh EE, Rooke TW. Intermittent compression pump for nonhealing wounds in patients with limb ischemia. The Mayo Clinic experience (1998-2000). Int Angiol 2002; 21:360.
  74. Isner JM, Baumgartner I, Rauh G, et al. Treatment of thromboangiitis obliterans (Buerger's disease) by intramuscular gene transfer of vascular endothelial growth factor: preliminary clinical results. J Vasc Surg 1998; 28:964.
  75. Kim HJ, Jang SY, Park JI, et al. Vascular endothelial growth factor-induced angiogenic gene therapy in patients with peripheral artery disease. Exp Mol Med 2004; 36:336.
  76. Idei N, Soga J, Hata T, et al. Autologous bone-marrow mononuclear cell implantation reduces long-term major amputation risk in patients with critical limb ischemia: a comparison of atherosclerotic peripheral arterial disease and Buerger disease. Circ Cardiovasc Interv 2011; 4:15.
  77. Fadini GP, Agostini C, Avogaro A. Autologous stem cell therapy for peripheral arterial disease meta-analysis and systematic review of the literature. Atherosclerosis 2010; 209:10.
  78. Matoba S, Tatsumi T, Murohara T, et al. Long-term clinical outcome after intramuscular implantation of bone marrow mononuclear cells (Therapeutic Angiogenesis by Cell Transplantation [TACT] trial) in patients with chronic limb ischemia. Am Heart J 2008; 156:1010.
  79. Motukuru V, Suresh KR, Vivekanand V, et al. Therapeutic angiogenesis in Buerger's disease (thromboangiitis obliterans) patients with critical limb ischemia by autologous transplantation of bone marrow mononuclear cells. J Vasc Surg 2008; 48:53S.
  80. Saito S, Nishikawa K, Obata H, Goto F. Autologous bone marrow transplantation and hyperbaric oxygen therapy for patients with thromboangiitis obliterans. Angiology 2007; 58:429.
  81. Durdu S, Akar AR, Arat M, et al. Autologous bone-marrow mononuclear cell implantation for patients with Rutherford grade II-III thromboangiitis obliterans. J Vasc Surg 2006; 44:732.
  82. Boda Z, Udvardy M, Rázsó K, et al. Stem cell therapy: a promising and prospective approach in the treatment of patients with severe Buerger's disease. Clin Appl Thromb Hemost 2009; 15:552.
  83. Baumann G, Stangl V, Klein-Weigel P, et al. Successful treatment of thromboangiitis obliterans (Buerger's disease) with immunoadsorption: results of a pilot study. Clin Res Cardiol 2011; 100:683.
  84. Inan M, Alat I, Kutlu R, et al. Successful treatment of Buerger's Disease with intramedullary K-wire: the results of the first 11 extremities. Eur J Vasc Endovasc Surg 2005; 29:277.
  85. Miyamoto K, Nishigami K, Nagaya N, et al. Unblinded pilot study of autologous transplantation of bone marrow mononuclear cells in patients with thromboangiitis obliterans. Circulation 2006; 114:2679.
  86. De Haro J, Acin F, Bleda S, et al. Treatment of thromboangiitis obliterans (Buerger's disease) with bosentan. BMC Cardiovasc Disord 2012; 12:5.
  87. Reilly MP, Mohler ER 3rd. Cilostazol: treatment of intermittent claudication. Ann Pharmacother 2001; 35:48.
  88. Yasuda K, Sakuma M, Tanabe T. Hemodynamic effect of cilostazol on increasing peripheral blood flow in arteriosclerosis obliterans. Arzneimittelforschung 1985; 35:1198.
  89. Dean SM, Satiani B. Three cases of digital ischemia successfully treated with cilostazol. Vasc Med 2001; 6:245.
  90. Lee T, Ra HD, Park YJ, et al. New routing alternative for proximal anterior tibial artery bypass in patients with Buerger disease. J Vasc Surg 2011; 54:1839.
  91. Sayin A, Bozkurt AK, Tüzün H, et al. Surgical treatment of Buerger's disease: experience with 216 patients. Cardiovasc Surg 1993; 1:377.
  92. Sasajima T, Kubo Y, Inaba M, et al. Role of infrainguinal bypass in Buerger's disease: an eighteen-year experience. Eur J Vasc Endovasc Surg 1997; 13:186.
  93. Singh I, Ramteke VK. The role of omental transfer in Buerger's disease: New Delhi's experience. Aust N Z J Surg 1996; 66:372.
  94. Agarwal VK. Long-term results of omental transplantation in chronic occlusive arterial disease (Buerger's disease) and retinal avascular diseases (retinitis pigmentosa). Int Surg 2007; 92:174.
  95. Nishikimi N. Fate of limbs with failed vascular reconstruction in Buerger's disease patients. Int J Cardiol 2000; 75 Suppl 1:S183.
  96. Graziani L, Morelli L, Parini F, et al. Clinical outcome after extended endovascular recanalization in Buerger's disease in 20 consecutive cases. Ann Vasc Surg 2012; 26:387.
  97. Hussein EA, el Dorri A. Intra-arterial streptokinase as adjuvant therapy for complicated Buerger's disease: early trials. Int Surg 1993; 78:54.
  98. Ates A, Yekeler I, Ceviz M, et al. One of the most frequent vascular diseases in northeastern of Turkey: Thromboangiitis obliterans or Buerger's disease (experience with 344 cases). Int J Cardiol 2006; 111:147.
  99. Chander J, Singh L, Lal P, et al. Retroperitoneoscopic lumbar sympathectomy for buerger's disease: a novel technique. JSLS 2004; 8:291.
  100. Watarida S, Shiraishi S, Fujimura M, et al. Laparoscopic lumbar sympathectomy for lower-limb disease. Surg Endosc 2002; 16:500.
  101. De Giacomo T, Rendina EA, Venuta F, et al. Thoracoscopic sympathectomy for symptomatic arterial obstruction of the upper extremities. Ann Thorac Surg 2002; 74:885.
  102. Swigris JJ, Olin JW, Mekhail NA. Implantable spinal cord stimulator to treat the ischemic manifestations of thromboangiitis obliterans (Buerger's disease). J Vasc Surg 1999; 29:928.
  103. Chierichetti F, Mambrini S, Bagliani A, Odero A. Treatment of Buerger's disease with electrical spinal cord stimulation--review of three cases. Angiology 2002; 53:341.
  104. Pace AV, Saratzis N, Karokis D, et al. Spinal cord stimulation in Buerger's disease. Ann Rheum Dis 2002; 61:1114.
  105. Donas KP, Schulte S, Ktenidis K, Horsch S. The role of epidural spinal cord stimulation in the treatment of Buerger's disease. J Vasc Surg 2005; 41:830.