Thromboangiitis obliterans with Rest Pain or Trophic Lesions When Intravenous Iloprost Has Not Achieved Healing

Patients with Thromboangiitis obliterans (Buerger's disease) who present with rest pain of the extremities or trophic lesions — including ischemic ulcers and gangrene — and who have not achieved adequate outcomes after a completed course of intravenous iloprost require a structured next-step approach.

Clinical scenario

Rest pain of extremities or trophic lesions of extremities (ischemic ulcers, gangrene)

Previous line — escalation condition

The prior treatment was intravenous iloprost. This protocol applies when iloprost has failed to achieve healing of trophic lesions and resolution of rest pain by 21–28 days, or complete healing without pain at 24 weeks.

Next-step approach (partial)

The next-step protocol involves surgical interventions — lumbar sympathectomy is among the options for patients in whom medical therapy has not achieved adequate outcomes. Additional procedures and patient-selection criteria are detailed in the full regimen.

Pain relief Ulcer healing Improved claudication distance

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1155/2013/156905

In a randomized study, 152 patients with Buerger's disease presenting with rest pain, with or without trophic changes, received intravenous iloprost or placebo.
Sympathectomy may be performed to decrease arterial spasm in patients with Buerger's disease.
In situ bypass should be considered in patients with severe ischemia who have target vessels.
Omentopexy is an attractive option, but it needs proper mobilization of omentum by experts and more surgical time, increasing complications.
In a study by Patwa and Krishnan who used Ilizaro's technique for TAO patient, a vertical tibial osteotomy with horizontal distraction was performed.
Sympathectomy has been shown to provide short-term pain relief and to promote ulcer healing in some patients with Buerger's disease, but no long-term benefit has been confirmed.
It was seen that in 60 patients followed up for 5 yrs there was significant improvement in 53 patient in terms of ulcer healing, decrease in major amputation, rest pain, and claudication distance.

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