Buerger disease is a rare non-atherosclerotic inflammatory vascular disease involving the small and medium-sized arteries and veins of young smokers, and is more common in males [1,2]. The risk of major amputation remains high, with an overall amputation rate of 33% with conservative treatment [3].
We present the rare case of a 37-year-old male with a confirmed diagnosis of Buerger disease, who suffered from severe ischemic pain, cold intolerance, purple color change, and progressive peripheral necrosis in 4 limbs for 1 year. Arteriography of the 4 extremities revealed segmental obstruction of all major arteries below the elbow and knee level, and relatively well-maintained patency of the distal stump in both radial and posterior tibial arteries by collateral circulation. To resolve the ischemia of the 4 limbs, we performed reconstruction of 4 arteries with long vein grafts: radial artery reconstruction with a cephalic vein graft in both hands, and popliteal artery to posterior tibial artery bypass reconstruction with a lesser saphenous vein in both lower legs, in order. After surgery, we reevaluated the vascular status of the reconstructed vessels with follow-up angiography (Figs. 1−3). The ischemic problems in all extremities significantly improved without ischemic pain, except for right third toe tip necrosis, over a follow-up period of 5 years (Fig. 4).
In Buerger disease, surgical revascularization has limitations due to the extensive vascular involvement characteristic of this condition, resulting in lower patency rates after surgery [1,2]. In this case of progressive 4-extremity ischemia in a young patient with segmental involvement in the main arteries, revascularization with long vein grafts was a very successful management strategy.