Emmanuel Angelin, Selvaraj Dheepak, Sen Indrani, Agarwal Sunil, Stephen Edwin, Kota Albert, Nair Sukesh Chandran, Antoniswamy Belavendra
Department of Vascular Surgery, Christian Medical College, Vellore, Tamil Nadu, India.
Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India.
Natl Med J India. 2019 May-Jun;32(3):134-136. doi: 10.4103/0970-258X.278685.
Thromboangiitis obliterans (TAO) or Buerger disease is a recurring progressive segmental vasculopathy that presents with inflammation and thrombosis of small and medium arteries and veins of the hands and feet. The exact cause remains unknown, with tobacco use (primarily smoking but also smokeless tobacco) being highly associated with the disease. The diagnosis is clinical and the lack of a diagnostic gold standard is a deterrent to diagnosing it in patients with atypical presentations. Obliterative endarteritis occurs perhaps due to a mixture of thrombosis and inflammation. The diagnostic sensitivity and specificity of D-dimer as a biomarker for thrombosis is well reported from its use in other areas such as deep vein thrombosis. Identification of a biomarker linked to the causation yields a diagnostic adjunct with a role in therapeutic decision-making, aiding diagnosis in atypical presentation, monitoring disease activity and gauging response to therapy.
Between April 2014 and May 2015, we studied serum D-dimer (a marker of thrombosis) in 62 patients with TAO and compared this to 330 normal age- and sex-matched controls. We included all patients with peripheral arterial disease clinically diagnosed to have TAO according to the Shionoya criteria. There was no history of thrombosis or arterial disease in the control group. The control group was matched for baseline characteristics such as age and sex. All patients underwent a standard diagnostic protocol including blood tests (haemoglobin and creatinine), electrocardiogram, chest X-ray and ankle brachial pressure index. Blood was collected using an evacuated tube system into a citrate anticoagulant tube for testing D-dimer.
All the 62 patients diagnosed to have TAO were men with an average age of 40 years (range 18-65 years). They all had a history of tobacco use and did not have other atherogenic risk factors (part of the diagnostic criteria). Medium-vessel involvement was present in 53 patients (85%) and the rest presented with additional involvement of the popliteal and femoral vessels. Upper limb involvement or superficial thrombophlebitis was present in 95% of patients. Laboratory and imaging studies were consistent with TAO. The groups were well matched for age (p = 0.3). The median and interquartile range for D-dimer values were 61 ng/ml and 41-88 ng/ml in controls (n = 330) and 247 ng/ml and 126478 ng/ml in patients (n = 62), respectively (p<0.001).
D-dimer levels are considerably elevated in patients with TAO. This indicates an underlying thrombotic process and suggests its potential role as a diagnostic adjunct. It also leads us to hypothesize a potential therapeutic benefit of anticoagulants in this disease.
血栓闭塞性脉管炎（TAO）或伯格氏病是一种复发性进行性节段性血管病，表现为手足中小动脉和静脉的炎症和血栓形成。确切病因尚不清楚，烟草使用（主要是吸烟，但也包括无烟烟草）与该病高度相关。诊断依靠临床判断，缺乏诊断金标准阻碍了对非典型表现患者的诊断。闭塞性动脉内膜炎可能是由血栓形成和炎症共同作用引起的。D - 二聚体作为血栓形成生物标志物的诊断敏感性和特异性在其他领域如深静脉血栓形成中已有充分报道。识别与病因相关的生物标志物可产生一种诊断辅助手段，在治疗决策中发挥作用，有助于非典型表现的诊断、监测疾病活动以及评估治疗反应。
2014年4月至2015年5月期间，我们研究了62例TAO患者的血清D - 二聚体（一种血栓形成标志物），并将其与330名年龄和性别匹配的正常对照进行比较。我们纳入了所有根据Shionoya标准临床诊断为TAO的外周动脉疾病患者。对照组无血栓形成或动脉疾病史。对照组在年龄和性别等基线特征方面进行了匹配。所有患者均接受了标准诊断方案，包括血液检查（血红蛋白和肌酐）、心电图、胸部X线和踝臂压力指数。使用真空采血管系统将血液采集到柠檬酸盐抗凝管中用于检测D - 二聚体。
所有62例诊断为TAO的患者均为男性，平均年龄40岁（范围18 - 65岁）。他们都有吸烟史，且没有其他动脉粥样硬化危险因素（诊断标准的一部分）。53例患者（85%）有中血管受累，其余患者伴有腘动脉和股动脉的额外受累。95%的患者有上肢受累或浅表血栓性静脉炎。实验室和影像学检查结果与TAO一致。两组在年龄方面匹配良好（p = 0.3）。对照组（n = 330）D - 二聚体值的中位数和四分位间距分别为61 ng/ml和41 - 88 ng/ml，患者组（n = 62）分别为247 ng/ml和126 - 478 ng/ml（p<0.001）。
TAO患者的D - 二聚体水平显著升高。这表明存在潜在的血栓形成过程，并提示其作为诊断辅助手段的潜在作用。这也使我们推测抗凝剂在这种疾病中可能具有治疗益处。
