A Middle-aged Woman Suffering Buerger’s Disease

fingertips of the right hand. Laboratory examination results (including immunology marker) were within normal limit. Doppler ultrasound and arteriography showed segmental stenosis and partial occlusion of distal arteries on all extremities. We assessed the patient with Buerger’s disease. The managements were oral analgesic and vasodilator medication. Endoscopic thoracal ganglion sympathectomy was performed, followed by amputation of the necrotic fingers. We did not perform a biopsy, so according to all examinations and also by Shionoya and Olin’s criteria, the patient was more likely to suffer from Buerger’s disease than other peripheral occlusive diseases. Case Report A Middle-aged Woman Suffering Buerger’s Disease D. Caroline, M. Aminuddin 1 Mitra Keluarga Kenjeran Hospital, Surabaya, Indonesia 2 Department of Cardiology and Vascular Medicine, Dr. Soetomo General Hospital, Surabaya, Indonesia


Introduction
Thromboangiitis obliterans (TAO) or Buerger's disease is a non-atherosclerotic, segmental inflammatory disease that most commonly affects the small and medium-sized arteries, veins, and nerves of the arms and legs. Von Winiwarter first described a patient with thromboangiitis obliterans in 1879. Twenty-nine years later, Leo Buerger provided a detailed and accurate description of the pathological findings in 11 amputated limbs [1] . The disease is found all over the world, but the highest incidence is found in the Middle East. TAO is said to be more common in Asian races than others [2] .The prevalence of the disease among all patients with peripheral arterial disease ranges from as low as 0,5 to 5,6% in Western Europe to values as high as 45 to 63% in India and16 to 66%in Korea and Japan [3] .
Buerger's disease is common in young men (between 40-45 years of age) who smoke.
However, the patient's spectrum of TAO has changed; the ratio of men to women decreases, the number of older patients increase, and the  [1,2] . Although the disease has been described since more than 100 years ago, the underlying pathology and etiology of the disease remain unclear [3] . The use of cigarettes or exposure to cigarettes is still the essence of the occurrence and the progressivity of this disease.

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Some researchers believe that TAO can also happen to non-smokers (although only <5% of cases). TAO cases on non smokers can be driven by cold, frostbite, trauma to the extremities, or the misuse of sympathomimetic drugs [1,5] . Until now there is no consensus establishing the diagnosis and there were no specific markers, so the diagnosis is based on clinical criteria (by excluding other causes) as well as angiography [1][2][3] .
Here we report a case of middle-aged non smoker woman with Buerger's disease.      followed by amputation of the necrotic fingers without any complication. The patient was discharged without any complains of ischemic gangrene after the surgical procedure.

Discussion
Since it was proposed by Buerger in 1908, the pathogenesis of Buerger's disease, or known as Thrombo angiitis obliterans (TAO), is still not clarified yet and the unity as a disease is still in debate. Men are exposed more often and there is a strong connection between smoking and this disease [4] . As mentioned earlier, the specific etiology is unknown. Secondary etiology that has a positive effecton this disease are age, gender, race, hereditary factors (HLA phenotype), autoimmune processes, occupation, and changes in blood components (coagulability, anticardiolipin antibodies, homocysteine and smoking) [5] .
According to an immunohistochemical study, TAO is an endarteritis due to cellular immunity mediated by T-cell and humoral immunity mediated by B cell and associated with activation of macrophages or dendritic cells in the intima wall [2] . Other factors which are considered to accelerate the disease are high levels of lipoprotein, degradation of elastin, antibody anticardiolipin, serotonin, and diabetes mellitus [5] .  [2,6,7] In this case, the patient was a woman, unlike most cases, and she did not smoke, butlived in  [3] .  [1,6,8] .
The CT or MRA does not currently have a role in the diagnosis of Buerger's disease. Some researchers believe that both modalities lack of spatial resolution to detect pathological conditions in small arteries [9] .
We Diagnostic criteria of Shionoya (1998) [3] : Smoking history; Onset before the age of 50 years; Infrapopliteal arterial occlusions; Either arm March 2020 | Vol 1 | Article 2 involvement or phlebitis migrans; Absence of atherosclerotic risk factors other than smoking.
Diagnostic criteria of Olin (2000) [3] : The most effective and ultimate therapy is to discontinue the use of cigarettes. Even smoking one ortwo cigarettes per day, using smokeless cigarettes (chewing tobacco), or using a nicotine substitutecan cause the disease to remain active [1,2] .  [7] . In Japan, where TAO's prevalencerate is quite high, there is a shift from surgical therapy to medical approaches due to the presence of aprostaglandin analogue [9,10] . Immuno suppressive therapy may be useful in some TAO patients suchas glucocorticoid and Azathioprine in addition to antiplatelet therapy and vasodilator. They significantly lowers the amputation rate [2] .
Interventional therapy is performed if there is anocclusion of the arteries. Surgical management includes sympathectomy and revascularization.
Clinical experience suggests that Raynaud's phenomenon in the legs can be repaired with sympathectomy [2] . It is said that sympathectomy might cure ischemic ulceration, reduce pain, butdoes not prevent or reduce the amputation ratep [1,9] . Thoracic  because when the level drops below the knee, bypass procedure will lead to decreasing flow, as well as the number of its patency [1,10] .
Surgical reconstruction of the arteries is not suitable for Buerger's disease, because the characteristic of thedisease is inflammation [2] . The patient initially intravenously. Unfortunately, we didn't performa biopsy of the affected finger, so that we couldn't determine the anatomic pathological abnormality findings to this patient's arteries.
Smoking cigarettes have an important role in the progression and prognosis of the disease. The newly associated ischemic lesions occur in patients who continue to smoke or start smoking again (after the quit-smoking period) [6] . Since the patient was not an active smoker, but a passive smoker, we encouraged her husband and son to cease smoking. The patientwas lost to follow up, but at least there was no recurrent ischemic necrotic occured until discharge.

Conclusion
Shionoya and Olin's criteria helped us exclude other disease. The managements were analgesic and oral vasodilator medication combined with surgical. Endoscopic thoracal ganglion sympathectomy was performed and followed by amputation of the nacrotic fingers. Then the next treatment was focused on dilating the small arteries, reduce the pain, and education to avoid smoke exposure.