Nonatherosclerotic Disease Research Articles

Symptomatic Cervical Carotid Artery Stenosis: Evolving Paradigms in Risk Stratification and Intervention.

Symptomatic carotid disease, characterized by atherosclerotic or non-atherosclerotic internal carotid artery disease with ipsilateral stroke symptoms, represents a critical condition in stroke neurology. This "hot carotid" state carries a high risk of stroke recurrence, with almost one-fourth of the patients experiencing recurrent ischemic events within 2 weeks of initial presentation. The global prevalence of significant carotid stenosis (conventionally defined as ≥50% narrowing) is estimated at around 1.8% in men and 1.2% in women and increases with age. Management of symptomatic carotid disease remains challenging, requiring a balance between urgent medical and surgical interventions and their associated risks. Current treatment approaches combine medical management, focusing on optimal antithrombotic therapy, with revascularization procedures such as carotid endarterectomy or carotid artery stenting. However, decision making has evolved beyond considering stenosis degree alone, now incorporating advanced imaging data on plaque composition and intraluminal characteristics. Even though there are numerous randomized trials, uncertainties persist regarding optimal management, particularly in light of improved medical therapies and emerging concepts like symptomatic non-stenotic carotid disease. Future research directions include exploring newer antithrombotic regimens, refining patient selection criteria for revascularization, and evaluating novel techniques like transcarotid artery revascularization.

NATURAL AGENTS IN THE MODULATION OF METABOLIC SYNDROME

Metabolic syndrome or syndrome X is a profound health issue across the world and a recognized risk elements for both atherosclerosis-related as well as non-atherosclerotic cardiovascular disease. There was remarkable variation in the definition and diagnostic parameters for metabolic syndrome, which represents a chronological advancement in perception about this ailment. Several triggers leading to the primary cause of persistent inflammation variables for metabolic syndrome are pathophysiological. Finding a reliable alternative medication that is ecological and spared from adverse effects, therefore will be a helpful tool in the battle counter to metabolic syndrome. In this set of circumstances, consuming functional foods or making the supposition that natural bioactive compounds (NBCs) exist might have an advantageous effect on controlling body mass, glucose metabolism, and hypertension, as well as endothelial destruction, enhancing lipid profiles, reducing inflammation, and reducing oxidative stress. NBCs like EGCG, curcumin, polyphenols, allicin, barberine, quercetin, hydroxytyrosol, resveratrol etc. shows activity against the risk factors for metabolic syndrome. This review emphasizes the latent activities of NBCs in the modulation of metabolic syndrome, its associates risk determinants, as well as in their prevention.

“Bead to death,” Fibromuscular Dysplasia Presenting as A Rapidly Enlarging Right Anterior Axillary Mass

Fibromuscular dysplasia (FMD) is a rare non-inflammatory, non-atherosclerotic arterial disease characterized by abnormal cellular proliferation and distorted architecture. It commonly affects the renal and extracranial carotid and vertebral arteries, but nearly all arterial beds may be affected, and multivessel involvement is common. We report a rare case of a 31-year-old Filipino female who presented with a rapidly enlarging right anterior axillary mass. Initial consideration was a bleeding soft tissue sarcoma as seen on chest CT scan, while whole abdominal CT scan with IV contrast revealed incidental findings of multiple aneurysms in the superior mesenteric artery, both renal arteries and right common iliac artery, suggestive of fibromuscular dysplasia. Further vascular imaging studies showed a looped left internal carotid, and a tortuous left brachial artery with beading pattern.

A case report with literature review: long-term follow-up of kidney autotransplantation in fibromuscular dysplasia.

Fibromuscular dysplasia is a rare, idiopathic, systemic, non-inflammatory, and non-atherosclerotic vascular disease that primarily affects young women. It often presents as renal artery stenosis. Fibromuscular dysplasia can induce tissue damage in the post-stenotic kidney. Treatment options include antihypertensive therapy, surgical revascularization, and transluminal angioplasty with stent implantation. However, kidney autotransplantation is an alternative when these treatments are not feasible. This study presents a case report of a 22-year-old woman with fibromuscular dysplasia, highlighting the long-term success of kidney autotransplantation and reviewing the related literature. A multidisciplinary approach was employed in the treatment of this patient presenting with intermittent headaches, hypertension, and acute kidney disease, andwho was diagnosed with fibromuscular dysplasia. She underwent left aorta-renal bypass and right autotransplantation. Following the procedure, her serum creatinine level decreased from 2.74 to 1.1mg/dL, with an eight-year follow-up confirming the favorableoutcome. Renal artery stenosis is a significant contributor to secondary hypertension, with fibromuscular dysplasia being a rarecause. While medical and interventional treatments are usually effective, complex cases may necessitate alternative approaches. Kidney autotransplantation, albeit uncommon, is an effective option for patients who are unresponsive to conventional therapies. This case demonstrates the successful management of fibromuscular dysplasia-associated renovascular hypertension via kidney autotransplantation, resulting in controlled blood pressure and preserved kidney function. In conclusion, kidney autotransplantation represents a valuable therapeutic option for severe renal artery stenosis caused by fibromuscular dysplasia, particularly when percutaneous procedures are impractical.

Non-atherosclerotic peripheral arterial diseases

Non-atherosclerotic peripheral arterial diseases

SIMULATION OF FLUID-STRUCTURE INTERACTION IN AN ARTERY ALTERED BY SEGMENTAL MEDIOLYSIS

Segmental arterial mediolysis (SAM) is an asymptomatic, non-atherosclerotic and non-inflammatory disease of unknown etiology. It affects medium-sized arteries and is characterized by vacuolization and lysis at the level of the media which can lead to dissection, steno-occlusion, or an aneurysm. In this article, a simulation of fluid-structure interaction in an artery altered by segmental mediolysis was reported. The study showed that the reduction in elasticity of the media layer of the artery due to the deterioration of collagen has little influence on the velocity field, the pressure field as well as on the deformations of the artery, thus conferring a silent and asymptomatic character to the pathology. The Von-Mises stress is very high at the level of the intima which can lead to arterial dissection with the appearance of a false channel. An increase in the Von-Mises stress of around 375 % was predicted by the COMSOL code. The combined effect of mediolysis and the increase in blood pressure causes increases in the Von-Mises stress at the level of the intima and the adventitia which are respectively 6.10 and 4.62 times greater than those of the healthy artery, which demonstrates that hypertension could be a determining factor in triggering arterial dissection.

Aortopathy - A surgical pathology experience.

Aortopathy is a non-inflammatory and non-atherosclerotic disease of aorta that results from significant 'degenerative' changes in the media. This often leads to thoracic aortic aneurysms and/or dissections in young individuals. This study aimed to analyze the clinical and pathological features of aortic resections performed for aortopathy. Over the span of 15 years (2008-2022), all surgically resected specimens of aorta showing aortopathy in all age groups were studied. Particular attention was paid to the changes in the media to assess the extent, grade and severity of aortopathy. During the 15-year study period, 73 surgically resected specimens of the ascending aorta showed features of aortopathy. There were 48 males and 25 females, who had chief complaints of dyspnea, chest pain and palpitation. The aortopathic manifestations observed were ascending aortic aneurysms (36 patients, 49.3%), aortic dissections (21 patients, 28.8%) and aneurysms with dissections (16 patients, 21.9%). Bicuspid aortic valve (24 cases), Marfan syndrome (13 cases) and hypertension (12 cases) were commonly identified. There was one case each of Loeys-Dietz syndrome, and aortopathy possibly related to blunt chest trauma. In a significant proportion of patients (22 cases), the cause remained elusive. Moderate to severe aortopathy was observed in 60 cases (82.2%). This study helps in standardizing the histological parameters of aortopathy. In patients where the cause is uncertain despite of detailed clinico-radiological assessment, there is a need for molecular and genetic studies.

Reversible Cerebral Vasoconstriction Syndrome And Fibromuscular Dysplasia: An Epiphenomenon Or A Causal Relationship?

Abstract Fibromuscular dysplasia (FMD) is a rare non-atherosclerotic arterial disease that primarily affects middle-aged Caucasian women. Carotid web (CW) is a variant of FMD characterized by a non- atheromatous, membrane-like tissue protrusion into the carotid bulb. Reversible cerebral vasoconstriction syndrome (RCVS) is defined by severe headaches and reversible narrowing of cerebral arteries, which typically resolves within three months. While most RCVS cases have identifiable triggers, a significant portion occurs without known causes. Recent studies have reported a high prevalence of neurovascular abnormalities in RCVS patients. We present a case of a thirty-year-old woman with a sudden-onset severe headache, diagnosed with RCVS associated with carotid web. The patient had no ischemic involvement and responded well to flunarizine treatment. Follow-up imaging showed no stenosis. This case highlights a potential association between carotid web and RCVS, suggesting that FMD may contribute to vascular hyperreactivity and presents as a risk factor for RCVS. Further investigations are needed to understand the underlying mechanisms connecting these two vascular disorders.

Treatment of renal artery fibromuscular dysplasia with drug-eluting balloon angioplasty and intravascular imaging: a case report

Fibromuscular dysplasia (FD) is a segmental, non-inflammatory and non-atherosclerotic disease of vascular smooth muscle of unknown etiology, which leads to stenosis of smalland medium-sized arteries. The choice of surgical treatment tactics for renal artery FD depends on the severity of clinical manifestations and the response to the conservative drug treatment used. Young age, female sex, high blood pressure with failure to achieve target values with therapy, as well as the absence of atherosclerotic involvement of other arterial systems gives reason to suspect renal artery FD. According to modern guidelines, the invasive treatment of hemodynamically significant renal artery stenoses includes transluminal drug-eluting balloon angioplasty. In this disease, renal artery stenting is not recommended. However, stent implantation is required if balloon angioplasty did not give the optimal result or in case of periprocedural complications, such as arterial dissection. Open reconstructive surgery is indicated for complex anatomy of the related artery, macroaneurysms in which stent grafts are ineffective, refractory intimal fibroplastic lesions, increased risk of endovascular treatment, or after unsuccessful endovascular intervention. The article presents a case of a young patient with renal artery FD, renovascular arterial hypertension, who successfully underwent renal artery transluminal drugeluting balloon angioplasty.

Tortuosity in non-atherosclerotic vascular diseases is associated with age, arterial aneurysms, and hypertension

BackgroundIncreased arterial tortuosity has been associated with various cardiovascular complications. However, the extent and role of arterial tortuosity in non-atherosclerotic vascular diseases remain to be fully elucidated. This study aimed to assess arterial tortuosity index (ATI) in patients with non-atherosclerotic vascular diseases and the associated factors.MethodsThis is a retrospective analysis of patients with non-atherosclerotic vascular diseases referred to the Malformation and Rare Vascular Disease Center at the University Hospital in Lausanne (Switzerland). Computed tomography angiography (CTA) images performed between October 2010 and April 2022 were retrieved and the aortic tortuosity index (ATI) was calculated. Patients were classified based on diagnosis into the following groups: arterial dissection & aneurysm, arteritis & autoimmune disease, hereditary connective tissue diseases, and fibromuscular dysplasia (FMD). Univariate and multivariate logistic regression analysis was used to determine potentially relevant predictors of aortic tortuosity.ResultsThe mean age upon computed tomography angiography (CTA) was 46.8 (standard deviation [SD] 14.6) years and 59.1% of the patients were female. Mean ATI was higher in patients over 60 years old (1.27), in those with arterial aneurysms (mean: 1.11), and in those diagnosed with hypertension (mean: 1.13). When only patients over 60 years old were considered, those diagnosed with connective tissue diseases had the highest ATI. At multivariate regression analysis, increasing age (p < 0.05), presence of arterial aneurysms (p < 0.05), and hypertension (p < 0.05) were independently associated with ATI.ConclusionsThe ATI may be a promising tool in diagnostic evaluation, cardiovascular risk stratification, medical or surgical management, and prognostic assessment in several non-atherosclerotic vascular conditions. Further studies with longitudinal design and larger cohorts are needed to validate the role of ATI in the full spectrum of vascular diseases.

Abstract 1102: Post Gwas Functional Genomics Analysis To Identify Non-coding Single Nucleotide Polymorphisms Controlling The Risk Of Spontaneous Coronary Artery Dissection

Background: Spontaneous Coronary Artery Dissection (SCAD) is a non-atherosclerotic coronary artery disease and the leading cause of acute myocardial infarction in young females. SCAD results from the combination of genetic susceptibility and acquired triggering factors including inflammation and sex hormones. Three loci have been revealed by two large-scale genome-wide association studies (GWAS) in SCAD. However, GWAS only reveals the statistical associations between the genetic loci and diseases, and the biological mechanisms remain unknown. Methods: GWAS-reported tag single nucleotide polymorphisms (SNPs) and the linked haplotype SNPs were collected. Synthesized oligonucleotides representing the SNP alleles were subjected to electrophoretic mobility shift assays (EMSA) with nuclear proteins extracted from vascular endothelial cells (ECs), smooth muscle cells (SMCs) and fibroblasts. Hi-C analysis was performed to predict the potential target gene(s) based on chromatin interactions. The functionality of the SNP-associated target genes was examined in cultured vascular cells by RNA silencing. Results: The risk allele of tag SNPs in three genetic loci (chr1q21.2, 6p24.11 and 12q13.1) were associated with 1.5 to 1.8-fold higher risk of SCAD. Intronic, non-tag SNP rs7549396 (G/A) in chr1q21.2 locus was identified as the functional SNP in EMSA, given its consistent allele-imbalanced gel shifting pattern in ECs, SMCs and fibroblasts. Hi-C analysis in human aortic tissue identified a 490kb long-range chromatin interaction between SNP rs7549396 and the promoter of Annexin A9 (ANXA9), an extracellular matrix (ECM) and an inflammation-related protein potentially associated with the pathogenesis of SCAD. The knockdown of ANXA9 in vascular cells showed significant changes in inflammatory makers (IL-1β, vCAM-1 and CCL-2) and ECM degradation enzyme (MMP-1). Conclusions: Leveraging our post-GWAS functional genomics approach, we identified functional non-coding SNPs in disease-associated genetic locus and predicted a novel potential pathogenic gene ANXA9 for SCAD. Further studies on the functions of this SNP and its associated target gene ANXA9 will provide genetics and mechanistic explanation for this mysterious disease.

CLINICAL CHARACTERISTICS OF PATIENTS WITH FIBROMUSCULAR DYSPLASIA WITH AND WITHOUT SPONTANEOUS CERVICAL ARTERY DISSECTION IN THE ARCADIA-POL STUDY

Objective: Fibromuscular dysplasia (FMD) is idiopathic, segmental, non-inflammatory, non-atherosclerotic disease affecting small and medium-sized arteries. FMD causes artery stenosis, although it may also lead to aneurysm, dissection, or arterial tortuosity. The aim of the study was to evaluate clinical characteristics of patients with spontaneous cervical artery dissection (SCeAD) and to assess prevalence of SCeAD among patients with FMD. Design and method: The ARCADIA-Pol is an ongoing study, initiated in 2015 at the Department of Hypertension, National Institute of Cardiology in Warsaw, Poland. Patients enrolled in the study met the inclusion criteria: presence or suspicion of FMD and/or radiologically documented episode of spontaneous dissection of any artery. Each patient underwent: clinical and 24h ambulatory blood pressure monitoring, biochemical tests, echocardiography, US Doppler of renal and carotid arteries and whole body angio-CT. We present data of 435 currently enrolled patients. Results: Among 435 patients included in the analysis SCeAD was confirmed in 77 subjects, most often in internal carotid arteries (68.8%). Mean age was 43,9 ± 9,6 years, majority of patients were women (64.9%). Hypertension (HT) was present in 59.7% patients, hypercholesterolemia in 44,2%. Among 77 subjects with SCeAD, the presence of typical FMD changes was confirmed in 35.1% cases. Patients with SCeAD and FMD were older and more often female as compared to those with SCeAD and without FMD. There were no differences in biochemical parameters or target organ damage parameters between SCeAD patients with and without FMD. Among 281 subjects with FMD, an episode of SCeAD was documented in 9.6% patients. Patients with FMD and SCeAD less often had HT. Women with FMD and SCeAD had more often a history of contraceptive pills use than those without SCeAD. No other differences were found between compared groups. Conclusions: FMD changes often coexist in patients with SCeAD (35.1%). In FMD patients complication of SCeAD occur relatively often (9.6%), which leads to conclusion that FMD is generalized arteriopathy. It is recommended to perform radiological screening in FMD patients to look for arterial complications in other vascular beds.

A review of histopathologic and radiologic features of non-atherosclerotic pathologies of the extracranial carotid arteries.

Diseases of the carotid arteries can be classified into different categories based on their origin. Atherosclerotic carotid disease remains the most encountered arterial wall pathology. However, other less-common non-atherosclerotic diseases can have detrimental clinical consequences if not appropriately recognized. The underlying histological features of each disease process may result in imaging findings that possess features that are obvious of the disease. However, some carotid disease processes may have histological characteristics that manifest as non-specific radiologic findings. The purpose of this manuscript is to review various non-atherosclerotic causes of carotid artery disease as well as their histologic-radiologic characteristics to aid in the appropriate recognition of these less-commonly encountered pathologies.

Impact of statins in the liver: A bane or a boon?

Treatment of hypercholesterolemia with statins is considered one of the cornerstones in the management of atherosclerotic cardiovascular diseases. Statins exert their hypolipidemic effects by inhibiting HMG-CoA reductase, the key enzyme in cholesterol biosynthesis. Beyond cholesterol reduction, statins exhibit pleiotropic effects, including anti-inflammatory, antioxidant, and antiproliferative actions, making them valuable in mitigating atherosclerotic and non-atherosclerotic diseases. Though concerns of hepatotoxicity have been associated with the use of statins, extensive evidence suggests that the risk of statin-induced liver injury (SILI) is rare, with an incidence of &lt;1%. Hepatic adverse effects include reversible asymptomatic transaminase elevation (most frequent), hepatitis, cholestasis, and rarely acute liver failure. While hepatotoxicity concerns should not be dismissed, the evidence overwhelmingly supports the safety of statins. Contrary to the myth of statin hepatotoxicity, real-world data and extensive research emphasize the safety and benefits of statins. They are therapeutic in various liver-related conditions, mainly non-alcoholic fatty liver disease. This scientific review aims to provide a comprehensive overview of statins, shedding light on their mechanism of action, hepatotoxicity concerns, and therapeutic potential in various liver-related conditions.

Wound, Ischemia, Foot Infection (Wifi) Classification System And Its Predictive Ability Concerning Amputation-Free Survival, Mortality And Major Limb Amputation In A Portuguese Population: A Single Center Experience.

Commonly used chronic limb-threatening ischemia (CLTI) classifications lack granularity and detail to precisely stratify patients according to risk of limb loss, expected revascularization benefit and mortality. The aim of this study is to evaluate in a Portuguese population the prognostic value of an updated CLTI classification based on Wound, Ischemia, and foot Infection (WIfI) proposed by the Society for Vascular Surgery. Single-center retrospective evaluation of prospectively collected data of consecutive patients with CLTI submitted to lower limb revascularization from January to December of 2017. All consecutive patients with chronic peripheral artery disease with ischemic rest pain or tissue loss were included. The exclusion criteria were patients with intermittent claudication, vascular trauma, acute ischemia, non-atherosclerotic arterial disease and isolated iliac intervention. The primary end-point was major limb amputation, mortality and amputation-free survival (AFS) at 30 days, 1 year and 2 year follow-up. Secondary end-points were minor amputation, wound healing time (WHT) and rate (WHR). A total of 111 patients with CLTI were submitted to infra-inguinal revascularization: 91 endovascular and 20 open surgery. After categorizing them according to the WIfI: 20 had stage 1 (18.52%), 29 stage 2 (26.85%), 38 stage 3 (35.19%) and 21 stage 4 (19.44%). Overall mortality rate was 1.8%, 17% and 22.3% at 30 days, 1 year and 2 years follow-up. Major amputation rate was 0.9%, 2.7% and 2.7% at 30 days, 1 year and 2 years follow-up. AFS rate was 97.3%, 82.1%, and 76.8% at 30 days, 1 year, 2 years follow-up. In multi-variable analysis, higher WIfI score was the only predictive factor for mortality and AFS. WIfI 3 and 4 were also associated with increased risk of non-healing ulcer. This study proved the prognostic value of the WIfI classification in a Portuguese population by showing an association between higher scores and increased mortality, lower AFS and non-healing ulcer.

Non-atherosclerotic coronary artery disease: an overview of a heterogeneous disease.

Non-atherosclerotic coronary artery disease: an overview of a heterogeneous disease.

Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease.

Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.

Machine Learning in Invasive and Noninvasive Coronary Angiography.

The objective of this review is to shed light on the transformative potential of machine learning (ML) in coronary angiography. We aim to understand existing developments in using ML for coronary angiography and discuss broader implications for the future of coronary angiography and cardiovascular medicine. The developments in invasive and noninvasive imaging have revolutionized diagnosis and treatment of coronary artery disease (CAD). However, CAD remains underdiagnosed and undertreated. ML has emerged as a powerful tool to further improve image analysis, hemodynamic assessment, lesion detection, and predictive modeling. These advancements have enabled more accurate identification of CAD, streamlined workflows, reduced the need for invasive diagnostic procedures, and improved the diagnostic value of invasive procedures when they are needed. Further integration of ML with coronary angiography will advance the prevention, diagnosis, and treatment of CAD. The integration of ML with coronary angiography is ushering in a new era in cardiovascular medicine. We highlight five use cases to leverage ML in coronary angiography: (1) improvement of quality and efficacy, (2) characterization of plaque, (3) hemodynamic assessment, (4) prediction of future outcomes, and (5) diagnosis of non-atherosclerotic coronary disease.

Knowledge Mapping of Global Status and Trends for Thromboangiitis Obliterans: A Bibliometrics and Visual Analysis.

Thromboangiitis obliterans (TAO) is a segmental nonatherosclerotic inflammatory vascular disease characterized by recurrent progressive inflammatory reactions and thrombosis in the small and medium-sized arteries and veins of the extremities. However, there are few bibliometric studies on TAO. Therefore, this study was employed to generalize the research status, hotspots and development trends of TAO-related research. The data from 1999 to 2022 were collected from the Web of Science core collection database, and analyzed through bibliometrics software. VOSviewer was utilized to carry out academic collaboration between different countries/regions, institutions, and authors, visualization map of co-cited authors, journals, reference, and co-occurring keywords. CiteSpace was used to analyze the dual-map of journals, keyword bursts, and timeline of keywords. Bar and pie charts in this study were statistically analyzed and graphed through Microsoft Excel 2021. Scimago Graphica was applied to map the academic collaboration between different countries/regions. A total of 553 literatures were involved in this study. Japan at the leading global position not only in the number of publications, but also total citations, average citations and H-index. Institution with the major contribution to TAO research is Mashhad University of Medical Sciences, and Nagoya University. Annals of Vascular Surgery, Angiology, Journal of Vascular Surgery are the main publication channel for articles related to TAO. Fazeli, B., Iwai, T., and Kihara, Y. are major contributors in this field. The studies on TAO keywords could be grouped into four clusters: Etiology, Mechanism, Cell therapy and Clinical therapy. Although the number of TAO publications has fluctuated over the past 20 years, it has generally shown a steady upward trend. Etiology and treatment research on TAO and some keywords such as trail, therapy, outcome, management, stem cells, angioplasty, and activation will become a hot spot in the future.

Current modalities for the diagnostic and management approach of buerger’s disease: a case report and comprehensive review

Background: Thromboangiitis obliterans (TAO or Buerger’s disease) is a non-atherosclerotic inflammatory vascular disease usually related to smoking. Until now, there is no consensus establishing the diagnosis and standard treatment. Case Illustration: A 74-year-old smoker woman complained of blackening and painful fingertips in both upper limbs. On upper-extremities examination, we found necrotic gangrene at the 3rd fingertips of the right hand, and the 2nd and 4th fingertips of the left hand, with limitation of the movement at the affected finger due to the pain. On laboratory findings, there was a leukocytosis, mild Anemia, no coagulopathy, and normal autoimmune screening. Doppler Ultrasonography showed vascular incompetence of the left palmar arch artery, with no deep or superficial vein thrombosis. Arteriography revealed multiple stenosis of the Left Radial artery and Right Ulnar artery with collateral corkscrew-shaped. The patient was diagnosed with peripheral Critical Limb Threatening Ischemia caused by TAO, which underwent conservative management for 10 days and Percutaneous Trans Angioplasty (PTA) ballooning. Discussion: Buerger disease commonly affects smoker men between 40-45 years old. Several clinical criteria were used to establish TAO, including Shinoya and Olin's criteria. There are still no specific management guidelines for TAO, and smoking cessation is the only accepted effective treatment to prevent the progression of the disease and avoid amputation, followed by conservative and interventional management for patients with Critical Limb Ischemia. Conclusions: Awareness of the entity and familiarity with the clinical, angiographic, and pathologic features are the keys to a prompt and correct diagnosis of TAO. Although still controversial, endovascular intervention is regarded as a potentially efficacious approach in TAO with critical limb ischemia management.