To evaluate the diagnostic performance of the ankle-brachial index (ABI) in patients with Buerger disease and to assess the impact of collateral circulation on ankle pressure measurements in the presence of angiographically confirmed infrapopliteal arterial occlusions. This retrospective study included 66 lower limbs from 45 male patients (mean age, 45.4 years [SD ± 9.7]) diagnosed with Buerger disease. All patients underwent digital subtraction angiography (DSA) and ABI measurement prior to endovascular intervention. Limbs were categorized according to the angiographic patency of the anterior and posterior tibial arteries. ABI diagnostic performance was evaluated using DSA as the reference standard, with emphasis on the prevalence of normal ABI values (≥0.90) in limbs with complete tibial artery occlusion. Angiography demonstrated complete occlusion of both tibial arteries in 50 of 66 limbs (75.7%). Despite severe infrapopliteal disease, 21 of these 50 limbs (42.0%) exhibited normal ABI values, indicating a high false-negative rate. The mean ABI in limbs with complete tibial occlusion was 0.82 (SD ± 0.20). Doppler-derived ankle pressure measurements were obtainable in 94%-98% of occluded tibial arteries due to extensive collateral circulation. ABI values did not differ significantly between limbs with isolated tibial occlusion and those with combined popliteal and tibial artery involvement (P > .05). ABI frequently underestimates disease severity in Buerger disease because collateral networks preserve ankle pressures despite critical infrapopliteal occlusions. ABI should not be used as a standalone screening tool, and adjunct physiologic testing or imaging is required for accurate vascular assessment.

Thromboangiitis obliterans (TAO) is a rare inflammatory occlusive vascular disorder that affects small and medium-sized vessels and often progresses to critical limb ischemia (CLI). Although various treatments have been used in advanced stages, endovascular interventions have increasingly gained attention as a limb-saving therapy. Due to limited and varied evidence in published studies, this systematic review and meta-analysis evaluates the early and long-term outcomes of endovascular treatments in patients with TAO-related CLI. This systematic review and meta-analysis was conducted according to PRISMA guidelines and registered on PROSPERO (CRD420251089226). PubMed, Scopus, WOS, Embase, and Google Scholar databases were searched with relevant keywords up to July 2025. A total of 27 studies involving 1,217 patients were included. Pooled outcomes were estimated using a generalized linear mixed model (GLMM). Heterogeneity was assessed using the I² statistic, and potential publication bias was examined via funnel plots and Egger’s test. The pooled technical success rate for endovascular procedures was 89%, with limb salvage rates of 94% at 6 months and 97% at 12 months. Primary patency was 56% at 6 months, 73% at 12 months, and 61% at 36 months; these findings highlight temporal variability, and cross-time comparisons should be interpreted with caution. Secondary patency was initially higher but also decreased over long-term follow-up. Restenosis rates were 15% early and 34% late. Major and minor amputation rates were 10% and 13%, respectively. No in-hospital mortality was reported. Endovascular therapy represents a safe and effective option for treating TAO-related CLI, especially in patients who are not candidates for surgery. While early results are promising, the loss of patency and rising restenosis over time highlight the importance of careful follow-up and proper patient selection. Our findings support a personalized, multidisciplinary approach to managing TAO and emphasize the vital role of smoking cessation in improving clinical outcomes. [Image: see text] The online version contains supplementary material available at 10.1186/s12893-026-03563-2.

Intramuscular injection of donaperminogene seltoplasmid (recombinant human hepatocyte growth factor plasmids) represents a gene therapy that treats patients with chronic limb-threatening ischemia (CLTI). The HOPE CLTI-2 trial was a phase 3, multicenter, double-blind, placebo-controlled study aimed to evaluate the efficacy and safety of seltoplasmid in patients with Rutherford class 5 CLTI. This study did not require participants to be ineligible for revascularization, allowing enrollment of patients with CLTI caused by either atherosclerosis (ASO) or Buerger disease (or thromboangiitis obliterans [TAO]). The primary endpoint was the complete ulcer healing rate at 6 months. A total of 242 participants (53.3% ASO versus 46.7% TAO) were enrolled, with 161 receiving seltoplasmid and 81 receiving placebo. Complete ulcer healing was achieved in 70 patients in the seltoplasmid group compared to 15 patients in the placebo group, resulting in an adjusted healing rate difference of 26.1% (95% confidence interval [CI]: 15.1%-37.0%; p < 0.001). The hazard ratio for healing was 2.31 (95% CI: 1.32-4.05; p = 0.004). The benefits of seltoplasmid on ulcer healing persisted in both TAO and ASO subgroups. Serious adverse events were rare. Our study demonstrated that seltoplasmid significantly improved ulcer healing rates in patients with Rutherford class 5 CLTI compared to placebo.

Uncertainties exist regarding the optimal management strategy for patients with thromboangiitis obliterans (TAOs). The aim of this study was to investigate the safety and effectiveness of common interventions used for treating patients with TAO. Endovascular treatment, revascularization, sympathectomy, stem cell therapy (SCT), and nonsurgical interventions were selected for inclusion in the study. Changes in mean visual analogue scale score and ankle brachial index (ABI) values were evaluated. In addition, the rate of ulcer healing, postintervention amputation, and overall complication rates were compared across interventions. A total of 1262 TAO patients (1159 males, 84 females), with a mean age of 38.4 ± 7.8 ys, were included in this systematic review. With an amputation rate of 16.6%, the endovascular treatment group showed statistically significant improvements in mean ABI and visual analogue scale scores (P < 0.05). There was a greater increase in ABI postoperatively with endovascular treatment compared to SCT (P < 0.05), and also a greater increase in ABI postoperatively with revascularization compared to SCT (P < 0.05). Meta-regression showed that both endovascular treatment and open surgical revascularization were superior to stem cell treatment for postoperative mean ABI improvement (P < 0.05). Interestingly, the rate of postoperative amputation was lower in the SCT group compared with the other two interventions. Our results indicated that all three interventions may be a reasonable therapeutic option for TAO. Endovascular intervention and open revascularization demonstrated superior outcomes.