Buerger’s disease
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Buerger's disease is a progressive inflammatory disease that causes blockages in small and medium blood vessels, most commonly in the lower limbs of young and middle-aged male smokers. It presents with symptoms like intermittent claudication pain, rest pain, ulceration, and gangrene. Investigations show decreased or absent pulses distal to blockages. Angiography reveals blockages, corkscrew collaterals, and poor distal blood flow in advanced cases. Treatment focuses on quitting smoking and medications to reduce inflammation and promote collateral circulation. Surgery may be needed for severe cases involving amputation or revascularization procedures like omentoplasty.
Buerger’s disease
- 2. Thromboangitis oblitrans (tao) Buerger’s disease is a segmental ,progressive ,occlusive ,inflammatory disease of small and medium sized vessels with superficial thrombophlebitis often may present as Raynaud’s phenomenon with microabscesses, along with neutrophil and gaint cell infiltration , with skip lesions. More common in lower limbs than upper limbs
- 3. Incidence Very commonly seen in young and middle aged males (20 – 40 yrs) Seen only in smokers and tobacco users Rarely can occur in females smokers Common in jewish people
- 4. Risk factors Smoking is prime risk factor >40 pack years hormonal influence ,familial factors Hypersensitivity to cigarette , Altered autonomic functions Lower socioeconomic group , Recurrent minor feet injuries Poor hygiene
- 5. Pathogenesis Smoke- carbon monoxide and nicotinic acid Vasospasm &hyperplasia of intima Thrombosis of vessels Oblitration of vessels Panarteritis – segmental
- 6. Artery ,vein and nerve are together involved Nerve involvement due to blockage of vasa nervosa causes rest pain Artery involvement leads to features like claudication pain With blockage – plenty of collaterals open up Collaterals maintain the blood supply to the ischemic area this is known as compensatory peripheral vascular disease. Disease progression due to smoking leads to blockage of collaterals also leading to severe ischemia known as decompensatory peripheral vascular disease or critical limb ischemia
- 7. Arterial lumen is blocked but not thickened like in case of atherosclerosis 10 % disease is bilateral 10% is seen in females but rare 10% seen in upper limbs Large arteries are not involved as in case of atherosclerosis
- 8. Shianoya’s criteria of buerger’s disease Male Tobacco user Disease onset before 45 yrs Distal extremity involved first with out embolic or atherosclerotic features Absence of diabetes mellitus or hyperlipidemia With or without thrombophlebitis
- 9. Classification of buerger’s disease Type 1 : upper limb TAO Type 2 : involving legs & feet – crural/infrapopliteal Type 3 : femoropopliteal Type 4 : aortoiliofemoral Type 5 : generalised
- 10. Clinical features Common in male smokers between 20-40 yrs of age group – smoker’s disease Intermittent claudication pain in foot and calf Recurrent migratory superficial thrombophlebitis Claudication pain Rest pain Ulceration and gangrene
- 11. Clinical features Absence / feeble pulsations distal to proximal ,dorsalis pedis ,posterior tibial , popliteal ,femoral arteries in lower limbs It may also present as Raynaud’s phenomenon
- 12. Investigations Blood sugar levels – DIABETES MELLITUS Lipid profile- any dyslipidemia Decreasesd Hb levels – delayed healing WBC count - infection
- 13. Corkscrew appearance of Collaterals due to dilation of vasa vasorum Arterial flow , flow rate, velocity, stenosis, block.
- 14. Transfemoral retrograde angiogram It shows blockage – site,extent, severity Corkscrew appearance of vessels – dilation of vasa vasorum Inverted tree/spider legs pattern of collaterals Severe vasospasm – corragated /rippled artery appearance Distal run off – amount of dye filling in the main vessel distal to the obstruction through collaterals Distal run off Good – then ischemia is compensated Poor – then it is decompensated
- 16. Ultrasound abdomen to see abdominal aorta for occlusion Segmental pressure measurement to localize the occlusion site CT Angiogram and MRI angiogram Ankle brachial pressure index Normal - >1 < 0.9 – ischaemia present < 0.3 –marked ischeamia + gangrene
- 18. PLETHYSMOGRAPHY: Segmental plethysmography is introduced by placing venous occlusion cuffs around thigh, calf, ankle Cuffs inflated to 65mmhg and pulsation is quantitative measure of arterial diseases.
- 20. Digital subtraction angiography:(DSA) Only vascular system seen
- 21. Treatment Quit smoking Pentoxiphylline increases flexibility of rbc’ss and hep them reach the microcirculation in a better way so as to increase the oxygenation Low dose aspirine 75mg OD- anti thrombotic Prostacyclins, Ticlopidine, praxylene, Carnitine- anti thrombotic effect Clopidogrel 75mg, Atorvostatin 10mg Cilostazole 100mg BD is a phosphodiasterase inhibitor which improves circulation All the drugs act on collateral level than at the diseased vessel
- 22. Analgesics are used to relieve the pain Xanthine nicotinate 3000mg from day 1 to 9000 mg on day 5 is given to promote ulcer healing and also increase claudication distance Naftidofuryl is used in intermittent claudication. It acts by altering tissue metabolism Intra muscular injections of VEGF promotes angiogenesis..
- 23. Care of limbs Buergers position and exercise Regular graded exercises upto the point of claudication improves collateral circulation In buerger’s position head end of bed is raised, foot end of bed is lowered to improve circulation In buerger’s exercise leg is elevated and lowered alternatively each for 2 mins for several times at a time to improve collateral circulation
- 24. Care of feet Exposure of feet cold and warm temperature should be avoided Trauma and pressure in the feet should be avoided Dryness of feet and leg should be avoided by applying oil Footwear should be worn with socks Heel raise of 2cm should be used reduces the calf muscle work which leads to improved claudication time
- 25. Chemical sympathectomy Symathetic chain is blocked to achieve vaso dilation by injecting local anaesthesic paravertebrally besides bodies of L2 L3 L4 vertebrae infront of lumbar fascia 5ml phenol in water can be used for long term efficiency, it is done under C- arm guidance Feet will become warm immediately after injection Complications 1) Spinal cord ischemia, risk of injecting phenol into IVC or aorta
- 27. Surgical management Omentoplasty - to revascularise the affected limb Profundoplasty – is done for blockage in the profunda femoris artery so as to open more collaterals across the knee joint lumbar sympathetectomy- to increase cutaneous perfusion as to promote ulcer healing, but it may divert blood from muscle towards skin causing more ischemia Amputations are done at different levels depending upon the severity usually below knee or above knee amputations are done
- 28. Omentoplasty
- 31. Ilzarov’s method- bone lengthening helps in improving the rest pain and claudication by creating neo-osteogenesis and improving overall blood supply the limb