I. To relieve pain
II. To arrest progression of disease
III. Medical management
IV. Chemical sympathectomy
V. Surgical procedures in TAO
VI. Surgery in atherosclerotic vascular
disease

I. TO RELIEVE PAIN
1.
Analgesics
• Simple analgesics may not help.
• Tramadol (50mg) one tablet, 3 times a day
• Ketorolac (10-20mg) one tablet, 3 times a day
– severe cases
• Narcotic analgesics – rest pain
2.
Buerger’s
position
Elevating head-end of the bed, causes venous
congestion & reflex vasodilatation
3.
Buerger’s
exercises
Elevation and dependency of limb for few
minutes.
4. Heel
raise
• Raising heels of shoes by 1-2cm
• ↓ work load on calf muscles = ↑ claudication
distance

II. TO ARREST PROGRESSION OF DISEASE
1. Stop smoking More beneficial in TAO patients than atherosclerotic patients.
2. Regular
exercise
• ↓ obesity
• Controls HTN
3. Diet
• Avoid fatty food, ↓ serum cholesterol
• Useful in hyperlipidaemia patients
4. Avoid injuries

III. MEDICAL MANAGEMENT OF PVD
Antiplatelet
Aspirin 75mg with or without
clopidogrel 75mg
↓ vascular death by 25%
Antismoking Stop smoking ↓ 10 year mortality rate from 54% down to 18%
Anticholesterol
Statins ↓ LDL cholesterol to at
least 100mg/dl
Slow release niacin is emerging as an important therapy in
patients with dyslipidaemia
Antihypertensives Decrease BP < 130/85mmHg ACE inhibitors, 𝜷-blockers
Antidiabetes Glycosylated Hb level < 7% Oral hypoglycaemic agents or insulin
Antivasospasm
(vasodilator)
Cilostazol – 50mg twice a day • Inhibits platelet aggregation
• A direct arterial vasodilator
PENTOXIFYLLINE
• 400mg 3 times a day
• 4-8 weeks
• Treat intermittent claudication
• Improves blood flow
• ↑ sperm motility
• Improves RBC deformability, ↓ blood viscosity, ↓ platelet
aggregation, thrombus formation, inflammation, innate
immunity
PROSTACYCLINS
• 2 ng/kg/min IV
• ↑ 2ng/kg/min every 15mins
• Max 16 ng/kg/min
• Inhibits platelet activation & effective vasodilator
• Prevents formation of platelet plug in 1° hemostasis

IV. CHEMICAL SYMPATHECTOMY
• Produce vasodilation of blood vessels of
LL
• Healing of ulcers
• Improve rest pain
1. 5ml of phenol in water is injected
beside the bodies of 2nd 3rd and 4th
lumbar vertebrae
2. Effect of drug → Warmth in the feet
PRECAUTIONS:
1. Lateral injection by using a lumbar puncture
needle.
2. Injection should be in front of lumbar fascia
(contains sympathetic trunk.
3. Avoid injuries to aorta & inf. VC
4. Done under X-ray control.
• 10-15 mins procedure
• Lie on stomach
• Local anaesthetic
• Allowed home shortly
afterwards (if feeling well)

V. SURGICAL PROCEDURES IN TAO
1. Lumbar
sympathectomy
INDICATIONS: Cutaneous ulcer & rest pain
• Depriving sympathetic nerve supply to LL blood vessels
• Vasomotor tone ↓, vasospasm ↓
• Rest pain improves, minor ulcerations heal d/t cutaneous vasodilation
2. Omentoplasty
• Temporary effect (not done nowadays)
• Part of the greater omentum is used to cover or fill a defect, augment arterial or portal
venous circulation, absorb effusions, or increase lymphatic drainage.
3. Conservative
amputation
• If toes are gangrenous
4. Below knee
amputation
• Last resort
• INDICATIONS: severe rest pain cases where all modalities of treatment have failed
• Risk of amputation after 10 yrs of disease is around 10%

VI. SURGERY IN ATHEROSCLEROTIC VASCULAR DISEASE (REVASCULARISATION)
INDICATIONS: Rest pain & pregangrenous changes in limb
***decision taken after an angiography
1. Treat risk factors
• Lipids: Dyslipidaemia
• Inhalation of tobacco: Smoking
• Pressure: HTN
• Insulin deficiency: Diabetes
• Disordered metabolism: Hyperhomocystinaemia
Aortoiliac disease
a.Bypass grafts
b.Aortoilliac
Endarterectomy
• Aortobifemoral or aortofemoral graft → it is bilateral and treated by using
aortabifemoral graft to bypass stenosis*****. (graft known as Y-graft)
• Open & closed endarterectomy (short segment, large artery)
Iliofemoral disease
• Iliofemoral bypass graft
• Balloon angioplasty
Femoropopliteal disease • Bypass graft eg. Polytetrafluoroethylene graft (PTFE), human umbilical vein graft
Profunda artery stenosis
• Profundoplasty
(using patch of Dacron/vein to widen origin of this vessel after doing endarterectomy)

REFERENCE
• SRB’S MANUAL OF SURGERY, SRIRAM BHAT M, 4TH EDITION.
• MANIPAL MANUAL OF SURGERY, 5TH EDITION.