Buerger's disease

1. 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

29. Above knee
amputation

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