A detailed study on understanding this arterial disorder

1. B Y
D R A D I THYA J V
B . S C , B A M S , M S ( AY U ) , P G D H S M , M C S I
ASSISTANT PROFESSOR,
BAMC,CHALLAKERE
Buergers Disease – Etiology,C/F & Treatment
Modalities

3. Buergers Disease – TAO ( Thrombo Angitis Obltierans)
 Its an arterial occlusive disorder .
 Its Non- atherosclerotic Inflammatory disease of the
Medium & Small sized arteries of peripheries.
 The clinical and pathologic findings of this disease
entity were published in 1908 by Leo Buerger in a
description of 11 amputated limbs

4. DEFINITION
 Buerger’s disease is a segmental, progressive ,occlusive
,inflammatory disease of small and medium sized vessels
with occasional superficial thrombophlebitis .

6. Understanding Intermittent Claudication
 Claudio means “I limp” a Latin word. It is a crampy
pain in the muscle of the limbs.
 Due to arterial occlusion, metabolites like lactic acid and
substance P accumulate in the muscle and cause pain.
 The site of pain depends on site of arterial occlusion.
 The most common site is calf muscles.
 Pain in foot is due to block in lower tibial and plantar vessels.
 Pain in the calf is due to block in femoro-popliteal segment.
 Pain in the thigh is due to block in the superficial femoral artery.
 Pain in the buttock is due to block in the common iliac or aorto-iliac
segment, often associated with impotence and is called as Leriche’s
syndrome.

7. Cause for Claudication pain
 Pain commonly develops when the muscles are
exercising.
 Cause for pain is accumulation of Substance P and
metabolites.
 During exercise increased perfusion and increased
opening of collaterals wash the metabolites.

9. Boyd’s classification of Claudication
 Grade I: Patient complains of pain after walking, and
distance in which pain develops is called as
‘claudication distance’. If patient continues to walk,
due to increased blood flow in muscle and opening of
collaterals metabolites causing pain are washed away
and pain subsides.
 ™Grade II: Pain still persists on continuing walk; but
can walk with effort.
 ™Grade III: Patient has to take rest to relieve the pain.
 Grade IV : REST PAIN

11. REST PAIN
 It is continuous aching in calf or feet and toes or in certain
region even at rest depending on site of obstruction.
 It is ‘cry of dying nerves’ due to ischaemia of the somatic nerves. It
signifies severe decompensated ischaemia. Pain gets aggravated by
elevation and is relieved in dependent position of the limb.
 Pain is more in the distal part like toes and feet. It gets aggravated with
movements and pressure.

12. REST PAIN
 Hyperaesthesia is common association with rest pain.
 Rest pain is increased in lying down and elevation of foot;
it may be reduced on hanging the foot down.
 Rest pain is worst at night and so patient is sleepless at
night.
 Rest pain is apparently reduced by holding the foot with
hand, probably due to suppression of transmission of pain
sensation.

14. Leo Buergers Statement on this Disease
 The disease (occurs) in young adults between the ages of
twenty and thirty-five or forty years…. Upon
examination we see that one or both feet are markedly
blanched, almost cadaveric in appearance, cold to the
touch, and that neither the dorsalis pedis nor the
posterior tibial artery pulsates…. After months… trophic
disturbances make their appearance…. Even before the
gangrene, at the ulcerative stage, amputation may
become imperative because of the intensity of the pain.
—Leo Buerger
1908 (Professor of Urology, 1879 to 1943)

15. ETIOLOGY
 It is a disease very commonly seen in young and middle
aged males commonly between 20-40 years in age.
 Seen only in smokers and tobacco users; not usually seen
in females due to genetic reasons (but can occur in females
very rarely).
 Almost always starts in lower limb, may start on one side
and later on the other side.
 Upper limb involvement occurs only after lower limb is
diseased.

17. ETIOLOGY
 It is common in Jewish people, Asians;
 Hormonal influence, familial nature, hypersensitivity
to cigarette.
 Lower socioeconomic group, recurrent minor feet
injuries, poor hygiene are other factors.

18. RISK FACTORS

21. Clinical Features
 Common in male smokers between the 20-40 years of
age group. It is a smoker’s disease.
 Intermittent claudication in foot and calf progressing to
rest pain, ulceration, gangrene.
 Recurrent migratory superficial thrombophlebitis.
 Absence/Feeble pulses distal to proximal; dorsalis pedis,
posterior tibial, popliteal, femoral arteries.
 May present as Raynaud’s phenomenon.

44. Investigations
 Blood routine including Blood sugar Profiles to r/o DM.
 Arterial Doppler and Duplex scan (Doppler + B
mode U/S).
 Transfemoral retrograde angiogram through
Seldinger technique:
 Shows blockage—sites, extent, and severity.
 Cork screw appearance of the vessel due to dilatation of vasa vasorum.
 Inverted tree/spider leg collaterals.
 Severe vasospasm causing corrugated/rippled artery.
 Transbrachial angiogram

45.  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

46. Cork Screw Appearance in Duplex Scan

49. TREATMENT
 Stop smoking.
“Opt for either cigarette or limb, but not both.”

51. TREATMENT
 Pentoxiphylline - flexibility of RBC’s and helps them reach the
microcirculation in a better way so as to increase the oxygenation
 Low dose of aspirin 75 mg once a day—antithrombin
activity.
 Clopidogrel 75 mg;
 atorvastatin 10 mg; parvostatin 40 mg;
 Cilostazole 100 mg bid - is a phosphodiesterase
inhibitor which improves circulation (ideal drug).

52.  Analgesics, often sedatives are used to make patient
compliant with AGONISING PAIN & Improve QOL.
 Xanthine nicotinate - 3000mg from day 1 to 9000 mg on
day 5 is given to promote ulcer healing and also increase
claudication distance.
 Naftidofurylis used in intermittent claudication. It acts
by altering tissue metabolism
 Intra muscular injections of VEGF promotes
angiogenesis

53. CARE OF THE LIMB
 Buerger’s position and exercise—regular graded
exercises up to the point of claudication improves the
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 minutes for several times at time.

54. CARE OF THE LIMB
 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
 Comfortable Footwear should be worn with socks
 Encourage the patient to always use Socks throughout the day
 Heel raise of 2cm should be used reduces the calf muscle work
which leads to improved claudication time.

56. INTERVENTIONAL TREATMENT
 CHEMICAL SYMPATHECTOMY :
 Sympathetic chain is blocked to achieve vasodilatation by
injecting local anaesthetic agent (xylocaine 1%)
paravertebrally beside bodies of L 2, 3 and 4 vertebrae in
front of lumbar fascia, to achieve temporary benefit.
 Long time efficacy can be achieved by using 5 ml phenol in
water.
 It is done under C-Arm guidance.
 Feet will become warm immediately after injection. Problems are—possible
risk of injecting phenol into IVC/aorta, spinal cord ischaemia

58. SURGICAL MANAGEMENT
 Omentoplasty to revascularise the affected limb.
 Profundaplasty is done for blockage in profunda femoris
artery so as to open more collaterals across the knee joint
(It often makes better perfusion to the knee joint and flap of
below-knee amputation).
 Lumbar sympathectomy to increase the cutaneous
perfusion so as to promote ulcer healing. But it may divert
blood from muscles towards skin causing muscle more
ischaemic.

60. SURGICAL MANAGEMENT
 Amputations are done at different levels depending on site,
severity and extent of vessel occlusion. Usually either
below-knee or above-knee amputations are done.

62. SURGICAL MANAGEMENT
 Ilzarov method of bone lengthening helps in
improving the rest pain and claudication by creating
neo-osteogenesis and improving the overall blood
supply to the limb.

63. PICTURES OF INTEREST

64. PICTURES OF INTEREST

65. PICTURES OF INTEREST

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68. PICTURES OF INTEREST

69. PICTURES OF INTEREST

70. PICTURES OF INTEREST

72. ASSIGNMENTS FOR YOU
 READ IN DETAIL AND FIND OUT FOR THE
MANAGEMENT OF Buergers Disease According to
Ayurveda.
 Importance of Raktha Mokshana in Peripheral Vascular
Disorders
 What is ABPI(Ankle Brachial Pressure Index) ? How to
do it.?
 Read in detail about examination of Arterial Disorders in
Clinical Examination book by S.Das.