MEDICAL SURGICAL NURSING

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 micro abscesses, 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. 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

6. 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

7. 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

8. 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

9. INVESTIGATIONS
▶ Blood sugar levels – DIABETES MELLITUS
▶ Lipid profile- any dyslipidemia
▶ Decreasesd Hb levels – delayed healing
▶ WBC count - infection

10. • CORKSCREW APPEARANCE OF
• COLLATERALS DUE TO
DILATION OF VASA
VASORUM
Arterial flow , flow rate, velocity,
stenosis, block.

11. 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

14. ▶ 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.

16. ▶ Digital subtraction angiography:(DSA)
▶ Only vascular system seen

17. TREATMENT
• 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
▶ Quit smoking
▶ Pentoxiphylline increases flexibility of rbc’ss and hep them reach the
▶ Cilostazole 100mg BD is a phosphodiasterase inhibitor which improves
circulation
▶ All the drugs act on collateral level than at the diseased vessel

18. 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

20. 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

21. 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

23. 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

24. OMENTOPLASTY

25. ABOVE KNEE
AMPUTATION

27. ▶ Ilzarov’s method- bone lengthening helps in
improving the rest pain and claudication by
creating neo-osteogenesis and improving
overall blood supply