Buerger's disease medium sized vasculitis.pptx

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

1. Buerger’s disease By DR. Sameh Attia Ali Basha Senior Registrar Vascular Surgery MBBCh , MSc, MRCS(A), EBVS, MD

2. Vasculitis A rterial vascular disease is usually associated with advanced age and raditional risk factors related to atherosclerosis. However , vasculitis and other uncommon

3. Vasculitis Vasculitis can differantiated from atherosclerotic disease by several clinical features, including : young age at presentation Apperance of traditional risk factors. Systemic apperance constitutional syndrome of fevers, chills, night sweats unexplained weight loss.

4. Vasculitis Evidence of a multisystem disorder on examination or laboratory testing, with elevated inflammatory biomarkers, is also suggestive. A temporal association with a new drug may suggest drug-related vasospasm or vasculitis . positive family history is a useful clue to an inherited vasculopathy such as pseudoxanthoma elasticum or neurofibromatosis.

5. Vasculitis Vessels of any size or location can be affected by vasculitis . Vasculitis implies inflammation of vessel walls, resulting in vascular damage and a wide variety of clinical signs and symptoms.

6. Vasculitis Vasculitis can be classified based on the predominant type of vessel involved (referred to as large-, medium-, or small-vessel vasculitis ). The major forms of small-vessel vasculitis are associated with the presence of antineutrophil cytoplasmic antibodies (ANCA) .

7. Vasculitis

8. Leo buerger

9. Leo buerger ( Vienna , September 13, 1879 –  New York , October 6, 1943) Was an   AustrianAmerican   pathologist ,  surgeon  and  urologist .  Buerger's disease  is named for him. It was in 1908 that Leo Buerger described with details in  The American Journal of Medical Sciences  the clinical and histopathological features of the disease that now bears his name- Thromboangiitis obliterans   He described its occurrence in certain ethnic groups of New York city, particularly Polish and Russian Jew

10. 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

11.   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

12. 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

13. Pathogenesis Smoke- carbon monoxide and  nicotinic acid Vasospasm hyperplasia of intima Thrombosis of vessels Oblitration of vessels Panarteritis – segmental

14.  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

15.  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

16. 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

17. 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

18. 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

19. 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

20.   Investigations  Blood sugar  levels – DIABETES MELLITUS  Lipid profile- any dyslipidemia  Decreasesd Hb levels – delayed healing  WBC count - infection

21. 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

22. Angiogram

23. Ultrasound abdomen  to see abdominal aorta for occlusion  Segmental pressure measurement to localize the occlusion site  Ankle brachial pressure index  Normal - >1  < 0.9 – ischaemia present  < 0.3 –marked ischeamia + gangren

24. CTA-MRA

25. Segmental pressure measurement

26. Digital subtraction  angiography:(DSA )

27. 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  Clopidogre l 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

28.  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.

29. 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

30. 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

31. 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

32. Chemical sympathectomy

33. 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

34. omentoplasty

35. Amputation

36. Amputation

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

38. Ilzarov’s method

39. Thank you