Buergers disease - By Dr Adithya J V, Asst.Professor, Dept. of General Surgery(Shalya Tantra),BAMC

A detailed study on understanding this arterial disorder

1. By Dr ADITHYA j v B.Sc,BAMS,MS ( Ayu ),PGDHSM,MCSI Assistant Professor, BAMC,Challakere Buergers Disease – Etiology,C /F & Treatment Modalities

2. 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

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

4. 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.

5. 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.

6. 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

7. 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.

8. 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 nigh t 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.

9. 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)

10. 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.

11. 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.

12. RISK FACTORS

13. 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.

14. 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

15. 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

16. Cork Screw Appearance in Duplex Scan

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

18. Opt for either cigarette or limb, but not both.”

19. 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).

20. 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

21. 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.

22. 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.

23. 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

24. 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 .

25. 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.

26. 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.

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35. 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 .