Buerger’s disease

BUERGER’S DISEASE

AJM

“Thromboangitis Obliterans is a distinctive disease that leads to vascular insufficiency, characterised by segmental, thrombosing, acute and chronic inflammation of medium sized and small arteries and sometimes secondarily extending into the veins and nerves”.

Leo Berger, 1879-1943, Professor of Urology, NYPMS, NY, USA, Described TAO in 1908

RISK FACTORS:• CIGARETTE SMOKING:

– Most consistent aspect of this disorder.– Hypersensitivity to intradermally injected tobacco

extracts.– Increased prevalence of HLA-A9 and HLA-B5 in

these patients– Common in India, Japan & Israel pointing to its

genetic influences!.

• SEX

MORPHOLOGY:• Sharply segmental acute and chronic vasculitis

of medium and small arteries.MICROSCOPY:• Inflammation permeates the arterial walls.• Thrombosis of the lumen.• May undergo organisation or recanalisation.• Thrombus contains microabscesses.• Characteristic migratory recurrent superficial

phlebitis.

CLINICAL FEATURES• The patient generally complains of pain while

walking at the arch of the foot.• Onset – Age: 20 -40 yrs. Spontaneous and gradual• Intermittent claudication, which progresses to ‘rest

pain’.• Swelling redness and slight pain• Postural dependency Trophic changes

Ulceration Gangrene.• DD: Raynaud’s disease, Senile gangrene

PHYSICAL EXAMINATION

Local examination:INSPECTION:1.Change in color.2.Signs of ischemia3.Buerger’s postural test.4.Capillary filling time5.Venous refilling

PALPATION:1.PALPATION OF BLOOD VESSELS.2.CAPILLARY REFILLING.3.VENOUS REFILLING.4.ALLEN’S TEST.5.COLD AND WARM WATER TEST.6.NEUROLOGICAL EXAMINATION.

INVESTIGATIONS

• BLOOD• URINE• STRAIGHT X-RAY• ARTERIOGRAPHY:

I. RETROGRADE PERCUTANEOUS CATHETERISATION.

II. DIRECT ARTERIAL PUNCTURE.

• DETERMINATION OF BLOOD VELOCITY BY ULTRASOUND DOPPLER.

• ISOTOPE TECHNIQUE• BLOOD LIPIDS.• INVESTIGATION FOR VASOSPASM

– Brown’s vasomotor Index.

• PLETHYSMOGRAPHY.

MANAGEMENT

• CESSATION OF SMOKING CAN ARREST THE DISEASE.

• MEDICAL– CILOSTAZOL– PENTOXIFYLLINE

• SURGICAL– TRANSLUMINAL ANGIOPLASTY & STENTING(PTE,

PTFE).– BYPASS GRAFTS.