Bedah - Buerger's Disease

7/29/2019 Bedah - Buerger's Disease

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BUERGERS DISEASE

Satria Pandu Persada Isma


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Background

Also known as thromboangiitis obliterans

Nonatherosclerotic, segmental, inflammatory,vasoocclusive disease

Affects the small- and medium-sized arteries and

veins of the upper and lower extremities

Strongly associated with heavy tobacco use.


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Patophysiology

Etiology is unknown

Exposure to tobacco is essential for bothinitiation and progression of the disease

Immunologic phenomenon that leads to

vasodysfunction and inflammatory thrombi

Prevalence of HLA-A9, HLA-A54, and HLA-B5 is

observed.


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Frequency

12.6-20 cases per 100,000 population (US)

More common in males (M:F ratio 3:1)

Most patients are aged 20-45


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History

Age younger than 45 years

Current (or recent) history of tobacco use

Presence of distal extremity ischemia

Exclusion of autoimmune diseases,hypercoagulable states, and diabetes mellitus

Exclusion of a proximal source of emboli

Consistent arteriographic findings


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History (contd.)

70-80%present with distal ischemic rest painand/or ischemic ulcerations on the toes, feet, orfingers

Involvement of large arteries is unusual

May also present with claudication of the feet,legs, hands, or arms and often describe theRaynaud phenomenon

May present with foot infections


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Physical Exam

Develop painful ulcerations and/or frankgangrene of the digits

Hands and feet are usually cool and mildly

edematous

Superficial thrombophlebitis (often migratory)

Paresthesias

Impaired distal pulses 80% percent of patients present with

involvement of 3-4 limbs.


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Physical Exam (contd.)

Determine the colour

Vascular angle

Capillary filling timeVenous filling

Pressure areas

Allens test

Temperature

Cappilary refilling

Feel all the pulsesAuscultate

Check all the

nerves


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Differentials

Raynaud phenomenon

Systemic lupuserythematosus

Antiphospholipid-antibody syndrome

Diabetes mellitus

Atherosclerosis

Carpal tunnel syndrome

Peripheral neuropathy

Neurotrophic ulcers

Trauma

Vasculitis, other causes


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Laboratory Workup

No specific laboratory tests confirm orexclude the diagnosis of Buerger disease

Primary goal of a laboratory workup inpatients thought to have the disease is toexclude other disease processes


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Imaging Studies

Angiography/arteriography

nonatherosclerotic, segmental occlusivelesions of the small- and medium-sized

vessels

corkscrew collaterals

Echocardiography


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Morphology

Segmental acute & chronic vasculitis withsecondary spread to contiguous veins andnerves

Inflammation permeates arterial wallsaccompanied by thrombosis of the lumen

Characteristically the thrombus containsmicroabscesses marked by a central focusof neutrophils surrounded bygranulomatous inflammation


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Medical Care

Absolute discontinuation of tobacco use isthe only strategy proven

Use of thrombolytic therapy remainsinconclusive

Intravenous iloprost ?

Use of well-fitting protective footwear

Avoidance of cold environments

Avoidance of drugs that lead tovasoconstriction


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Surgical Treatment

Surgical revascularization for Buergerdisease is usually not feasible

Autologous vein bypass

Sympathectomy

Amputation


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Diet & Activity

No dietary restrictions are needed

Encourage cardiovascular exercise, activityshould be restricted by symptoms only


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Complications

Ulcerations

Gangrene

Need for amputation

Rare occlusion of cerebral, coronary,renal, splenic, or mesenteric arteries


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Prognosis

Among patients with who quit smoking,94% avoid amputation

Patients who continue smoking there is a43% chance that an amputation will berequired sometime during a 7-8 year

period

Mortality is rare


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GRAZIE

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Bedah - Buerger's Disease