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Buerger’s disease

  • Also known as thromboangitis obliterans (TAO)
  • Progressive non-atherosclerotic disease characterised by inflammation and thrombosis of small and medium sized vessels of the limbs

Epidemiology

  • Young males – especially smokers
  • More common in Jewish people
  • Starts on the lower limb – may start unilaterally and later progress to contralateral limb one side and later on other side
  • Upper limb involvement occurs only after lower limb

Etiology

  • Smoking
  • Hormonal influence
  • Family history of TAO
  • Low socioeconomic group, poor hygiene

Pathophysiology

  • Strongly associated with tobacco use
  • Increased cell-mediated sensitivity to type I and III collagen
  • Inflammatory process is initiated in the tunica intima of small and medium sized vessels – leads to panarteritis
  • Eventually artery, vein and nerve are involved – nerve involvement causes rest pain

Classification

  • Type I – upper limb TAO (rare)
  • Type II – involves leg(s) and feet
  • Type III – femoropopliteal
  • Type IV – aortoiliofemoral
  • Type V –generalised

Clinical Features

  • Intermediate claudication in foot and calf – progresses to rest pain, ulceration and gangrene
  • Recurrent migratory superficial thrombophlebitis
  • Diminished pulses – dorsalis pedis, posterior tibial, popliteal, femoral arteries
  • May present as Raynaud’s phenomenon

Investigations

  • Arterial Doppler
  • Transfemoral retrograde angiogram
  • Corkscrew appearance of vessel
    • Inverted tree/spider leg collaterals
  • US Abdomen – to see abdominal aorta for block/aneurysm

Treatment

  • Smoking cessation
  • Drugs
    • Vasodilators – nifedipine
    • Pentoxyphylline – increases flexibility of RBCs and helps them reach microcirculation
    • Low dose aspirin 75mg – antithrombin activity
    • Clopidogrel 75mg
  • Care of limbs
    • Buerger’s position and exercise
      • Position – head end of bed raised, foot end lowered to improve circulation
      • Exercise – leg elevated and lowered alternatively
    • Care of feet – avoid extreme temperatures, trauma, pressure, dryness
  • Surgery
    • Omentoplasty – revascularise affected limb
    • Profundaplasty – for blockage in profunda femoris artery to open more collaterals
    • Amputations
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