buerger's disease and chronic arterial occlusion (2)

Chronic Arterial Occlusion

• Differs from Acute Arterial Occlusion in:• Collaterals have developed.• Causes dry gangrene• Color and temperature changes are less

marked.We shall discuss Buerger’s Disease as

prototype of Chronic Arterial Occlusion

Buerger’s Disease Introduction & History.

Buerger’s Disease(Thromboangiitis obliterans)In 1908 Leo Buerger described a Disease :1.Young males2.Severe Ischemia of extremities3.Addicted to cigarette smoking4.Migratory superficial phlebitis5.Histology: Thrombosis of both arteries and veins

with marked inflammatory reaction.

Buerger’s Disease Etiology

• Not known• Associated with:

1.Cigarette smoking2.Male sex ?hormonal influence. The

disease is rare in female smokers.3.Lower socio-economic status.

poor hygiene.4.h/o cold injury and repeated fungal

infections.

Buerger’s Disease Etiology

5.Hypercoagulability Raised fibrinogen levelsHyperaggregability of platelets during acute attacks.

Genetic factors6.Familial predisposition7.HLA A9 & HLA B58.Rare in blacks.9.High incidence in Jews.

Buerger’s Disease Etiology

• Autonomic Over activitybecause there is

Severe peripheral vasospasm

Hyperhidrosis.

Buerger’s Disease Etiology

• Autoimmune factors• Antibodies to collagen are +nt• Lymphocyte mediated sensitivity to

collagen.• Antibodies to Rickettsial organisms

+nt.

Buerger’s DiseasePathology

1.Thrombosis of Arteries and Veins of medium to small size.

2.Digital Vessels are commonly involved.3.Dense aggregates of Polymorphs within the

thrombus.4.Associated panvasculitis.5.No necrosis of vessel wall.

Buerger’s DiseasePathology

6.Microabscesses later in course of disease.7.Giant cells appear8.Later on thrombus gets organized.9. Then recanalisation may occur.10.Old lesions: Chronic inflammatory

infiltrates & extensive fibrosis involving artery, vein and peripheral nerves.

Buerger’s Disease Clinical Features

Almost exclusively in males.Starts between 20-35 yearsTypical patient is a heavy smoker who started

smoking early in life.Ischemia of lower limbs.Upper extremities are also involved.Migratory superficial phlebitisIschemic areas are sharply demarcated.

Buerger’s Disease Clinical Features

Pain is excruciatingCold sensitivityFoot claudication less often calf Raynaud’s Phenomenon.Remissions on abstinence and exacerbation

with restarting.

Buerger’s Disease Clinical Features

• Clinical course is protracted and painful but benign:

Intermittent claudication > Rest Pain > Postural color changes > Trophic changes > Ulceration and gangrene of digits then entire foot or hand.

May ultimately require quadruple amputations

Buerger’s Disease Clinical Features

• Physical ExaminationExamine:

-Colour-Temperature

Changes are less marked than Acute Arterial Occlusion

-Pulse Pattern

Buerger’s Disease Clinical Features

• Physical Examination• Absence of Radial and ulnar digital pulses• Signs of Chronic ischemia

Loss of hair from digitsSkin Atrophy

Atrophy of foot muscles• Absence of PT & DP

Brittle nailsBlanching on elevation and rubor on dependency.

Buerger’s Disease Clinical Features

• Physical Examination:moistureSensationBruit –ntVenous refilling nails, veinsSensation• Ankle Brachial Pressure Index

Buerger’s Disease Clinical Features

• Physical Examination:Allen Test

Buerger’s Disease Clinical Features

• Physical Examination:Ankle Brachial Pressure Index=Ankle Systolic pressure/Arm systolic pressureNormal->1Claudication-1-0.5Impending gangrene <0.5

Buerger’s Disease Clinical Features

• General Physical Examination: -Palpation and auscultation for all pulses.-Abdomen for Aortic Aneurysm-CVS for:

ArrhythmiasValvular diseaseCongenital heart disease

Buerger’s Disease Clinical Features

• Physical Examination• Advance cases

Edema Superficial PhlebitisUlcerationsGangrene

Buerger’s Disease Clinical Features

Most patients cannot stop smoking despite multiple amputations.

Life threatening complications are infrequent.Occasionally involvement of mesenteric or

cerebrovascular circulation.

Buerger’s DiseaseIncidence

• Frequency depends on criteria used for diagnosis.

• Clinical:young men with Ischemia high incidence.

• Arteriography: Uncommon• Histology: RareSome investigators doubt existence of

Buerger’s Disease

Buerger’s DiseaseIncidence

• Probably 7-8 cases/100,000 white males between 20-44 years of age.

• Presently less than 1% of patients presenting with severe ischemia of extremities in US

• Israel & Eastern Europe- 5%• Japan- 16%• Much more in Asia.

Buerger’s Disease Differential Diagnosis

1.Diabetic foot.2.Popliteal Aneurysm3.Repeated Arterio-arterial embolisations4.Collagen disorders

Buerger’s Disease Diagnostic Studies

• Angiography is the mainstay of diagnosis. It shows:-Segmental obliteration of medium sized arteries of forearm and calf.-Smooth intima of large arteries.-Digital arteries are frequently involved.-Collateral circulation is well developed as evidenced by:

Tree roots,Corkscrew,Spider leg appearances.

Unusual corrugated /rippled appearance of an artery.

Buerger’s Disease Diagnostic Studies

• Other testsDoppler UltrasoundDuplex ImagingPlethysmography

Buerger’s Disease Diagnostic Studies

• Other tests Plethysmography:Records changes in the volume of a limb with each

pulse.Can be done with-

-Strain Gauge-Photo-Impedance-Air

Buerger’s Disease Management

• Analgesics:Narcotics should be used cautiouslyPeripheral/Sympathetic nerve blocks.Cervical/Lumbar Sympathectomy

• Stopping smoking• Foot care• Anticoagulants• Dextran• Phenylbutazone

Buerger’s Disease Management

• Pyridinolcarbamate• Inositol Niacinate• Steroids• Prostaglandins

Buerger’s Disease Operative Therapy

• Arterial reconstruction/Angioplasty usually impossible.

• Micro vascular transplantation of omentum.• Amputation:

Required for gangrene even for pain.

Amputation at the lowest possible level is indicated.

Other Chronic Arterial Occlusive Disease

• Aortoiliac disease• Femoropoliteal disease• Tibioperoneal disease• Diabetic foot• Upper Extremity Ischemia• Extracranial occlusive cerebrovascular

disease

Other Chronic Arterial Occlusive Disease

Aortoiliac disease (Leriche’s Syndrome)Triad of 1. Claudication2. Impotence3. Absence of gangrene

Aortoiliac disease (Leriche’s Syndrome)

• Rest pain, ulceration or gangrene indicate distal disease or Aortoarterial embolisation.

• Absent lower limb pulses.

Aortoiliac disease (Leriche’s Syndrome)

• Investigations :Aortography.

Aortoiliac disease (Leriche’s Syndrome)

• Medical Management:-Daily exercise to the point of claudication-Cessation of smoking.-Drugs are ineffective-Protection of feet-Low dose Aspirin-Alcohol in moderation-Statins

Aortoiliac disease (Leriche’s Syndrome)

• Surgical Therapy:• Direct Aortic reconstruction• Extraanatomic bypass• Balloon Dilatation• Prosthetic replacement

Femoropopliteal Occlusive Disease

• Site is distal superficial femoral artery• Calf claudication• Normal femoral pulse with absent popliteal

and pedal pulses.• Arteriography

Femoropopliteal Occlusive Disease

• Medical management: Same• Surgical management:

-Direct arterial reconstruction-Bypass-Endarterectomy

Tibioperoneal Occlusive Disease

• Diabetes Mellitus• Buerger’s Disease• Arterioarterial embolism

Diabetic Foot

• High susceptibility to infection• Neuropathy• Angiopathy

Diabetic Arterial Occlusion

• Popliteal artery and its branches are involved.

• Microangiopathy does not play a role in diabetic foot.

Diabetic foot

• Clinical features:GangreneRampant infectionTrophic ulcers:

-Sharply demarcated-punched out -on sole over a pressure point

Diabetic Foot

• Management:-Wide debridement-May be combine with arterial reconstruction.-Major amputation may be required to prevent

death from septic shock.-Dry gangrene may be treated conservatively.

Diabetic Foot

• Management of trophic ulcer:- Local cleansing.- Protection from trauma- Avoidance of weight bearing- Antibiotics- Local debridement.

Vascular Problems of upper extremity

• Etiology:• Atherosclerotic Stenosis• Thromboembolism• Trauma• Tumor• Inflammatory diseases• Thoracic Outlet Syndrome• Vasospastic disorders.

Vascular Problems of upper extremity

• Etiology:• Atherosclerosis, Thromboembolism and

Aneurysms are less common than in LL.

Vascular Problems of upper extremity

• Examination:• Adson’s Test for Thoracic Outlet Syndrome• Exaggerated military posture.

Vascular Problems of upper extremity

• Angiography• X-Ray for cervical rib• Biopsy for arteritis.

Vascular Problems of upper extremity

• Management:Low dose AspirinEmbolectomyExcision of first rib/cervical rib.BypassVein patch graftIntraarterial Streptokinase/UrokinaseAngioplasty.

Vascular Problems of upper extremity

• Raynaud’s Syndrome:Attacks of –Intense pallor followed byCyanosis thenRubor of distal extremities in response to cold

or emotional stress.

Raynaud’s Syndrome:

• Clinical features:Women are affected moreAssociated with autoimmune diseasesUnder the age of 30 yearsUsually both hands are affectedUse of vibrating tools

Raynaud’s Syndrome:

• Diagnosis:-Typical history-Digital blood pressure monitoring in

response to cold.-Photoplethysmography

Raynaud’s Syndrome:

• Treatment:• Nifedipine• Cervical Sympathectomy.

Extracranial Cerebrovasular Occlusive Disease

• CVA : Cerebrovasular Accidents is caused by-

• Hemorrhage• Thrombosis or• Infarction due to embolism

Extracranial Cerebrovasular Occlusive Disease

• Source of emboli is Atherosclerosis of Extracranial vessels.

• Most common cause of TIA i.e.. Transient Ischemic Attack

Extracranial Cerebrovasular Occlusive Disease

• Diagnosis:• Bruit in the neck• Duplex imaging• Oculoplethysmography• Angiography

Extracranial Cerebrovasular Occlusive Disease

• Treatment:• Antiplatlet Therapy• Thrmboendarterectomy

Extracranial Cerebrovasular Occlusive Disease

• Subclavian Steal Syndrome:• Caused by stenosis of Subclavian Artery proximal

to the origin of Vertebral Artery.• Reversal of flow in vertebral artery• Ischemia of brain and arm• Bruit• Angiography• Treatment by operative reconstruction

Visceral Ischemic Syndromes

• AKA. Intestinal Angina• Occlusion of:1. Superior Mesenteric2. Celiac Axis3. Inferior Mesenteric

arteries.

Visceral Ischemic Syndromes

• Can be Acute or Chronic

Visceral Ischemic Syndromes Etiology

• Atherosclerosis• Sometimes bands from diaphragm may

compress Celiac axis.• Aneurysm• Vasculitis• Collagen disorders

Visceral Ischemic Syndromes Clinical Features

• Post prandial Abdominal Pain• Weight loss.• Small meal syndrome or food fear• Evidence of chronic vascular occlusion

elsewhere.

Visceral Ischemic Syndromes Diagnostic Studies

• AngiographyUsually multiple vessels are found to be

affected.

Visceral Ischemic Syndromes Management

• Bypass using saphenous vein or prosthetic vein.

One stage correction of all lesions.

Acute Mesenteric Artery Occlusion Etiology

• Embolism

Acute Mesenteric Artery Occlusion Clinical Features

• Triad of 1. Catastrophic Abdominal Pain2. Cardiac lesion capable of producing

emboli3. Diarrhea and vomitingH/o embolic event.

Acute Mesenteric Artery Occlusion Diagnostic Studies

• Angiography

Acute Mesenteric Artery Occlusion Operative Therapy

• Embolectomy +- Intestinal resection, second look procedure

Renovascular Hypertension

• Renal Artery occlusion

Renin production

Renin substrate Angiotensin I

Angiotensin II

Renovascular Hypertension

• 5 to 15% of Hypertensives• Clues Atypical essential hypertension:-Abrupt-Early or late age.-H/o flank pain worsening of HPN-Accelerated/Malignant HPN

Renovascular Hypertension

• Bruit in upper abdomen

Renovascular Hypertension Diagnostic Studies

• Intravenous Urography• Intravenous DSA• Radionuclide imaging• Angiography• Renal vein renin estimation• Plasma Renin Activity• Renal biopsy

Renovascular Hypertension Non Operative Therapy

• Percutaneous Transluminal Angioplasty

Renovascular Hypertension Operative Therapy

• Nephrectomy• Endarterectomy• Aortorenal bypass• Splenorenal • Gasroduodenal• Hepatic a.• Iliac artery• Reconstruction• Bench work surgery