dr. boni - buerger

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dr. Bonifacius Lukmanto SpB.

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Dr. Boni - Buerger

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Page 1: Dr. Boni - Buerger

dr. Bonifacius Lukmanto SpB.

Page 2: Dr. Boni - Buerger

IntroductionNonatherosclerotic Vascular disease

Characterized by the absence or minimal presence of atheromas, segmental vascular inflammation, vasoocclusive phenomenon, and involvement of small- and medium-sized arteries and veins of the upper and lower extremities.

Strongly associated with heavy tobacco use.Progression of the disease is closely linked to continued

use.Typical presentations are rest pain, unremitting ischemic

ulcerations, and gangrene of the digits of hands and feet.Described in Germany by von Winiwarter in an 1879 and

published by an American man called Leo Buerger.

Page 3: Dr. Boni - Buerger

PathophysiologyThe etiology of Buerger disease is unknown.

The disease mechanism underlying Buerger disease remains unclear.

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FrequencyThe disease has decreased over the

past half decade in United States.More common in males (male-to-

female ratio, 3:1).Most patients with Buerger disease

are aged 20-45 years.

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ClinicalHistory

Diagnosis of Buerger disease is difficult to establish.

Most patients (70-80%) Buerger disease present distal ischemic rest pain and/or ischemic ulcerations on the toes, feet, or fingers.

Progression of the disease lead involvement of more proximal arteries, but involvement of large arteries is unusual.

Patients may also present with claudication of the feet, legs, hands, or arms.

Foot or arch claudication erroneously attributed to an orthopedic problem.

Late in the course of their disease present with foot infections and, occasionally, with florid sepsis.

Page 6: Dr. Boni - Buerger

Clinical

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PhysicalPainful ulcerations and/or frank gangrene of

the digits.The hands and feet are usually cool and

mildly edematous.Superficial thrombophlebitis.Paresthesias (numbness, tingling, burning,

hypoesthesia) of the feet and hands and impaired distal pulses.

> 80% of patients present with involvement of 3-4 limbs.

Page 8: Dr. Boni - Buerger

PhysicalPoint-Scoring system by Papa are using the

following criteriaOnset before age 45Tobacco use.Exclusion of atherosclerosis or proximal

source of emboli.Lack of hypercoagulable state.Lack of definable arteritis (ie, progressive

systemic sclerosis, giant cell arteritis).Classic arteriographic findings.Involvement of digital arteries of finger or

toes.

Page 9: Dr. Boni - Buerger

PhysicalSegmental involvement (ie, "skip areas").Corkscrew collaterals.No atherosclerotic changes.Classic histopathologic findings.Inflammatory cellular infiltrate within

thrombus.Intact internal elastic lamina.Involvement of surrounding venous tissues.

Page 10: Dr. Boni - Buerger

Physical

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Table 1. Scoring system for the diagnosis of thromboangiitis obliterans (x)

Positive points

Age at onset Less than 30 (+2)/30-40 years (+1)

Foot intermittent claudication

Present (+2)/ by history (+1)

Upper extremity Symptomatic (+2)/ asymptomatic (+1)

Migrating superficial vein thrombosis

Present (+2)/ by history only (+1)

Raynaud Present (+2)/ by history only (+1)

Angiography; biopsy If typical both (+2)/ either(+1)

Page 12: Dr. Boni - Buerger

Table 1. Scoring system for the diagnosis of thromboangiitis obliterans (x)Negative points

Age at onset 45-50 (-1)/more than 50 years (-2)

Sex, smoking Female (-1)/ nonsmoker (-2)

Location Single limb (-1)/no LE involved (-2)

Absent pulses Brachial (-1)/femoral (-2)

Arteriosclerosis, diabetes, hypertension, hyperlipidemia

Discovered after diagnosis 5.1-10 years (-1)/2.1- 5 years later (-2)

Page 13: Dr. Boni - Buerger

Table 1. Scoring system for the diagnosis of thromboangiitis obliterans (x)

Page 14: Dr. Boni - Buerger

Table 2. Sum of points defines the probability of the diagnosis of thromboangiitis obliterans

Number of points Probability of diagnosis

0-1 Diagnostic excluded

2-3 Suspected, low probability

4-5 Probable, medium probability

6 or more Definite, high probability

Page 15: Dr. Boni - Buerger

WorkupLaboratory Studies

No specific laboratory tests confirm or exclude the diagnosis of Buerger disease.

Imaging StudiesAngiography/arteriography.Echocardiography: exclude a proximal source of

emboli as the cause of distal vessel occlusion.Other Tests

An abnormal Allen test.Histologic Findings

Biopsy is rarely needed unless the patient presents with unusual characteristics, such as large-artery involvement, or age older than 45 years.

Page 16: Dr. Boni - Buerger

Angiography/arteriography

Page 17: Dr. Boni - Buerger

TreatmentMedical Care

Absolute discontinuation of tobacco use is the only strategy proven to prevent the progression of Buerger disease.

No forms of therapy are definitive.Surgical Care

Autologous vein bypass of coexistent large-vessel atherosclerotic stenoses in patients with severe ischemia who have an acceptable distal target vessel.

Sympathectomy.