Buerger’s Disease

Alternative name:
 thromboangiitis obliterans

Definition:
 Is a recurring progressive inflammation and thrombosis (clotting) of small and
medium arteries and veins of the hands and feet. It is strongly associated with
use of tobacco products, [1] primarily from smoking, but also from smokeless
tobacco.
History
 King George VI and Buerger’s Disease

- As reported by Alan Michie in God Save the Queen, published in 1952 (see
pages 194 and following), King George VI was diagnosed with the disease in
late 1948 and early 1949. Both legs were affected, the right more seriously than the
left. The King's doctors prescribed complete rest and electric treatment to stimulate
circulation, but either unaware of the connection between the disease or smoking
(the King was a heavy smoker) or unable to persuade the King to stop smoking, the
disease failed to respond to their treatment. On March 12, 1949, the King underwent
a lumbar sympathectomy, performed at Buckingham Palace by Dr. James R.
Learmonth. The operation, as such, was successful, but the King was warned that it
was a palliative, not a cure, and that there could be no assurance that the disease
would not grow worse. From all accounts, the King continued to smoke.

 Felix von Winiwarter

- Buerger's disease was first reported by Felix von Winiwarter in 1879

in Austria. It wasn't until 1908, however, that the disease was given its first accurate
pathological description, by Leo Buerger at Mount Sinai Hospitalin New York City.
[6]
Buerger called it "presenile spontaneous gangrene" after studying amputations in
11 patients
Prevalence:

 Buerger's is more common among men than women. It is more common

in Israel, Japan, India, and Manipur along the "old silk route" than in the United
States and Europe. The disease is most common among South Asians.

Causes:

 Tobacco smoking

Prognosis

 Buerger's is not immediately fatal, but it is life-shortening. Amputation is common

and major amputations (of limbs rather than fingers/toes) are almost twice as
common in patients who continue to smoke. Death rate has not been consistently
shown as higher in patients who do not cease smoking but for this and other
health concerns quitting is highly recommended. Female patients tend to show
much higher longevity rates than men. Despite the clear presence of
inflammation in this disorder, anti-inflammatory agents such as corticosteroids
have not been shown to be beneficial in healing, but do have significant anti-
inflammatory and pain relief qualities in low dosage intermittent form. Similarly,
strategies of anticoagulation (thinning of the blood with aspirin or other agents to
prevent clots) have not proven effective. The only way to slow the progression of
the disease is to abstain from all tobacco products.

Feature:

 There is a recurrent acute and

chronic inflammation and thrombosis of arteries and veins of the hands and feet.
The main symptom is pain in the affected areas. Ulcerations and gangrene in the
extremities are common complications, often resulting in the need
for amputation of the involved extremity.
  This disease was first reported by Leo Buerger in 1908, who described a disease
in which the characteristic pathologic findings — acute inflammation and
thrombosis (clotting) of arteries and veins — affected the hands and feet.
Another name for Buerger’s disease is thromboangiitis obliterans.

Diagnosis:

M.Buerger

A concrete diagnosis of thromboangiitis obliterans is often difficult as it relies heavily on

exclusion of other conditions. The commonly followed diagnostic criteria are outlined
below although the criteria tend to differ slightly from author to author. Olin (2000)
proposes the following criteria: [2]

1. Typically between 20–40 years old and male, although recently females
have been diagnosed.
2. Current (or recent) history of tobacco use
3. Presence of distal extremity ischemia (indicated by claudicating, pain at
rest, ischemic ulcers or gangrene) documented by noninvasive vascular testing
such as ultrasound
 4. Exclusion of other autoimmune diseases, hypercoagulable states, and
diabetes mellitus by laboratory tests.
5. Exclusion of a proximal source of emboli by echocardiography and
arteriography
6. Consistent arteriographic findings in the clinically involved and
noninvolved limbs.

Buerger’s disease can be mimicked by a wide variety of other diseases that cause
diminished blood flow to the extremities. These other disorders must be ruled out with an
aggressive evaluation, because their treatments differ substantially from that of
Buerger’s disease. For Buerger’s there is no treatment known to be effective.

Diseases with which Buerger’s disease may be confused include atherosclerosis (build-
up of cholesterol plaques in the arteries), endocarditis (an infection of the lining of the
heart), other types of vasculitis, severe Raynaud’s phenomenon associated with
connective tissue disorders (e.g., lupus or scleroderma), clotting disorders of the blood,
and others.

Angiograms of the upper and lower extremities can be helpful in making the diagnosis of
Buerger’s disease. In the proper clinical setting, certain angiographic findings are
diagnostic of Buerger’s. These findings include a “corkscrew” appearance of arteries that
result from vascular damage, particularly the arteries in the region of the wrists and
ankles. Angiograms may also show occlusions (blockages) or stenosis (narrowing) in
multiple areas of both the arms and legs. The changes are particularly apparent in the
blood vessels in the lower right hand portion of the picture (the ulnar artery distribution).

To rule out other forms of vasculitis (by excluding involvement of vascular regions
atypical for Buerger’s), it is sometimes necessary to perform angiograms of other body
regions (e.g., a mesenteric angiogram).

There is no test can confirm whether you have BD. Instead your doctor will likely order
tests to rule out more common conditions including:

 Blood test
- Blood tests to look for certain substances can rule out other conditions that
may cause similar signs
and symptoms. For instance, blood tests can help rule out scleroderma, lupus, blood
clotting disorders
and diabetes, along with other diseases and conditions.

 Allen’s Test
- Your doctor may conduct a simple test called the Allen's test to check blood
flow through the arteries carrying blood to your hands. In the Allen's test, you make a
tight fist, which forces the blood out of your hand. Your doctor presses on the arteries
at each side of your wrist to slow the flow of blood back into your hand, making your
hand lose its normal color. Next, you open your hand and your doctor releases the
pressure on one artery then the other. How quickly the color returns to your hand
may give a general indication about the health of your arteries. Slow blood flow into
your hand may indicate a problem, such as Buerger's disease.
 Angiogram
- An angiogram, also called an arteriogram, helps doctors see the condition of
your arteries. Doctors
inject dye into an artery and then take X-rays or other types of images. Images show
any blockages in
the artery. Your doctor may order arteriogram be performed on both of your arms
and your legs —
even if you don't have signs and symptoms of Buerger's disease in all of your limbs.
Buerger's disease
almost always affects more than one limb, so even though you may not have signs
and symptoms in
your other limbs, this test may detect early signs of vessel damage.
Symptoms:
 Pain
 Foot cramps
 Cold sensitivity in some cases
 Rubor of the foot
 Absence of pedal pulse
 Redness of cyanotic discoloration upon progression of disease
 Gangrene
 Intermittent Claudication (Pain even at rest)
 Paresthesia
 Poikilothermia
Anatomy and Physiology
The disease is typically encountered in heavy smokers, often before the age of
35 years.
Thromboangiitis obliterans is marked by segmental thrombosing, acute, and
chronic inflammation of intermediate and small arteries and veins in the extremities.
It begins with nodular phlebitis, followed by Raynaud's-like cold sensitivity and leg
claudication.
Acute lesions consist of neutrophilic infiltration of the arterial wall, with mural or
occlusive thrombi
Containing microabscesses, often with giant cell formation and secondary
involvement of the adjacent vein and nerve.
Late lesions show organization and recanalization.
The cause is unknown.
The vascular insufficiency can lead to excruciating pain and ultimately gangrene
of the extremities
Three layers of the arteries and veins
 Tunica Intima

 Tunica Media

 Tunica Adventitia

Lumen-cavity of the blood vessels

Arteries-thicker than veins it is more elastic and can contract than veins
Arterioles-small arteries that delivers blood to the capillaries
Capillaries-connects arterioles with Venules and allows the exchange of gases, wastes,
and nutrients between blood and the tissue cells.
Venules -small vessels that connects the capillaries to veins
Veins-have more fibrous tissues and they have internal valves to ensure blood flow in
one direction
Venous sinuses -veins with thin walls.
 Pathophysiology

Predisposing Factors: Precipitating Factors:

Male Environment: Pollution
20 – 35 years of age Smoking

Micro thrombi formation (nicotine)

Neutrophil polymorphs

Occlusion in the lining of the blood vessels

Impairment in the blood circulation

 Inflammation in the blood vessels

Pain, intermittent claudation, cyanosis, numbness, swelling, absence

of pulse, poikilothermia and paresthesis

Buerger’s Disease

Untreated: Septicemia Treated: Amputation

Prosthesis

Management:

A. Surgical Intervention
 Sympathectomy
- is a surgical procedure that destroys nerves in the sympathetic nervous
system. The procedure is done to increase blood flow and decrease long-
term pain in certain diseases that cause narrowed blood vessels. It can also be used
to decrease excessive sweating. This surgical procedure cuts or destroys the
sympathetic ganglia, collections of nerve cell bodies in clusters along the thoracic or
lumbar spinal cord.
 Amputations for gangrenous tissue
- An amputation usually refers to the surgical removal of the whole or part of
an arm/hand or a leg/foot. Amputation of a toe or leg is one of the oldest surgical
procedures.
 Ganglionectomy to remove ganglions
- ganglionectomy, also called a gangliectomy, is the surgical removal of
a ganglion. The removal of a ganglion cyst usually requires a ganglionectomy.
Such cysts usually form on the hand, foot or wrist and may cause pain or impair
body function. Aspiration of the cyst andsteroid injections are typically performed
first. If they fail, the cyst is excised under local, regional or even
 general anesthetic. Ganglionectomies are also performed for other reasons, such
as the treatment of chronic pain.

B. Non Surgical Intervention

 Calcium Channel Blockers
 Anti-Platelet agents
 Vasodilator (rare because it causes dilation of healthy vessels
Nursing Interventions:
 Encourage client to stop smoking.
 Trauma to the extremities must be avoided.
 Instruct client to use neutral soap and body lotion to prevent drying of the skin.
 Fingernails and toe nails should be carefully trimmed.
 Instruct to eat fruits and vegetables which promotes healing and prevents tissue
breakdown.
 Well fitting shoes should be worn to prevent foot injury and blister.
 Instruct client to take low fat and low cholesterol diet.

Discharge Planning

Medication
-As prescribed by the physician
-Vasodilator

Exercise
-Ambulate as tolerated

Treatment
- Gradual cessation of smoking
- Amputation
- Ganglionectomy
- Sympathectomy

Health teaching
-Discuss the etiology of the condition
-Ways to avoid injury
-Proper footcare including nail trimming.

Outpatient Care
-Follow up checkups as indicated by the physician.

Diet
-High in protein. Low in cholesterol diet.

Spiritual
-Continue Religious practices