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Table 1
Some Distinguishing Clinical Features of Thromboangiitis Obliterans (TAO) and
Arteriosclerosis Obliterans (ASO)
Factor TAO ASO
Age at onset Usually < 40 yr. Usually > 40 yr.
Isehemia of one or Frequent Absent
more fingers
Superficial thrombophlebitis Frequent Absent
in nonvaricose veins
Diabetes mellitus Rare Present in approximately
20% of cases
Hypercholesteremia Rare Present in approximately
50% of patients less
than 60 yr. of age
Calcification of Absent Present in approximately
involved arteries 85% of cases
Bruits over abdominal Absent Present in approximlately
aorta or iliac or 20% of eases
femoral arteries
Decreased or absent pulsations, Infrequent, particularly Present in almost all
in one or both popliteal early in course of patients without diabetes
arteries the disease who are less than 60
yr. of age
Sudden occlusion of femoral Rare Occurs in approximately
or iliac arteries 20% of cases
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the distance that a person affected can walk of an iliac or femoral artery. The pain ex-
before onset of claudication, indicates an in- tends over a large portion of the extremity
crease in the arterial insufficiency of the and may follow the sensory distribution of
affected limb. When intermittent claudication a large nerve trunk. It is paroxysmal, shock-
develops for the first time in a patient more 'like, shooting or cutting and may be associ-
than 40 years old, it is usually due to ASO. ated with burning sensations and paresthesia.
Ischemic rest pain, located in the distal The pain is frequently severe an'd difficult to
part of the extremity, may be severe,and is relieve.
usually worse at night. It indicates a serious Physical Signs
degree of arterial insufficiency. Numbness and Significant occlusive arterial disease of the
paresthesia of the toes or foot are often pre- extremities may be diagnosed before the onset
cursors of rest pain and indicate moderately of symptoms by routine determination of
severe arterial insufficiency. The patient may pulsations of peripheral arteries at every
notice increased sensitivity of the affected examination. The examination should include
extremity to cold. careful and unhurried palpation of the radial
The pain of tlceration and gangrene is and ulnar arteries at the wrists, the abdominal
similar to ischemic rest pain, although it is aorta, and the femoral, popliteal, posterior
usually more localized and probably results tibial, 'and dorsalis pedis arteries. Absence
from inflammatory chailges associated with or reduction in the amplitude of pulsation
infarction, secondary infection, and ischemia in any of these arteries except the dorsalis
of sensory nerve endings. pedis or possibly the posterior tibial arteries
The pain of ischemic neuropathy is usually usually indicates occlusive arterial disease.
due to entensive chronic or sudden occlusion It should be kept in mind, however, that ana-
Circulation, Volume XXVII, May 1963
96 t JUERGENS
tomnic anomalies may account for the sym- Plethysmography and skin-temperature stud-
mnetrical absence of pulsation in the posterior ies are not necessary to establish a diagnosis
tibial arteries in as many as 8 per cent and or even to determine the best type of treat-
in the dorsalis pedis arteries in as many as ment. Although the oscillometer is still used
15 per cent of normal people.6 The amplitude by some physicians, it probably gives less
of pulsation in each artery may be graded reliable and less consistent information than
from 0 (absent) to 4 (normal). Such sys- careful assessment of the pulses by digital
tematic recording of pulsations allows a rela- palpation.
tively accurate evaluation of the arterial eir- All patients with occlusive arterial disease
culation at a given time and is of value in should be tested for hyperglycemia, since a
assessing progression of the disease process. large number of patients with ASO have
Elevation and dependency tests allow an latent or frank diabetes. Determinations of
estimation of the cutaneous isehemia. With blood lipids may be advisable also, particu-
the patient in the supine position, the hips larly for younger patients with occlusive ar-
are flexed and the feet are elevated for ap- terial disease, since the concentration of cho-
proximately 30 to 60 seconds. This empties lesterol in the blood is elevated in about
the visible superficial veins of the foot and 50 per cent of men and 75 per cent of women
causes varying degrees of pallor of the skin with ASO who are less than 60 years of age.7
of the ischemic foot. The feet are then made Diabetes mellitus or hyperlipidemia or both
dependent. The time required for normal are rarely encountered in patients with TAO.
color to return and for refilling of the emptied Roentgenographic evidence of atheromatous
veins is noted. In occlusive arterial disease calcification of the arteries of the pelvis or
the return of color takes longer than 10 lower extremities occasionally may be useful
seconds and refillin-gf of the veins takes longer in distinguishing ASO from TAO. Electro-
than 15 seconds. These observations are in- cardiograms are advisable in patients with
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valid when venous incompetence with retro- ASO, whether or not symptoms of coronary
grade venous filling is associated. Persistent heart disease exist, because of the frequency
rubor of the skin of the distal portion of the with which coronary sclerosis is associated
foot and toes is usually present when the with arteriosclerosis of the arteries of the
arterial circulation is greatly impaired. Other extremities.
indications of arterial insufficiency are cool- Arteriograms are almost never necessary
ness and atrophy of the distal portion of in making a diagnosis of occlusive arterial
the affected extremity. Occlusion of a smaller disease of the extremities. Although arterio-
digital artery may be manifested by a cya- graphic distinctions between ASO and TAO
notic, cool digit and occasionally by cutaneous exist,3 the exact nature of the obstrueting
infarets. In cases of ASO, isehemic ulceration lesions cannot always be determined by this
and gangrene usually are confined to the toes means. Arteriograms are frequently neces-
or heel; in cases of TAO, ulceration and gan- sary, however, to determine the exact site
grene may affect the finger tips also. The and extent of the obstructing arterial lesions
typical ischemic ulcer has a grey-black base if arterial surgery is contemplated. Arteriog-
with little or no granulation tissue; con- raphy is rarely justifiable when the clinical
comitant local infection often is present; the findings indicate that the obstructing lesions
most frequent organism is Staphylococcus are entirely distal to the popliteal arteries or
aureus. when it is certain for other reasons that a
direct surgical attack will not be made. In
Laboratory and Special Studies the absence of clinical evidence of involvement
Relatively few laboratory data are needed of the adbominal aorta or iliac arteries, the
to corroborate a clinical diagnosis of chronic femoropopliteal system may be better visual-
occlusive arterial disease of the extremities. ized by percutaneous injection of contrast
Circulation, Volume XXVIIJ, May 1963
SYM1POSIUM-PERIPHERAL VASCULAR DISORDERS 967
loomr
medium into the common femoral artery on I f",
Nom lpopulation
,K-
the affected side; otherwise an aortogram ~~~~~9B85 97.7 IG; p pu u on
93.6
should be made. Both femoral arteriography 90
a graft, insertion of a prosthetic tube to region, may occur even if the surgery has been
bypass an occluded segment, or thronmboen- performed by experienced vascular surgeons.
darterectomy.1 The last procedure is being used Unfortunately, amputation of a finger is
with increasing frequency and occasionally sometimes necessary in cases of TAO and
a patch graft of plastic material or autog- amputation of a lower extremity is sometimes
enous vein is sutured in at the same time necessary in cases to TAO and of ASO. If gan-
to enlarge the lumen. Bypassing procedures grene is extensive and there is evidence of
are used when the occlusive lesion is too ex- toxeinia, amputation should not be delayed.
tensive for thromboendarterectomy. Recon- When there is severe and intractable isehemic
structive arterial surgery is applicable for rest pain without gangrene, amputation may
occlusions that are proximal to the trifurea- be necessary if a thorough trial (at least
tion of the popliteal artery, and operability 6 weeks) of medical or of other surgical
depends on the occlusion being segmental, treatment fails to control the pain. It is
that is, there must be an adequate arterial frequently advisable to administer antibiotics
lumen above and below the occlusion. Recon- before and after the amputation.
structive arterial surgery for chronic occlu- References
sive peripheral arterial disease is practically 1. ALLEN, E. V., BARKER, N. W., AND HINES, E. A.,
limited to ASO involving the abdominal aorta, JR.: Peripheral Vascular Diseases. Ed. 3.
iliac, and femoral arteries. Arteriosclerotic oc- Philadelphia, W. B. Saunders Company, 1962,
clusion of the subelavian or brachial arteries 1044 pp.
rarely produces severe ischemic symptoms and 2. WESSLER, S., MING, S., GUREWICH, V., AND
FREIMAN, D. G.: A critical evaluation of
TAO almost always involves the smaller dis- thromboangiitis obliterans: The case against
tal arteries, which are inoperable for technical Buerger's disease. New England J. Med. 262:
reasons. 1149, 1960.
Direct arterial operation in nondiabetic 3. McCKUSICK, V. A., HARRIS, W. S., OTTESEN, 0. E..
GOODMAN, R. M., SHELLEY, W. M., AND BLOOD-
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patients is chiefly indicated for disabling in- WELL, R. D.: Buerger 's disease: A distinet
termittent claudication. As mentioned previ- clinical and pathologic entity. J.A.M.A. 181:
ously, this type of surgical procedure is not 5, 1962.
lifesaving because patients rarely die as a 4. MCPHERSON, J. R., JUERGENS, J. L., AND GIFFORD,
result of ischemia of tissue distal to the R. W., JR.: Thromboangiitis obliterans and
arteriosclerosis obliterans: Clinical and prog-
arterial obstruction. If the disease is progres- nostic differences. Unpublished data.
sing rapidly or if amputation seems inevitable, 5. JUERGENS, J. L.: Intermittent claudication. M.
an arterial operation is justified in the hope Clin. North America 42: 981, 1958.
that amputation can be avoided or can be 6. SILVERMAN, J. J.: The incidence of palpable dor-
made at a lower level. This type of procedure salis pedis and posterior tibial pulsations in
soldiers: An analysis of over 1,000 infantry
should not be employed merely because an soldiers. Am. Heart J. 32: 82, 1946.
arterial lesion is present, and it cannot be 7. JUERGENS, J. L., BARKER, N. W., AND HINES,
recommended as a routine prophylactic meas- E. A., JR.: Arteriosclerosis obliterans: Review
ure for preservation of an affected limb, since of 520 cases with special reference to patho-
genic and prognostic factors. Circulation 21:
the incidence of gangrene is relatively low 188, 1960.
in the usual uncomplicated case of ASO. In 8. SCHADT, D. C., HINES, E. A., JR., JUERGENS,
selecting patients for arterial reconstructive J. L., AND BARKER, N. W.: Chronic athero-
surgical procedures, consideration must be sclerotic occlusion of the femnoral artery.
given to the fact that postoperative occlusion J.A.M.A. 175: 937, 1961.
9. Council on Foods and Nutrition: The regulation
of an inserted graft or an endarterectomized of dietary fat: A report of the council.
segment, particularly in the femoropopliteal J.A.M.A. 181: 411, 1962.