Buerger’s Disease

By :-
Dr.Mohit Singhania
(Intern)
 Complaint

Blackish discoloration of
the toes
 History of present illness
• Patient complaint left toes blackened until soles of the feet
• Patient feel painful
• The complaint arises since 2 months ago after baypass
• Legs feel numb
• The patient has done hyperbarik since on until now as much as
27 times. After hyperbarik, patient feel his legs like an electric
shock. Patient has consul with cardiologist
• Past medical history
- patient has hypertention and CHF & CAD on November 6th 2015
- patient have been treated to the community health centre with complaint
sweating, dizziness in the nape, and restless

• Family history of disease

- Patient have a family history of hypertension and four brothers of patient
have died of hearth disease.

• Treatment history:
– Patient taking amlodipin since 4 years ago. Patient perform CABG on
November 6th 2015, and patient also perform hyperbaric at the
hospital.
• Personal History
Patient smoked since senior high school as 18
cigarettes everyday. Patient taking traditional
herbal medicine. All this time, the patient has
habits of eating padang food and innards.
 Physical examination
General condition Vital sign
• Ill impression : moderete • Blood pressure: 90/60
• Nutritional status : good mmHg
• Awareness : Compos • Pulse: 90b/m
mentis • Temperature: 36ᴼC
• RR: 18b/m
General status
Head : Normocephal
Eye : clear cornea, blackish brown iris color, pupil isokor, direct light reflex +/+,
indirect light reflex +/+, conjunctival pallor -/-, sclera jaundice -/-
Nose : normal, no discharge, no blood
Mouth : OH good

Ear : Normotia, no discharge and blood

Neck : Thyroid and lymph nodes no enlarged
Thorax
Lung : Symmetrical, breath sound Vesikuler +/+, Wh -/-, Rh -/-
hearth : hearth sound I &II reguler, gallop (-), murmur (-)
chest and breasts : there are stitches in the sternum after CABG.
Abdomen : flat,noisy bowel (+), Timpani, tenderness (-)
 Physical examination
Urogenital : Normal
Limb : There are gangrens on digiti left toes
I,II,III,IV,V

View before amputation

 Investigation
Hematologic

Routine blood  
TLC 7.600/ul
RBC 4.10 million/ul
Hemoglobin 11.9 g/dl
Hematocrit 36%
PLT 224.000 thousand/ul
Hemostasis  
Blood time 3’00
Cloting time 11’30

Clinical chemistry

Blood glucose  

Blood glucose in the time 141 mg/dl

Treatment
Post
Pre operation operation
operation
• Ceftriaxon 2 • Injection RL • Injection
gr 20 drops lasix 1 amp
• Inj ceftriaxon • ISDN 5 mg
2x1 under tongue
• Inj ketorolac
3x1
• Amputation
digiti left toes
I,II,III,IV,V
• Skin graft
• Bedrest
• Changing
bandages
every 2 days
 Surgery
• Types of surgery : Pro amputation digiti left toes I,II,III,IV,V
• Position : Supine
• Anesthesia : SAB
• Surgery report:
– Position of supine with SAB
– Asepsis and antisepsis location operating
– Incision edge of the wound necroting
– Spin of area necroting digiti I-V pedis sinistra
– Do amputation and necroting
– Followed with skin graft ( FTSG)
– Drain in inguinal
– Doing suture
– Thick bandage
View after amputation
 
Literature review
 Anatomy
Artery
 Thigh and gluteal region : femoral artery and obturator
artery

 Leg : anterior leg (anterior tibial artery), posterior leg

(dorsalis pedis artery)

 Foot : dorsalis pedis artery and posterior tibial artery

Venous
• Deep vein
 gluteal : inferior and superior gluteal vein
 thigh : external iliac vein and femoral vein
 Foot and leg : anterior tibial vein, posterior and fibular vein, popliteal
vein, plantar vein
• Superficial vein
 great saphenous vein
 small saphenous vein
 Histology

The intima
The media
The adventitia
 Definition

Thromboangiitis obliterans (TAO) is an inflammatory,

nonatherosclerotic, occlusive disease of small and medium-sized
arteries and veins that involves distal vessels of the extremities.
Cause and risk factor
• tobacco exposure of any kind, including smoking,
chewing or snuff.
• Aged (predominately 20 to 40 years old)
• more common in men
• Genetics
• Hypercoagulability
• endothelial dysfunction
• immunologic mechanism
• high cholesterol
• high blood pressure
• diabetes
Pathogenesis

smoking

Genetic
Endothelial
dysfunction

Bueger
disease

Immunologic
mechanism
Hypercoability
Pathology
 Clinical description
 Two or more limbs being affected
 Discoloration of the affected limb
 Pain which may increase with activity such as walking and
decrease with rest
 Numbness and tingling in the limbs
 Raynaud's phenomenon
 Skin ulcerations and gangrene of the digits, which are
common
 Pulses which may be decreased or absent in the affected
extremity
 Later symptoms which include enlarged, red, tender cord-like
veins
Diagnostic method
Non-invasive vascular
evaluation
• used to check for a lack of
atherosclerotic lesions and
can identify the distal sites
of symptomatic arterial
occlusion and other sites of
lesions
Angiography
• The most important diagnostic
criterion is the smooth and regular,
non-atherosclerotic nature of the
artery wall both at the site of, and
also proxmally to arterial
occlusions.
• In the legs, infrapopliteal lesions
predominate
• In the arms, the lesions primarily
concern the radial and cubital arteries
Laboratory
Treatment
• Drug
- vasodilator
- spinal cords stimulators
• Surgical
- sympathectomy
- distal limb amputation
 Skin graft and flaps
• Graft are measure aimed to remove
healthy skin and attach to the skin wound
• Without carrying its own blood supply
Skin graft • Consist of Full thickness- full thickness
skin grafts and split thickness skin grafts

• Flaps are elevated from a donor site and

transferred to the recipient site with an
intact vascular supply
• It survives by carrying its own blood
Flaps supply
• Consist of local, regional and distant
flaps
Example for flap regional
All of the following are the clinical feature
of thromboangitis obliterans except:
a. Raynaud’s phenomenon
b. Claudication of extremities
c. c. Absence of popliteal pulsed.
d. Migratorysuperficial throhmbophlebitis
Not included in treatment of Buerger’s
disease:
a. Lumbar sympathectomy
b. Endovascular stent
c. Rheostatic agent
d. Extra-anatomical bypass
Drugs used for TAO are –
1. Propanolol
2. Xanthinol nicotinate
3. GTN
4. All of the above
Thank you