RECENT TRENDS IN MANAGEMENT OF BUERGERS DISEASE

SEMINAR ON

Chairperson Moderator Dr. V.K. Raina Dr. Pawan Agrawal Speaker Dr. Sumeet Jaiswal

SPECIAL INVESTIGATIONS 1. Doppler ultrasound : Based on doppler effect. The frequency shift is proportional to the velocity of the blood flow. It may be analysed audibly and may be recorded graphically. It gives quantitative information about the degree of stenosis. 2. Plethysmography : Method of assessing changes in volume due to arterial supply to that particular part. Recently, segmental plethysmography has been introduced by placing venous occlusion cuffs around the thigh, calf and ankle. The cuffs are inflated to 65 mmHg and the pulsation is the quantitative measure of the arterial diseases. 3. Phonangiography – Vibrations of low frequently in the arterial wall due to disturbances in blood flow can be analysed audibly.

4. Isotope technique – Xenon 133 injected Intramuscularly and its clearance is used to study the blood flow in the calf muscles. Recently technetium has become the isotope of choice. Gamma camera is used to picturise the blood flow in a limb.

5. Arteriography : Most reliable method. Gives information about the size of the lumen, the course, constriction and dilatation of the arteries and collateral circulation. Hypaque 45 (sodium diatrizoate) is the contrast medium often used. Method generally used : Retrograde percutaneous catheterization.

Retrograde percutaneous catheterization Needle and a cannula are introduced into common femoral artery. Dangers (i) iodine sensitivity and (ii) dissection of the arterial wall. Prevented by trial injection of 5 to 10 ml of 45% hypaque to ascertain the position. Free flush arteriography : here tip of the catheter lies in aorta. ‘Bolus’ of 30 ml. contrast medium is injected. Series of X-rays are taken. Selective angiogram : Tip of the catheter is introduced into the corresponding artery.

6. Magnetic resonance angiography (MRA): Advantage : (iii) Non invasive (ii) Contrast agent is non nephrotoxic Limitation : (v) High cost (ii) Poor availability (iii) Over estimation of degree of stenosis ⇒ Uses bolus chasing method ⇒ Images are obtained in coronal and sagittal plan adjustment can be done in bolus dose and time, infusion rate, region of interest ⇒ Time of flight (TOF) MRA : 2-D and 3-D TOF MRA detect flow related phenomenon ⇒ Better than contrast enhanced MRA for evaluating infrapopliteal vessels

Treatment – 2. Abstinence from tobacco 3. Drugs – (ilioprost) 4. Arterial surgery 5. Omental transposition 6. Sympathectomy 7. Neurostimulator devices 8. Gene Therapy 9. Ilizarov technique

1.

Abstinence from tobacco – It is only proved treatment guideline to present disease process. Treatment by any modality is useless if smoking is continued. Drugs :

2.

(a) Prostaglandins – Prostaglandin I2 (ilioprost) has antiplatelet and vasodilator activity. Effective in both cutaneous and muscular vessels. Intraarterial infusion is done. Adminished in such a low dose that its effect is restricted to target area only Adverse effect is avoided because of extensive degradation of PG I2 during passage to pulmonary circulation. Intraarterial route is effective more than I/V route (15

(b) Dextran –It Cause hemodilution, decrease blood viscosity and improve microcirculation. (c) Intraarterial thrombolytic therapy – low dose streptokinase (1000 U bolus followed by 5000 U/m) can be used but results are variable. (d) Praxiline (Niftidrofuryloxalate) – It alter tissue metabolism, increase claudication distance by allowing a greater O2 supply to tissue no proved benefit. (e) Trental (oxypentifylline) – It has effect on whole blood viscosity by reducing rouleax formation. No proven benefit

Arterial surgery revascularisation

(I)

Surgical

bypass

or

Various by pass procedures are attempted but none of them is convincing (a) Direct arterial reconstruction – Some time it is feasible inspite of multiple occluded distal arteries, if successful it provides the most effective healing of ischemic lesion.

(b) If involvement of artery is above knee, by pass surgery may be possible Synthetic graft are employed for aorto or ileo femoral by passes while autologus vein is graft of choice for infrainguinal bypass (II) AV fistula –: If there is arterial involvement only with little pathology in veins. Arterialisation of veins by creating av fistula between artery proximal to site of block and adjacent veins

Omental transposition Pedical omental graft transfer can be used here because of its tremendous angiogenic properties. Omental pedical is based on right gastroepiploic artery (as it has longer length). For bilateral procedure both epiploics are used. A subfacial tunnel is made from inferior end of laparotomy incision to inguinal and further down to ankle medially. Omentum is lengthened and brought down to distal most portion of affected limb through subcutaneous tunnel.

Improvement – - Ulcer healing - Rest pain - Claudication distance Complication - Gastric devascularisation and necrosis in bilateral cases - Palalytic ileus - Gastrichaemorrhage - Omental necrosis and wound infection

Sympathectomy It causes Vasodilation Increase blood flow to skin and subcutaneous tissue Healing of superficial ischemic ulceration Abolish rest pain (a) Surgical (b) Chemical

It is not beneficial in intermittent claudication Types

Surgical Sympathectomy : lumbar sympathectomy is done by extraperitoneal approach. L1L2L3 and sometimes L4 symp ganglion is resected. Complication – Paralytic ileus, injury to genitofemoral nerve, ureteric injury, Injury to major vessel (aorta, IVC), bowel injury. Laproscopic sympathecomy :It is being used recently. Here denervation is accomplished by endoscopic surgical retroperitoneal approach Advantage : (i) Much less operative trauma (ii) Less morbidity (iii) Less chance of complication

Chemical sympathectomy : Fluroscopic or ultrasound guided injection of 5 ml of 6.7% phenol is done by retroperitoneal route at L3L4 level and require no anesthesia. - Effects are temporary Percutaneous chemical LS with alcohol with CT control- It is under evaluation and seems to be better than traditional chemical L-S. Side effects : (I) Injury to surrounding structures by needle (II) Post sympathetic neuralgia Radiofrequency denervation : A new percutaneous approach for sympathectomy using radiofrequency as denervation source, have less post sympathetic neuralgia.

Neurostimulator devices : spinal cord stimulator are : neurostimulator device used for pain management. They modify electrical nerve activety. Limitations of these devices are : -Data based on randomized control trials not available -Can be safely useful only in selected group of patients -Lack of sufficient information

Principles : Based on gate control theory of pain which explain the physiology of pain in terms of electrical conduction across nerve synapses, based on ionic changes in CM and spaces between nerve cells. The flow of nerve impulse from peripheral to central nervous system is regulated by cells in dorsalhorn of spinal cord. The location and type of ionic activity either open or close the pain gate.

Patient selection – Used as late treatment from chronic pain. Used only after other treatment modalities like pharmacological, surgical, physical, psychological have been tried. Procedure – Firstly Demonstration of pain relief with temporary implanted electrod is made. optimal electrod placement and pain response to various frequency is determined. A device is implanted by placing a multiple electrod lead in epidural space along the spinal column using a Tuohy needle. Some times a small laminectomy is performed to insert a paddle type lead. After implantation a handheld programmer control various leads of stimulation.

Safety and efficacy : More effective in neuropathic pain rather than visceral/ muscular pain. Provide a major benefit for lesion improvement is end stage patients. Patient having Tc PO2 > 10 mg (transcutaneous O2 (pressure) respond better. Improves ulcer healing and pain relief. Limb salvage not improved. Complication of SCS : Infection in 3-5% Burning sensation at implantation site Spasm Urinary hesitancy

Gene Therapy : Useful in persistent pain and ischemic ulcers. Based on hypothesis that sufficient exposure of vascular bed to an angiogenic protein will stimulate neovascularisation. It ensure continuous expression of angiogenic protein and prolonged exposure is targeted vascular bed. Various angiogenic factors can be used Such as VEGF, HGF1 del-1 etc.

Gene therapy : VEGF - Most widely used. Stimulate collateral circulation. It is DNA fragment can be deposited on arterial wall. The hydrogel balloon operates like an angioplasty balloon covered with a hydrophillic layer which delivers the DNA fragment when inflated. A single intrarterial bolus of VEGF recombinant human protein result in angiographic, hemodynamic, physiologic and histological evident augmentation of collateral circulation more recently I/M route has been used to take advantage of vascular distribution of this angiogenic cytokine. The peripheral muscle cells can perform the transcription and translation into human DNA protein. Indication – Can be used in – Rest pain Ischemic ulcer Intermittent claudication

Hepatocyte growth factor – Potent angiogenic I/M infusion of naked HGF plasmid DNA is performed in ischemic limb. Advantage – Severe complication and adverse side effect of gene transfer are absent. Effects : (1) Reduction of pain related symptom (2) Increase in angle pressure index more than .1 (3) Diameter of ischemic ulcer reduced. Can be sole therapy for chronic limb ishcemia in future. (c) Extracellular matrix protein Del-1 The ECM protein Del-1 is ECM protein that accumulate around angiogenic vessel and promote angiogenesis. restore muscle function. It bind to integrin alphabeta 5 on resting endothelium, convert in to angiogenic endothelium by inducing expression of proangiogenic molecules integrin alpha B3.

Ilizarov Technique :- The physiological basis is the law of Tension Stress. When living tissue are subjected to uniform planar distraction force after atraumatic corticotomy, in the presence in intact functions, new tissue regenerate in the limb. Not only does the new bone forms, but blood vessels, nerves, muscles, fascia and skin form as well. Thus, it is the phenomena of distruction neohistogenesis.

There is increase in the formation of capillaries in the zone of the ‘Regenerate Bone Formation’ and in rest of the limb by an increase in the collateral circulation.

OPERATIVE TECHNIQUE -Widening of the bone is performed not lengthening. -Longitudinal osteotomy is performed In the upper part of the tibia. -Osteotomy is very slowly distracted apart. -Gap would fill up with regenerative tissue (bone and vascular tissue). Consists of two rings. One in each metaphysis. Connected with a long rod. Longitudinal osteotomy is made on the anteromedial face. Triangular fragment is about 12 to 15 cm long. The osteotomies have a width of only mm. Periosteum is not damaged. Distraction done with the help of olive wires or crossed plain wires at the rate of about 0.25 mm, three to four times a day.

OLIVE WIRE METHOD • Olive wires are drilled in from the anterolateral crest of the tibia, passing through the triangular fragment to exit from the posteromedial corner and the skin. • Olive to pass through the holes. They rests against the inner cortex of the triangular fragment. • Olive wires connected to a long steel plate. This steel. • When the nuts are turned, triangular fragment widened.

The Modified Crossed Wire Technique •Achieves horizontal distraction simply and atraumatically. • Plain K wires are inserted through the postero-medial aspect into the triangular fragment. • Four wires are inserted, angulated anteriorly to the midcoronal plane. 4 wires are inserted in a plane angled slightly posterior to the mid-coronal. • Wires stop within the triangular fragment. • All the wires are connected to individual bolts and attached to a steel plate. • Wires do not cross physically, the resultant vector of wires pull the triangular fragment horizontally. • Advantage : No olive wires are needed, no incisions or predrilling is required for insertion and removal, and the procedure is simple and atraumatic.

Rate And Rhythm Of Distraction The ideal rate of distraction (widening) is one mm per day in fractions of ¼ mm 4 times a day. It the entire 1 mm per day distraction is done in one step, the bone formation may be poor. The lesser the range and more frequent the rhythm, better is the bone and vessel formation.

POSTOERATIVE COURSE Full weight bearing possible within a few days. Total distraction is 1.5 to 2 cm. This much volume of ‘regenerate bone’ is sufficient to increase vascularity of the. The pain relief and appearance of warmth commences after 15 to 20 days (coincides with the formation of new blood vessels). The Ilizarov apparatus is retained on the limb until the regenerate bone matures and hardens which is usually 2.5 to 3 months. RESULTS • Dramatic pain relief • Increased Claudication distance • Limitation of gangreneous spread

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