A STUDY OF AETIO-PATHOGENESIS OF THROMBO ANGIITIS
OBLITERANS
Put on the net by Dr.Sunil Furtado. Published by Dr. Sharath
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Introduction
The incidence of arterial
disease has assumed alarming proportions all over the world. Considering the fact that the basic
aetiological factors in acquired arterial disease are not yet fully understood
and the precise biochemical abnormalities as yet to be fully elucidated there
is a need for further study to gain insight into this disease.
Obscure medical treatment cannot
be directed to correct or reverse the cause of the disease once it is
established.
Acute occlusions of the
arterial tree are catastrophic in their appearance and progress, yet yield good
results with early therapeutic measures.
Chronic obstructive lesions on the other hand are a bugbear for the
clinician both in terms of diagnosis and treatment. The vast majority of such chronic occlusive
lesions are the result of Atherosclerosis, Thromboangiitis
Obliterans, Diabetes Mellitus and certain other uncommon causes.
Occlusion of the
peripheral arteries used to concern the surgeon only as his/her unpleasant duty
to amputate the gangrenous limb. Now his
aim and endeavour is to forestall the progress and
prevent this tragic finish.
The basis of surgical
treatment is the correction of the pathological and haemodynamic disturbances,
produced by these lesions and restoration of normal circulation.
Thromboangiitis
obliterans or Buerger’s
Disease is a generalized occlusive vascular disease affecting predominantly
young males of low socioeconomic status with special predilection to involve
the lower extremities. The disease has
worldwide distribution though it is more prevalent in
Buerger in his first
paper published in 1908 brought out a new concept of pathogenesis, which
concluded that the disease started as an acute inflammation of vessels, which
leads to formation of thrombi.
Pathologically it is a segmented or focal affection of smaller vessels
of extremities with stages of exacerbation and remissions. The occlusion of vessel by thrombus contains
focus of intense polymorph infiltration.
The whole thickness of vessel wall is involved by neutrophils and most
of these vessels thrombose. These
changes give way to chronic inflammation and thrombus is replaced by
granulation tissue. The lesion almost
always begins in medium sized or small arteries but seldom-large vessels.
This study is based on
the aetiopathogenesis of ThromboAngiitis
Obliterans, cases of which were identified and
treated in
Aim of Study
The present study was
undertaken with the following objectives.
1.
To determine the various
etiologic factors in Thrombo Angiitis
Obliterans (T.A.O).
2.
Histopathological confirmation of
the disease in clinically diagnosed Thrombo Angiitis
Obliterans.
History
Five great eras can be recognised in the evaluation of knowledge of peripheral vascular disease.
The
First Era: (Hippocrates 460 B.C. to
377 B.C.). He described gangrene and the
effects of vascular insufficiency.
The
Second Era: (Leonardo DeVinci
1452 to 1515 A.D.). He dissected the
human body and observed that the arteries of the young were elastic and
straight, where as in the aged they were thick, rigid and tortuous.
The
Third Era: (William Harvey 1578 to 1657
A.D.). This is the era of Physiological
Investigation. William Harvey showed
that the blood circulates in a closed system of vessels.
The Fourth Era: (Anton Von Leeuwenhock 1632 to 1723 and J.L. Pouiseoulle). This era was of application of optics, mathematics and physics.
The
Fifth Era: This is the era of
electronics, which is continuing to grow and expand rapidly.
In 1879, the year in
which Leo Buerger was born in
In 1921 Oppel performed the first adrenalectomy
wrongly assuming that the adrenal was responsible for TAO. In 1923, Robin Witz
claimed to have isolated gram-negative bacilli from the blood culture of TAO
patient. In 1925 Maleng
and Miller succeeded in isolating a variety of organisms
viz., Staphylococci and other types of gram-negative bacilli from cultures of
tissues taken from the neighborhood of the involved vessels in T.A.O.
In 1947 Leriche and his senior produced a paper on 98 Adrenalectomies combined with lumbar sympathectomies. At the European Congress of Vascular Surgery
in 1952, Dos Santos and Fantaise stated that adrenalectomy and sympathectomy was an operation of value,
which apparently seemed to slow down or even check the progress of
disease. Out of 66 patients treated they
registered 74% of good results.
The existence of Burgers
Disease as a distinct process appeared unquestioned until 1960, when Wessles et al seriously challenged Buerger’s
original description. In 1962 Victor A. McKusick
published a paper on Buerger’s Disease, “ A distinct clinical and pathologic entity” and
demonstrated the characteristic pathological extents in the involved vessels.
Review of Literature
Incidence:
TAO cases have been found
all over the world and no particular area is said to be epidemic or
endemic. This is one of the commonest
peripheral vascular diseases in Asian countries. TAO is widely prevalent in most parts of the
country. 0.4 to 0.6% are TAO out of the
total annual surgical hospital admissions and this is the commonest cause of
limb ischaemia.
A study from
A Mayo clinic series
reported TAO having an incidence of 0.4% as compared to arteriosclerosis
obliterans that accounted for all remaining cases.
Anatomy:
Development
of lower limb vessels.
The primary arterial
trunk or axis artery of the lower limb arises from the dorsal root of the
umbilical artery and courses along the posterior surface of the thigh.
The femoral artery that
develops later passes along the ventral surface of the thigh and opens up a new
channel to the lower limb. It arises
from a capillary plexus; connected proximally with the femoral branches of the
external iliac artery and distally with the axis artery near the popliteal
origin.
At the proximal margin of
popliteus, the axis artery gives off primitive
Posterior Tibial and Peroneal branches that run distally on the dorsal surface
of that muscle and on Tibialis Posterior to enter the
sole of the foot. At the distal border
of Popliteus, the axis artery gives a perforating
branch, which passes between the tibia and the
fibula and then runs downward towards the dorsum of the foot, forming the
Anterior Tibial Artery and the Arteria
Dorsalis Pedis.
The femoral artery
gradually increases in size and coincident with this increase, most of the
artery that is present proximal to its communication
with the femoral artery disappears.
Anatomy of lower limb arteries
Femoral Artery: This is the continuation of external iliac artery. It begins at the mid-inguinal point and runs
downwards. At the junction of the middle
and lower third of the thigh, it passes through an opening in adductor magnus to become the popliteal artery.
Femoral sheath:
It is formed by transversalis fascia in front and the iliac fascia behind
and contains the femoral vessels. It is
funnel shaped. The broad upper end is
directed upwards and the lower narrower end fuses with the adventitia of
vessels about 3-4 cm below the inguinal ligament. The lateral wall is vertical and is pierced
by the femoral branch of the genitofemoral
nerve. The medial wall is oblique and is
pierced by long saphenous vein and lymphatics.
It contains three
compartments.
1.
Lateral – contains femoral
artery.
2.
Middle – contains femoral vein.
3.
Medial – this has the femoral
canal that contains a lymph node and fat.
Surface Anatomy:
The femoral artery corresponds
to the upper 2/3rd of a line that joins a point in the fold of the
groin present midway between anterior superior illiac
spine and pubic symphysis to the adductor tubercle, when the thigh is flexed,
abducted and rotated laterally.
Branches of femoral artery:
i)
Superficial Inferior epigastric
artery;
ii)
Superficial circumflex Iliac artery;
iii)
Superficial external pudendal artery;
iv)
The deep external pudendal artery;
v)
Muscular branches to sartorius, vastus medialis and adductor muscles and
vi)
Profunda femoris artery.
Profunda Femoris artery:
It arises from the
lateral side of the femoral artery about 3.5cm below the inguinal
ligament. At first it is lateral to the descending femoral vein. Later it passes between the pectineus and the adductor longus
and then lies between the latter and the anterior surface of adductor brevis.
Variations of profunda femoris
artery:
a)
It sometimes arises from the
medial side of femoral artery and courses in front of femoral vein and passes
backwards around its medial side.
b)
It may arise from posterior side
of the femoral artery.
c)
Its point of origin may vary between 2.5 to 5cm below the inguinal ligament.
Branches:
a)
The lateral circumflex femoral
artery.
b)
The medial circumflex artery.
c)
The perforating arteries are 3 in
number.
The Anastomosis at the back of Thigh:
An important chain of
anastomosis stretches from the gluteal region to
popliteal fossa and is formed from above downwards as follows.
a)
The circumflex femoral artery and
lateral circumflex artery.
b)
The gluteal
arteries anastomose with the terminal branches of the medial circumflex femoral
and lateral circumflex artery.
c)
The perforating arteries
anastomose with each other.
d)
The fourth perforating artery
anastomoses with the superior muscular branches of the popliteal artery.
e)
The descending genicular artery branches.
Collateral Circulation:
If the femoral artery is
blocked above the origin of profunda femoris artery, the main channels of collateral circulation
are formed by the following anastomoses.
a)
The superior and inferior gluteal branches of the internal iliac artery with the
medial and lateral circumflex femoral and the first perforating branch of the arteria profunda femoris.
b)
The obdurator
branch of the internal iliac artery with the medial circumflex femoral of the profunda femoris artery.
c)
The internal pudendal
branch of the iliac artery with the superficial and the deep external pudendal branches of the femoral artery.
d)
The deep circumflex branches of
the external iliac artery with the lateral circumflex femoral branch of the arteria profunda femoris.
Popliteal artery:
The popliteal artery is
the continuation of the femoral artery and courses through the popliteal
fossa. It commences at the opening in
the adductor magnus at the junction of the middle and
lower 1/3rd of the thigh and courses downward and slightly laterally
up to the intercondylar fossa of the femur.
It then runs vertically
downwards to the lower border of popliteus where it
divides into anterior and posterior tibial arteries.
Surface Anatomy:
A line that begins at the
junction of the middle and lower 1/3rd of the thigh can represent the popliteal
artery. 2.5cm medial
to the midline of the limb at the level of the knee joint. If then descends vertical to the level of the
tibial tubercle.
The Anastomoses Around The Knee-Joint:
Around and above the
patella and on the contiguous ends of the femur and tibia, an intricate
arterial anastomosis is present and forms superficial and deep networks.
The superficial network:
It is situated between
the fascia and skin over the patella and forms 3 well defined arches; one,
above the patella in the loose connective tissue over the quadriceps femoris and the second, below the patella in the fat behind
the ligamentum patellae.
It lies on the lower end
of the femur and upper end of the tibia around their articular
surfaces and sends numerous offshoots in to the interior of the joint. The vessels forming the anastomosis are the
medial and lateral circumflex, the descending branch of the lateral circumflex
femoral, the circumflex fibular and the anterior tibial recurrent arteries.
The Anterior Tibial Artery:
The anterior tibial
artery is one of the two terminal branches of the popliteal artery and arises
at the lower border of the popliteus. Situated at first on the back of the knee, it
passes forwards between two heads of the tibialis
posterior through a gap in the interosseous membrane
and comes medial to the neck of the fibula.
If next descends on the anterior surface of the interosseous
membrane and gradually approaches the tibia.
In the lower part of the leg it lies on the bone.
It lies midway between
the 2 malleoli on the front of the ankle joint and continues on to the dorsum
of the foot as the Dorsalis pedis artery.
Variations:
1.
This vessel may be smaller than
usual or may be absent when the perforating branches of the posterior tibial or
the perforating branches of the peroneal
artery supplies the foot.
2.
The artery occasionally deviates
to the fibular side of the leg but regains its usual position at the front of
the ankle.
Branches:
1.
The posterior tibial recurrent
artery.
2.
The anterior tibial recurrent
artery.
3.
The muscular branches.
4.
The anterior medial malleolar artery.
5.
The anterior lateral malleolar artery.
The arteries around the ankle joint anastomose freely
with one another and form networks below the corresponding malleoli. The anterior medial maleolar branch of the
anterior tibial artery forms the medial malleolar network, along with the medial
tarsal branches of the dorsalis pedis
artery and the malleolar and calcaneal
branches of the posterior tibial artery and branches from the medial plantar
artery. The lateral malleolar
network formed by the antero-lateral malleolar branch of the anterior tibial artery the lateral
dorsal branch of the dorsalis pedis
artery, the perforating and the calcaneal branches of
the peroneal artery and twigs from the lateral
plantar artery.
The Arteria Dorsalis Pedis:
The Arteria
Dorsalis Pedis, the continuation of the Anterior
Tibial Artery. It passes distally from
the ankle joint along the tibial side of the dorsum of foot to the proximal
part of the first intermetatarsal space. From there it descends into the sole of the
foot between the two heads of the first dorsal interosseous
muscle and completes the plantar arch.
At its junction with this artery, it gives off the first plantar
metatarsal artery.
The Posterior Tibial Artery:
The posterior tibial
artery begins at the lower border of the popliteus
opposite the interval between the tibia and fibula and passes downwards and
medially on to the back of the leg. In
the lower part of its course, it is situated midway between the medial malleolus and the medial process of the tubercalcaneii
(Medial tubercle of the Calcaneus). It divides under the cover of the origin of
the Adductor Hallucis into the medial and lateral
plantar arteries.
Surface Anatomy:
The posterior tibial
artery runs from the middle of the calf at the level of neck of fibula to a
point midway between the medial malleolus and the
prominence of the heel. In the later
situation, its pulsations can be felt.
Branches:
1)
The circumflex fibular artery
2)
The peroneal
artery.
Sympathetic Ganglia in Relation to Lower Limbs:
The lumbar ganglia are
very variable in their site and size.
Usually there are four ganglia present on each side but their
arrangement need not necessarily be identical on both sides. The ganglia are usually fused and the
thickness of the trunk varies greatly.
Inconsistency of position of the first lumbar ganglion is very
frequent. It usually lies by the side of
second and third lumbar vertebrae partly or completely covered by the crus of
the diaphragm and occasionally lie either above or below it. Its recognition is essential for its ablation
and will relieve the vasoconstrictor influence over the lower extremity as far
down as the level of knee joint.
The lumbar ganglia lie on
the anterolateral aspect of vertebral column behind
the peritoneum and along the medial border of psoas muscle. The lumbar veins and arteries are present behind
them although occasionally one of them may be found crossing in front. The right trunk is partly covered by the
inferior venacava and the left trunk is lateral to the abdominal aorta.
Control of Peripheral Circulation:
I.
Nervous control of limb blood vessels:
The nervous control is constituted by the existence of
vasoconstrictor and vasodilator fibres.
It is generally agreed that the skin of the fingers,
toes, hands and feet is supplied with vasoconstrictor fibres. The rate of flow of blood is governed by the
tone of arterioles.
Unlike in the hand, vasodilator fibres supply the
forearm. The central nervous system
vasomotor fibres via sympathetic fibres that send impulses through mixed nerves
to arteries arterioles arteriovenous anastomoses control the vessels of the
limb.
II.
Metabolic control:
The products of local metabolism have a direct influence
on the vessels in their vicinity and produce appropriate alterations in the calibre of vessels.
This is best exemplified by ligation of a main
vessel, which causes an accumulation of metabolites in the tissues distal to
the ligation resulting in dilatation of collateral
vessels.
Similar adjustments of local circulation are produced in
response to injury, which causes the release of Histamine.
III.
Control by Temperature:
Arteries capillaries and veins react to an increase in
temperature by dilatation and contract when cooled. The metabolic needs of tissues are reduced
when they are cooled and hence, in the cold season there is lesser energy
expenditure. The vessels of the skin
shrink to conserve body heat. The
reverse is the case in summer.
Phenomenon of Vasoconstriction:
The vasomotor nerves to
the vessels of the body are sympathetic and exert a tonic action. They maintain the tonic action over arteries,
arterioles and capillaries, arteriovenous anastomoses and veins. The tone is abolished by cutting these
fibres.
A)
Vasoconstriction of central
nervous system origin:
This is seen normally in response to apprehension,
emotion, anger, fear, etc. As a reflex
it may be produced by cold or by painful stimulation to the skin. This effect is supplemented by the release of
adrenaline from the suprarenals that produces generalized vasoconstriction of
skin and splanchnic vessels.
B)
Local vasoconstriction due to
trauma:
This may be seen when the bullet fragment of a shell
passes close to an artery or when fracture of a bone adjacent to an artery
occurs. There occurs an abrupt
contraction of a segment of the artery, which may be complete
or partial, lasting hours or days. It is
said that this spasm is due to a reflex effect of the sympathetic nerves
initiated by trauma.
The narrowing of an artery that occurs due to structural
changes is generally permanent, whereas, the narrowing that occurs due to
arterial spasm is transitory.
Phenomenon of Vasodilatation:
Vasodilatation causes an
increase in the size of arteries and arterioles.
a)
Generalized Vasodilatation: This
is of central nervous system origin.
Vasodilatation is produced when warm blood goes to the hypothalamic
region in fever and thyrotoxicosis. The vasodilatation is due to the effect of
raised blood temperature on hypothalamic centres.
Types of Classification of Occlusive Arterial Disease
I.
Degenerative Arteriopathies:
a)
Atherosclerosis
b)
Medial Arteriosclerosis
Sclerosis, (Monckeberg sclerosis)
c)
Cystic Medial Necrosis, Marfans
syndrome
d)
Cystic Adventitial degeneration,
Unilocular or Multilocular cysts in the arterial wall
e)
Fibromuscular dysplasia
It is common in renal arteries and causes hypertension.
II.
Occlusive Disease of diverse
origin:
i)
Thrombo angiitis
obliterans
ii)
Vasculitis
Polyarteritis
Systemic lupus erythematosus
Erythema nodosum
Systemic giant cell arteries
Nodular Vasculitis
Idiopathic medial arteriopathy
(Takayasus disease)
iii)
Infection
a)
Leprosy
b)
Tuberculosis
c)
Syphilis
d)
Septicemia
e)
Mycotic
III.
Raynauds phenomena and allied vasospastic disease:
1.
Raynauds disease is without any associated or contributory condition or disease.
2.
Raynauds phenomenon is associated with some underlying condition or disease.
Example:
a) After trauma
1.
Related to occupation
a)
Pneumatic hammer disease
b)
Occupational occlusive arterial
disease of hand
c)
Occupational Acro-osteolysis
d)
Vasospastic phenomenon of typists
and pianists
2.
Following injury or operation.
b) In Neurogenic
lesions
(a)
Shoulder girdle compression
syndrome
(b)
Carpal tunnel syndrome
(c)
Other diseases of nervous system
c) In occlusive arterial disease
(a)
Atherosclerosis
(b)
TAO
(c)
Embolism
(d)
Thrombosis
d) In Intoxication with heavy metals and in ergot poisoning.
e) Miscellaneous diseases and conditions
(a) Scleroderma
(b) Rheumatoid Arthritis
(c) Dermatomyositis
(d) Cryoglobulinemia
(e) Myxoedema
IV.
Occlusive vascular diseases
related to environmental temperature
1.
Pernio syndrome
Acute chilblains
Chronic chilblains
Trench foot and immersion foot
2.
Frost bite
3.
Eythromelagia
V.
Trauma
1.
Mechanical trauma
-
Complete severance
-
Laceration
-
Traumatic vascular spasm
-
Local thrombosis
-
Secondary hemorrhage
-
Delayed traumatic Aneurysm or A.V.
fistula
2.
Iatrogenic e.g., after
arteriogram
3.
Non mechanical arterial injuries
-
Thermal burns
-
U.V. light, short wave diathermy
and ultrasound
-
Electric shock
-
Irradiation
4.
Neurovascular compressor
syndromes of thoracic outlet
Histology of Blood Vessels
Arteries:
There are three layers: Intima, Media and Adventitia, which constitute the wall of
an artery. They have different function
in health and are subject to different diseases.
The tunica intima is relatively acellular
and is lined by a delicate endothelium.
It is separated from tunica media by the internal elastic lamina. The function of the intima
is to provide a non-wettable lining. Damage to the intima
invites the deposition of platelets, which acts as the starting point for
thrombosis.
The tunica media provides
strength for the arterial wall. It is
composed of smooth muscle in smaller arteries and arterioles, where as in
larger vessels, elastic tissue is also present.
The Tunica Adventitia
consists of areolar tissue and serves to carry the vasavasorum and a plexus of nerves, which are destined for
the media.
Capillaries:
Its wall consists of a single
layer of flattened endothelial cells.
Veins:
Veins are wider than arteries.
Valves are present in the veins of the limbs.
It also has three layers.
Pathology and Pathogenesis
Atherosclerosis:
Gross
appearance.
Arteries are frequently
enlarged and are irregular tortuous, firm, inelastic
(brittle) and cord like sections of such arteries reveal irregular thinning of
the medial coat, extensive irregular atheromas that project into the lumen and
occlusion of the lumen by thrombi. The
first distinguishing gross lesion of the intima is
the fibrous plaque. The lesions are
raised thickened and yellowish white in colour. Fatty streaks on the intimal surface of medium size and other larger arteries
are thought to be the precursors of fibrous plaques although not all such fatty
streaks necessarily become fibrous plaques.
The third stage of the
lesion of Atherosclerosis is the complicated lesion that causes occlusion of
lumen. In some instances, there is a
large projecting plaque that may contain a recent hemorrhage. But most occluding lesions consist of an Atheromatous plaque plus a fresh or organized
thrombus. In some advanced lesions
softening and ulceration of the Atherosclerotic arterial wall may lead to
Aneurysm formation.
Microscopic features:
1.
Thickening of Intima
2.
Fibroblastic proliferation subintimally
3.
Phagocytes may be seen containing
fairly large aggregates of lipid material the so-called “foam cells”.
Advanced Stage:
The more advanced
Atherosclerotic plaque shows the following.
1.
An endothelial layer covers the
plaque itself.
2.
Beneath this there is fibrous
tissue with fibroblasts and inflammatory cells.
3.
Rather large amounts of sudanoplilic material are found both extracellularly
and within the lipophages or form cells in the deep
portion of plaque.
4.
The plaque may show evidence of revascularisation and may contain blood pigment or small
hemorrhages.
5.
Calcium deposition.
6.
Internal elastic lamina is
usually frayed irregularly thickened and fragmented.
7.
Media may show degeneration and
fragmentation of the elastic and muscle fibres and may also show fibrosis and
calcium deposition. Rarely ossification
of media may also be seen.
Pathogenesis:
Accumulation of lipid
material in the subintimal layer occurs.
From here it is taken up by smooth muscle cells which later breakdown,
liberating lipid material. This incites
the reaction that characterises the atheroma. Collagen
proliferation and destruction of the smooth muscle and elastic tissue of the
media occurs shedding of the intrima and thrombus
formation over the intimal irregularity also
occurs.
The development of the
final ischaemic manifestation of Atherosclerosis occurs through the following
four stages.
1.
Fatty streaks
2.
Fibrous plaques
3.
Partial or complete occlusion of
the artery by thrombus or less commonly by hemorrhage into the plaque
4.
Ischaemic changes in the tissue
supplied by the artery.
Etiology:
1.
Role of highly saturated fats and
cholesterol
The above have been proven to be key factors for
assessing risk of premature Atherosclerosis.
2.
Hypertension
3.
Diabetes mellitus
4.
Cigarette smoking
The association between smoking and lower extremity arterial disease may infact, be even stronger than between smoking and coronary heart disease.
5.
Physical exercise – Lack of
physical exercise predisposes to Atherosclerosis
6.
Genetic factors.
Pathology and pathogenesis of Thrombo Angiitis Obliterans
T.A.O. produce
a characteristic pathological picture that has been described by Buerger, McKusick. This
picture is quite distinct from that of other vascular lesions such as
Atherosclerosis Obliterans. Simple arterial thrombosis, Polyarteritis nodosa and
secondary type of thrombophlebitis.
TAO is primarily a
disease of the blood vessels of the extremities. It involves the lower limbs more commonly and
more severely than the upper extremities.
Typical lesions in the extremities are rare and usually develop only
when the disease has been present in the extremities for some time.
Mostly it is a disease of
medium and small sized arteries, commonly involved are posterior tibial,
anterior tibial, radial, ulnar, plantar, palmar and digital arteries. Larger vessels like femoral popliteals brachial are affected late and only when the
disease is severe and progressive unlike arteriosclerosis. TAO also affects periarterial structures like veins and nerves. Small and medium size veins are chiefly
affected.
The T.A.O lesions are
distinctly segmental, normal segments of the vessels are situated between
diseased segments of vessels. The line
of demarcation between them is fairly distinct.
The lesions are episodic
and the lesions throughout a singly affected segment seem to be essentially of
the same age.
Local accumulation of
lipid and deposits of calcium are not found in the lesions at any stage of the
disease.
The disease produces
organic occlusion of vessel. The
occlusion is permanent and usually complete, which is followed by development
and enlargement of collaterals and anastomotic vessels.
The secondary anatomical
effects of disease are the results of ischaemia and malnutrition of tissues
complicated by congestion in some cases, trauma and infection.
The severity of disease
is directly proportionate to the rapidly and extent of arterial occlusion and
is inversely proportional to the rapidity and extent to which the collateral
arterial circulation can develop.
Macroscopic:
The vessels affected
appear to be constricted both at the site of occlusion and in neighborhood
segments where occlusion does not exist.
The occluded segments are definitely indurated
but not brittle. In the early lesions,
the occluding mass within the vessel may be red or brown. In older lesions the occluding mass appears
yellowish. The arteries are more
frequently obliterated than their accompanying veins. Sometimes occlusions occur at two different
levels in the same vessels and between the sites of occlusion the lumen is
entirely patent.
Histological Changes:
The lesions are an
inflammatory non-supportive, pan-arteritis,
pan-phlebitis with thrombosis but without necrosis of the wall of the vessel.
Acute Changes:
Thickening of intimae due
to proliferation of the intimal cells with occasional
small collections of lymphocytes in isolated portions of intima
where cellular proliferation is most marked.
The internal elastic
lamina is intact, wary or slightly thickened or occasionally split. But in Atherosclerosis it is stretched out,
distorted and deficient in parts (Kinmonth). The media has a few cellular infiltrations
and is intact. The muscle fibres are well preserved
The adventitia contains
many fibroblasts, and endothelium of the vasa vasorum
will have proliferation.
The lumen is occluded by
a thrombus that is extensively organised and contains
numerous endothelial cells and fibroblasts.
The thrombus of recent onset is cellular and may contain round cells
with occasional giant cells of the foreign body type.
The leucocytes in acute
lesions are few or sometimes not found at all, even though acute inflammatory
cells infiltrate the vessel wall, no micro abscesses are detected.
Chronic Changes:
Picture is same as in the
acute lesion except that the thrombus is less cellular more fibrotic and
organized by minute canalizations. As
the perivascular fibrosis prevents dilatation of channels, the new channels
invariably fail to maintain the nutrition of the part affected.
Secondary Pathological Changes:
Occurs
in skin, muscles, bone, nerves, soft tissues, etc. These are the result of primarily ischaemia
of the tissues of the limbs.
Contributing factors may be capillary and venous congestion, tissue
atrophy, minor or major mechanical, chemical and thermal injuries to ischaemic
tissues and secondary infection.
Clinical classification of TAO
Allen-Barker-Hynes’ have classified the disease into 8 groups.
1.
Arterial occlusion causing
intermittent claudication as the only symptom.
2.
Intermittent claudication with
cold digits and mild rest pain.
3.
Severe ischaemic neuritis.
4.
Marked colour changes and Raynauds phenomenon.
5.
Minor gangrene with local
infection.
6.
Gangrene of digits.
7.
Severe gangrene spreading on to
foot or hand.
8.
Thrombophlebitis as major or only
complaint.
Richards has published his classification based on the
natural history of the disease. He
grouped the patients into 5 classes.
1.
Acute
2.
Episodic
3.
Slowly progressive
4.
Acute arterial occlusions
5.
Upper limb group.
Boyd (1938) states that clinically it is
possible to classify the disease depending upon the level of arterial
involvement.
He classified it as proximal, distal and mixed groups.
Etiology: The cause is not known.
Age: Common between the ages of 25-40 years.
Sex: Formerly considered to be exclusively a disease of male. Recent reports show that there is an increase
in the incidence of the disease in female, consistent with the increase in
their smoking habits.
Race: T.A.O is known to be present throughout the world and no race or
colour is known to be immune.
Heredity: No hereditary basis is established.
Occupation: Has no relation. But is believed to be more common in farmers from low socioeconomic
group.
Climate: Geographic location and climate are questionable factors. However cold has a deleterious effect on
patients suffering from T.A.O by causing vasoconstriction superimposed on
arterial occlusion.
Tobacco: The great majority suffering from T.A.O are heavy smokers.
If the patient with T.A.O
continues to smoke, the disease has a tendency to progress inspite
of treatment. But if the patient
discontinues smoking the disease tends to run a favourable course and
exacerbations and new vascular occlusions are rare.
Nicotine is said to be
the cause of spasm of blood vessels decreased oxygenation of blood, increase
production of new platelets, increase coagulability of blood and increased free
fatty acids.
Changes in Blood:
The evidence that changes
that favour hypercoagulability occurs in the blood of patients who have T.A.O
is inconclusive.
Clinical Features:
1.
Intermittent Pain
2.
Colour Changes
3.
Skin Temperature
4.
Absence of Arterial Pulsation
5.
Nutritional Changes
6.
Swelling and Oedema
7.
Miscellaneous Observations.
Pain:
1.
Intermittent Pain:
This type of pain is dependent on
i)
Temperature
ii)
Exercise and
iii)
Posture
i)
Intermittent pain dependent of
temperature:
The onset of such pain depends upon exposure to either
cold or warmth.
The best example of the former is Raynauds
disease. Raynauds
phenomenon may also appear as a secondary manifestation of Thromboangiitis
Obliterants (T.A.O) due to exposure to cold. This pain is rarely severe.
ii)
Intermittent Pain Dependent on
Exercise:
This type of pain is otherwise known as intermittent
claudication. The term stems from the
Latin verb Claudicare, meaning to limp. The French Veterinary Surgeon Bouley first
described it in 1981 as a cause of recurrent limping in horses. It was found to be associated with
obliteration of the main artery of leg.
Intermittent claudication in man is an indication of obstruction to the
free flow of blood to the tissues of the affected limb. It may be due to Atherosclerosis, Diabetes,
and TAO of the main artery of the limb. Arterio venous fistula, aneurysm or thrombosis of the main
arterial trunk may also cause this. Intermittent claudication is a symptom and
not a disease. It only indicates that
the muscles in active exercise are not receiving enough blood. Its onset is thus experienced in those groups
of muscles that are actively engaged in exercise e.g. small muscle of foot,
muscles of calf and muscles of thigh.
The amount of exercise necessary to produce pain remains remarkably
constant. To begin with it is usually
after a very long walk, may be after a mile.
But as the disease progresses and with it the degree of vascular
occlusion, the distance of claudication becomes gradually reduced.
It is important to note that intermittent claudication is
brought on only by exercise and never as a result of standing and sitting. It is always an accompaniment of obliterative disease of a major artery in the involved
limb. It ceases promptly with
discontinuation of exercise.
The pain becomes very severe and reaches the zenith of
intolerance as the patient continues to walk and compels him to stop. It is described as a “CRAMP”. It starts as a vague pain of fatigue and
progresses to a sharp and shooting pain down to the muscles of calf and
foot. Many patients complain of pain
with exercise in one limb only, but careful study will reveal that both limbs
are affected. This is due to the pain in
the severely affected limb, preventing the patient from walking sufficiently
far enough, to produce the limp in the better limb.
The site of claudication is a rough measure of the level
of vascular occlusion. It is more
commonly observed in the calf and small muscles of the foot than in the thigh
because in the later part there is a generous collateral circulation to
compensate for the partial occlusion of the main vessel. No region of the extremity (both upper and
lower) is exempt. Claudication is only a
reflection of insufficient blood supply to a part and this may be experienced
in advanced stages. Even abdominal
intermittent claudication is described.
In normal individuals, exercise produces vasodilatation
due to production of tissue metabolites and spasm is unusual. In patients with vasospastic claudication,
the pulsations which are present before exercise maybe lost after exercise,
presumably because of spasm. But a
careful study will reveal arterial disease too.
Many workers have confirmed the diminution of pulsations in
arteriosclerotic subjects after exercise.
The explanation given by Boyd et al (1949) is that, after exercise, the arterio-capillary bed in the muscle widens and the systolic
stroke volume is distributed in a greater bed than before.
Mechanism of
Claudication: The studies of Lewis
(1936) stand foremost in explaining the cause of pain. He observed that claudication was not due to
arterial spasm, but was the result of accumulation of excessive ‘P’ substance
due to inadequate blood flow.
iii)
Intermittent Pain Dependent on
Posture:
Chronic venous congestion due to long standing varicose
veins or due to venous thrombosis produces a constant dull ache in the lower
extremities. It subsides on taking rest
in a recumbent position or on elevation of the limbs. This pain has no relation to exercise.
iv)
Nocturnal cramp:
It is a sudden acute muscle cramp occurring whilst the
patient is in bed or at rest and is the result of an exaggerated involuntary
tonic contraction of a muscle or a group of muscles. It is more frequent in the abductor group of
muscles of the great toe and in the muscles of the calf. It has been proved to occur in myopathies and in normal muscles as a result of fatigue and
exposure to cold. It should not be
confused with Intermittent Claudication.
This nocturnal cramp occurs at rest and is relieved by exercise where as
the Intermittent Claudication essentially occurs during exercise and subsides
with rest. Nocturnal cramps may be
present in individuals with vascular insufficiency.
A.
Persistent Pain:
a)
Persistent pain of ischaemia and
gangrene: It is extremely severe.
Partial relief is obtained by dependency and application of heat. But elevation and cold increase the severity.
b)
Pain of sudden arterial
occlusion: It is characterized by a sudden or delayed shooting pain in the
direction of the main trunk. The limb
distal to the obstruction becomes useless and numb. The cause was thought in the past to be due
to occlusion by an embolus. But the
present concept is that it is due to ischaemia produced by spasm.
c)
Pain of Arthritis, Phlebitis and
Lymphangitis: Acute Inflammation of arteries causes pain. The patient, as in T.A.O, notices this unless
thrombosis sets in. The pain is of full
and diffuse in nature along the course of vessels. Phlebitis has a similar pain.
2.
Colour Changes:
Lewis classic monograph (1936) concludes that skin colour
is a good index of the adequacy of peripheral blood flow when the normal
responses to environmental conditions are known.
The colour of skin attributable to circulation depends on
two factors (i) Amount of blood (ii) Colour of blood. The depth of the colour of skin depends upon
the amount of blood contained with in the capillaries of the skin. This may be decreased when the limb is
elevated and increased when the limb is lowered by passive filling of minute
vessels.
When the circulation of skin is slow there is a cyanotic
tinge to skin. A violet tinge is a sign
of complete arrest of flow. The colour
of skin also depends on the temperature.
When the body temperature is raised, the tissue takes up more oxygen and
if the flow of blood does not increase correspondingly the onset of cyanosis is
hastened. Colour changes may be
intermittent or constant. The former may
be affected by
(i)
Posture and
(ii)
Temperature.
A.
Effect of Posture:
Abnormal response of skin colour to change of posture is
an important feature of the occlusive arterial disease. Normally when the limb is elevated, there is
only a minimal change of colour that is not marked and quickly disappears on
assuming normal posture. In a diseased
limb, the degree of pallor that occurs on elevation of limb is a rough
indicator of the adequacy of circulation.
This pallor can be uniform or patchy.
On bringing the limb down, colour returns to
normal in less than ten seconds. But in
a diseased limb this time may be forty-five to sixty seconds or more.
B.
Effect of Temperature:
This is seen in Raynauds
phenomenon where in on immersion of the limb in cold water, a series of changes
are seen ranging from cyanosis to pallor and rubor.
Progressive and persistent cyanosis often heralds the onset
of actual gangrene. It may also be noted
in chronic venous congestion. The
so-called “Stay Pigmentation”. It may
also be seen in Acrocyanosis.
3.
Skin Temperature:
The skin temperature of resting limb is dependent upon
the balance between the amount of heat brought to it by the blood and the
amount of heat lost to its surroundings, when the blood flow to a limb is
reduced the amount of heat brought to it is reduced. Hence the part becomes cool. Environmental factors also influence the skin
temperature, but when both limbs are examined under identical conditions, the
colder one may be justly assumed to have impaired flow. Whether it is due to organized changes in the
vessels or due to vasospastic factors can only be determined by a repeat
examination after release of vasomotor control.
Clinically temperature differences are best made out by
the dorsal aspect of the middle phalanx of fingers, which can distinguish
temperature differences as small as one degree centigrade. Recording skin temperature only once is
valueless. It has to be repeated
frequently under identical basal conditions.
4.
Absence of Arterial Pulsations:
All arteries are felt against a bone. If constitutes an important part of
examination. While searching for
pulsations, the volume and amplitude of pulsations are recorded and compared
with the other limb. The vessels are
examined in the following order.
Femoral artery: It is palpated in the groin just below the inguinal
ligament keeping the leg in the extended positions midway between anterior
superior iliac spine and symphysis pubis.
Popliteal artery: Its pulsations may be difficult to feel in the obese
person. It is palpated in either of two
positions.
1.
While examining the patient in
the face down position, the leg is flexed at the knee and the popliteal artery
is palpated in the upper part of the popliteal fossa.
2.
It is described to palpate the
vessel with the patient lying on his back and the leg is flexed at knee and
then the artery is palpated with both the index fingers in the lower part of
the popliteal fossa.
Dorsalis Pedis Artery:
It is palpated with the
patient in the recumbent position. The
heel is supported by the hard and with the other hand. The artery is palpated in the middle of the
dorsum of the foot just lateral to the tendon of extensor hallucis
longus, just proximal to the first inter metatarsal
space.
Posterior Tibial artery:
It is palpated on the
medial aspect of the ankle, mid way between the medial malleolus
and tendoachillis.
Its variations should be kept-in mind.
Peroneal artery:
It is sometimes palpable
in front of the ankle joint toward the lateral malleolus.
Radial artery:
It is examined at wrist
the lower end of the Radius, between the tendon of Flexor Carpi
Radialis and Branchioradialis.
Ulnar artery:
Felt at the wrist, on the
medial aspect.
Brachial artery:
It is palpated in the
middle of the arm by applying gentle pressure against the medial aspect of the humerus.
Digital arteries:
These are difficult to
palpate. The best method is to hold each
finger at its base between the index finger and the thumb in such a manner so
as to feel the pulsations.
Abdominal aorta, temporal
and carotid arteries may be examined to exclude any generised
involvement of arterial trunk.
5.
Nutritional changes:
Atrophy: In chronic arterial insufficiency, muscles, subcutaneous
tissue, skin and skin appendages show the affect of long standing impairment of
blood supply. These are most noticeable
in the distal parts of the limb. Thus
diminution in the amount of and complete loss of hair on dorsum of toes is a
good index of the severely and duration of ischaemia. Presence of hair even when there is an
occlusion is an evidence of good collateral circulation. The shape form and rate of growth of nails
may also be affected.
The skin becomes glossy,
parchment like and the digital pulp atrophies.
Muscle washing can be detected by measurements. Atrophy of several inches of calf muscles is
not infrequent, though part of it is due to disuse.
Chronic sepsis: Impaired circulation undermines the tissue resistance so
that chronic paronychia and whitlow may arise
spontaneously or following careless manicure.
Such affiliations become chronic and recurrent as, impaired circulation
handicaps healing. In such instances,
diabetes and fungal infections should be excluded.
Ulceration: Superficial tissue loss in the legs is a more frequent
accompaniment of chronic venous insufficiency (C.V.I.) than that of chronic
arterial insufficiency. In the arm the
ulceration due to C.V.I. does not occur and spontaneous tissue loss is always
due to arterial disease.
In the legs, varicose
ulcer is an example of C.V.I. Arterial
ulcers following trauma may occur at the site of injury where as, spontaneous
ulcers are mostly found on the anterolateral aspect
of the limb. Such ulcers, especially in Thromboangiitis Obliterans tend
to be deep, indolent and are accompanied by severe rest pain. Hypertension occasionally produces similar
but bilaterally symmetrical ulcers.
Gangrene: Massive death of the tissue is the end phase of severe
ischaemia. It often follows
ulceration. Gangrene does not always
mean an impaired circulation because physical and chemical trauma can also cause
gangrene. In diabetes and T.A.O. the
inflammatory reaction is severe and hence severe rest pain is present.
Gangrene usually begins
in the digits and in arterial obstruction of the lower limbs, usually on the
undersurface of the fifth or first toe.
But if it is precipitated by trauma it arises at the site of trauma.
6.
Swelling and Oedema:
Swelling of the extremities of peripheral vascular origin
is due to one of three causes (i) Obstruction to the
flow of lymph (lymph edema) (ii) Obstruction to flow of venous blood due to
C.V.I. (iii) Diffusion of fluid from the small vessels into the surrounding
tissues due to prolonged dependency.
7.
Miscellaneous Observations:
Anaesthesia: It may develop rapidly after an episode of acute arterial occlusion such as embolism. This anaesthesia is of glove and stocking nature and is present distal to the site of occlusion.
Hyperaesthesia:
It may complicate
ischaemic neuropathy in T.A.O.
Buergers angle of circulating insufficiency:
This has been recommended
to estimate the state of circulation in a limb.
A normal limb retains its
colour even when held at ninety degrees to the horizontal unlike an ischaemic
limb that develops pallor after elevation to an angle less than ninety
degrees. This angle is called Buergers angle.
Investigations
The main object of
investigations is to establish absolute diagnosis and secondly to determined
the need for therapy and type of therapy suitable for a patient.
Most of the conditions of
vascular disease can be diagnosed on the basis of general history, clinical
examination and few simple tests. But
more elaborate investigations are necessary to determine the accurate level of
obstructive pathology when surgical intervention is contemplated.
The general physical
examination includes a complete evaluation of the vascular state of the
patient, colour and warmth of skin and state of skin appendages.
The detailed recording of
peripheral pulses is very essential. A
routine auscultation of arteries along their course for bruit is essential to
note any stenotic lesions.
Routine investigations
like urine for sugar and albumin, serum cholesterol; X-ray and ECG for cardiac size and
coronary state, serological studies for evidence of syphilis are done.
Tests of vasomotor tone:
These tests give us
information about the degree of vasospasm due to sympathetic over activity.
Peripheral Nerve Block:
Various nerve blocks
including posterior tibial block, lumbar paravertebral block and epidural and spinal anaesthesia are
found to be helpful in assessing the degree of vasospasm.
In lower limbs the
lateral popliteal nerve at the head of fibula or posterior tibial nerve behind
the medial malleolus can be blocked with 1% Xylocaine, for upper limb ulnar
nerve at elbow can be blocked.likewise median nerve
at wrist can be blocked. Any rise in
skin and oral comparative are recorded.
Rise of skin temp –
Rise of oral temp
Brown’s
Vasomotor Index =
Rise of
oral temperature
Operation is not advised
unless the index is 3.5 or more.
Skin Temperature Study:
It is best done by an
electrically devised thermocouple in a thermostatically controlled room. Normally there is a very slight difference in
skin temperatures between symmetrical points over the body. A prompt rise of skin temperature due to the
above procedures indicates predominant vasospasm and predicts a good response
to sympathetic denervation. The more delayed and smaller the increase in
skin temperature, more likely that it is due to organic disease and so, less
satisfactory is the response to sympathectomy.
Finally, skin temperature recordings give only an account of cutaneous
circulation. Nevertheless even with the
above limitation, this method remains a simple and reasonably reliable index of
the rate of blood flow in the part being studied.
The calculation of
Brown’s vasomotor index is seldom used now and is of little practical or
prognostic value.
Plain Radiography of the Limbs:
In healthy people
arteries are not visible in a plain x-ray.
When the arterial wall is pathological and calcified, that part of the
vessel wall will cast a shadow that is apparent radiologically.
This calcification may be
due to Arterosclerosis or Monckeberg’s
Sclerosis in the former, it is irregular in distribution and is localized to a
few selected sites such as the middle and lower thirds of femoral artery,
popliteal artery just above the bifurcation of posterior tibial arteries. In Monekeberg’s
sclerosis, the calcification is uniform and tubular in appearance. In Thromboangiitis Obliterans no calcification is seen either in arteries or
in veins.
The Doppler Ultrasonic Flow Detector:
It is the most ubiquitous
instrument in vascular diagnosis. This
instrument detects the frequently shift of ultrasound from moving particles in
the blood and processes them in a variety of ways ranging from an audible sound
to a colour flow map, as a component of a Duplex scanner. This technique offers the advantage of
simplicity. Its major disadvantage is
that it does not detect disease in the absence of haemodynamic alterations.
Colour Doppler:
It is a very useful
noninvasive test. This instrument is a
modified Duplex scanner that overcomes the technical difficulty of the
test. This provides a colour image in
which the velocity and direction of blood flow is keyed to the colour of the
image at all points within the vessel.
Duplex scanner combines
pulsed Doppler measurements with a B-mode ultrasound image. In addition to providing an image of vascular
lesion and the anatomic profile of the arteries, it also allows for estimation
of blood flow by providing data of velocity of blood flow.
Colour Doppler Parameter:
1.
Critical stenosis:
It refers to the degree of arterial narrowing that is
required to produce a significant reduction in distal pressure or flow. There is an exponential relationship between
pressure drop and lumen size.
Large and Medium sized arteries: Critical stenosis values
= 50% diameter reduction and 75% area reduction.
Once stenosis has occurred,
intermittent claudication occurs.
2.
Peak flow velocity:
It is the maximum velocity encountered within the lumen
of the vessel under consideration.
3.
Vortex flow:
It is a localised, slowly
swirling or stagnant blood flow and is often described as a ‘Flow Eddy’. Vortex flow occurs distal to areas of
arterial stenosis and at sites of bifurcations.
A vortex is created when blood accelerates through a vascular stenosis
and decelerates rapidly.
4.
Indices of Colour Doppler:
A – Pulsatality Index P.I =
A-B/Mean
B – Resistive Index R.I = A-B/A
C – Acceleration Index A.I = Vmax
– Vmin/t / Vmax.
A = Maximal Doppler shift frequency (Velocity) in one
cardiac cycle.
B = Minimum Doppler shift frequency (Velocity) in one
cardiac cycle.
Mean = The time average of
Maximum Doppler shift frequency (Velocity) of the cardiac cycle.
5.
Grading of Arterial Disease in
Lower limbs – Duplex criteria (Eugene Strandness):
I.
II.
1-19% stenosis: Wall
irregularities present. Normal waveforms
with spectral broadening but no increase in peak systolic velocity.
III.
20-40% stenosis: These lesions
are not associated with a pressure gradient at rest. Increase in peak systolic velocity of more
than 30% but less than 100% is oberved. Reverse flow component.
IV.
50-99% stenosis: There is greater
than 100% increase in peak systolic velocity within the narrowed area. Loss of reverse flows and marked spectral
broadening.
V.
100% stenosis: No flow in
artery. Total occlusion.Monophasic
pre-occlusive thump is heard proximal to occlusion.
Indications:
1.
Postoperative assessment of graft
patency.
2.
Routine baseline scans for follow
up studies.
3.
A decrease in ankle-brachial
indices.
4.
Presence of a thrill, bruit or pulsatile mass on physical examination.
5.
New claudication or other
vascular symptoms.
6.
A reduction in velocity of
greater than 30 cm per second from a previous Duplex scans.
Arteriography:
Visualization of vessels
by intra-arterial injection of radio-opaque substances affords information that
can be very significant. The state of
the arterial wall, the presence of collateral system of vessels and the smaller
impalpable vessels are easily recognized.
Indications:
1.
To confirm the presence and to
identify the nature of obliterative arterial disease.
2.
To establish the location and
extent of block.
3.
To visualize distal run off.
4.
To assess collaterals.
Contrast Media:
A great variety of
substances were used in the past like Sodium bromide, Sodium Iodothanate
etc. Most of which are abandoned for
fear of ill effects. 35-50% iodine is
the contrast medium of choice.
Before arteriography, the patient is tested for sensitivity to the
media being injected by giving 1ml. of it intravenously. In the absence of any side reactions such as
rise in pulse rate, coughing, discomfort or rash, an intra arterial injection
of 20cc. of the contrast for lower limbs and 15cc. for upper limbs will be
adequate to demonstrate the entire arterial trunk. If the patient is sensitive, a
desensitization course may be given starting from 0.5cc. of
iodine I.V. and increasing to 10cc.within a week, at the end of which an
Arteriography is done.
Closed method of
injection of radio opaque contrast medium is the method of choice, since by
open method a simple procedure is turned into a formal operation. If percutaneous method fails, the open method
may be resorted to. It should be carried
out under general anaesthesia this avoids pain produced by arterial puncture
and prevents movements of the limb that is essential for a good radiograph.
Arteriography of the
lower limb by the femoral artery if palpable, is
carried out below the inguinal ligament.
If the pulse is absent, aortography is necessary.
Direct Technique:
A short beveled needle is
used to pierce the femoral artery. The
flow of blood back into the syringe containing the contrast occurs. With another syringe, 20cc. of the selected
medium is injected rapidly and a series of x-rays are taken. A mechanical device is of great advantage.
Modified Seldinger Tecnique:
Most radiographers use
the percutaneous technique described by Seldinger. A guide wire is advanced under fluoroscopic
control to the appropriate site. A
catheter is advanced over the wire. Then
the wire is withdrawn and the contrast is injected.
Interpretation of Arteriograms:
It needs great care
because any error in the technique or a premature exposure may give an
appearance that may be mistaken for disease.
In reading an arteriogram the following points need close observation.
1.
The anatomical arrangement of the
main vessel.
2.
The presence of any irregularity
in the wall.
3.
The presence of any block in a
major vessel.
4.
The extent of collateral
circulation.
5.
Patency of the vessel distal to the block.
A normal Arteriogram shows smooth vessel walls and the calibre diminishes gradually towards the periphery. In the thigh, superficial femoral and profunda femoris arteries are
clearly retained. Around the knee
descending genicular branches are seen. In the leg anterior and posterior tibial
arteries and peroneal artery are clearly outlined.
Appearance in Thrombo Angiitis Obliterans and Atherosclerosis
In T.A.O it is more
common for the smaller calibre peripheral vessels to
be affected first hence it is not uncommon for the femorals
to be relatively normal. The limit of
thrombosis is nearly clear-cut and regular.
Rarely is the main trunk patent distal to thrombus. It is not uncommon to find extensive multiple
blocks affecting all major vessels extending up to the knee or even above
it. Proximal to the block, the vessel is
smooth and is in no way irregular or tortuous.
The arteriographic
differentiation of TAO from degenerative arterial disease can be made out in
most instances.
Collaterals in T.A.O are
numerous but are very small and provide a less adequate circulation than those
in degenerative arterial disease where they are not so numerous but are of good
calibre. In
degenerative arterial disease besides the irregular moth eaten appearance of
the main trunk, the main vessels are often patent distal to the block. In some cases, however the differentiation
may be impossible.
Segmental Pressure Gradients:
In a normal person, the
ankle pressure when measured in supine position is equal or higher than the
brachial (arm) systolic blood pressure.
Ankle B.P
Pressure
Index = =
One
Brachial B.P
Normally the pressure index is greater than 1, 0.9 with intermittent claudication, 0.26 to 0.05 with rest pain and impending gangrene.
Flexible Angioscopy:
Technical refinements and
miniaturization of fibreoptic endoscopes have resulted in the development of a
new flexible angioscope designed specifically for
intravascular visualization.
Diagnosis
The exact diagnosis of
T.A.O cannot be made, as there are no definite criteria for it. But in a case of male smoker less than 50
(later modified by Wong to 40 vide infra), years of age with evidence of
occlusive arterial disease of infra inguinal vessels with the absence of
peripheral pulses can be assumed as a case of T.A.O.
I.
Diagnostic criteria for Buergers Disease (Wong et al)
Ř
Age below 40 years
Ř
Chronic smoker usually male
Ř
Involvement of medium to small
arteries of the lower limbs with rest pain, intermittent claudication,
ischaemic ulcer or gangrene
Ř
Similar upper limb involvement
Ř
Thrombophlebitis
Ř
Raynauds phenomenon
Ř
Absence of atherosclerosis,
collagen disease hematological disorders or sources of embolism at the time of
diagnosis.
II.
Angiographic criteria for Buergers Disease (Mckusick et al)
Ř
Vessel appearance predominantly
small and tapering
Ř
Flow of contrast – arterial fade
out with or without early venous filling
Ř
Small and medium size distal
vessel involvement
Ř
Segmental or focal and
intermittent occlusion of vessels, often bilateral
Ř
Smooth and even caliber proximal
vessels
Ř
Spider leg or tree root
configuration of collateral vessels
Ř
Abnormal corkscrew tortuosity of
small apparently recanalised vessels.
Treatment
Since the etiology is
unknown, most of the methods of therapeutic approaches are empirical. The primary aim of the treatment is to
prevent gangrene or at least retard its progress. If the case has become refractory to conservative
management sooner or later some part of operative intervention will be required
to increase blood supply or relieve pain.
Scheme of Approach:
Conservative Management:
1.
General care and protection
measures
2.
Abstinence from smoking to arrest
progress of disease
3.
Drugs
4.
Physical therapeutic procedures
to increase blood flow
5.
Procedures to relieve pain.
Radiological Interventional Procedures
Surgical:
Sympathectomy
Omental transfer
Amputation
General Care:
The patient should take
high protein diet and low fat. Vascular
exercise should be performed with the feet horizontal for 10 minutes, followed
by foot down position for 10 or more minutes.
The head of the bed should be elevated on 10cm blocks so that blood flow
is toward the feey at all times. A firm mattress should be used so that
buttocks do not sag. Massage of limbs is
to be avoided. Feet should be washed
daily with tepid water and bland soaps.
Interdigital clefts are soaked in potassium permanganate to prevent
fungal infections. Shoes should be
large, soft and produce no pressure on feet.
Direct heat to legs by hot water bottles heat lamps avoided.
Exercise and abstinence from smoking:
Smoking cessation is
frequently combined with exercise therapy in patients with intermittent claudication, cigarette smoking is the most significant
independent risk factor for development of chronic peripheral arterial
occlusive disease and is associated with progression of established disease and
a higher likelihood of disabling claudication limb threatening ischaemia,
amputation and the need for intervention.
Drugs:
Antibiotics
Vasodilators
Haemorrheologic
agents
Other agents
Hemodilution
Antithrombotic
therapy
1.
Suitable systemic and local
antibiotics are used depending on culture and sensitivity report.
2.
Vasodilators:
Collaterals are already maximally dilated in patients with
intermittent claudication, hence the role of
vasodilators is doubtful.
Xanthinol nicotinate is one of the commonly used
vasodilators. Slow Complamina
I.V. infusions have been tried in healing skin ulcerations and for relief of
rest pain.
3.
Hemorheologic Agents:
Decreased erythrocyte deformability and abnormal whole
blood viscosity are present in individuals with peripheral arterial disease and
offer potential therapeutic targets for agents that affect viscosity.
The actual improvement in walking distance attributable
to pentoxifylline is often unpredictable. A small increase in claudication distance has
been noted in individuals with markedly reduced walking distances earlier. Pentoxifylline has
been reported to improve abnormal erythrocyte deformability, reduce blood
viscosity and decrease platelet activity and plasma hypercoagulability.
4.
Other Agents:
Other agents found to be ineffective in the treatment of
intermittent claudication on the basis of results of randomized clinical trials
include ketanserin (serotinin
antagonist) suloctidil, nifedipine
and EDTA chelation therapy.
5.
Hemodilution:
Hemodilution with removal of red cells and infusions of hydroxyethyl
starch has been shown to improve walking distance in some trials. But hemodilution
therapy is clinically impractical.
Antithrombotic Therapy:
Aspirin alone or combined
with Dipyridamole will delay the progression of established arterial occlusive
disease.
The antiplatelet agent
ticlopidine has also been evaluated and reports suggest beneficial effects in
relieving symptoms, increasing walking distances and improving ankle pressure
indices.
PGI may provide temporary
relief of rest pain in patients with severe arterial insufficiency and may
promote healing of ischaemic ulcerations when given intra arterially.
Physical Therapeutic Procedures:
Rest in
bed, Buergers position, Buergers
exercise, and avoidance of vasoconstriction by preventing exposure to cold and
drugs that produce vasoconstriction.
Procedures to relieve Pain:
Repeated use of various
analgesics may be necessary for the temporary relief of pain.
Radiological Interventional Procedures:
1.
Percutaneous Transluminal
Angioplasty
2.
Intra vascular stents
3.
Intra arterial thrombolysis
1.
Percutaneous Transluminal
Angioplasty (PTA):
Currently the primary indications for an interventional
procedure in patients with lower extremity arterial disease include
a)
Incapacitating claudication
interfering with work or lifestyle.
b)
Limb salvage in patients with
limb threatening ischaemia as manifested by pain at rest, non healing, ulcers
and or infection or gangrene and
c)
Vasculogenic Impotence
PTA is an appropriate choice when two important criteria
are met. These include arterial disease
localized in a vessel segment less than 10 cm. in length and availability of a
skilled vascular interventionalist.
PTA of iliac arteries is associated with better long-term
success rates than more distal angioplasty.
Factors predicting outcome of P.T.A.
Factors predictive of favourable outcome included
claudication as the indication for the procedure. A stenotic
rather than occlusive lesion, good distal run off, more proximally situated
lesion.
2.
Intra vascular stents:
Currently available intravascular stents
are either balloon expandable (e.g., the Palmaz and Streckter Stents) or self-expandable
(e.g., the Wallstent and Gianturco
Stents). At
present the role of stents in treatment of lower
extremity arterial disease is unclear.
3.
Intraarterial thrombolysis:
Thrombolytic agents like tissue plasminogen activator streptokinase, urokinase have been used for acute arterial embolism. Based on a review of literature, Hess has
suggested that local thrombolytic therapy can be used
for all arterial thrombosis existing for 6-8 months and all embolic occlusions
present for 6-8 weeks.
Lumbar Sympathectomy:
In the extremities, the
vascular response to sympathetic stimulation is vasoconstriction with blanching
and cooling of skin and increased sweating, whereas blocking of the system
results in increased blood flow through cutaneous arteriovenous fistulae and
cessation of sweating thereby resulting in increased dryness, warmth and
accentuation of pink color. Effect on
blood flow to the muscles are considered incidental to the effect as flow in
the skin and are overshadowed by the local effect of muscle metabolites.
Indications:
1.
Patients with advanced ischaemia
resulting in pain at rest.
2.
Ischaemic ulcers
3.
Frank gangrene or impending
gangrene
4.
Distal arterial occlusion
5.
Failure of direct arterial
surgery in symptomatic patients.
Technique of Sympathectomy:
There are three
approaches to the lumbar sympathetic chains.
The transperitoneal anterior approach, the
extra peritoneal anterior flank approach (
The ultimate aim is to denervate the lower limb.
If it is required to be done on both sides it can be done at the same
time by the transperitonial route. The
position of lumbar ganglia is very variable and inconstant.
An oblique subcostal incision is made which extends upto a point 1˝" short of the umbilicus, after
arranging the patient in lateral position.
All the muscles are cut in the line of incision. The peritonium is
pushed medially and psoas muscle identified.
At the inner border of psoas muscle, a finger against the lumbar vertebral
bodies can roll the lumbar sympathetic chain.
On the right side special care should be taken to avoid injury to
inferior venacava and to the thin walled intercostal and lumbar veins, which enter into it. For a
complete sympathetic denervation of lower extremity,
it is necessary to remove the 1st and 2nd lumbar
ganglia. For denervation
of the foot and leg alone 2nd and 3rd ganglionectomy
is sufficient. The first ganglion has to
be removed for denervation of thigh.
Some causes of failure of sympathectomy:
1.
Wrong selection of patient
2.
Progress of disease
3.
Incomplete denervation
4.
Accessory ganglia
5.
Accessory sympathetic nerves,
which do not pass through the sympathetic trunk, are left untouched.
Omentoplasty:
Casten
and Alday first studied omental transplantation.
Omentoplasty is a
procedure in which greater omentum is released either from the right or left
side of the greater curvature of stomach depending on upon which sides the
transplantation is contemplated. The
omentum is released from the greater curvature of the stomach with an intact
epiploic artery one side. It is brought
down in the subcutaneous tunnel in the medial side of the limb upto the ankle and is fixed to the muscle. Through the intact epiploic artery ischaemic
limb will get some nourishment. A rich
lymphatic supply probably aids in cleaning infection whereas its vascularity
promotes angiogenesis in compromised tissue.
Direct Arterial Surgery:
TAO is a disease of small
and medium sized vessels and segmental involvement is present and it is
episodic in nature so the direct arterial surgery has a limited role in T.A.O.
Serial arteriography is the most important investigation to decide
the suitability of the case for bypass surgery.
Endarterectomy and Thrombo Endarterectomy:
Dos
This procedure is
suitable for reestablishing patency of occluded arteries.
The absence of the
endothelial lining of an artery does not necessarily lead to intravascular
thrombosis.
Reboul
coined the term endarterectomy but Leriche preferred
the term thromboendarterectomy.
Principles of Endartectomy:
Fatty atherosclerotic
lesions involve the subintimal layers and to a lessor extent the media. At the later stage the internal elastic
lamina is fragmented and the atherosclerotic changes affect the media.
Cleavage Plane:
As a rule normal planes
of cleavage are close either to the internal elastic lamina or external elastic
lamina. Based on the extent and location
of the mural lesions the following three cleavage planes are found most commonly.
1.
Sub Intimal:
Cleavage plane is located between intima
and media outside of internal elastic lamina.
2.
Trans Media:
Lies between the involved and intact
layer of the media usually between the inner three quarters and outer quarter.
3.
Subadventitial:
Is situated between the media and the
adventitia along the inner surface of the external elastic membrane.
Since it is not possible to know preoperatively which
cleavage plane is available great care should be taken to determine in each
individual case its exact location.
Residual Arterial Wall:
Within minutes of
surgical procedure the inner surface of the residual wall becomes covered with
a fibrin layer. Subsequently an inner
fibrous coat is formed which may lead occasionally to reduction of the arterial
lumen. For this reason, the most external
cleavage plans should be used to avoid subsequent stenosis.
Technique:
Thrombo-endarterectomy
may be carried out by three different methods.
1.
The direct technique of Dos
Santos
2.
Gas endarterectomy of Sawyer and
associates
3.
Eversion endarterectomy of Conolly and De Bakey, etc.
Arterial Bypass:
Joger
in 1913 first described the principle of bypass grafting. In 1948, Kunten
introduced the technique of a parallel shunt for an occluded artery-using end
to side anastomosis both proximally and distally. The rationale for this technique is the
transport of arterial blood around an occluded segment while avoiding operative
trauma and interference to concomitant veins and collaterals. This technique has been widely accepted in
reconstructive arterial surgery.
The various common bypasses for Aorto Iliac
and Infra inguinal occlusive diseases are:
1) Aorto-Iliac,
2) Aorto External Iliac bypass (in presence of common
iliac block), 3) Aorto femoral bypass, 4) Ilio femoral bypass (Block in External Iliac artery), 5) Femoro Popliteal bypass, 6) Femoro-Tibial
bypass, 7) Extra anatomic bypass.
Graft Materials:
Aorto Femoral Bypass:
A bifurcated dacron graft or less commonly Polytetrafluoroethylene (PTFE) is utilised
to bypass the stenotic lesions. In Aorto femoral
grafting, patency is excellent with any conduit. The five and ten year patencies
of Aortoiliac reconstructions are 90% and 75%
respectively.
Dacron Grafts:
These are constructed in
either a knitted or a woven configuration.
The advantages of the knitted structure are excellent tissue in growth
that occurs through the wide interstices of the graft and the technical case of
handling at the time of operation. Preclotting with the patient’s blood is required, to avoid
massive haemorrhage when blood flow through the graft is initially
established. Knitted grafts have also
been associated with degeneration and aneurysmal
dilatation over a period of time.
For woven Dacron grafts, preclotting is infrequently required and graft dilatation
is less common. Dacron grafts have been
coated with albumin or collagen, eliminating the need for preclotting
and aneurysmal dilatation has not yet been reported
with these coated Dacron grafts.
PTFE grafts also need not
be preclotted and aneurysmal
dilatation has not yet been reported.
Infra Inguinal Bypass:
The selection of conduit
material is of paramount importance in infra inguinal arterial reconstruction
as the long-term patency rate is highly dependent on two primary factors 1)
Site of outflow 2) Type of bypass material.
Saphenous
vein is the best infra inguinal bypass conduit material, conduit must be
credited for the reintroduction of the autogenous
vein for arterial reconstruction. Among
prosthetic graft PTFE is the most commonly used. Dacron is infrequently employed.
The patency of Saphenous vein grafts is better
than that of prosthetic grafts and the problem with postoperative infection is
reduced by avoidance of prosthetic material.
If great Saphenous
vein is not available lesser saphenous or cephalic
veins can be used.
In the absence of autogenous veins, some surgeons have used fresh homologous veins. Although the antigenicity of venous tissue is low, it is nonetheless important to match the compatibilities of the ABO system of donor and recipient. Tice and Zerbina have tested homologous veins preserved at 50°C for as long as 3 months and have showed good results.
Bypass in Aorto Iliac Disease:
Aorto
femoral bypass is currently the treatment of choice for symptomatic Aorto-Iliac occlusive disease.
Procedure:
Once the graft is
selected and the patient has been systematically heparinised,
the proximal anastomosis between the graft and the infrarenal
aorta is created using either an end to end or end to side technique. The graft limbs are then delivered to the
femoral vessels through tunnels that are created besides the external iliac
arteries. The distal anastomosis is
placed at the common femoral level through bilateral groin incisions.
Aorto
iliac bypass eliminates the needs for grion incisions
but the patency rate is substantially lower than Aorto
femoral bypass.
Bypass in Infra-inguinal occlusions:
The two most commonly
preferred infra inguinal reconstructions are as femoro-popliteal
and femoro-tibial bypasses.
Popliteal to tibial and popliteal to pedal bypasses are
performed less frequently as are more distal reconstructions to the arteries of
the foot. There are two general
techniques used in autogenous vein bypass procedures,
differentiated by the orientation of vein in relation to the direction of blood
flow and the alignment of venous valves.
i)
The reversed bypass technique:
Excises the vein in its entirety and reverses it such
that the caudal end is anastomosed proximally and the
cranial end distally.
ii)
Insitu vein bypass technique:
First performed in 1960s, the vein is left in usual
orientation and the venous valves are disrupted to allow blood to flow from the
cranial end of vein to the caudal end.
Advantages and disadvantages have been demonstrated with
each method but most studies have failed to document significant difference in
long-term patency rates when precise operative technique was employed.
Extra Anatomic Bypasses:
Indications:
1.
Patient’s medical condition
renders the risk of major intra abdominal procedure unacceptable.
2.
Lower extremely ischaemia in
presence of an infected aortic graft.
3.
Re-operation for Aorto-femoral graft occlusion.
4.
In reoperation
in a sexually active male to avoid the possibility of postoperative sexual
dysfunction.
Prosthetic grafts are almost always employed. The best results of extra anatomic bypass
procedures are achieved with femoro- femoral bypass
grafts. 5 years patency rates of these
grafts range between 50-70%.
Reconstruction of Profunda femoris
artery:
In the presence of
occlusive disease of the superficial femoral artery, the profunda
femoris artery plays the chief role of collateral
circulation between the Iliac and popliteal arterial systems. Clinical and angiographic data have provided
direct and abundant evidence of this significant fact.
Ischaemia both chronic
and acute of the lower extremity, whether due to Aorto-iliac
of femoro-popliteal disease, can often be managed by
increasing arterial pressure and flow through this artery. Under these circumstances, the profunda femoris is truly the
artery of revasclarisation of the leg and foot. Its reconstruction, whether isolated or
combined with any other procedures has assumed in recent years an increasingly
important role in the management of occlusive arterial disease of the lower
extremity.
The operative procedures designed to achieve patency
of profunda femoris artery
consist of Endarterectomy or Thromboendarterectomy,
usually associated with a patch graft.
Reconstruction of the profunda femoris artery or profundoplasty
may be performed either as sole procedure or more commonly in combination with
reconstruction of the Aorto Iliac segment.
Angioscopy:
Intraoperative angioscopy
has become an attractive technique for evaluating bypass grafts and arterial
procedures, since the introduction of small flexible catheters with
high-resolution optical systems.
Angioscopy requires irrigation with saline accompanied by inflow and
sometimes outflow occlusion to provide a visually clear image. The use of a specifically designed infusion
pump with high and low flow rates has greatly facilitated the
visualization. Experience is required to
manipulate properly the angioscope within a bypass
graft to obtain complete visualization.
It has been most widely used to inspect insitu
saphenous vein graft to ensure complete valve lysis and to exclude unligated
venous branches. Ideally 1.4mm diameter angioscope may be used in such grafts, introducing the angioscope through a sheath placed through the most
proximal branch of the Saphenous
vein that is left unligated for this purpose. Saline irrigation is administered through the
sheath. Prior to angioscopy it is useful
to identify and ligate as many venous side branches
as possible to optimize distal irrigation and visualization. Angioscopy can be used in other sites if
blood flow can be temporarily excluded which sometimes requires the use of
balloon occlusion catheters if proximal control is not surgically accessible.
Because angioscopy is an
invasive intraluminal procedure it has several
possible complications including endothelial injury leading to late
hyperplasia, creation of intimal flaps and fluid
overload due to excess irrigation.
Experimental studies have documented that mild intimal
injury does occur but only after multiple repeated passages of larger diameter angioscopes.
Atherectomy:
It is defined as the
removal of atheroma from diseased arteries. Although several devices
have been designed to percutaneously perform atherectomy
in peripheral vessels, only three have been approved for clinical use: the Simpson
Atherocath, the Auth Rotablator
and the Transluminal Extraction Catheter. The present state of these technologies
however greatly limits their general applicability and usefulness for the
treatment of peripheral arterial disease.
Except for unusual lesion morphologies, atherectomy
has not proved superior to routine PTA.
Minor Amputation:
Amputation of a digit or
a part of the digit is indicated when an ulcer refuses to heal, when there is
severe pain restricted to the affected digit and when there is gangrene limited
to the toe.
Transmetatarsal
amputation is the amputation of choice in the foot in selected cases as
advocated by Mekiffrick, especially so after a
sympathectomy. Amputations like Choparts, Lisfrancs and Symes are not considered suitable. If amputation of the toes alone or a transmetatarsal amputation does not leave a satisfactory
stump, then a below knee amputation is indicated.
Major Amputation:
The chief indications are
1.
Presence of gangrene that extends
into the foot with proximal ischaemia.
2.
Severe rest pain uncontrolled by
any means.
The selection of a proper site for amputation should be
done carefully to prevent ischaemia in the stump and re-amputation. The decision should be based on a thorough
clinical examination coupled with radiological investigations.
A below knee amputation can always be done if the
popliteal artery is patent. If femoral
artery is blocked the success of this operation is less assured. A simple and valuable procedure, perhaps is
to proceed for a below knee amputation without a tourniquet and note the
condition of the muscles and the degree of bleeding from the small arteries and
capillaries. If the blood supply to the
muscles is found to be fairly adequate the amputation can be completed below
the knee.
It is always better to do a below knee amputation
whenever possible. The patient can go
around better without much disability with an artificial limb. The importance of a below knee amputation is
still more in cases where both legs are involved.
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
MATERIALS AND METHODS
A study
of cases of lower limb Ischaemia due to Thrombo Angiitis
Obliterans.
Patients and Methods:
In this series we have
taken 22 cases of TAO for study during the period August 1999 to July 2001.
The 22 cases were
selected after preliminary screening of number of patients with non-healing
ulcer, gangrene and history of intermittent claudication. Patients whose onset of symptoms above the
age of 50, patients with history of atherosclerosis, diabetes and peripheral
neuropathies were not considered.
Patients having chronic ulcers due to diseases like varicose veins were
also not considered.
These 22 patients were
subjected to elicitation of proper history, physical examination and
investigations. In the history more
stress was given to features like site, nature and duration of pain,
claudication distance, rest pain, previous history of treatment, details about
smoking, chewing pan and alcohol intake.
In physical examination,
more importance was given to palpation of different arterial pulses and skin
temperature at different levels. Blood
pressure, signs of thrombophlebitis, skin changes, sensory changes and muscle
power were taken into account.
Investigations Included:
Routine Investigations
Hb,
TC, DC, ESR
Urine Sugar, Albumin and
Microscopy
Blood Urea, Serum
Creatinine, Random Blood Sugar.
Bleeding time, Clotting
time and VDRL
Chest X-ray and ECG were
taken in most of the patients.
Histopathological evaluation
of Dorsalis pedis artery was done in all.
Doppler Study:
10 amongst the 22
patients underwent Doppler evaluation.
These cases showed obstruction to flow at various levels in the small
vessels. Doppler findings in these cases
were consistent with the physical findings.
Dorsalis Pedis Artery Biopsy:
The arterial biopsies in
this present series were done in all the 22 cases studied. In most of them the biopsy was done as a part
of definitive management i.e. along with below knee amputation, lumbar
sympathectomy, Omentoplasty, under anaesthesia.
Method of Arterial Biopsy (Standard for all biopsies):
The site of skin incision
is chosen as 2-finger breadth below the ankle joint on the dorsum of the
foot. Under local
Anaesthesia 1.5cm transverse skin incision given in between the tendons of
extensor hallucis and digitorum. Skin, subcutaneous tissues are cut through
and dorsalis pedis artery
with vein and nerve identified between the two tendons, 1cm length of the
artery was excised between ligatures. Only one biopsy was done. The excised
portion preserved in formalin and sent for histopathology. The specimens were
studies within 2 days of receipt of specimen by different pathologists.
Observations in the study of 22 cases of T.A.O
Age incidence
Maximum age at the onset
of symptoms is 49 and minimum age at the onset of symptoms is at 25 years.
Age incidence at the onset of symptoms
Age at the time of
Onset
|
No. Of Cases |
Percentage |
|
21-30 |
2 |
9.0% |
|
31-40 |
12 |
54.55% |
|
41-50 |
8 |
36.37% |
Sex Incidence:
In this series we didn’t
come across any females with TAO. So in
our series sex incidence is 100% males.
Occupation
|
No. of Patients |
Percentage |
Manual labour/coolie
|
11 |
50% |
|
Agriculture |
11 |
50% |
|
Drivers |
- |
- |
|
Beedi workers |
- |
- |
|
Others |
- |
|
Income:
We have taken Rs.500 per month as a dividing time between
lower income and middle-income groups.
Group
|
No. of Cases |
Percentage |
Lower income group upto 500
|
8 |
36.36 |
|
Middle income group 500-1000 |
14 |
63.64 |
|
Higher income group > 1000 |
- |
- |
Religion:
Religion
|
No. of Cases |
Percentage |
Hindu
|
19 |
86.36 |
|
Muslim |
2 |
9 |
|
Christian |
1 |
4.64 |
Marital Status:
Marital Status
|
No. Of Patients |
Percentage |
Married
|
20 |
90.91 |
|
Unmarried |
2 |
9.09 |
Smoking:
In our series all the
patients were smokers so incidence of smoking in our series is 100%.
Number of cigarettes/beedies smoking per day
No. of Beedies/Cigarettes
|
No. of Patients |
Percentage |
Below 10
|
- |
- |
|
10-20 |
18 |
81.82% |
|
20-30 |
4 |
18.81% |
|
30-40 |
- |
- |
Duration of smoking before onset of symptoms
Years of Smoking
|
No. Of Patients |
Percentage |
|
1-10 Years |
5 |
22.73 |
|
11 Years & above |
17 |
77.27 |
Other habits
Other Habits
|
No. of Patients |
Percentage |
Alcohol
|
12 |
54.55 |
|
Chewing Tobacco |
3 |
13.67 |
Containing
Pan/Mixtures Both
|
|
|
Admission in Hospital:
Significant number of
patients seeking admission were previously diagnosed and treated for T.A.O.
Admission in
Hospital
|
No. of Patients |
Percentage |
|
First time admission |
|
|
|
Readmission |
|
|
Incidence of Limb Involvement RT Left
Pain:
Pain was present in 22
cases.
Type of Pain
|
No. Of Cases |
Percentage |
|
Intermittent Claudication |
2 |
9.09 |
|
Intermittent Claudication with Ulcer/Gangrene
related Pain |
1 |
4.55 |
|
Rest pain |
19 |
86.36 |
Claudication Distance:
Claudication
Distance
|
No. of Patients |
Percentage |
|
Rest Pain |
20 |
90.90 |
|
Below 10 |
|
|
|
10-25 |
|
|
|
25-50 |
2 |
9.10 |
Trauma:
In 2 cases history of
trauma was there where in it resulted in ulcer of foot.
Physical Examination:
Ulcer: Total 11 patients came with chronic non-healing ulcer over the
lower extremities mainly in the distal part of foot.
Patients with history of
trauma - 2
Ulcer associated with
gangrene - 9
Ulcer associated with
oedema - 2
Ulcer associated with pregangrene -
0
Gangrene:
Total number of patients
with gangrene - 20
Gangrene associated with
ulcer - 9
Gangrene associated with
edema - 1
Pregangrenous State:
No. Of patients with pregangrenous state -
0
Oedema:
Oedema was present in - 3
cases
Oedema associated with
ulcer - 2
Oedema associated with
gangrene - 1
Thrombophlebitis:
Signs of thrombophlebitis
observed in - 1 case
- Associated with ulcer - 0
- Associated with
gangrene - 1
Duration of Symptoms:
Duration of Pain
|
No. of Patients |
Percentage |
|
Within 15 days |
0 |
0 |
|
1-30 Days |
0 |
0 |
|
1-6 Months |
6 |
27.28 |
|
6 Months-1 Year |
5 |
22.73 |
|
1-4 Years |
9 |
40.90 |
|
Above 4 Years |
2 |
9.09 |
Pulsations:
All peripheral pulses
were palpated. Abnormalities detected commonly in dorsalis
pedis, posterior tibial and
popliteal arteries.
All other pulsations were felt normally in most of cases except feeble
femoral puslation in 1 case.
Bilateral absence of post tibial and dorsalis pedis - 3
Unilateral absence of post tibial and dorsalis pedis - 19
Popliteals were involved in bilateral involvement -
1
Unilateral involvement
- 4
Bilateral involvement of arterial pulsation - 19 (86.36)
Bilateral symptomatic disease -
11 (50.0)
In some cases these
findings were confirmed by Doppler ultrasound.
Even though pulsations were deficient in both sides in some patients,
symptoms were confined to one side only.
Skin Temperature:
In many cases both the
limbs had subnormal temperature basically below the knee, with the side with
signs of ischaemia being cold.
Investigations:
Doppler study
10 cases amongst the
study group Doppler study had been done.
The study confirmed most of the palpatory
findings.
Bilateral absent Dorsalis pedis and Posterior
tibial pulsations observed in - 3
Unilateral absence of posterior tibial and
Dorsalis pedis in -7
In most cases Doppler study showed deficient collateral
formation distal to the obstruction.
Dorsalis Pedis Artery Biopsy Reports:
Biopsy of the artery has
been done in all the 22 cases studied.
In a few the biopsies were done as part of definitive management.
Treatment Given:
Most of the patients in
this series needed some form of surgical intervention.
General Measures:
All the patients were
advised to stop smoking following measures were given to all the patients
irrespective of the made of treatment.
·
Bed rest and protein rich diet.
·
Antibiotics.
·
Pentoxifylline.
·
Analgesics for pain relief.
·
Acetyl salicylic acid.
·
General wound care / ulcer care
(cleaning & dressing).
Conservative Treatment:
The general measures
mentioned above have been given in 1 patient.
But all the other patients needed surgery in one form or other.
Minor Amputations:
Minor amputations like
toe amputations were done along with lumbar sympathectomy in 10 patients.
Major Amputations:
Below knee amputation was
done in 8 patients.
Lumbar Sympathectomy:
Lumbar sympathectomy
alone was done in 1 patient.
Lumbar Sympathectomy with Amputation:
Lumbar sympathectomy with
minor amputation was done in 10 patients.
Lumbar sympathectomy with major amputation was done in 0 patients.
Omentoplasty:
Unilateral pedicled
omentoplasty was done in 2 cases.
In them one patient
omentoplasty was done along with minor amputation and lumbar sympathectomy.
Summary of Treatment:
Age incidence at the onset of symptoms
Mode of treatment
|
No. of Patients |
Percentage |
|
Conservative treatment alone |
1 |
4.54 |