����Buerger's disease (Thromboangiitis obliterans)�

Almetwaly ragab

Prof. of vascular and endovascular surgery 

• This is a clinical syndrome of occlusive arterial disease that is characterized by multiple segmental occlusions of medium and small arteries of the lower limbs.

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Etiology

is unknown.

• Buerger's disease affects males only
• It starts at an earlier age than atherosclerosis, between 20-40 years.
• The disease occurs exclusively in smokers; it may represent as an allergic response to nicotine.
• Interdigital fungus infection is a common association.

Pathology����

• The disease has patchy distribution and an episodic course.
• It affects the neurovascular bundle distal to the popliteal artery.
• shows an inflammatory reaction (panvasculitis and neuritis, The lumen of the artery is obstructed by a thrombus which becomes organized
• Affection of the nerves by the inflammatory process and the early block of arteries explain the severe pain that is present in many cases.

Clinical features���

• 1. General profile
• Usually young males (20–40 years)
• Strong history of cigarette smoking / tobacco use
• No evidence of diabetes, hypertension, or hyperlipidemia
• 2. Symptoms
• Intermittent claudication → pain in feet, calves, or arms during exertion
• Rest pain (especially at night, relieved by hanging leg out of bed)
• Ischemic ulcers on toes, fingers, or heel
• Gangrene of digits in advanced stages
• Raynaud’s phenomenon (cold-induced

digital pain, color changes)

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3. Signs�

• Reduced or absent distal pulses (foot or hand arteries)
• Trophic changes: thin, shiny skin; brittle nails; loss of hair on affected limb
• Ischemic ulcers (painful, punched-out, usually at tips of toes/fingers)
• Gangrene (dry or wet, often multiple digits)
• Migratory superficial thrombophlebitis (tender red cord-like veins)
• Positive Buerger’s test: pallor on elevation

and dependent rubor when limb is lowered

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Differences between atherosclerosis and Buerger's disease�

4. Investigations (supportive)�

• Doppler ultrasound: reduced distal flow
• Arteriography: segmental occlusion, corkscrew collaterals
• Laboratory Investigations

There is no specific laboratory test for Buerger’s disease.

ESR, CRP – may be mildly raised, but often normal.

• Arteriography is rarely necessary to confirm the diagnosis.
• This is because the disease affects distal vessels and distal run off is known to be absent.
• There fore there is no possibility for arterial reconstruction, and consequently no need for arteriography

CT Arteriography

Treatment

• Smoking must be stopped to avoid disease progress.
• Control of blood pressure, Anti-platelets:
• Sympathectomy gives good results.
• Amputation of one or more digits or toes is indicated for persisting pain or gangrene and can be performed adjacent to the line of demarcation with satisfactory primary healing.

MCQs on Buerger’s Disease�

• 1. Buerger’s disease (Thromboangiitis obliterans) is most strongly associated with:�A. Diabetes mellitus�B. Hypertension�C. Cigarette smoking�D. Hyperlipidemia
• 2. The most common age group affected by Buerger’s disease is:�A. Children below 10 years�B. Young adults (20–40 years)�C. Middle-aged adults (40–60 years)�D. Elderly (> 65 years)
• 3. The main type of vessels affected in Buerger’s disease are:�A. Large arteries (aorta, iliacs)�B. Small and medium-sized arteries and veins of extremities�C. Coronary arteries�D. Pulmonary arteries
• 4. A characteristic clinical feature of Buerger’s disease is:�A. Intermittent claudication�B. Raynaud’s phenomenon�C. Migratory superficial thrombophlebitis�D. All of the above

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• 5. Which investigation is most useful to support the diagnosis of Buerger’s disease?�A. ECG�B. Arteriography (angiography)�C. Chest X-ray�D. Echocardiography

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• 6. The “corkscrew” collateral vessels on angiography are typically seen in:�A. Atherosclerosis�B. Buerger’s disease�C. Takayasu’s arteritis�D. Polyarteritis nodosa
• 7. The definitive treatment of Buerger’s disease is:�A. Anticoagulation therapy�B. Cessation of smoking�C. Corticosteroid therapy�D. Thrombolysis
• 8. Which of the following statements is TRUE regarding Buerger’s disease?�A. It is common in women and rare in men�B. It primarily affects visceral arteries�C. It is an inflammatory non-atherosclerotic vascular disease�D. It is usually unrelated to smoking

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1. C
2. B
3. B
4. D
5. B
6. B
7. B

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Short essay on burgers disease

1/ Define Buerger’s disease and mention the age group most commonly affected.

2/ List the risk factors and etiological association of Buerger’s disease.

3/ Describe the pathological changes in Buerger’s disease.

4/ Write the main clinical features of Buerger’s disease.

5 Enumerate the diagnostic investigations and the characteristic angiographic findings in Buerger’s disease.

6/ Outline the complications of Buerger’s disease.

7/ principles of management of Buerger’s disease.

8/ Compare Buerger’s disease with atherosclerotic peripheral arterial disease (age, risk factors, pathology, and presentation).

9/ Write short notes on:

(a) Raynaud’s phenomenon in Buerger’s disease

(b) Migratory superficial thrombophlebitis

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Describe the pathological changes in Buerger’s disease.��

• Buerger’s disease (Thromboangiitis obliterans) is a non-atherosclerotic, segmental, inflammatory occlusive disease affecting small- and medium-sized arteries and veins, usually in the limbs of young male smokers.
• Pathological changes:
• Acute Stage:
• Acute inflammatory thrombus within the lumen of affected vessels.
• Thrombus contains microabscesses formed by collections of neutrophils surrounded by granulomatous inflammation.
• The internal elastic lamina and media are preserved, unlike in atherosclerosis.
• Vessel wall inflammation is mild compared to the thrombus itself.
• Subacute Stage:
• The thrombus becomes organized, with infiltration by inflammatory cells and partial recanalization.
• Still, the architecture of the vessel wall remains largely intact.
• Chronic Stage:
• The thrombus is replaced by fibrous tissue, leading to permanent luminal occlusion.
• Vascular wall fibrosis develops, but elastic lamina remains intact (helps distinguish it from atherosclerosis).
• Segmental distribution of lesions with skip areas is typical.
• Venous and Neural Involvement:
• Superficial phlebitis (vein inflammation) is common.
• Inflammation and fibrosis may extend to adjacent nerves, explaining the severe ischemic pain.

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Vasospastic disorders

Raynaud's disease

Definition of Raynaud’s Disease�

• Raynaud’s disease is the primary (idiopathic) form of Raynaud’s phenomenon.�It is a vasospastic disorder of small arteries and arterioles, usually affecting the fingers and toes, without any associated underlying disease.�It presents with episodic, reversible color changes (white → blue → red) in response to cold or emotional stress.
• 👉 In exams:
• Raynaud’s disease = Primary (idiopathic) form
• Raynaud’s phenomenon = Secondary form (associated with connective tissue or vascular disease)

• The aetiology of the disease is not exactly known.
• Certain factors are suggested
• Abnormal sensitivity of the small arteries and arterioles of the hands, and less commonly the feet, to cold.
• Increased sympathetic tone.
• Psychological instability.
• The presence of cold agglutinins in the blood which cause agglutination of RBCs on exposure to a low temperature.

Clinical features�

• For the diagnosis of Raynaud's disease certain criteria should be fulfilled.
• The disease is bilateral and symmetrical and is much more common in young females, in both hands.
• The attacks are precipitated by coldness or emotional.

• The attack consists of 3 consecutive phases
• Pallor; due to spasm of the digital arterioles.
• Cyanosis; due to dilatation of the capillaries which are filled with slowly flowing deoxygenated blood.
• Redness. As the attack passes off, the arterioles dilate and oxygenated blood passes into the dilated capillaries. The attack is accompanied by pain and is called Raynaud's phenomenon.

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4. The radial and ulnar pulses are preserved

5. No major gangrene. Only minute patches of ulceration or gangrene may occur

Grades of Raynaud's disease�

• First grade presents only with Raynaud's phenomena.
• Second grade presents with mild trophic changes in the tips of fingers and nails.
• Third grade presents with gangrene of the tips of fingers.

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Treatment�

• In the early stages conservative measures are tried.
• The patient is advised to avoid cold weather and to wear woolen gloves in Winter time.
• Vasodilator drugs.
• Calcium channel antagonists. amlodipine (Norvasc)

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• In severe cases cervico-dorsal sympathectomy is performed.
• Its immediate results are good but usually the symptoms recur after sometime, but are at least, not severe.

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Raynaud's phenomenon

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• Color changes similar to those of Raynaud's disease may accompany a large group of organic diseases.
• Causes of Raynaud's phenomenon include
• Thoracic outlet syndrome
• Certain occupations as typists, pianists and laborers who use vibrating tools.

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• Collagen diseases as rheumatoid arthritis, scleroderma, systemic lupus erythematosus and dermatomyositis
• Vascular disorders as atherosclerosis or Buerger's disease. Cryogloubulinaemia.
• Drugs as chronic administration of ergot-containing drugs for migraine.
• Atrophic disorders of limbs, e.g. after poliomyelitis.�

Treatment

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• should be directed to the original problem.
• Vasodilators and ca channel blocker are prescribed

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MCQs on Raynaud’s Phenomenon

• 1. Raynaud’s phenomenon is characterized by:�A. Thrombosis of digital arteries�B. Vasospasm of small arteries and arterioles of fingers and toes�C. Atherosclerosis of peripheral arteries�D. Autoimmune destruction of capillaries
• 2. The typical sequence of color changes in Raynaud’s phenomenon is:�A. Red → Blue → White�B. White → Blue → Red�C. Blue → White → Red�D. White → Red → Blue
• . 3. Common triggers for Raynaud’s attacks include all EXCEPT:�A. Exposure to cold�B. Emotional stress�C. Cigarette smoking�D. High blood pressure
• 4. Raynaud’s phenomenon is more common in:�A. Elderly men�B. Young women�C. Children under 10 years�D. Patients with diabetes mellitus only

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• 5. Raynaud’s phenomenon associated with systemic sclerosis is classified as:�A. Primary Raynaud’s disease�B. Secondary Raynaud’s phenomenon�C. Vasculitis�D. Thrombophlebitis
• 6. Which of the following is the drug of choice in severe Raynaud’s phenomenon?�A. Beta blockers�B. Calcium channel blockers (e.g., Nifedipine)�C. Corticosteroids�D. Anticoagulants
• 7. Which clinical sign is typical of Raynaud’s phenomenon?�A. Intermittent claudication�B. Livedo reticularis�C. Migratory superficial thrombophlebitis�D. Triphasic color changes in digits
• 8. In primary Raynaud’s disease, which of the following is TRUE?�A. More common in young females�B. Usually associated with connective tissue disorders �C. Leads rapidly to gangrene�D. Always requires surgical treatment

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1. B
2. B
3. D
4. B
5. B
6. B
7. D
8. A

Short essay on vasospastic disease

• Define Raynaud’s phenomenon.
• Write the etiology and risk factors of Raynaud’s phenomenon.
• Write the clinical features and classical sequence of color changes in Raynaud’s phenomenon.
• Differentiate between primary Raynaud’s disease and secondary Raynaud’s phenomenon.
• Enumerate the systemic diseases associated with secondary Raynaud’s phenomenon.
• List the investigations useful in the diagnosis of Raynaud’s phenomenon.
• Write the principles of management of Raynaud’s phenomenon.

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