Thromboangiitis obliterans (TAO), earlier referred to as Burger’s disease is a rare, progressive, non-atherosclerotic, inflammatory condition that usually involves small and medium arteries of the upper and lower extremities
The disease is segmental in distribution
The swollen inflamed vessels can become narrowed or blocked by clots
It typically occurs in male smokers
Ages commonly affected are between 20-50 years
The disorder is reported commonly in Asia, the Middle East, the Mediterranean, and Eastern Europe.
Initial presentation may be with leg, foot arm, or hand claudication and can be misdiagnosed as joint or muscular issues
With progression, there is calf claudication, and ultimately pain even at rest and ischemic ulcerations on the toes, feet, or fingers, referred to Raynaud's
The treatment of TAO is mainly smoking cessation. In patients who cease smoking, the halt in progression is impressive, and risk of amputation is reduced
ETIOLOGY OF TAO
The exact cause of Burger's disease remains unclear. Although, tobacco clearly plays a role in the development of TAO, the mechanism is not clear. It is believed that chemicals in tobacco may irritate the lining of the blood vessels, causing them to become inflamed and swollen
Genetic predisposition and autoimmune pathology have also been suggested as possible causes
Chronic gum disease
Age <45 years
PATHOLOGY OF TAO
There is thrombosis in small to medium arteries and veins accompanied by a dense neutrophil aggregation, presence of multinucleated giant cells and foci of microabscesses. In contrast to atherosclerosis, which affects only the intimal and medial layers of the artery, all three layers of the artery namely the adventitia, media and intima are affected in TAO
CLINICAL FEATURES OF TAO
Pain in legs and feet or in your arms and hands that comes and goes. This pain is triggered by use of hands or feet and reduces when on stopping the activity (claudication). Rarely it may occur at rest.
Tingling or numbness in the hands or feet.
Pale, reddish or blue-tinted fingers and toes
Painful swelling in the leg along the length of superficial veins due to presence of clot
Fingers and toes that turn pale following cold exposure (Raynaud's phenomenon).
Painful sores on fingers and toes due to occlusive clots
COMPLICATIONS OF TAO
Gangrene of fingers and toes. The affected toe or finger becomes bluish-black, loss of sensation and foul smell due to superadded bacterial infection of dead necrotic tissue. It is a potentially life threatening
condition and treatment involves amputation of the affected part
HISTORY & PHYSICAL EXAMINATION
Typical history of claudication pain – pain triggered by activity such as walking and relieved by rest
History of smoking
Pain and tingling of extremities at rest in severe cases
Reduced or absent pulse in the hands and feet.
Perform Allen test (Ask patient to close hand tightly and occlude both radial & ulnar pulse for 30 seconds. Ask patient to open his hand. There will be pallor of the palm. Now release the ulnar pulse. A positive Allen test occurs when there is persistent pallor in the palm indicating absence of collateral blood flow to the hand. In negative Allen test, flushing of the palm will occur within seconds of releasing the ulnar pulse indicating normal blood flow in the hand
More than half the cases have superficial vein thrombosis and thrombophlebitis
There are no specific tests to diagnose TAO. Serological tests must be done to rule out diabetes, autoimmune arteritis and thrombophilic states
Doppler imaging may demonstrate non-atherosclerotic segmental occlusions of small and medium arteries of hands and feet).
Arteriography may show the characteristic "pig-tailing" or "corkscrewing" of the arteries representing small collaterals around occluded segments. However, these are not specific to TAO.
Echocardiography should be done to rule out proximal source of emboli.
Biopsy – A small sample of blood vessel is obtained and examined under the microscope. Refer above for typical histological findings and distinguishing features from atherosclerotic disease
Although no specific treatment is there for TAO, the most effective way to stop the progression of disease is to quit using all tobacco products. Even a few cigarettes a day can be dangerous in Burger’s disease
It is accepted that surgery is rarely indicated if patient stops smoking.
To quit smoking, nicotine products should not be used as they can worsen the condition. Non-nicotine products must be used
Symptomatic treatment with calcium channel blockers or other vasodilators may be advised particularly in the presence of concurrent Raynaud's phenomenon
Prostaglandin analogs such as intravenous iloprost are used to treat associated pain and ischemic complications
Nerve surgery – surgical sympathectomy
Therapeutic angiogenesis – medications to stimulate growth of new blood vessels
Bosentan (Tracleer) - This medication has been approved to treat pulmonary hypertension. The drug was shown to benefit some patients with TAO
Endovascular therapy - A thin catheter is threaded into the blood vessels and may be able to open up narrowed blood vessels, restoring blood flow. However, this procedure isn't widely used because the success rate has not been impressive
Avoid exposure to secondhand smoke
Skin and extremities care – prompt treatment and attention to minor cuts and bruises
Regular physical activity
The outcomes are good in patients who cease smoking, but for those who continue to smoke, amputation of toes or fingers is quite common
THROMBOANGIITIS OBLITERANS -FINAL MBBS REVISION
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- Full Name: Lakshmi Venkataraman
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