[PDF]THROMBOANGITIS OBLITERANS
 

4. THROMBOANGITIS OBLITERANS (TAD) (Buerger's Disease) GENERAL CONSIDERATION
     Buerger's disease is an episodic and segmental inflammatory and thrombotic
process of the arteries and veins, principally in the limbs. It is seen most commonly
in men between ages 25 to 40 who smoke. The effects of the disease are almost solely
due to ischemia, complicated in the later stages by infection and tissue necrosis. The inflammatory process is intermittent, with quiescent periods lasting weeks, months, or years.
     The arteries most commonly affected are the plantar and digital vessels in the
foot and those in the lower leg. The arteries in the hands and wrists may also become
involved. Different arterial segment may become occluded in successive episodes; a certain amount of recanalization occurs during quiescent periods.
     Superficial migratory thrombophlebitis is a common early indication of the
disease.
     The cause is not known, but alteration in the collagen in the vessels suggests
that it may be a collagen disorder. Damage to the blood vessels by pathogenic cold
and its invasion into the deep tissues cause swelling and pain of the foot.
     In traditional Chinese medicine, the swelling and pain of the foot is thought to be the damage of the blood vessels by cold which passes through the skin and causes
CLINICAL MANIFESTATIONS
     The signs and symptoms are primarily those of arterial insufficiency, and the differentiation from arteriosclerotic peripheral vascular disease may be difficult, however, the following findings suggest Buerger's disease.
     A. The patient is a man between age 20 to 40 who smokes.
     B. There is a history or finding of small, red, tender cords resulting from migratory superficial segmental thrombophlebitis, usually in the saphenous tributaries rather than the main vessel. A biopsy of such vein often gives microscopic proof of Bureger's disease.
     C. Intermittent claudication is common and is frequently noted in the palm of the hand or arch of the foot. Rest pain is common and, when present, is persistent. It tends to be more pronounced than in the patient with atherosclerosis, numbness, diminished sensation and pricking and burning pains may be present as a result of ischemic neuropathy.
     D. The digit or the entire distal portion of the foot may be pale and cold, or there may be rubor that may remain relatively unchanged by posture; the skin may not blanch on elevation and on dependency the intensity of the rubor is often more pronounced than that seen in the atherosclerotic group. The distal vascular changes are often asymmetric, so that not all of the toes are affected to the same degree. Absence or impairment of pulsations in the dorsalis pedis, posterior tibial, ulnar or radial artery is frequent.
     E. Trophic changes may be present, often with painful indolent ulcerations along the nail margins.
     F. There is usually evidence of disease in both legs and possibly also in the hands and lower arms. There may be a history or findings of Raynaud's phenomenon in the finger or distal foot.
     G. The course is usually intermittent with acute and often dramatic episodes
followed by rather definite remissions. When the collateral vessels as well as the main channels have become occluded, an exacerbation is more likely to lead to gangrene and amputation. The course in the patient with atherosclerosis tends to be less dramatic and more persistent.
DIAGNOSIS
     Essentials of diagnosis.
     ? Almost always in young men who smoke.
     ? Extremities involved with inflammatory occlusions of the more distal arteries, resulting in circulation insufficiency of the toes or fingers.
     ? Thrombosis of superficial veins may also accur.
     ? The course of the illness is intermittent and amputation may be necessary,
especially if smoking is not stopped.
     In traditional Chinese medicine, the condition is termed "Tuoju," which simply
means that gangrene of the fingers or toes with excruciating pain at first, and after
rather a long time necrosis and sloughing off of the skin, subcutaneous tissues,
muscles and bones, resembling thromboangiitis obliteration.
TREATMENT
I. Treatment in Western medicine.
     1. Smoking must be given up. The disease is almost sure to progress if this advice is not heeded.
     2. Surgical measure.
     A. Sympathectomy. Sympathectomy is useful in eliminating the vasospastic
manifestations of the disease and aiding in the establishment of collateral circulation to the skin. It may also relieve the mild or moderate forms of rest pain. If amputation of a digit is necessary, sympathectomy may aid in healing of the surgical wound.
     B. Arterial grafts. Arterial grafting procedures are seldom indicated in patients with Buerger's disease because they do not usually have significant occlusive disease in the iliofemoral region.
     C. Amputation. The indications for amputation are similar in many respects to
those outlined for the atherosclerotic group, although the approach should be more
conservative from the point of view of preservation of tissue. Most patients with
Buerger's disease who are managed carefully and stop smoking do not require amputation of the fingers or toes. It is almost never necessary to amputate the entire
hand, but amputation below the knee is occasionally necessary because of gangrene
or severe pain in the foot.
II. Treatment in traditional Chinese medicine.
     1. Herb therapy
     A. For accumulation of cold and stasis of Qi.
     The pain of the legs and toes of the patient is related to cold weather and
intermittent claudication is common. The affected foot is pale and cold. Most patients are men and heavy smokers. The dorsal pulse of foot becomes weak or not felt. The rule of treatment is to eliminate the stagnant and activate the blood with Tao Huang Shi Wu Tang Jia Jian.
     The formula is composed of:
     Chinese angelica 25g
     Unpeeled root of herbaceous peony 25g
     Prepared rhizome of rehmannia rhizoma 12g
     Chua