Definition
An inflammatory & segmental chronic arterial occlusive disease with periodical episode, which mainly affects median & small calibre arteries and veins in extremities, esp. lower limbs. It mostly occur in young & middle-aged males.
Etiology Smoking !!!
Pathology
 Artery → vein ， distal → proximal ；
 Segmental distributed lesions, relatively normal between 2 diseased segments;
 Active phase: non-suppurative inflammation affects whole blood vessel wall, with lymphocytes infiltration & vascular thrombi;

Late phase: inflammation regression, thrombi organization, neo-capillary formation;

Ischemic alterations of nerve, muscle, skeleton, etc.
▲ Clinical manifestations
Insidious onset, slow progression, periodical episode, aggravated by smoking.

Chronic ischemia in extremities;

Recurrent migratory phlebitis.
▲ Clinical manifestations of chronic ischemia in extremities
 Coldness & lowering skin temperature in affected limbs;
 Pallor / cyanosis;
 Paresthesia;
 Intermittent claudication & rest pain;
 Tissue malnutrition: thinness of skin, ischemic ulcer → gangrene;

Weakness / absence of distal pulses in affected limbs.
▲ Diagnosis

Young & middle-aged males ；
 History ：
① Most pts. have history of smoking, no risk factors of predisposed atherosclerosis (hypertension, diabetes mellitus, hyperlipemia);
② Migratory phlebitis.

Chronic ischemic presentations in affected limbs;
 Weakness / absence of pulses of dorsal pedis A. & posterior tibial A;
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▲ Diagnosis
 Physical examinations: Buerger’s test;
 Auxillary examinations:
① Plethysmography
② Ultrasound: wave tracing, segmental arterial pressure measurement, ankle brachial index(ABI)
ABI>1.0: normal
0.5<ABI<1.0
： ischemia
ABI<0.5
： severe ischemia
③ Arteriography
▲ Therapy
Principle ： prevent from progression, improve & increase blood circulation in lower limb.

General management;

Drug treatment;
 Hyperbaric oxygen treatment: increase blood oxygen diffusion in extremities;
 Surgical treatment: arterial reconstruction, increase blood supply;
 Management of ulcer.
▲ General management
•
Absolutely forbid smoking ；
•
Avoid of coldness, humidity & injury;
•
Forbid local fomentation;
•
Proper pain-releasing;
•
Walk training / Buerger movement.
▲ Drug treatment
 中医中药：四妙勇安汤加减；
 扩血管和抑制血小板聚集药物：
①前列腺素 E1(prostagladin E1, PGE1)
②α 受体阻滞剂和β 受体兴奋剂
③ 2.5%MgSO4 溶液静脉滴注
④低分子右旋糖酐
 抗生素：广普 / 根据细菌培养和药敏。
▲ Surgical treatment

Lumbar sympathectomy: 2 、 3 、 4 腰交感神经和神经链。
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适应征：腘动脉以远动脉狭窄 / 闭塞，第一、二期患者；
 Arterial reconstruction:
① Bypass;
② Thromboendarterectomy ；
③ staged arterio-venous reversal.
Definition
A systemic disease mainly occurs in old pt. & in large & median calibre arteries, most often in distal aortic A. & ilio-femoro-popliteal A.
High risk factors
•
Hyperlipemia
•
Hypertension
•
Diabete mellitus
•
Obesity
•
Smoking
•
Others
▲ Clinical manifestations
According to progression & numbers of collaterals
Presentations of chronic ischemia

Coldness & decreased skin temperature in affected limbs;

Pallor / cyanosis;

Paresthesia;
 Intermittent claudication & rest pain;

Tissue malnutrition: thinness of skin, ischemic ulcer → gangrene;
 Weakness / absence of distal pulses in affected limbs.
▲ Diagnosis
• Old pts;
•
History ： Most pts. have high risk of predisposed arteriosclerosis
(hypertension, diabetes mellitus, hyperlipemia);
• Chronic ischemic presentations in affected limbs;
•
General examinations: blood lipid, blood sugar, EKG, examinations of ocular fundus ；
• Vascular non-invasive examinations: segmental arterial pressure measurement, ABI, ultrasound;
• DSA;
• MRA.
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▲ Treatment
Improve & increase blood supply in lower extremities.
 Conservative treatment;

Surgical treatment.
▲ Conservative treatment
Purpose:
Control blood pressure, lowering blood lipid, relieve hyper-coagulative state & promote collaterals formation.
Indications:

Assistant therapeutics to operation;

With diffused lesions, not candidate for operation;

High-risk pt., with no surgical tolerance.
▲ Surgical therapy
Conventional operations:
•
Endarterectomy: short segmental occlusion in aorto-ilio-femeral A.;
•
Bypass operations;
Endovascular interventions:
•
Percutaneous transluminal angioplasty, PTA;
•
Stent implantation.
Composition of emboli
•
Thrombosis
•
Atheromatous plaque
•
Fat
•
Substances from neoplasm
•
Air
•
Foreign body
•
Other
Sources of emboli
• Cardiac origin: rheumatoid / coronary heart disease, atrial fibrillation, bacterial endocarditis, etc;
• Vascular origin: atheromatous plaque, thrombi desquamate;
•
Iatrogenic origin: post-arterial catheterization;
•
Others.
▲ Clinical manifestations
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5P ：
•
Pain ：疼痛；
•
Paresthesia ：感觉异常；
•
Paralysis ：运动异常；
•
Pulselessness ：无脉；
•
Pallor ：苍白；
Poikilothemia ：皮温异常。
▲ Diagnosis
•
Previous history: companied with atrial fibrillation eg. heart diseases;
•
Sudden onset;
• With “5P” clinical presentations;
•
DSA helps to confirm.
▲ Treatment
Early diagnosis, early treatment.
Conservative therapy:
•
Emboli in small-sized A., with sufficient collaterals;
• High-risk pt., with no surgical tolerance;
• Obvious signs of gangrene, operation does no use to limb salvage.
Thrombolytic, anti-coagulative & anti-platlet therapy:
尿激酶 (urokinase, UK) 、肝素 (heparin)
糖尿病足
Diabetic foot
多发性大动脉炎
Takayasu’s arteritis
雷诺综合征
Raynaud’s syndrome
动静脉瘘
Arterio-venous fistula
淋巴水肿
Lymphedema
Questions
1.
Try to describe clinical manifestations and clinical stages of
5

Buerger’s disease.
2.
According to clinical stages of Buerger’s disease, try to describe its therapeutic strategies.
3.
Try to depict clinical manifestations of arteriosclerosis obliterans
(ASO) in lower extremities.
4.
The differential diagnosis of Buerger’s disease to arteriosclerosis obliterans (ASO) of lower extremities.
5.
Try to depict therapy to arteriosclerosis obliterans (ASO) of lower extremities.
6.
Try to depict the main point in the diagnosis of acute arterial thrombosis and the importance of early diagnosis.
7.
Try to depict therapy to acute arterial thrombosis.
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