Buerger’s disease, Thromboangitis obliterans, TAO

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：
①Most pts. have history of smoking, no risk factors of predisposed
atherosclerosis (hypertension, diabetes mellitus, hyperlipemia);
②Migratory phlebitis.
 Chronic ischemic presentations in affected limbs;
 Weakness / absence of pulses of dorsal pedis A. & posterior tibial A;

1
▲ Diagnosis
 Physical examinations: Buerger’s test;
 Auxillary examinations:
①Plethysmography
②Ultrasound: 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
③Arteriography
▲ 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.

▲ Surgical treatment
 Lumbar sympathectomy
 Arterial reconstruction
①Bypass;
②Thromboendarterectomy；
③staged arterio-venous reversal.

Arteriosclerosis obliterans, ASO

2
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.
▲ Treatment
Improve & increase blood supply in lower extremities.
 Conservative treatment;
 Surgical treatment.
▲ Conservative treatment
Purpose:
Control blood pressure, lowering blood lipid, relieve hyper-

3
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.
Acute arterial embolism
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
5P：
• Pain
• Paresthesia
• Paralysis： Pulselessness
• Pallor： Poikilothemia

4
▲ 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:
(urokinase, UK)、 (heparin)
Diabetic foot
Takayasu’s arteritis
Raynaud’s syndrome
Arterio-venous fistula
Lymphedema

Questions
1. Try to describe clinical manifestations and clinical stages of
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.