ROLE OF LUMBER SYMPATHECTOMY IN A CASE OF THROMBOANGITIES OBLITERANS

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INTRODUCTION

Thromboangitis obliterans is non atherosclerotic vascular

disease also known as burger's disease. It's have unknown etiology,

although a hypercoagulable state has been observed in association with

exacerbation of ischemic symptoms in patients with the disease, but it's

causal significance is exactly not known.

It's characterized by the absence or minimal presence of

atheromas, segmental vascular inflammation and involvement of small

and medium sized arteries of extremities. It's mostly occurring in young

adult males. There is genetic predisposition in case of Buerger's disease

like HLA DR 2 antigen, but significance of these immunologic findings

remains to be resolved.

The condition is strongly associated with heavy tobacco use and

chronic smoking which plays a pivotal role in disease development and

progression.

Lumbar sympathectomy has a role in surgical management of

thomboangitis obliterans by relief of pain or increase in claudication

distance, healing of ulcer and tropical skin lesions, improvement in signs

of ischemia.

As thomboangitis obliterans has unknown etiology mostly affect

young male with low socio-economic class group with loss of man power

and also no definitive treatment is established for the disease, which

inspired me for the study of role of lumbar sympathectomy in case of

thromboangitis obliterans.

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AIMS OF STUDY

The study was conducted with the following aim:

1. To analyze various indications of lumbar sympathectomy in young

adults.

2. To study the outcome of sympathectomy in form of relief of pain.

3. To study the outcome of sympathectomy in form of healing of ulcer.

4. To study the morbidity, mortality, and complication of Lumbar

Sympathectomy.

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REVIEW OF LITERATURE

Thromboangitis obliterans is a chronic non-specific, non-

necrotising, non-suppurative disease of unknown etiology, involving

segmental, episodic inflammation of small and medium sized vessels and

neurovascular bundle, with normal architecture of vessel wall & normal

vasa vasorum. Thucydide in 420 BC while examining the "occurrence of

gangrene of extremity in several young persons" give the earliest

reference to the thromboangitis obliterance.

In 460 BC hippocrate described gangrene and peripheral vascular

disease. In 1578-1659 Wiliam Havery performed methods of

investigation showed that blood circulates in closed system.

Quesnay (1739) described that gangrene resulting from arterial

occlusion. Friedlander (1879) suggested the term arteritis obliterance.

First reported case of thromboangitis obliterans was described in

germany by Von Winiwarter in an 1879 titled "a strange form of

endarteritis and endophlebitis with gangrene of the foot". The first

sympathectomy was performed by Dr. Alexander in 1889. Liven (1907)

gives importance of smoking in thromboangitis obliterans.

Leo buerger in brookline Newyork, in 1908 described pathology

clinical manifestations and treatment of Thromboangitis obliterans.

Buerger referred to the clinical presentation of thromboangitis obliterans

as a "presenile spontaneous gangrene"

Dr. A Kotzareff (1920) performed thoracic sympathectomy for

hyperhidrosis (excessive sweating) as it showed that it would cause

anhidrosis (total inability to sweat) from the nipple line upwards. Royle

and Hunter (1924) described lumbar sympathectomy for spastic paralysis.

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Adson and brown (1930) performed lumbar sympathectomy for

vasospastic disorder. Diez modified the method of sympathectomy.

Sympathectomy itself is relatively easy to perform; however accessing

the nerve tissue in the chest cavity by conventional surgical methods was

difficult, painful and spawned several different approaches. So the

posterior approached was developed by Dr. A. W. Adson in 1908, and

required resection of ribs.

Dr. E.D.Telford came up with a supraclavical (above the collar-

bone) approach in 1935 which was less painful than the posterior

approach, but more prone to damaging the nerves and blood vessels. In

late 1980 endoscopic version of thoracic sympathectomy was pioneered

by Dr. Goren Claes and Christer Drott at the Boras hospital in Sweden. In

addition to lumbar sympathectomy, hyperhidrosis and raynaud's disease,

Dr. E.D. Telford used the endoscopic thoracic sympathectomy for facial

blushing and psychiatric disorders such as social phobia and agoraphobia

and also for the hyperactive bronchial tubes.

In 1991 retroperitoneoscopic lumbar sympathectomy was carried

out by Rulli F, Galata G, Micossi C, Dell's Isola C.

Anatomy

The sympathetic system is a part of autonomic nervous system

which is made up of

1) Preganglionic fibers

2) Ganglia

3) Postganglionic fibers

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Preganglionic fibers: -

These are small medullated nerve fibers incorporated with cranial

and spinal nerves.

After a course, long in cranial nerves and short in spinal nerve, they

leave corresponding nerve and run independent to the ganglia.

Ganglia :-

These are structures where synapsing between pre and post

ganglionic sympathetic fibers occur. The following group of ganglia are

important:-Lateral, terminal and collateral

Lateral (Paravertebral ganglia):-This is essentially a chain of ganglia,

situated immediately lateral to the vertebral column extending from the

neck to the coccyx.

Collateral (Prevertebral ganglia ) :- situated in relation to the abdominal

aorta and its branches. Three collateral ganglion are well known: - a)

celiac b) superior mesenteric c) inferior mesenteric ganglion. Terminal

ganglia: - they are situated near the bladder and rectum.

Post ganglionic fibers :-

These are non medullated and to this group belong all the grey

rami communicants. These fibers pass to the viscera along with blood

vessels and reach the more superficial part.

Sympathetic nervous system:

Preganglionic nerve fibers arise from the lateral column of grey

matter in T1-L2 segments of the cord. They leave the cord in the anterior

roots of the corresponding spinal nerves; run a short course in the mixed

spinal nerve and beyond the junction of the posterior primary rami leave

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the spinal nerves as white rami communicantes (myelinated) to join the

symopathetic trunk. A white ramus joins the sympathetic trunk from each

spinal nerve from T1-L2.

Sympathetic trunks:

These trunks present as paired paravertebral sympathetic trunks

which consist of ganglia joined by nerve fibers. The trunks extend from

the base of the skull to the coccyx where they join to form the ganglion

impar. There are 3 cervical, 11 thoracic, 4 lumbar and 4 sacral ganglia.

It should be noted that only the ganglia from Tl to L2 receive white

rami communicantes and that the trunk above and below these levels is

formed by the continuation of white rami. From the sympathetic trunk the

fibers may follow one of the following paths:

Postganglionic Sympathetic Axons

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Hypothalamus

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1) SOMATIC FIBRES:-

They enter the paravertebral sympathetic trunk to synapse in

ganglia corresponding to their spinal segments of origin or with grey rami

communicants (non myelinated postganglionic fibers) to every one of the

31 paired spinal nerves. These postganglionic fibers supply

vasoconstrictor fibers to arterioles, secretary fibers to sweat glands and

pilomotor fibers to the somatic distribution of the skin.

2) VISCERAL FIBRES:-

a) The thoracic viscera synapse in the cervical and upper thoracic

ganglia and the grey postganglionic fibers reach the viscera

through the cardiac, oesophageal and pulmonary pexuses.

b) To the abdominal viscera traverse the ganglia in the paravertebral

chain without synapse and enter one of the splanchnic nerves and

synapse in one of the abdominal prevertebral plexuses.

c) To the adrenal medulla run through the paravertebral trunk without

synapsing and proceed in the greater splanchnic nerves through the

celiac plexus to the adrenal medulla.

d) To the cranial structures such as the dilator papillae, superior tarsal

muscle, nasal and salivary glands

Cervical sympathetic trunk:-

This nerve trunk lies in the prevertebral fascia between the carotid

sheath and the prevertebral muscles(longus colli and capitis) behind.at it's

lower part it is continuous with the sympathetic trunk in the thorax; above

it is continued into the skull as the internal carotid nerve. There are three

ganglia on the cervical sympathetic trunk. The upper and lower are large

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the middle small. Each of three ganglia gives

1) Gray rami communicantes to the cervical nerves

2) Cardiac nerves

3) Plexus to an artery

Lower two cervical segmental ganglia fused with the first thoracic

ganglion which is known as the stellate ganglion.

Image

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Thoracic sympathetic trunk: -

This portion of the trunk is usually comprised of 11 ganglia of

which the first is fused to the inferior cervical ganglion. The upper 10

ganglia lie outside the parietal pleura against the heads of the ribs and the

lower 2 ganglia lie on the sides of the bodies of the corresponding

vertebrae. The sympathetic trunk becomes continuous with the lumbar

sympathetic trunk when it passes into the abdomen dorsal to the medial

arcuate ligament.

Branches:

1) Grey rami communicantes to the spinal nerves.

2) Visceral branches from the upper 6 ganglia to the pulmonary and

cardiac plexus.

3) Splanchnic nerves:

a) The greater splanchnic nerve consist of myelinated

preganglionic fibers from the 5th to the 10th thoracic ganglia. It

descends obliquely on the bodies of the vertebrae, cross the

crus of the diaphragm and end in the celiac ganglion in the

celiac plexus.

b) The lesser splanchnic nerve arise from the 9th and 10th thoracic

ganglia and pierces the crus of the diaphragm and joins the

aorticorenal ganglion.

c) The lowest splanchnic nerve arises from the last thoracic

ganglion and enters the abdomen with the sympathetic trunk

and ends in the renal plexus.

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Lumbar sympathetic trunk: -

There is a lumbar sympathetic trunk on each side. The trunk lies

retroperitoneally on the anterolateral surface of the bodies of the lumbar

vertebrae along the medial margin of the psoas major muscle. The trunk

lies anterior to the lumbar arteries and veins may pass anterior to it. On

the right side the trunk is overlapped by the inferior vena cava and on the

left side it is partially covered by the aorta. Lateral aortic lymph nodes lie

in close association with the trunk, the genitofemoral nerve passes

through the fibers of the psoas major muscle and then lies on the anterior

surface of the muscle lateral to the sympathetic trunk. The ureter also lies

lateral to the sympathetic trunk.

The first and second lumbar ventral rami send white rami

communicantes to the corresponding lumbar ganglia. There are usually 4

ganglia on each side the first lumbar ganglia may lies above the fascia of

the medial arcuate ligament or under the insertion of the cms. The

sympathetic trunk below the last lumbar ganglion divides into 2 or 3 fine

branches which pass posterior to the common iliac artery and continues

as the pelvic part of the sympathetic trunk.

Branches:-

1) Splanchnic nerves pass from the ganglia to join the celiac

intermesenteric and superior hypogastric plexus.

2) Grey rami communicantes from all the ganglia to the lumbar spinal

nerves.

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Pelvic part of the sympathetic system:-

This part of the sympathetic trunk is situated in the extraperitoneal

tissue in front of the sacrum medial to the anterior sacral foramina. The

trunks converge caudally to form the ganglion impar on the anterior

aspect of the coccyx. There are normally 4 or 5 sacral ganglia. The

sympathetic trunk gives rise to grey rami to the sacral and coccygeal

nerves. Medial branches join the inferior hypogastric plexus.

Physiology:

Control of blood flow in the limbs is a dual process by

sympathetic control or by chemical/hormonal influence.

All arteries are contractile to appropriate stimuli. This ability to

constrict or to dilate is greatest in arteries, which have a high proportion

of muscle tissue in their tunica media. The mechanism which regulates

the caliber of arteries is complex one:

Nervous control through the sympathetic system.

Chemical

Autonomous activity of arterial wall itself.

All these three sets act together and it is the net result of their

combined activity which determines the circulation of the part.

Nervous control:

Through the sympathetic system stimulation of sympathetic

nerves causes vasoconstriction and sympathectomy results in

vasodilatation.A constant flow of nerve impulse is passing along

sympathetic fibers which are concerned with vasoconstrictor tone, which

is imposed mainly upon the vessels which receive the greatest number of

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sympathetic fibers. If the peripheral nerve is divided or blocked

vasodilatation occurs in the appropriate dermatome.

Autonomous control:

Autonomous activity controls the caliber of blood vessel by smooth

muscles of vessels which maintain the basal tone which independent of

the influence of nerves or hormones. Function of the autonomic system:-

Heart: - cardiac stimulation

Increase heart rate contractility and bathmotropic

effects.

Blood vessels: - Constriction of cutaneous and splanchnic

arterioles

Coronary and skeletal arteriolar dilatation

Venoconstriction

Redistribution of blood in the body.

Skeletal muscle: - Increased glycogenolysis

Increased strength

Hyperglycemia

Gut:- Spasm of the sphincters and inhibition of general

Smooth muscles

Inhibition of peristalsis and tone

CNS:- Papillary dilatation

Retraction of the eyelids

Increased alertness

Loss of sleep

Genitourinary: - Relaxation of detrusor and spasm of sphincter

Semen ejaculation

Thermoregulation: Cutaneous vasoconstriction

Maintains skin temperature by capillary

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circulation

Regulates sweat gland secretion

Piloerection lipolysis

Raised body temperature

Respiratory: - Bronchodilatation

Tachypnoea

Hormonal and chemical control

Adrenaline and noradrenaline are important hormonal substances. There

are two types of adrenergic receptors.

Alpha constrictor

-noradrenaline

-serotonin

They are related to increase blood pressure and peripheral

vasoconstrictor.

Beta (dilator)

-isopropyl

-histamine

-bradykinin

They lead to peripheral vasodilatation. Muscle metabolites

-acetyl choline

-adenosine

They cause skeletal muscle and smooth muscle contraction.

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Pathology

Thromboangitis obliterans is a low grade inflammatory non

suppurative pan-arteritis or pan phlebitis with associated thrombosis but

without necrosis of the wall.

The thrombus becomes organized by means of a heavy growth of

fibroblasts which produce organic occlusion of the vessel lumen. The

disease begins in medium sized or small artery and veins. The lesion is

distinctly segmental and episodic.

Primarily a disease of blood vessels of extremities, however lower

limbs are involved more after than the upper limbs. Occlusion results in

destruction or impairment of the function of the involved segment.

Occlusion is followed by extensive development of collaterals and

anastomotic vessels.Secondary pathological effects are the results of

ischemia and malnutrition of tissues.

Severity of disease is directly proportionate to how much rapidly

and how much extensive collateral circulation develops.

Macroscopic changes:-

It depends on the age of lesion the vessels appear somewhat

contracted at the site of occlusion.

Initially as the time passes it becomes yellowish sometimes, there is

fresh red thrombus on either side of an old one. Artery is more frequently

involved than vein.

Typically segmental, affecting small and medium sized arteries,

especially of the lower extremities are seen. Involvement of the arteries is

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often accompanied with involvement of adjacent veins and nerves. Mural

thrombi are frequently present in the vessels.

Microscopic changes:-

Acute stage of panarteritis in Buerger's disease

There is infiltration of all the coats of artery and vein by

lymphocyte, plasma cells and polymorphonuclear cells. The intima is

somewhat thickened by endothelial proliferation. Muscle fibers of media

are atrophied. Adventitia is extensively infiltrated by fibrous tissue and

round cells. The internal elastic lamina remains intact but is thickened

and sometimes duplicated.

At the site of intimal proliferation the lumen is occluded by a soft

red thrombus sometimes round cells and foreign body giant cells are also

present. Later on recanalisation takes place and is visible as an irregular

centrally placed lumen but it is not sufficient to maintain the nutrition of

the part.

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The lesion in the vein resemble to those in the arteries. In advanced

stages the cellular infiltrate is predominantly mononuclear and contain an

occasional epitheloid cell granuloma with langhan's giant cells. The

thrombi undergo organization and recanalisation takes places, in chronic

cases, marked fibrosis of the media is present.

Aetiology

It is a chronic nonspecific non-necrotising nonsuppurative disease

of unknown etiology, involving segmental episodic inflammation of

small and medium sized vessels and neurovascular bundle with normal

architecture of vessel wall and normal vasa vasorum.

A non atherosclerotic vascular disease also known as buerger's

disease.There is absence or minimal presence of atheromas. Exact

etiology is not known because no single aetiological mechanism has been

found satisfactory.

Age: most common between 20-45 years Sex: Almost exclusively in

male

Only ablout 1% in female

Male to female ratio 3:1

Female are immune from this disease which is attributed to:

1) hormonal effects

2) x chromosome predisposition may play some role

3) less smoking in female

Race: Dr. Buerger initially showed more tendency of this disease to

develop in jews but all religions are equally susceptible.

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Buerger disease is relatively less common in people of northern

European descent.Natives of India korea and japan and Israeli jews of

Ashkenazi descent have the highest incidence of disease. Occupation:

Occurs usually in low socio-economic group. Climate: Cold has a

deleterious effect on patient who have thromboangitis obliterans and

disease tends to be worse in cold. Probably a secondary effect as a result

of vasoconstriction superimposed on arterial occlusion. Severe

thromboangitis obliterans is also seen in patients who always resides in

warm climate.

Infection: The inflammatory reaction due to bacterial and viral

contamination, gram negative organisms were cultured from the blood of

the patients. Infection of these organisms in rabbit produced dry gangrene

in lower limbs.

Blood changes: Increase in viscocity of the blood

Rapid coagulation of venous blood

Metabolic disorder: Diabetes mellitus

Because of diabetes microangiopathy (which causes decreased blood

supply) to the area, neuropathy (minor trauma are more common). High

risk for infection and decreased generalized resistance all collectively

causes gangrene of the part more commonly.

Atherosclerosis: Leads to vascular occlusive effect on cardiac function.

Auto immune: This is based on the finding of both antibodies and

lymphocyte sensitivity to collagen in thromboangitis obliterans.

Trauma: Trauma to vessels may lead to ischaemic changes of the part

due to arterial occlusion by

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1) thrombosis

2) spasm

3) subintimal haematoma

Familial tendency: No such cause can be established. Tissue typing of

patients with thromboangitis obliterans has shown greater prevalence of

HLA- A and HLA-B antigen .this suggest that disease is an

immunogenetic entity related to absence of protective gene.

Smoking: Use of tobacco particularly for smoking is the most important

etiological factor in Buerger's disease tobacco chewing also has effect on

vessels.

The composition of tobacco smoke

Chief ingradients are:-

1) nicotine (acute effects)

2) tars(chronic effects)

Nicotine from smoke of cigars and pipes is obtained without

inhalation as it is alkaline and unionized lipid soluble absorbed in the

mouth.

Cigarettes smoke is acidic and nicotine is ionized and insoluble in

lipid.so smoke or cigarette is inhaled. Tobacco smoke contains carbon

monoxide.

Substance:- polycyclic hydrocarbons and N-nitroso compounds are

carcinogenic.

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Types of smoking:

a) non pharmacological

pshychological

sensorimotor

b) pharmacological

indulgent

sedative

stimulant

addictive

Nicotine is absorbed through mucous membranes. The plasma life is 2

hours.

Nicotine can both stimulate and depress nervous tissue functions. There is

vasoconstriction in the skin and vasodilatation in the muscle. Tachycardia

and rise in blood pressure of blood by increasing platelet adhesiveness.

Passive smoking:

It is difficult to measure the extent of the risk to health from passive

smoke exposures. Composition:

1) nicotin

2) carbon monoxide

3) -ammonia

4) carcinogens (benzopyrene)

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Effect of smoking:

It may affect oxygen dissociation from hemoglobin in

peripheral tissue and produce hypoxia. Carbon monoxide is directly toxic

to vessels mainly endothelial cells.

It also causes spasm of vessel wall by direct effect. It affect

catecholamine metabolism and thus causes vasoconstriction. Produce

hypercoagulable state leading to thrombosis.

Nicotine is responsible for vasoconstriction. Number and

duration of smoking has direct relation to the state of disease.

Alcohol:-Chronic alcoholism causes nutritive problems lead to decreased

enzyme activity of intestinal and gastric juices. Cirrhosis of liver is

common consequence of alcoholism leads to anaemia. Even though local

application has cooling and refreshing effect oral administration may

cause vasodilatation.

Clinical features:-

Intermittent claudication:-

Claudication is used here to describe the muscle pain due to

accumulation of the excessive p substance owing to inadequate blood

flow. It is a pain in the muscles usually in the calf and is described by the

patient as a cramp.

Pain develops only when the muscle are working.

Pain disappear when the exercise stops or at rest.

Site of pain depend on the levels of arterial occlusion:

In Buerger's disease - arterial occlusion is mostly in lower tibial

or plantar arteries- so pain is mostly in the foot.

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Boyd's classification:-

Grade 1- pain stalls sometimes if the patient continues to walk the

metabolites increases the muscle blood flow and sweep the p substances

produced by exercise and pain disappears.

Grade 2-pain continues and patient can still walk with efforts.

Grade 3- pain compels the patient to take rest.

Rest pain:- This pain is continous and aching in nature. This pain seems

to be due to ischaemic changes in the somatic nerves. It is the cry of the

dying nerves. Pain worse at night, gets aggravated by elevation of leg

above the level of the heart and relieved by hanging the leg below the

level of the heart. Severity of disease can be assessed by claudication

distance. This distance which patient can walk without pain is called

claudiction distance. It is altered by walking uphill or against a wind the

speed of walking or by change in general health such as anaemia or heart

failure.

Duration of claudication:

Progress: Whether progressive, regressive or stationary.

Duration of rest: As severity of disease increase claudication distance

decreases and time of rest increases.

Coldness of affected part: Earliest subjective manifestation of the disease

usually in foot, toes or lingers.

Sensory changes:-

Burning pain, tingling, numbness etc. often occur when nerve trunk is

involved in disease.

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When muscle pain begins, the patient often feels numbness pins

& needle sensation and other types of paraesthesia in skin of foot, due to

shunting of blood from skin to muscle.

Motor changes: -

Muscular wasting and weakness because of disuse atrophy due to pain

and because of decreased blood supply lead to decreased nutrient and

wasting.

Ulceration and gangrene: -

Patient may present as painful, superficial erosion between toes. There

may be small shallow indolent nonhealing ulcer on the dorsum of the

foot, on the skin and around malleoli. There may be dry gangrene of toes

or fingers. There may be edema of leg or may be history of migratory

thrombosis.

Examination:-

thining of skin shininess

diminished growth of hair

loss of subcutaneous fat

trophic changes in nails

brittle and show transverse ridges.

Minor ulceration in pressure areas such as heel, malleoli, ball of foot, tip

of toes etc.

Temperature changes:-

Affected limb is colder than those of a normal limb, this is due to

ischemia and detected by palpation or by thermometer.

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Capillary filing time:-

After elevation of legs, the patient is asked to sit up and hang his leg

down by the side of table.

A normal leg will remain pink as it was in elevated position. An

ischemic leg will first become pallor when elevated and gradually

become pink in horizontal position. This change of color takes place

slowly and is called the capillary filling time.

In severe ischemia it takes about 20-30 seconds to become pink

then the ischemic limb again changes color and become purple red

quickly. This is due to filling of dilated skin capillaries with

deoxygenated blood.

Venous refilling: -

After keeping the limb elevated for a while if it is then laid flat on

bed, there will be normal refilling of the veins within five seconds.

In ischaemic limb, it will be delayed.

If a normal limb is raised to about 90degree there will be gradual

collapse or guttering of the veins but in ischemic limb the veins are seen

collapsed either in the horizontal position or as soon as it is lifted to 10

degree above horizontal level.

Buerger's postural test:-

This test must be carried out in broad day light. The patient lies on

his back on the examining table. The patient is asked to raise his legs one

after the other keeping the knees straight. The legs of a normal individual

remain pink even if they are raised to 90 degree. But in case of an

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ischaemic limb elevation to a certain degree will cause marked pallor and

the veins will be empty and guttered. The angle between the limb and the

horizontal plane at which such pallor appear is called 'Burerger's angle'. A

Buerger's angle of less than 30 degree indicates severe ischemia.

Ulceration and gangrene:-

May occur spontaneously but in 50 % cases, they follow mechanical,

chemical or thermal trauma. Gangrene may involve either tip or entire

digit, sometimes whole foot or leg may also be affected. It is usually dry

gangrene. Moist gangrene occurs when secondary infection takes place.

Impaired arterial pulsation:-

Usually dorsalis pedis and /or posterior tibial pulsation are absent.

Impairment of popliteal or femoral pulsation is less frequent but, may

occur in advanced cases.

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Arterial pulsation:

Artery Affected

site

Site of palpation

Dorsalis

pedis

Fore foot Against the middle cuneiform bone just

lateral to the tendon of extensor hallucis

longus at the proximal end of the first web

space

Posterior

tibial

Foot Behind the medial malleolus against

calcaneum

Anterior

tibial

Foot Midway between the two malleoli against

the lower end of tibia

Popliteal Leg(calf) -supine position with flex knee in the lower

part of the popliteal fossa against the back of

tibia. -In prone position- with flex knee,

against the lower end of the femur.

Femoral Thigh Just below the inguinal ligament midway

between anterior superior iliac spine and

symphysis pubis, against the head of the

femur

Common

iliac

Gluteal

region

Plantar arch Finger

Radial Hand Against the lower end of the radius

Ulnar Hand Against the lower end of the ulna

Brachial Forearm Lower area behind tendon of biceps against

humerus

Axillary Arm Against the head of humerus

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Investigations:-

Non invasive Doppler ultrasound:-

Principle:-

An ultrasound beam is passed through the skin to an underlying blood

vessel and is reflected from red cells. The reflected sound is detected by

receiving crystal mounted in the transducer close to the emitting crystral.

The pitch of audio frequency signal is proportional to the velocity of

blood flow within the vessel under study. Indication:-

To measure arterial blood flow status pre-operatively as well as post

operatively. Advantages:-

Noninvasive

Can be performed repeatedly

Results can be recorded in form of: - graphical tracing

Video recording Tracing over the plate Limitations:- false results - as it

cannot be used for capillary circulation.

Pressure index:-

Measurement of systolic pressure by means of a cuff around the

ankle is done. Normally ankle systolic pressure at rest is equal to or

greater than brachial systolic pressure. Difference between brachial and

ankle pressure also called systolic gradient is 0 or negative.

If the ankle systolic pressure at rest is more than 5 mm of mercury

below brachial pressure an occlusion proximal to the point of

measurement can be diagnosed. Systolic pressure measurement after

exercise is helpful in differentiating vascular from nonvascular walking

disability.

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Pressure index: - ankle pressure/arm pressure

Normal value is 1, value less than 0.9 suggests ischemia.

Limitations :-

False high values, due to poor compressibility of the arteries are

most common in diabetes and in chronic renal insufficiency and in

indurated edema.

Skin temperature:-

This is valuable when they are taken from symmetrical areas of the

extremities. Methods:-

Palpation of skin is a rough guide but estimate the difference of as

little as 1 degree Fahrenheit. Measured by the mercury skin thermometer

but its not very accurate.

Skin thermometer based on thermo-couple. In thromboangitis

obliterans the affected part is colder than other part due to decreased

blood supply to the part. But in the presence of infection or

pregangrenous condition the part may be warm.

Invasive:-

Paravertebral block:-

Used for pre-operative confirmation of diagnosis as well as for

assessment of results of sympathectomy.With certain precaution,the

method is safe, painless and harmless.

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Arteriography :-

Indication:-

In young patients cause other than arteriosclerosis is

suspected.

When surgical opening of lumen is proposed

To know vascular status of the part

Method:- By injecting conray(28) or (240) or urograffin (76%)

in the artery under fluoroscopic control.

Use-

To detect the levels of obstruction

Condition of collaterals

Help to distinguish Buerger's disease from

areteriosclerosis.

Show number and length of block

Help to decide what type of treatment and at what

level to be operated.

Diagnostic criteria:-

Multiple occluded segments in small and medium sized arteries in

forearm, hand, foot or leg.

The collateral circulation established through the vasa vasorum

surrounding the thrombosed segment 'cork screw' appearance of fine

vessels is considered typical.

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The normal outline of tibial plantar and digital arteries is replaced by

network of numerous thin, fine tortuous shaped vessels which often end

abruptly- with no prolongation and may be displayed as tree roots or

spider legs (martorell's sign). The patent distal circulation may be visible

through collateral circulation.

Limitation:-

Invasive process

Sensitivity to dye

Should not use to assess abnormalities of function

Complication:-

Dissecting aneurysm

Hemorrhage

Embolism

Digital substraction angiography

With far less discomfort and anger, and usually the information is

adequate to help to decide whether to perform an operation and how best

to do it. Intra arterial digital substraction angiography shows the popliteal

tibial and even pedal arteries very well, often they have not been seen on

conventional arteriography as in a patient with rest pain or gangrene.

Isotope technique:-

Xenon 133/ technetium 99 dissolved in isotonic saline, injected

im/iv and clearance of which is used to study the blood flow in calf

muscle, for this gama camera is used.

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MANAGEMENT

Arrest the progress of disease:-

care of foot

correction of anaemia

control of diabetes or other disease

regular exercise within limits of pain

anticoagulant therapy

low molecular weight dextran

stop smoking

Promote circulation:-

Mechanical

Buerger's position:- 12 cm elevation of head end of

bed. Buerger's exercise:- repeated 2 minute

elevation and dependency of limb for 8-10 times a

day.

To regulate the temperature of the affected part

In pregangrenous condition- local cooling In

ischaemic pain - Local heating

Local alcohol

Medical treatment:-

Vasodilator drugs:-

Arlidine

Dose:- 3-6 mg tds

Muscle relaxant

32

Side effects:-

Cardiac arrhythmia

Peptic ulcer

Headache

Other vasodilators are:-

Prostaglandin E2

Papaverin

Duvadilin

Phenoxy benzamine

Dose:- 20-60 mg / day

Arteriolar dilator

Side effects:-

Palpitation

Giddiness

Postural hypotension

Antiplatelet drugs:-

Prevents platelets aggregation

Used in thrombotic disease.

Aspirin

Dose:- 325 mg half tab /day

Dipyridamole

Dose: 400mg tds orally or iv •

Improving capillary circulation by increasing the flexibility of RBCs.

Decreasing the blood viscosity.

Inhibit the platelets aggregation.

33

Contraindication:-

Pregnancy

Bleeding tendencies

Prexiline:- Alters tissue metabolism to increase claudication distance.

Pentoxyphylline:-Decrease rouleaux formation and so decrease blood

viscosity

Local application of alcohol

Analgesic Antibiotics

Electrical blankets: -

Affected limb at room temperature

Trunk and remaining limbs are heated by electric blankets.

Reflex heating and vasodilation of affected limb may occur.

Sympathectomy

Sympathectomy will release vasomotor tone and will increase blood flow

through collateral arterioles, therefore it has been widely used in the

treatment of patients with occlusive and vasospastic diseases of the

extremities like Buerger's disease.

Indications:-

intermittent claudication

rest pain

ulcer to improve healing

- gangrene to lower down level of amputation

- presence of ischemic changes

- along with other vascular surgery

- excessive sweating (hyperhidrosis)

- causalgia

34

Lumbar sympathectomy:-

Preganglionic fibers for the lower limb arise from the spinal cord from

the lower four or five thoracic and upper two lumbar nerves.

Removal of second and third lumbar ganglia denervates the limb from the

middle of the thigh distally.

Removal of the first ganglion denervates the groin and the upper half of

the thigh. Lumbar sympathectomy does not affect sexual function when

done on unilateral side

During bilateral sympathectomy first lumbar ganglion preserved on

atleast one side because bilateral removal may lead to impotence due to

paralysis of the ejaculatory mechanism.

Plan of operation: The plan of operation is to remove the lumbar

sympathetic ganglionated nerve from at least the first to fifth lumbar

vertebra including afferent and efferent rami to the chain and the terminal

portion of the sympathetic trunk. If sympathectomy is to be performed

bilateral then the first ganglion should be removed only on one side.

Anaesthesia: General endotracheal anesthesia is desirable since there is

some chance of entering the pleural cavity superiorly.

Position: Place the patient in the laeral position with the side to be

operated upon upward. The area between the twelfth rib and the pelvic

crest should be centered over the break in the operating table or over the

kidney rest. The lower led is extended and the upper leg is flexed to

provide relaxation of the psoas muscle.

35

Procedure:

Extraperitoneal approach Intraperitoneal approach

Extraperitoneal approach:-

Through transverse or oblique loin incision

Begin the skin incision at the tip of the twelfth rib, carry it downward and

medially to meet the lateral border of the rectus sheath at a point 2 cm

below the umbilicus

If the space between the twelfth rib and the iliac crest seems ample,

incision may be brought 1 or 2 cm below the twelfth rib without

removing it.

Incise the external oblique and internal oblique muscles in the direction

of skin incision.

Transversus abdominis incised in the direction of its fibers

Properitoneal fat and peritoneum are found directly under the transverses

muscle anteriorly.

Retract the edges of the divided transversus abdominis and bluntly dissect

the peritoneal sac and it's content medially.

As this dissection performed psoas muscle and other structures in

retroperitoneal area will be seen.

36

Avoid the groove behind the quadratus lumborum muscle.

Sympathetic chain is identified by palpating the chain with it's

characteristic ganglia in the position in groove between the vertebral

bodies and the psoas muscle.

On right side it is behind the inferior vena cava

On left side it is overlapped by the aorta Hold the sympathetic chain taut

with nerve hook, and trace it upward and downward.

1st ganglion must be looked for higher up under the cover of the cms of

the diaphragm and grasp the superior portion of the sympathetic chain

with a hemostat. Trace the chain downward one or more lumbar veins are

encountered they are usually posterior to the chain, which is gently

dissected of them. If the chain goes behind the veins it may be easier to

isolate and divide the veins.

The inferior portion of the sympathetic chain lies under the iliac vessels

and should be carefully dissected out. Usually at the level of the iliac

vessels the sympathetic chain has divided into two or three terminal

branches. Apply silver clips to these and divide the chain inferiorly. Close

the incision in layers. Transversus abdominis, internal oblique and

external oblique with vicryl 2-0 by interrupted suture skin with ethilon 2-

0 by vertical mattress suture.

Intraperitoneal approach

Indication:-

For bilateral operation

When peritoneum is to be open for some other condition

Abdomen is opened through lower midline or paramedian incision. For

left side posterior peritoneum is incised along the lateral side of the

37

descending colon and for right side the caecum and ascending colon may

be mobilized.

Cervico-thoracic sympathectomy

Vasospastic disease of the upper extremities that does not respond to

medical treatment may be treated by cervicodorsal sympathectomy. The

cervocodorsal sympathetic chain is removed from the level of the sixth

cervical vertebra inferiorly to the fourth thoracic ganglion.

Supraclavicular approach

This implies the removal of atleast second and third thoracic ganglion

which contains the cells of the most of post ganglionic fibers supplying

the upper limb.

For complete denervation of the upper limb a small lower part of the

stellate ganglion should also be removed as in case of causalgia of the

arm. In intaractable and disabling hyperhidrosis of the hands requires

only stellate ganglionectomy. Anaesthesia Endotracheal general

anesthesia

Procedure:

Incision and surgical approach

1) place the patient in the supine position with the head turned away from

the side of the incision and the neck somewhat hyperextended

make the incision above and parallel to the clavicle from the

midportion of the sternocleidomastoid muscle lareally to the

anterior edge of the trapezius muscle.

2) Divide the platysma and the clavicular head of the sternomastoid

muscle.

38

3) Divide the omohyoid muscle near it's clavicular origin

4) Retract the prescalene fat pad laterally retract the jugular vein

medially and identify the phrenic nerve overlying the anterior

scalene muscle.

5) Retract the phrenic nerve medially and divide the anterior scalene

muscle close to it's attachment at the first rib.

Identification of stellate ganglion and cervical sympathetic trunk

1) Identify and exposure the subclavian artery and ligate and divide the

thyrocervical arterial trunk. Palpate the stellate ganglion as it lies on

the neck of the first rib lateral to the vertebral artery and in close

proximity to the vertebral vein.

2) Lift the stellate ganglion with a nerve hook and with gentle blunt and

sharp dissection identify it's dumbbell shape and its various rami.

Trace the sympathetic chain upward upto the transverse process of

the sixth cervical vertebrae where the vertebral artery dips

posteriorly to enter the foramen in the transverse process.

Exposure and removal of sympathetic ganglia

1) with sharp and blunt dissection, mobilize the pleura from the entire

circumference of the first rib. Posteriorly the attachment ate more

dense. Detach the apical pleura from the upper dorsal pleura from the

upper dorsal vertebrae and the subclavian artery and push it

downward.

2) Divide the highest intercostals artery if it is present. The artery

crosses the thoracic inlet after the pleura over the cupula of the lung

has been pushed downward. Hold the pleutra laterally and the necks

39

of the first four ribs. If the thoracic inliet throghout the circle of the

first rib is large, the pleura can be mobilized as far as the azygous

vein on the right side and the fourth or fifth dorsal vertebra on the

left side. Divide the insertion of the posterior scalene muscle if

necessary to enlarge the thoracic inlet.

3) Place a nerve hook under the sympathetic chain, lift it from the

vertebrae. Identify and clip the various rami with silver clips. At the

lower end of the resection place several clips across the chain to

mark the inferior limit of the resection.

4) Divide the chain inferiorly below the third dorsal ganglion or lower

when feasible the trace it syperiorly dividing the rami of the stellate

ganglion, and mark the upper extent of the resection with silver

clips.

Closure

1) Leave a no.20 catheter in the extrapleural space along the spine until

closure of the skin is airtight.

2) Suture the clavicular head of the sternomastoid muscle. Do not

attempt suture of the scalene or the omohyoid muscle.

3) Suture the platysma with fine silk.

4) After a correct sponge count close the skin airtight around the

catheter

5) Aspirate the catheter while the anesthesiologist applies positive

pressure to the lungs this inflates the lung and prevents dead space.

6) Withdraw the catheter with continuous suction and apply a dressing.

40

Anterior transthoracic approach

Sympathectomy by the transthoracic route removes the dorsal

sympathectic chain usually from the first to the fifth dorsal vertebra,

including the cardiac rami or nerves. Indication

Vasospasm or arterial insufficiency of the upper extremity that relapses

after stellate or cervical ganglionectomy

Paroxysmal auricular tachycardia refractory to all medical therapy.

Anesthesia General endotracheal anaesthesia

Procedure

1) Place the patient in the supine position with the arm elevated and

supported tilt the table away from the side to be operated upon.

2) Make a long incision in the third intercostals space extending from

the sternum laterally to the anterior axillary line.

3) Incise the pectoralis major muscle in the direction of it's fibers.

4) Incise the intercostals muscles and pleura widely to permit spreading

the ribs. Insert the rib spreader.

5) Free the lung if necessary and retract it inferiorly holding it in place

with a Harrington retractor.

6) Tilt the table to the left about 15 degrees and visualize the superior

vena cava and phrenic nerve. The mediastinal structures wll be

retracted medially. On the left side the aorta and subclavian artery

are seen.

41

Removal of the sympathetic nerve and ganglion

1) Identify the ganglionated chain beneath the parietal pleura on the

vertebral bodies close to the necks of the ribs.

2) Incise the pleura overlying the sympathetic chain and place three

dural clips on the chain to mark the distal end of the resection for

radiographic identification at a later date. This will be at the level of

the hilum of the lung, normally about the level of the fifth dorsal

vertebra.

3) Remove the sympathetic chain from below upward dividing the rami

connecting it to the spinal nerves as they are encountered

4) Identify the neck of the first rib and the first dorsal ganglion that is

the lower part of the stellate ganglion the upper part of the stellate

ganglion will not be completely visualized from this approach.

5) Mark the upper extent of the resection with a dural clip and divide

the chain between the ganglia on the neck of the first rib.

Closure

1) Place an anterior chest tube in the fourth intercostals space through

a small separate stab incision

2) Approximate the ribs with pericostal sutures.

3) Close the pectoral fascia, superficial fascia and skin in layers.

Through supraclavicular incision the ganglion may be approach above or

below the arch of the subclavian artery.

Sternomastoid and scalenus anterior muscles are divided subclavian

artery is retracted downwards, thyrocervical trunk ligated, the

suprapleural membrane is detached from the inner border of the first rib.

The sympathetic chain is found crossing the neck of the ribs.

42

Axillary approach

It gives easy and direct access to the upper thoracic ganglion but is less

convenient for the stellate ganglion.

Incision is made in the medial wall of the axilla in 2nd intercostals space.

The only important structure is nerve to serratus anterior.

After division of intercostals muscles pleural cavity is entered and lung is

drawn downwards. The chain should be seen through parietal pleura.

Posterior approach

In the method part of 3rd rib is resected posteriorly, but it causes certain

amount of after pain so it is not recommended

Other surgery

Omental transplantation Placental implantation

Amputation

Amputation in the case of TAO is a palliative method and done in the

presence of gangrene of part or functionally dead part. Indication:-

Ulcer and gangrenous lesion of digits

Intractable pain

Severe infection

Failure of conservative treatment or sympathectomy

43

Complications: -

Laceration of the lumbar and iliac vein and the inferior vena cava

on the right side in lumbar sympathectomy

Damage to intercostals vessels.

Injury to the ureter

On left side emboli may be dislodged from the aorta and iliac

vessels.

Retroperitoneal haemorrhage-especially in patients on

anticoagulant therapy.

Postsympathetic pain usually begins in two weeks after

sympathectomy is often nocturnal and generally remits

spontaneously within three months. It is deep and boring in nature

involving the thigh and may require narcotics

Bilateral removal of the lower most preganglionic fibers may result

in failure of ejaculation.

Post operative abdominal distension is usually a result of paralytic

ileus and may require nasogastric intubation.

Local care of ischemic areas is carefully continued during the pre-

operative and post-operative period to prevent major amputation.

Damage to the nerve to serratus anterior, giving rise to winging of scapula.

Mortality from lumbar sympathectomy ranges from one to 6.5% is

usually from cardiac or pulmonary complication and occurs usually

in very aged person.

Following inadequate removal of the sympathetic chain,

regeneration of nerve may occur.

Misdiagnosis of chain during operation.

Excessive sweating in non denervated area as a compensatory

mechanism.

44

MATERIAL AND METHODS

A prospective study of 70 patients admitted between June 2004 to

December 2006 in whom thromboangitis obliterans was diagnosed and

lumbar sympathectomy was performed which was carried out at S.S.G.

Hospital &medical college Baroda. In all the cases a detailed history and

physical examination was entailed as per proforma.

Survey was made in the surgical wards and cardiothoracic wards of our

hospital at regular interval for a patients of Buerger's disease& for a

patient in whom lumbar sympathectomy was planned. A personal study

of these patients during hospitalization i.e. from admission till discharge

& their subsequent follow up was carried out.

Following general data was recorded in each patient in form of 1) age 2)

sex 3) socio-economic status.

A detail history of patient's illness and their progression about

intermittent claudication, rest pain, ulcer & gangrene etc. were taken and

recorded. Personal history of smoking was carried out in detail and noted.

A special note was made regarding presence or absence of anemia and

malnutrition.

A thorough general and systemic examination was carried out.

Local examination was carried out in detail about type of gangrene, line

of demarcation, tropical skin lesion and signs of ischemia i.e. loss of hair

over skin, thinness of skin, loss of subcutaneous fat,shininess and brittling

of nail etc. Peripheral pulsation was palpated and examined in detail and

mentioned.

45

Routine investigations was carried out in all 70 patients which are as

follow:-

1) Hemoglobin

2) CBC

3) ESR

4) RBS

5) Bl.urea and serum creatinine

6) ECG

7) Chest x-ray

Whereas special investigations were carried out as and when

required in whom lumbar sympathectomy was done, these special

investigations are as follows:-

1) serum protein

2) blood grouping and cross matching

3) arterial Doppler study

4) fundus examination

Diagnostic criteria:-

All 70 patients in this study was diagnosed as buerger's disease on

the basis of minor and major criteria that is

1) smoking history

2) onset before the age of 45 years

3) infrapopliteal arterial occlusive lesions

4) either upper limb involvement or phlebitis migrans.

5) absence of atherosclerotic risk factor other than smoking.

46

Scoring system for the diagnosis of thromboangiitis obliterans was

carried out as per table given below.

Positive points

Age at onset Less than 30 (+2)/30-40 years (+1)

Foot intermittent claudication Present {+2)1 by history (+1)

Upper extremity 1 Symptomatic (+2)1 asymptomatic

(+1)

Migrating superficial vein

thrombosis

Present (+2)/ by history only (+1)

Raynaud Present {+2)1 by history only (+1) If

typical both (+2)1 either(+l)

Angiography; biopsy

Negative points

1 Age at onset 45-50 (-l)/more than 50 years (-2)

Sex, smoking Female (-1)/ nonsmoker (-2)

Location Single limb (-l)/no LE involved (-2)

Absent pulses Brachial (-l)/femoral (-2)

Arteriosclerosis, diabetes, j

hypertension, hyperlipidemia

Discovered after diagnosis 5.1-10 years

(-1)72.1-5 years later (-2)

The probability of the diagnosis of thromboangiitis obliterans was

considered on bases of sum of points as below.

47

Number of points Probability of diagnosis

0-1 Diagnostic excluded

2-3 Suspected, low probability

4-5 Probable, medium probability

6 or more Definite, high probability

Causes: Propagating agents include cigarettes; chewing tobacco, nicotine

patches, and secondhand tobacco smoke (the latter two have been

implicated as propagating agents of the disease only in former smokers)

were noted.

All patients were conservatively treated which are as follows:

1) Vasodilators:- pentoxyphyline

Aspirin Ibuprofen

2) Others:- Care of foot

Correction of anaemia

Regular exercise within limits of pain

Abstinence of smoking Surgical management:

Lumbar symopathectomy was performed through transverse or oblique

loin incision through extraperitoneal route. The external oblique, internal

oblique and transverse abdominis muscles are incised along the line of

incision. Blunt dissection done after retracting the peritoneum medially.

So the psoas muscle and other structures in the retroperitoneal area will

come into view, then sympathetic chain with it's characteristic ganglia

identified. Sympathetic chain is behind the inferior vena cava on right

48

side, and overlapped by aorta on the left side. Silver clips applied over the

sympathetic chain or ligated with silk 2-0 and divided. Incision closed in

layers, and dressing applied.

Post-op care:-

Skin temperature was recorded in each cases. Dressing over the local

tropical skin lesion site done.

Follow up:-

Follow up of each patient in OPD basis was carried out and

record made about it. In form of healing of ulcer, increase in claudication

distance, blackening of toe increased or remain static, pain remain persist

or not.

Whether continuation of vasodilator drugs

Whether patient may stop the smoking or not

Thus detailed study was carried out as per Proforma attached.

49

PROFORMA

ROLE OF LUMBAR SYMPATHECTOMY IN THROMBOANGITIS

OBLITERANS Name:-

Age/sex:-

Address:- Date of admission:-

Occupation:- Date of operation:-

Monthly income:- Date of discharge:-

Chief complaints:-

C/o pain in right/left leg C/o blackening of toe/foot Origin, duration and

progress:-

1) pain - unilateral/bilateral

site -

character

radiation

intermittent claudication

claudication distance

rest pain

effect of exercise -1) cold,

2) warmth

3) limb affected

-upper limb- right/ left

-lower limb -right / left

4) numbness with or without-hyperaesthesia anaesthesia

5) ulcer

6) gangrene

50

7) trophic changes

8) constitutional symptoms: fever and others.

9) Impotence

Past history:-

P/h/s/o similar complain in opposite limb

P/h/s/o any drug history i.e. ergot poisoning

P/h/s/o previous treatment

1) Medical 2) Surgical

Family history:-

1) diabetes

2) arteriosclerosis

3) hypertension

4) syphilis/others

Personal history:-

apetite alcohol

smoking sleep

chewing tobacco other habit

Menstrual and obstetric history:-

Examination of vessel:-

51

Peripheral pulsation:-

Right left

Dorsalis pedis

Anterior tibial

Posterior tibial

Popliteal

Femoral

Brachial

Axillary

Carotid

Condition of wall

1) thickness

2) calcification

3) examination of vein – thrombophlebitis

varicosity

Buerger's test

Raynaud's test Examination of nerve lesion:-Examination of lymph

node:-Systemic examination:-

1) CVS

2) RS

3) CNS

4) metabolic disorder Diabetes

52

Anaemia

5) others

Investigations:-

blood: HB,TC, DC, ESR

urine: albumin, sugar micro

blood sugar: FBS, PP2BS

blood urea

VDRL

plain xray chest (PAview)

ECG

Fundus examination

Doppler study

Arteriography

Occillometry Diagosis: Treatment :-

1) Medical

vasodilator others

2) Surgical

sympathetic block

sympahtectomy

arterialisation of femoral vein

amputation

Complication:

Follow Up:

53

RESULTS & ANALYSIS

I have studied 70 cases of thromboangitis obliterans admitted from

June 2004 to December 2006, at Sir Sayaji Rao General Hospital, &

Medical College Baroda.

Study includes role of Lumbar sympathectomy in Thromboangitis

Obliterans, it's outcome in form of relief of pain, in form of healing of

ulcer.

Following is the detailed analysis of the 70 cases of

Thromboangitis obliterans.

Age:-

The disease is common in young age particularly in third and fouth

decade.

From the Table No.l it is evident that the maximum No. of patients

were in the age group 26-40 years, which included 45 patients.

In this study the median age is 28 years with age range from 22 years

to 70 years.

54

Table No.l: shows the distribution of 70 patients in various age groups.

Age - years No. of cases Percentage

21-25 3 4.28

26-30 10 14.2

31-35 16 22.8

36-40 19 27.1

41-50 17 24.2

51-60 3 4.28

61-70 1 1.42

>70 1 1.42

Total 70 100

Age distribution is represented graphically as follows.

55

Sex:-

Table No.2: sex distribution of patients

sex No. of cases Percentage

Male 67 95.71

female 3 4.28

Total 70 100.00

Out of total 70 patients, 67 patients were male and 3 patients were

female.

56

Socio-economic status:-

Table No.3: Distribution of socio-economic groups

Income in Rs./month No. of cases Percentage

<400 1 1.42

400-600 36 51.42

600-800 23 32.85

800-1000 8 11.42

>1000 2 2.85

total 70 100.00

On analyzing the socio-economic status of 70 patients, it was found that

59 patients were coming from lower socio-economic group.

8 patients have monthly income of 800 Rs. & two patients have > 1000

income per month.

Smoking :-

Smoking is most common factor in thromboangitis obliterans. In present

series, all were chronic and heavy smokers out of this, almost all were

bidi smokers.

57

Table No. 4: Distribution of smoking

No. of bidi/day No. of cases

<10 11

10-15 15

15-20 16

20-25 18

25-30 7

>30

Non-smoker 3

total 70

58

TableNo.5: Duration of smoking in years

Duration of years No. of cases

10-15 28

15-20 26

20-25 9

25-30 2

30-35 1

>35 1

Total 70

Out of 70 patients, 67 patients were chronic smoker & 3 were non-

smokers. 49 patients taking 10-25 bidies/day & 54 patients were chronic

smoker of long duration of about 10-20 years.

59

Symptoms:-

Table No. 6: symptoms and their percentage found in our patients is

tabulated as follows.

Symptoms No. of cases Percentage

Intermittent claudication 70 100.00

Ulcer 24 34.28

Gangrene 51 72.85

Ulcer & Gangrene 17 24.28

All the patients in this series presented with intermittent claudication.

Most of them were having rest pain & associated ulcer or gangrene.

Out of 70 patients 57 patients have unilateral symptoms & thirteen

patients have bilateral symptoms

60

Site of involvement of limb:

Table No. 7: Site of involvement of limb

Side of limb No. of patients Percentage

Right lower limb 36 51.42

Left lower limb 21 30

Both lower limb 13 18.57

Out of 70 patients, right lower limb affected in 36 patients, left lower

limb affected in twenty one patients and bilateral lower limb involvement

in thirteen patients.

61

Peripheral pulsation:

Table No. 8: level of lesion

Absent

pulsation

Level of lesion No. of cases percentage

Dorsalis pedis Forefoot 9 12.85

Dorsalis pedis &

posterior tibial

Foot 51 72.85

Popliteal &

below

Calf & foot 10 14.28

Femoral &

below

Lower limb 0

Radius & ulna Finger 1 1.42

In most of the patients both dorsalis pedis and posterior tibial were not

palpable

Out of 70 patients, 51 patients have both dorsalis pedis and posterior

tibial were not palpable, 9 patients were only dorsalis pedis not palpable

& 10 patients have popliteal and below pulsation not palpable

62

Investigation :-

Haemoglobin:-

Majority of patients were anaemic with 70-75% patients

having haemoglobin less than 10 %. Table 9: level of hemoglobin

Haemoglobin gram% No.of cases

<7 0

7-9 12

9-11 35

>11 23

Skin temperature:-

Skin temperature was assessed by palpatory method by comparing with

opposite limb; most of the patient has decrease temperature in the

involved limb, mostly at the dorsum of the foot.

Doppler study :-

In present series Doppler study was done in 70 cases. The Doppler study

could point out the site of occlusion more precisely than the clinical

method. Post operative Doppler study was done in 6 patients, but it did

not show any changes, as the Doppler probe which I use was not so

sensitive to detect the change in capillary and arteriolar blood flow.

Arteriographv:-

Antegrade femoral arteriography was done in eight patients. They have

absent pulsation at popliteal artery and arteriography done to rule

63

out atherosclerosis. All showed block below the popliteal artery with few

collaterals. In two patients post operative arteriography was performed it

demonstrated increased collateral with good blood supply to the

previously affected part.

Medical treatment:

Medical treatment in the form of vasodilator analgesic and antibiotics

given to all patients preoperatively as well as post operatively as an

adjuvant treatment of surgery, as only medical line of treatment is not

adequate for the patient of thromboangitis obliterans.

Surgical treatment:

Sympathectomy

Lumbar sympathectomy was done in all the patients with or with out

local amputation.In all patiens sympathectomy was performed by extra

peritoneal route and about 5 cm length of sympathetic chain was resected

at the level of third lumbar vertebra.In all patients sympathectomy was

performed on one side only.

Out of 70 patients right lumbar sympathectomy was done in 39

patients,and left lumbar sympathectomy was performed in 31 patients. In

23 patients lumbar sympathectomy with associated local amputation was

done.

Lumbar sympathectomy is supposed to most useful in the the case of

thromboangitis obliterans , of course only sympathectomy is effective in

early stage only.

64

Table 10: surgeries done in patients.

Surgery No. of patients Percentage

Right sympathectomy 39 55.71

Left sympathectomy 31 44.28

Sympathectomy with

amputation

23 32.85

Only amputation 1 1.42

Lumbar sympathectomy with

subsequent amputation

3 4.28

Chemical sympathectomy:- (paravertebral block)

Lumbar paravertebral block ws given in 19 patients results were good.

Patients had relief from pain and increase in skin temperature. But it is

used only as pre-operative assessment of effect of sympathectomy not as

a curative method.

Amputation:-

Out of 70 patients only 17 patients required local amputation in which 12

patients required great toe amputation and five patient required little toe

amputation.

65

Table 11: amputations done in patients

Local amputation No. of cases Percentage

Great toe 12 17.14

Little toe 5 7.14

Out of 70 patients, five patients had post operative abdominal

wound infection and they were treated by local dressing and antibiotics.

Twenty two patients had persistent symptoms of rest pain, out of twenty

two patients, five patients had shown no improvement in healing of ulcer

and two had spreading of gangrene.

Out of these twenty two patients, seventeen patients required

amputation of local part (great toe, little toe) of limb, two patient required

higher amputation (BK) for spreading of gangrene, and only one patient

required STSG for non-healing ulcer. Intra operative and post-operative

mortality was nil.

Table 12: post operative complications

Complication No. of patient Percentage

persistent pain 22 31.42

non-healing of ulcer 5 7.14

spreading of gangrene 2 2.85

local part amputation 17 24.28

66

Follow-up:-

Out of 70 patients, only fifty one patients had attended OPD for follow-

up and out of them, twenty nine patient had no complain and twenty two

patient came with complication of reappearance of symptoms like rest

pain and ulcer at local site, one patient have gangrene of local part. In

these twenty two patients, most of all continue smoking.

Table 13: follow up of patients.

Follow-up No. of patients Percentage

No complaints 29 41.42

reappearance of pain 15 21.42

ulcer 7 10

gangrene 1 1.42

67

DISCUSSION

I have studied 70 cases of Thromboangitis obliterans & Role of

Lumbar Sympathectomy in case of Thromboangitis obliterans from July

2004 to December 2006 at Sir Sayajirao General Hospital & Medical

College Baroda.

Complete discussion of study was given below.

Age:-

Age - years No. of cases Percentage

21-25 3 4.28

26-30 10 14.2

31-35 16 22.8

36-40 19 27.1

41-50 17 24.2

51-60 3 4.28

61-70 1 1.42

>70 1 1.42

The disease is common in young age particularly in the third and

fourth decade. The youngest patient is 22 years old and oldest one is 70

years. As this patient has below popliteal pulsation absent along with rest

pain without signs of atherosclerosis. In present series majority of patient

belong to 26-40 years of age group with median age is 28 years.

Incidence is similar with Dr.John poler's series where common age is 32

years & ranges from 16-40 years.

68

Sex:-

Sex No. of cases Percentage

Male 67 95.71

Female 3 4.28

Total 70 100.00

In present series out of 70 patients there are 67 male while only three

female.

In Dr. Michal J.Sise (san diego calif) series there are 30 men and three

females out of thirty three patients.

In Kim et al. series there are 58 male and three female patients out of 61

patients.

Causes of higher incidence in western female are:

- More smoking in western female

- Because of illiteracy in our country only, so very few female attend

the hospital.

Socio-economic status:-

Income in Rs./month No. of cases Percentage

<400 1 1.42

400-600 36 51.42

600-800 23 32.85

800-1000 8 11.42

>1000 2 2.85

Total 70 100.00

69

59 patients out of 70 patients came from lower socio-economic

status. In Kim et al. series there are 49 patients of lower socio-economic

group. Apart from financial restraints people, from lower socio-economic

status are usually illiterate with low intelligence, so they ignore the

disease & doesn't like to do early treatment for their disease. Lower

socio-economic class group patient came in advanced stage of disease

once gangrene or ulcer occurs.

Smoking:-

No. of bidi/day No. of cases

<10 11

10-15 15

15-20 16

20-25 18

25-30 7

>30 -

Non-smoker 3

Total 70

Smoking is most common etiological factor in Thromboangitis

obliterans. In present series almost all patient were chronic and heavy

smokers out of this all were bidi smokers.

70

Duration of smoking in years No. of cases

10-15 28

15-20 26

20-25 9

25-30 2

30-35 1

>35 1

Total 70

Smoking leads to tissue hypoxia by shift of oxygen dissociation curve to

the left & also leads to spasm of vessel wall.

In present series & also in perez Berkhardt et al. (1999) series most of

heavy and chronic smoker patient have early presentation of the disease.

Symptoms:

Symptoms No. of cases Present series (%) Romeo s beradi (%)

Intermittent

claudication

70 100.00 46.50

Ulcer 24 34.28 16.20

Gangrene 51 72.85 12.50

Ulcer &

gangrene

17 24.28

Comparing the present series with the other series ( Romeo s

Beradi's series) it is observed that the patients of this series had come

after extensive progress of the disease with severe symptoms and signs.

Most of the symptoms were unilateral only.

71

Peripheral pulsation:-

In most of the patients both dorsalis pedis and posterior tibial were not

palpable.

Absent

pulsation

Level of

lesion

No.of cases Present

series %

Dr.Joseph

Mill%

Romeo S

Beradi%

Dorsalis

pedis

Forefoot 9 12.85 35.00 33.30

Dorsalis

pedis&

posterior

tibial

Foot 51 72.85 38.00 26.00

Popliteal &

below

Calf &

foot

10 14.28 26.00

Femoral &

below

Lower

limb

0 42.30

Radius &

ulna

Finger 1 1.42 27.00

Out of 70 patients, 51 patients have both dorsalis pedis and

posterior tibial were not palpable, 9 patients were only dorsalis pedis not

palpable & 10 patients have popliteal and below pulsation not palpable.

In comparing the present series with other series ( Dr.Joseph mill &

Romeo s Beradi's series), it's suggest that most of the patient having

absent pulsation below the popliteal artery in case of thromboangitis

obliterans.

72

Investigation:

Haaemoglobin:

Haemoglobin gram% No. of cases

<7 0

7-9 12

9-11 35

>11 23

In the present series and also seen in the others series (Baker et al.)

it's suggest that patient with haemoglobin <10gm% having tissue hypoxia

and spasm of arterial wall in chronic stages leads to vasoconstriction and

progression of the disease

Doppler study:-

In present series Doppler study was done in all 70 patients. As seen

in other series (Dr.Joseph mill) it's suggest that Doppler study could point

out the site of occlusion most precisely than the clinical method.

Medical treatment

In present series and also seen in the other series (Kim et al.(1976)

& Perez Brkhardt et al.(1999), all patient were treated with vasodilator

drugs.

73

Surgical treatment:

Sympathectomy:

Lumbar sympathectomy was done in all the patients with or with

out local amputation. In all patients sympathectomy was performed by

extra peritoneal route and about 5 cm length of sympathetic chain was

resected at the level of third lumbar vertebra. In all patients

sympathectomy was performed on one side only.

Surgery No. of patients Percentage

Right sympathectomy 39 55.71

Left sympathectomy 31 44.28

Sympathectomy with

amputation

23 32.85

Only amputation 1 1.42

Lumbar sympathectomy with

subsequent amputation

3 4.28

Lumbar sympathectomy is supposed to most useful in the case of

thromboangitis obliterans , of course sympathectomy is effective in early

stage only.

74

Post op recovery:

Improvement

in symptoms

No.of

cases

Percentage Kim et

al.(1976)

Baker et

al.(1994)

Perez Burkhardt

et al.(1999)

Rest pain 57 81.42 60 86 58.5

Healing in

tropic lesions

46 65.71 63.6 64 61.7

amputation 17 24.28 26.7 32.5 18.3

Out of 70 patients 57 patients have symptomatic improvement in

rest pain in form of increase in claudication distance, 46 patients had

shown healing in ulcer and tropical lesions and only 17 patients required

subsequent local amputation after sympathectomy. As compare with

other series it's suggested that about 81.42% having symptomatic

improvement in rest pain, 65.71% patient had shown healing at tropical

site and only 24.28% patient required local amputation of gangrene after

sympathectomy.

Complication :-

Out of 70 patients, five patient had post operative abdominal

wound infection and they were treated by local dressing and antibiotics.

Twenty two patients had persistent symptoms of rest pain, out of twenty

two patient, five patient had shown no improvement in healing of ulcer

and two had spreading of gangrene.

Out of these twenty two patients, seventeen patients required

amputation of local part (great toe, little toe) of limb, two patient required

higher amputation (BK) for spreading of gangrene, and only one patient

75

required STSG for non-healing ulcer. Intra operative and post-operative

mortality was nil.

Complication No. of patients Percentage

persistent pain 22 31.42

non-healing of ulcer • 5 7.14

spreading of gangrene 2 2.85

local part amputation 17 24.28

In present series and also seen in Baker et al. series, it shows that

31.42% patient have reappearance of symptoms in form of persistent or

increase in severity of pain and 24.28% patient required local part of

amputation.

Follow up:

Out of 70 patients, fifty one patients had attended OPD for follow-

up and out of them twenty nine patient had no complain and twenty two

patient came with complication of reappearance of symptoms like rest

pain and ulcer at local site, one patient have gangrene of local part. In

these twenty two patients, most of all continue smoking.

76

Follow-up No. of patients Percentage

No complaints 29 41.42

reappearance of pain 15 21.42

Ulcer 7 10

gangrene 1 1.42

stop smoking 26 37.14

continuous vasodilator drug 25 28.57

In present series and also seen in other series ( Romeo S Beradi),

about 37.14% patient stop smoking, 28.57% patient continues their

vasodilator drugs, 21.42% patient had persistent or recurrence of pain and

only 1 patient developed gangrene. This signifies that the patient who

stop smoking have more improvement in symptoms and those who

continues smoking have aggravated the symptoms or early progression of

the disease.

77

SUMMARY

70 patients of Buerger's disease and role of lumbar

sympathectomy in thromboangitis obliterans were studied consecutively

and prospectively at Sir Sayajirao General Hospital & Medical College,

Baroda.

All cases in whom lumbar sympathectomy was done from July

2004 to December 2006 were studied. AH cases were analyzed on the

basis of a preset established proforma for age & sex distribution of

patients, diagnosis indication for lumbar sympathectomy, post-operative

complication and their follow-up.

Majority of the patient were between third and fourth decade of

age group. Sex ratio was 23:1. Mostly all patients are chronic and heavy

smoker. The data was maintained and in the end analyzed for several

variables and was compared with other available studies.

Majority of the patient have intermittent claudication &/or rest

pain as presenting symptoms and other associated symptoms are ulcer,

gangrene and hyperaesthesia of the local part mostly at the sole of foot.

Most of patients have absent pulsation below the popliteal artery and few

have block at popliteal artery.

All patient were investigated, apart from routine investigation

(CBC, RBS,S.Protein) specific investigation done were Doppler study

and pressure index. Arteriography was done in few patient as they had

popliteal pulsation absent. Almost all patients were treated with

vasodilator group of drugs along with local care of foot and exercise.

Paravertebral block was given in 26% of patient to see for the

symptomatic improvement and also see for the feasibility of the

sympathectomy in particular patient.

78

Lumbar sympathectomy was done in all patients. Post operative

complications were minimal in form of persistent pain in only

18(25.71%) patient. Only two patient required amputation for the

spreading gangrene, other recovered on continuous vasodilator drugs.

Overall progression of disease was hampered and there is

symptomatic improvement in form of healing of ulcer, increase in

claudication distance, improvement in skin temperature were seen.

Lumbar sympathectomy was useful and gives symptomatic relief in

thromboangitis obliterans.

79

CONCLUSIONS

Thromboangitis obliterans is common in male of third and fourth

decade, coming from low socio-economic group, affecting lower

limb more commonly and patient are usually chronic smokers.

Bulk of the patient is from the 21 -40 years of age group.

Thromboangitis obliterans affects male predominantly.

Though thromboangitis obliterans can affect only extremity, lower

limb is mostly affected.

Smoking has definite relation with the development of disease.

Number of bidi is also having important role.

Onset of disease and its progress is affected by type, quantity and

duration of smoking.

Patient who continue their smoking are not improved more by any

treatment.

Usual presenting symptoms are intermittent claudication or rest

pain with or without ulcer/ gangrene.

Paravertebral block offers important pre-operative tool to assess

the ultimate response of sympathectomy.

In early stages of thromboangitis obliterans , sympathectomy offers

very good palliation while in late stages with established gangrene ,

amputation is required in addition.

Gangrenous changes require amputation.

Sympathectomy gives good result in the form of relief of pain,

healing of ulcer or increase in claudication distance.

80

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84

ABBREVIATIONS

Rt LL : right lower limb

Lt LL : left lower limb

DP : dorsalis pedis

PT : posterior tibial

UL : upper limb

M : male

F : female

+ : present

: absent

85