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ROLE OF LUMBER

SYMPATHECTOMY IN
A CASE OF
THROMBOANGITIES
OBLITERANS

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.

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.

REVIEW OF LITERATURE
Thromboangitis obliterans is a chronic non-specific, nonnecrotising, 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.
4

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 collarbone) 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

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
6

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

Hypothalamus

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)
a)

VISCERAL FIBRES: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

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

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.

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.

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

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

Blood vessels: -

effects.
Constriction

of

cutaneous

and

splanchnic

arterioles
Coronary and skeletal arteriolar dilatation
Venoconstriction
Skeletal muscle: -

Redistribution of blood in the body.


Increased glycogenolysis
Increased strength

Gut:-

Hyperglycemia
Spasm of the sphincters and inhibition of general
Smooth muscles

CNS:-

Inhibition of peristalsis and tone


Papillary dilatation
Retraction of the eyelids
Increased alertness

Genitourinary: Thermoregulation:

Loss of sleep
Relaxation of detrusor and spasm of sphincter
Semen ejaculation
Cutaneous vasoconstriction
Maintains skin temperature
circulation
Regulates sweat gland secretion

by

capillary

Piloerection lipolysis
Respiratory: -

Raised body temperature


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

vasoconstrictor.
Beta (dilator)
-isopropyl
-histamine
-bradykinin
They lead to peripheral vasodilatation. Muscle metabolites
-acetyl choline
-adenosine
They cause skeletal muscle and smooth muscle contraction.

peripheral

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

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.

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.

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

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.

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)

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.

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.

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.

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

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.

Arterial pulsation:
Artery
Dorsalis

Affected
site
Fore foot

pedis

Site of palpation
Against the middle cuneiform bone just
lateral to the tendon of extensor hallucis
longus at the proximal end of the first web

Posterior
tibial
Anterior
tibial
Popliteal

Foot

space
Behind

Foot

calcaneum
Midway between the two malleoli against

Leg(calf)

the lower end of tibia


-supine position with flex knee in the lower

the

medial

malleolus

against

part of the popliteal fossa against the back of


tibia. -In prone position- with flex knee,
Femoral

Thigh

against the lower end of the femur.


Just below the inguinal ligament midway
between anterior superior iliac spine and
symphysis pubis, against the head of the
femur

Common

Gluteal

iliac
Plantar arch
Radial
Ulnar
Brachial

region
Finger
Hand
Hand
Forearm

Against the lower end of the radius


Against the lower end of the ulna
Lower area behind tendon of biceps against

Arm

humerus
Against the head of humerus

Axillary

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.

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.

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.

UseTo 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.

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.

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-

ischaemic pain - Local heating


Local alcohol
Medical treatment:Vasodilator drugs:Arlidine
Dose:- 3-6 mg tds
Muscle relaxant

local

cooling

In

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.
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
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.

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.

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 20 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

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.

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

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.

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.

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.

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 2 nd 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

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 preoperative 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.

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.

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.

Scoring system for the diagnosis of thromboangiitis obliterans was


carried out as per table given below.
Positive points
Age at onset
Foot intermittent claudication
Upper extremity

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


Present {+2)1 by history (+1)
1 Symptomatic (+2)1 asymptomatic

Migrating superficial vein

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

thrombosis
Raynaud

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


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

Angiography; biopsy
Negative points
1 Age at onset
Sex, smoking
Location
Absent pulses
Arteriosclerosis,

diabetes, j

hypertension, hyperlipidemia

45-50 (-l)/more than 50 years (-2)


Female (-1)/ nonsmoker (-2)
Single limb (-l)/no LE involved (-2)
Brachial (-l)/femoral (-2)
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.

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

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.

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
-upper limb- right/ left
-lower limb -right / left

4)

numbness with or without-hyperaesthesia anaesthesia

5)

ulcer

6)

gangrene

affected

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:-

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

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:

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.

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


Age - years

No. of cases

Percentage

21-25

4.28

26-30

10

14.2

31-35

16

22.8

36-40

19

27.1

41-50

17

24.2

51-60

4.28

61-70

1.42

>70

1.42

Total

70

100

Age distribution is represented graphically as follows.

Sex:Table No.2: sex distribution of patients


sex

No. of cases

Percentage

Male

67

95.71

female

4.28

Total

70

100.00

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


female.

Socio-economic status:Table No.3: Distribution of socio-economic groups


Income in Rs./month

No. of cases

Percentage

<400

1.42

400-600

36

51.42

600-800

23

32.85

800-1000

11.42

>1000

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.

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

>30
Non-smoker

total

70

TableNo.5: Duration of smoking in years


Duration of years

No. of cases

10-15

28

15-20

26

20-25

25-30

30-35

>35

Total

70

Out of 70 patients, 67 patients were chronic smoker & 3 were nonsmokers. 49 patients taking 10-25 bidies/day & 54 patients were chronic
smoker of long duration of about 10-20 years.

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

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.

Peripheral pulsation:
Table No. 8: level of lesion
Absent

Level of lesion

No. of cases

percentage

Dorsalis pedis

Forefoot

12.85

Dorsalis pedis &

Foot

51

72.85

Calf & foot

10

14.28

Lower limb

Finger

pulsation

posterior tibial
Popliteal &
below
Femoral &
below
Radius

& ulna

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

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

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

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.

Table 10: surgeries done in patients.


Surgery

No. of patients

Percentage

Right sympathectomy

39

55.71

Left sympathectomy

31

44.28

Sympathectomy with

23

32.85

Only amputation

1.42

Lumbar sympathectomy with

4.28

amputation

subsequent amputation

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.

Table 11: amputations done in patients


Local amputation

No. of cases

Percentage

Great toe

12

17.14

Little toe

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
persistent pain
non-healing of ulcer
spreading of gangrene
local part amputation

No. of patient
22
5
2
17

Percentage
31.42
7.14
2.85
24.28

Follow-up:Out of 70 patients, only fifty one patients had attended OPD for followup 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

10

gangrene

1.42

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

4.28

26-30

10

14.2

31-35

16

22.8

36-40

19

27.1

41-50

17

24.2

51-60

4.28

61-70

1.42

>70

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.

Sex:Sex

No. of cases

Percentage

Male

67

95.71

Female

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

1.42

400-600

36

51.42

600-800

23

32.85

800-1000

11.42

>1000

2.85

Total

70

100.00

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

>30

Non-smoker

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.
Duration of smoking in years

No. of cases

10-15

28

15-20

26

20-25

25-30

30-35

>35

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
Intermittent

No. of cases Present series (%)

Romeo s beradi (%)

70

100.00

46.50

Ulcer

24

34.28

16.20

Gangrene

51

72.85

12.50

Ulcer

17

24.28

claudication

&

gangrene
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.
Peripheral pulsation:In most of the patients both dorsalis pedis and posterior tibial were not
palpable.

Absent
pulsation
Dorsalis

Level of No.of cases


lesion

Present

Dr.Joseph

Romeo S

series %

Mill%

Beradi%

Forefoot

12.85

35.00

33.30

Foot

51

72.85

38.00

26.00

Calf &

10

14.28

pedis
Dorsalis
pedis&
posterior
tibial
Popliteal &
below

foot

Femoral &

Lower

below

limb

Radius &

26.00

Finger

0
1

42.30
1.42

27.00

ulna

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.

Investigation:
Haaemoglobin:
Haemoglobin gram%

No. of cases

<7

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.

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

23

32.85

Only amputation

1.42

Lumbar sympathectomy with

4.28

Sympathectomy

with

amputation

subsequent amputation

Lumbar sympathectomy is supposed to most useful in the case of


thromboangitis obliterans , of course sympathectomy is effective in early
stage only.

Post op recovery:
Improvement No.of Percentage
in symptoms cases
Rest pain
Healing

in

Kim et

Baker et Perez Burkhardt

al.(1976) al.(1994)

et al.(1999)

57

81.42

60

86

58.5

46

65.71

63.6

64

61.7

17

24.28

26.7

32.5

18.3

tropic lesions
amputation

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

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

7.14

spreading of gangrene

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 followup 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.
Follow-up
No. of patients
No complaints
29
reappearance of pain
15
Ulcer
7
gangrene
1
stop smoking
26
continuous vasodilator drug
25

Percentage
41.42
21.42
10
1.42
37.14
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.

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.

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.

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.

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ABBREVIATIONS

Rt LL

: right lower limb

Lt LL

: left lower limb

DP

: dorsalis pedis

PT

: posterior tibial

UL

: upper limb

: male

: female

:
: absent

present