Thromboangiitis obliterans (Buerger’s disease)
This is a condition characterised by occlusive disease of the small and medium-sized arteries (plantars, tibials, radial, etc.), thrombophlebitis of superficial or deep veins, and Raynaud’s syndrome occurring in male patients in a young age group (usually under the age of 30 years). Usually one or two of the three manifestations are present and occasionally all three. The condition does not occur in women or nonsmokers. It is not, as used to be stated, more common in Russian Jews; cases are seen in different races all over the world. Histologically, localised inflammatory changes occur in the walls of arteries and veins leading to thrombosis. The usual symptoms and signs of arterial occlusive disease are present. Gangrene of the toes and fingers is common and progressive. Arteriography sometimes shows a characteristic ‘corrugation’ of the femoral arteries as well as the distal arterial occlusions and helps to distinguish the condition from presenile atherosclerosis. Other forms of arteritis, e.g. polyarteritis nodosa, must be excluded.
A formal vascular assessment should be undertaken, e.g.ESR, autoantibodies, coagulation screening and lipid profile.
The treatment is total abstinence from smoking. While this will arrest the disease it will not reverse established arterial occlusions. A mere reduction in smoking is not sufficient to prevent the relentless progression of this devastating condition. Established arterial occlusions may be treated along the usual lines and sympathectomy may be a useful adjunctive procedure. Nevertheless, amputations, conservative if possible, may eventually be required.
Other types of arteritis
Other types of arteritis are encountered in rheumatoid arthritis, diffuse lupus erythematosus and polyarteritis. Treatment is similar. Diabetes was discussed earlier.
Temporal, occipital and ophthalmic arteritis
Localised infiltration with inflammatory and giant cells leads to arterial occlusion, ischaemic headache and tender, palpable, pulseless (thrombosed) arteries in the scalp. The major catastrophe of irreversible blindness occurs when the ophthalmic artery is occluded. A raised ESR and a positive temporal artery biopsy call for immediate prednisolone therapy to arrest and reverse the process before the ophthalmic artery is involved. The dose must be reduced as soon as possible, in line with clinical improvement and a fall in the ESR, to a maintenance dose which is controlled under long-term surveillance.
Takayasu’s arteriopathy (syn. obliterative arteritis of females, pulseless disease) causes narrowing and obstruction of major arteries. It usually pursues a relentless course.
Cystic myxomatous degeneration
An accumulation of clear jelly (like a synovial ganglion) in the outer layers of a main artery may occasionally be encountered, especially in the popliteal artery. The lesion so stiffens the artery that pulsation disappears and claudication occurs when the limb is flexed (as on walking up stairs). Arteriography shows a smooth narrowing of an otherwise normal artery and a sharp kink or buckling when the knee is flexed. Decompression, by removal of the myxomatous material, is all that is required, but the ganglion’ may recur and require excision of part of the artery with interposition vein graft repair.
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