THROMBOANGIITIS OBLITERANS (BUERGER’S DISEASE)
Buerger’s disease is characterized by recurring inflammation of the intermediate and small arteries and veins of the lower and (in rare cases) upper extremities. It results in thrombus formation and occlusion of the vessels. It is differentiated from other vessel diseases by its microscopic appearance. In contrast to atheroscle-rosis, Buerger’s disease is believed to be an autoimmune disease that results in occlusion of distal vessels.
The cause of Buerger’s disease is unknown, but it is believed to be an autoimmune vasculitis. It occurs most often in men be-tween the ages of 20 and 35 years, and it has been reported in all races and in many areas of the world. There is considerable evi-dence that heavy smoking or chewing of tobacco is a causative or an aggravating factor (Frost-Rude et al., 2000). Generally, the lower extremities are affected, but arteries in the upper extremi-ties or viscera can also be involved. Buerger’s disease is generally bilateral and symmetric with focal lesions. Superficial throm-bophlebitis may be present.
Although this condition is different from atherosclerosis, Buerger’s disease in older patients may also be followed by atherosclerosis of the larger vessels after involvement of the smaller vessels. The patient’s ability to walk may be severely limited. Patients are at higher risk for nonhealing wounds because of impaired circulation.
Pain is the outstanding symptom of Buerger’s disease. The pa-tient complains of foot cramps, especially of the arch (instep clau-dication), after exercise. The pain is relieved by rest; often, a burning pain is aggravated by emotional disturbances, nicotine, or chilling. Cold sensitivity of the Raynaud type is found in one half the patients and is frequently confined to the hands. Digital rest pain is constant, and the characteristics of the pain do not change between activity and rest.
Physical signs include intense rubor (reddish blue discoloration) of the foot and absence of the pedal pulse but with normal femoral and popliteal pulses. Radial and ulnar artery pulses are absent or diminished. Various types of paresthesia may develop.
As the disease progresses, definite redness or cyanosis of the part appears when the extremity is in a dependent position. In-volvement is generally bilateral, but color changes may affect only one extremity or only certain digits. Color changes may progress to ulceration, and ulceration with gangrene eventually occurs.
Segmental limb blood pressures are taken to demonstrate the dis-tal location of the lesions or occlusions. Duplex ultrasonography is used to document patency of the proximal vessels and to visu-alize the extent of distal disease. Contrast angiography is per-formed to demonstrate the diseased portion of the anatomy.
The treatment of Buerger’s disease is essentially the same as that for atherosclerotic peripheral arterial disease. The main objectives are to improve circulation to the extremities, prevent the pro-gression of the disease, and protect the extremities from trauma and infection. Treatment of ulceration and gangrene is directed toward minimizing infection and conservative débridement of necrotic tissue. Tobacco use is highly detrimental, and patients are strongly advised to stop using tobacco completely. Symptoms are often relieved by cessation of smoking and other uses of tobacco.
Vasodilators are rarely prescribed because these medications cause dilation of only healthy vessels; vasodilators may divert blood away from the partially occluded vessels, making the situa-tion worse. A regional sympathetic block or ganglionectomy may be useful in some instances to produce vasodilation and increase blood flow.
If gangrene of a toe develops as a result of arterial occlusive dis-ease in the leg, it is unlikely that toe amputation or even trans-metatarsal amputation will be sufficient; usually, a below-knee amputation or, occasionally, an above-knee amputation is nec-essary. The indications for amputation are worsening gangrene, especially if the infected area is moist, severe rest pain, or fulmi-nating sepsis.
If an amputation is performed, immediate postoperative care in-cludes elevating the stump for the first 24 hours to promote ve-nous return and minimize edema. The incision is monitored for signs of hematoma (unapproximated suture line, discoloration or ruddy color changes of the skin along the suture line, tenderness with palpation, or oozing of dark blood from the suture line). The nurse assesses the fit of the elastic bandages and ensures the integrity of the wrap and continued ability to fit two fingers be-tween layers of the wrap. Distal skin color and warmth are as-sessed, if accessible, and recorded. Elastic bandages are removed and reapplied as prescribed by the surgeon (eg, every 6 hours using figure-of-eight turns).
The patient may experience grief, fear, or anxiety related to loss of the limb. The patient is encouraged to discuss his or her feelings. Spiritual advisors and other health care team members are consulted as appropriate. Recovery and rehabilitation require consultation among health care providers (eg, physicians, physical and occupational therapists, prosthetists, dietitians, nurses, dis-charge coordinators). The patient may decide to be fitted for and learn to use a prosthetic device. Rehabilitation facilities, home care, and outpatient therapy can assist the patient to adapt to the changes in lifestyle.
Discharge planning includes assessing the patient’s ability to manage independently. The patient is assisted in developing a plan to stop using tobacco and to manage pain. The patient may need to be encouraged to make the lifestyle changes necessary with a chronic disease, including modifications in diet, activity, and hygiene (skin care). The nurse determines whether the pa-tient has a network of family and friends to assist with activities of daily living. The nurse ensures that the patient has the knowl-edge and ability to assess for any postoperative complications such as infection and decreased blood flow. The Plan of Nursing Care describes nursing care for patients with peripheral vascular disease.
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