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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