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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
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
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
Hypothalamus
1)
paired
spinal
nerves.
These
postganglionic
fibers
supply
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
greater
splanchnic
nerve
consist
of
myelinated
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
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: -
Gut:-
Hyperglycemia
Spasm of the sphincters and inhibition of general
Smooth muscles
CNS:-
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: -
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
hormonal effects
2)
3)
vasoconstriction
superimposed
on
arterial
occlusion.
Severe
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
medial
malleolus
against
Thigh
Common
Gluteal
iliac
Plantar arch
Radial
Ulnar
Brachial
region
Finger
Hand
Hand
Forearm
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.
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.
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
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.
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.
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.
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
inadequate
removal
of
the
sympathetic
chain,
mechanism.
(+1)
Present (+2)/ by history only (+1)
thrombosis
Raynaud
Angiography; biopsy
Negative points
1 Age at onset
Sex, smoking
Location
Absent pulses
Arteriosclerosis,
diabetes, j
hypertension, hyperlipidemia
Number of points
Probability of diagnosis
0-1
Diagnostic excluded
2-3
4-5
6 or more
Care of foot
Correction of anaemia
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)
5)
ulcer
6)
gangrene
affected
7)
trophic changes
8)
9)
Impotence
Medical
2)
Surgical
Personal
history:-
apetite
alcohol
smoking
sleep
chewing tobacco
other habit
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
Medical
vasodilator others
2)
Surgical
sympathetic block
sympahtectomy
arterialisation of femoral vein
amputation
Complication:
Follow Up:
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
No. of cases
Percentage
Male
67
95.71
female
4.28
Total
70
100.00
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
No. of cases
<10
11
10-15
15
15-20
16
20-25
18
25-30
>30
Non-smoker
total
70
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.
No. of cases
Percentage
Intermittent claudication
70
100.00
Ulcer
24
34.28
Gangrene
51
72.85
17
24.28
No. of patients
Percentage
36
51.42
21
30
13
18.57
Peripheral pulsation:
Table No. 8: level of lesion
Absent
Level of lesion
No. of cases
percentage
Dorsalis pedis
Forefoot
12.85
Foot
51
72.85
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
No.of cases
<7
7-9
12
9-11
35
>11
23
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.
No. of patients
Percentage
Right sympathectomy
39
55.71
Left sympathectomy
31
44.28
Sympathectomy with
23
32.85
Only amputation
1.42
4.28
amputation
subsequent amputation
No. of cases
Percentage
Great toe
12
17.14
Little toe
7.14
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
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:
-
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
No. of cases
<10
11
10-15
15
15-20
16
20-25
18
25-30
>30
Non-smoker
Total
70
No. of cases
10-15
28
15-20
26
20-25
25-30
30-35
>35
Total
70
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
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
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
4.28
Sympathectomy
with
amputation
subsequent amputation
Post op recovery:
Improvement No.of Percentage
in symptoms cases
Rest pain
Healing
in
Kim et
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
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
No. of patients
Percentage
persistent pain
22
31.42
non-healing of ulcer
7.14
spreading of gangrene
2.85
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
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.
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
Lt LL
DP
: dorsalis pedis
PT
: posterior tibial
UL
: upper limb
: male
: female
:
: absent
present