Rare case in wards commonest cause of amputation

LETZ NOW DISCUSS ON ANOTHER RARE CASE IN WARDS COMMONEST CAUSE OF AMPUTATION AFTER RTA in the hospital , although DM is less in our institute but worlwide is more

1 Thromboangiitis obliterans (TAO), an inflammatory vasculopathy also known as Buerger disease, is characterized by an inflammatory endarteritis that causes a prothrombotic state and subsequent vaso-occlusive phenomena ( vv imp.)

2 The inflammatory process is initiated within the tunica intima.( vv imp )

3 It characteristically affects small and medium-sized arteries as well as veins of the upper and lower extremities.

4 The condition is strongly associated with heavy tobacco use, and disease progression is closely linked to continued use.

5 Patients often present with moderate-to-severe claudication that can quickly progress to critical limb ischemia featuring rest pain or tissue loss.

6 Features of acute limb ischemia (eg, pain, paresthesia, palor, mottling, poikilothermia, paresis, and pulselessness) are common signs and symptoms encountered in the emergency setting.

7 Pharmacologic therapy is generally ineffective; abstinence from tobacco is the only measure known to prevent disease progression.

8 Given the arteritis of the small and medium-sized vessels, surgical or endovascular revascularization may not be possible, because of the absence of a distal target for revascularization.

9 As the disease evolves, amputation may be the only viable option.

10 Patients with TAO exhibit hypersensitivity to intradermally injected tobacco extracts, increased cellular sensitivity to collagen types I and III, elevated serum anti–endothelial cell antibody titers, and impaired peripheral endothelium-dependent vasorelaxation.

11 They also show a higher prevalence of human leukocyte antigen (HLA)–A9, HLA-A54, and HLA-B5, suggesting a genetic component to the disease.

12 Most patients with TAO are aged 20-45 years; the disease does not occur in pediatric or elderly patients.

13 TAO is more common in males (male-to-female ratio, 3:1); however, the incidence in women is believed to be increasing, probably as a consequence of the growing frequency of smoking among women.

14 Physicians should counsel patients that the level of tobacco avoidance required to achieve resolution of their disease often necessitates that they rigorously limit their exposure even to secondhand smoke.

15 This can be extremely difficult for patients who live with another smoker, and it is therefore not unreasonable to consider referring such patients (and their loved ones) to multidisciplinary smoking cessation programs.

16 Olin et al asserted that the following criteria must be met for the diagnosis to be made with reasonable certainty -

1 Age younger than 45 years

2 Current (or recent) history of tobacco use

3 Presence of distal extremity ischemia (indicated by claudication, pain at rest, ischemic ulcers, or gangrene) documented by noninvasive vascular testing

4 Exclusion of autoimmune diseases, hypercoagulable states, and diabetes mellitus by laboratory tests

5vExclusion of a proximal source of atheroemboli by echocardiography and arteriography

6 Consistent arteriographic findings in the clinically involved and noninvolved limbs

17 Most patients with TAO (70-80%) present with distal ischemic rest pain or ischemic ulcerations on the toes, feet, or fingers

18 Progression of the disease may lead to involvement of more proximal arteries, but involvement of large arteries is unusual.

19 Patients may also present with claudication of the feet, legs, hands, or arms and often describe experiencing the Raynaud phenomenon (a pathologic vasospastic process involving pain, paresthesias, and color changes of the digits of the hands and feet in response to cold or anxiety).

20 The hands and feet of patients with the disease are usually cool and mildly edematous.

21Superficial thrombophlebitis (often migratory) occurs in almost half of patients with TAO

22 Paresthesias (numbness, tingling, burning, hypoesthesia) of the feet and hands and impaired distal pulses in the presence of normal proximal pulses are usually found in patients with severe disease.

23 More than 80% of patients present with involvement of three or four limbs.