Outline of Buerger’s Disease

Buerger’s disease is one of vasculitic syndrome, which affects the blood vessels of hands, arms, legs and feet, resulting in ischemia (circulatory disorder). It affects mainly Asian males (Japanese, Korean, Chinese, Southeast Asian, Indian, Turkish, Arab, Eastern European, etc), 30-40 years of age. Smoking is intimately related to the appearance and development of this sickness. Females make up to 5% of the cases. This disease may also develop among people who have not smoked in the past, yet most of these cases are supposed to be caused by passive smoking (second hand smoke: breathing on the “smoke” of other people). The blood vessels have become choked and ischemia symptoms appear, and when diagnosed with Buerger’s Disease, quiting smoking and medical treatment are the first choice of treatment. For patients with Buerger’s disease, it is absolutely essential to quit smoking before the treatment begins, and if the patient immediately quits smoking, recovery is very fast and promissing. During the acute phase of the disease, the medication doesn’t affect the patient, and angiography often fails to visualize distal arteries. In the case, the medical treatment must be continued for another 1 -2 weeks. After the interval, ischemia ameliorates and the disease clinical stage moves to the intermediate to chronic phases. In the intermediate or the chronic stages, most of patients are complaining disabling claudication, and full recovery is expected, bypass surgery using autogenous vein graft (blood vessel transplant) is necessary. Yet if the patient continues smoking, no treatment will prove effective at all. Patients who cannot quit smoking will not be cured by any types of the treatments, and eventually could suffer major amputations to their lower limbs. In some rare cases, even death, due to the clotting of the carotid and the cervical arteries might occur. In Japan, the Ministry of Health, the Labour and Welfare has designated this as a serious disease since 1973, so the treatment cost for patients diagnosed with it is covered by the Japanese government, and the incidence of Buerger’s disease has been declining, with decreasing the numbers of smokers.

How is it diagnosed?

Commonly, when 30-40 year-old Asian males who smoke 20 or more cigarettes per day present the following symptoms: fingers and toes feel cold and hurt, ulcerations and gangrene appear (Fig. 36-a,b), or when there is intermitent claudication to the calf and soles of the feet. In these cases, Buerger’s disease can be suspected, so the patient must undergo examination for various types of vascular disorder, including finally an arteriography. Arteriography demonstrates characteristic findings of Buerger’s disease (Fig. 37,38). Along the blood vessels a black pigmentation begins to accumulate. This is also a characteristic of a sickness called wandering phlebitis, which affects the veins of arms and legs. We cannot diagnose Buerger's Disease when the patient is diabetic or has high blood pressure, or when it is suspected that the patient is developing arteriosclerosis simultaneously. If, after the patient is referred to a medical specialist for examination, she concludes that the sickness is Buerger's disease, she will forward the various pertinent tests to the local Prefectural Comittee for Buerger's disease, to fill out the necessary forms for its recognition. On receiving official recognition, a notebook will be issued, and the patient will be exempted from any costs related to the treatment of this sickness. Renewal of the exemption is required once a year.

Fig. 36-a Fig. 36-b Fig. 37 Fig. 38

Influence of smoking

It is known that smoking is the cause of many diseases, such as arteriosclerosis and lung cancer. Yet there is no other ailment that directly suffers the effects of smoking as strongly as in the case of Buerger’s disease. As the deterioration of the disease’s symptoms and smoking are intimately related, before beginning the treatment, evidence of smoking is objectively measured. There is a very easy way to find out whether the patient smokes or not. A sample of venous blood is taken out and the concentration of carbon monoxide in the hemoglobin is measured. If it is more than 1%, then the patient is considered to be a smoker , and treatment is suspended. One cigarette can contract the blood vessels for about 20 minutes. Thrombosis, due to smoking, spreads causing the circulatory disorder to become stronger. People affected by Buerger’s disease say that they smoke in order to alleviate the pain. Of course, this is absolutely untrue—eventually smoking only makes the pain become stronger.

How is it treated?

If the patient is able to abstain from smoking, the treatment will be successful. The ischemic ulcers on the toes cause an intense pain that sometimes doesn’t allow the patient to sleep at night. If the patient strictly abstains from smoking and takes the vasodilators prescribed, the pain disappears after one to four weeks, and the ulcers also heal naturally. If after several months, when the ulcers are completely healed, the patient begins to smoke again, the ulcers will also re-appear. People who repeat this pattern of quitting smoking and then starting to smoke again, will have to undergo treatment for the ulcers all over again, and will progressively lose their toes (Fig. 39-a, b). In the end, the patient might lose all of them (Fig. 40). It is the same for the fingers, only that they become shorter and shorter (Fig. 41). As long as the patient refrains from smoking, Buerger’s Disease, in other words, the circulatory disorder, will not deteriorate again. However, the recovery is not complete, as arteries that have already become blocked will not become open again. This occlusion of the arteries will still cause the hands and fingers to feel cold, and in the legs, among other things, a symptom called intermittent claudication will continue. Intermittent claudication means that after walking a small distance, there is a feeling of intense pain at the calf and the soles of the feet which doesn’t allow the patient to continue walking, and forces him to stop for rest before becoming able to start walking again. Hurrying up and climbing staircases become extremely difficult, so it turns up to be a huge hindrance both in daily life and in work, especially for males of working age. Some vasodilators can be effective in these cases (under 30%), yet the majority are not, so to cure intermittent claudication, bypass surgery becomes absolutely necessary. Moreover, in cases where the patient is abstaining from smoking, but the ischemic pain of toe ulcer or gangrene does not disappear, and does not allow him to sleep, or when the extent of the ulcerations or gangrene is such that it is assumed that treatment can take a very long time, then bypass surgery is necessary.

Fig. 39-a Fig. 39-b Fig. 40 Fig. 41

What are the effects of bypass surgery?

For Buerger’s disease, bypass surgery attempts to cure mainly circulatory disorder to the legs. In this surgery, part of a superficial vein (the great saphenous vein, please refer to the chapter on the treatment of occlusive arteriosclorosis) is extracted and transplanted to the affected arteries of the lower limbs. Some difficulties experienced in bypass surgery for patients with Buerger’s disease, include spasms in the arteries that are connected to the transplanted vessel that make the vessels extremely narrow (Fig. 42); the veins of the legs that are going to be used for transplant have also become inflamed. In the case, several veins from the arms and the opposite leg are put together and then implanted, making this quite a complex surgery. Bypass surgery can also be carried out to the arteries of the instep (Fig. 43) the soles of the feet (Fig. 44-a, b, c, d). If it is successful, the pain will cease completely, and the ulcerations will heal. Some reasons why the transplanted vessel might become blocked again: 1) in cases where the surgery was not properly carried out, 2) in cases where a bad quality vein was used as an implant, 3) in patients who resume smoking after surgery. In case 1), if you have the surgery, this is a very important factor in an unsatisfactory result, and it will become evident when the surgeon's report is checked. Even if your surgeon has no report, this possibility cannot be ruled out. In case 2), the quality of the implant vein can be checked preoperatively. Regarding 3), this is most difficult to confirm, yet it is the most common reason why the bypass becomes blocked in the case of Buerger's disease (Fig. 45-a,b,c). If it is successful, then the pain will cease completely, and the ulcerations will heal. Some reasons why the transplanted vessel might become blocked again: 1) in cases where the surgery was not properly carried out, 2) in cases where the vein used as an implant was of a bad quality, 3) when the patients resume smoking after surgery. In case 1), if you will have the surgery, this is a very important factor to have a satisfactory result, and will become evident when checking reports of the surgeon’s own. Even if your surgeon has no report, this possibility cannot be ruled out. 2) can be checked preoperatively. Regarding 3), this is most difficult to confirm, yet it is the most common reason why the bypass becomes blocked in the case of Buerger’s Disease . In order to make this a successful operation, and to give the longest possible life to the implanted vessel, the only condition is to quit smoking.

After surgery, the patient will visit every three months so as to be checked regarding his progress, and in every one of those visits, we will check the amount of carbon monoxide in his hemoglobin in his venous blood, and confirm whether he is or not smoking. If we overcome these obstacles, we can guarantee the patency of bypass graft for 20 years or more. After 20 years, when the patient reaches the age when arteries begin to harden (arteriosclerosis), the implant itself also might start hardening (atherosclerosis of vein graft), so it is often necessary to carry out the revision surgery for the transplanted vein graft.

Fig. 42 Fig. 43 Fig. 44-a Fig. 44-b Fig. 44-c Fig. 44-d Fig. 45-a Fig. 45-b Fig. 45-c

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