Thromboangiitis obliterans - Clinicals, Diagnosis, and Management

Vascular

Clinicals - History

Fact Explanation
Introduction The condition also called as Buerger's disease and characterized by non atherosclerotic segmental inflammation of small and medium sized arteries, thrombophlebitis of the
superficial or deep veins and Raynaud’s syndrome. The core aetiology of the disease is tobacco smoking though few cases are reported following chewing of tobacco and marijuana. So the disease is typically seen in smoking young males and due to higher incidence of smoking in females currently females are also suffering from the illness. It does not occur in paediatric and geriatric population. The progression of the diseases is directly related to the continued consumption of tobacco. Though the exact pathophysiology is yet to be disclosed current evidence shows inflammatory thrombi formation which could be due to an abnormalities in immunoreactivity. In summary this is an irreversible disease causing ultimate limb amputation due to the inadequate perfusion of end organs which causes ischaemia and finally gangrene. Although the disease is commonest at extremities it can affect cerebral, coronary, renal, retinal and mesenteric circulation as well.
Introduction
The condition also called as Buerger's disease and characterized by non atherosclerotic segmental inflammation of small and medium sized arteries, thrombophlebitis of the
superficial or deep veins and Raynaud’s syndrome. The core aetiology of the disease is tobacco smoking though few cases are reported following chewing of tobacco and marijuana. So the disease is typically seen in smoking young males and due to higher incidence of smoking in females currently females are also suffering from the illness. It does not occur in paediatric and geriatric population. The progression of the diseases is directly related to the continued consumption of tobacco. Though the exact pathophysiology is yet to be disclosed current evidence shows inflammatory thrombi formation which could be due to an abnormalities in immunoreactivity. In summary this is an irreversible disease causing ultimate limb amputation due to the inadequate perfusion of end organs which causes ischaemia and finally gangrene. Although the disease is commonest at extremities it can affect cerebral, coronary, renal, retinal and mesenteric circulation as well.
Intermittent claudication Intermittent claudication is the ischaemic pain occurring in exerting limbs due to poor perfusion of the musculature during exertion due to arterial insufficiency and it is reproducible with same exertion and relieved by resting. So during the initial presentation they might complain pain in the foot or calf with walking and reliving with resting. If the exertion continued through the pain the pain may ascends to proximal muscle groups in extensive occlusion or might get worsen. After the resting the pain can be reproduced when walking similar distance. Similar phenomena would occur when exerting the upper limbs. Walking distance will depend on the severity of the arterial occlusion.

Type of symptoms of claudication will differ according to the site of the occlusion.
Eg:
In aortoiliac obstruction claudication will present in both buttocks, thighs and
calves and patient will suffer from impotence.
In iliac obstruction there will be unilateral claudication in the thigh and
calf and sometimes in buttock.
In femoropopliteal there will be unilateral claudication in the calf.
In a distal obstruction claudication will present in calf and foot.
Intermittent claudication
Intermittent claudication is the ischaemic pain occurring in exerting limbs due to poor perfusion of the musculature during exertion due to arterial insufficiency and it is reproducible with same exertion and relieved by resting. So during the initial presentation they might complain pain in the foot or calf with walking and reliving with resting. If the exertion continued through the pain the pain may ascends to proximal muscle groups in extensive occlusion or might get worsen. After the resting the pain can be reproduced when walking similar distance. Similar phenomena would occur when exerting the upper limbs. Walking distance will depend on the severity of the arterial occlusion.

Type of symptoms of claudication will differ according to the site of the occlusion.
Eg:
In aortoiliac obstruction claudication will present in both buttocks, thighs and
calves and patient will suffer from impotence.
In iliac obstruction there will be unilateral claudication in the thigh and
calf and sometimes in buttock.
In femoropopliteal there will be unilateral claudication in the calf.
In a distal obstruction claudication will present in calf and foot.
Rest pain With the ischemia, patient will have continuous pain at rest. pain will be more at night, on lying down/ elevation( due to further reduction of blood supply with the effect of gravity). It characteristically relief with hanging down. So patient will used to sleep on chairs/ on a bed will hanging legs for a long time. Rest pain
With the ischemia, patient will have continuous pain at rest. pain will be more at night, on lying down/ elevation( due to further reduction of blood supply with the effect of gravity). It characteristically relief with hanging down. So patient will used to sleep on chairs/ on a bed will hanging legs for a long time.
Coldness and numbness over the limb moderate to severe ischemia can present with these symptoms. Coldness and numbness over the limb
moderate to severe ischemia can present with these symptoms.
Ulceration and discoloration With severe ischemia ulceration can be occur. Ulcers are common on the dorsum of the feet, on the shins and around the malleoli. In gangrene (dry gangrene) there will be discoloration of the limb. Ulceration and discoloration
With severe ischemia ulceration can be occur. Ulcers are common on the dorsum of the feet, on the shins and around the malleoli. In gangrene (dry gangrene) there will be discoloration of the limb.
Features suggestive of arterial occlusion With this condition arteries in all systems can affect causing various symptoms.
Eg:
Brain strokes can occur giving features of paralysis, paresthesia and cranial nerve palsy.
In spinal cord, features of infarction like limb paralysis, paresthesia, bladder/ bowel dysfunction.
In bones, ischemic pain at site of the joint/back pain and fractures following long bone infarction can be seen. Myocardial infarctions can occur following hypoperfusion of the myocardium( chest pain, difficulty in breathing, dizziness).
In lungs there will be shortness of breath and pleuritic type chest pain.
In mesentry, acute abdominal pain will be the presentation.
In digits, painful fingers and toes with small bone infarction.
In kidneys infarction of medulla with papillary necrosis may lead to fail in concentrating urine causing high urine out put, dehydration and nocturnal enuresis. Chronic liver failure with micro infarction causing loss of appetite, yellowish discoloration of eyes.
Splenic infarction leads to recurrent infections like upper/ lower respiratory tract infections and diarrheal illnessess.
Features suggestive of arterial occlusion
With this condition arteries in all systems can affect causing various symptoms.
Eg:
Brain strokes can occur giving features of paralysis, paresthesia and cranial nerve palsy.
In spinal cord, features of infarction like limb paralysis, paresthesia, bladder/ bowel dysfunction.
In bones, ischemic pain at site of the joint/back pain and fractures following long bone infarction can be seen. Myocardial infarctions can occur following hypoperfusion of the myocardium( chest pain, difficulty in breathing, dizziness).
In lungs there will be shortness of breath and pleuritic type chest pain.
In mesentry, acute abdominal pain will be the presentation.
In digits, painful fingers and toes with small bone infarction.
In kidneys infarction of medulla with papillary necrosis may lead to fail in concentrating urine causing high urine out put, dehydration and nocturnal enuresis. Chronic liver failure with micro infarction causing loss of appetite, yellowish discoloration of eyes.
Splenic infarction leads to recurrent infections like upper/ lower respiratory tract infections and diarrheal illnessess.
development of severe pain and bluish discoloration over tip of fingers after exposure to cool water This Raynaud’s syndrome caused by peripheral digital ischemia. development of severe pain and bluish discoloration over tip of fingers after exposure to cool water
This Raynaud’s syndrome caused by peripheral digital ischemia.
Features suggestive of superficial thrombophlebitis Patient will have localized pain. this will gradually progress with the time. Areas will be more painful to the touch. Features suggestive of superficial thrombophlebitis
Patient will have localized pain. this will gradually progress with the time. Areas will be more painful to the touch.
Features suggestive of deep thrombophlebitis (deep vein thrombosis) Patient will suggestive of sudden onset pain, swelling, redness and warmth of the limbs. Features suggestive of deep thrombophlebitis (deep vein thrombosis)
Patient will suggestive of sudden onset pain, swelling, redness and warmth of the limbs.
Features suggestive of venous embolism. Patient can develop feature suggestive of pulmonary embolism such as sudden on set difficulty in breathing, chest pain, dyspnoea. Features suggestive of venous embolism.
Patient can develop feature suggestive of pulmonary embolism such as sudden on set difficulty in breathing, chest pain, dyspnoea.
History of tobacco smoking/ chewing. The exposure to tobacco is mandatory for the diagnosis as the sole risk factor is that. Rarely there will be a association with use of marijuana. History of tobacco smoking/ chewing.
The exposure to tobacco is mandatory for the diagnosis as the sole risk factor is that. Rarely there will be a association with use of marijuana.

Clinicals - Examination

Fact Explanation
General examination Seen whether patient is in pain (with the prolonged pain), depressed, level of hydration, pallor and features of chronic smoking like nicotine stains. General examination
Seen whether patient is in pain (with the prolonged pain), depressed, level of hydration, pallor and features of chronic smoking like nicotine stains.
Examination of a limb with claudication Inspection:
Walking distance of the pain will give an idea of the severity.

Palpation;
Bilateral femoral and distal pulse will be absent in aortoiliac obstruction.
Unilateral femoral and distal
pulses will be absence in iliac obstruction.
In femoropopliteal obstruction femoral pulse will be palpable with absent
unilateral distal pulses.
Only ankle pulses will be absent with palpable femoral and popliteal pulses in a obstruction distal to femoropopliteal region.

Auscultation:
In aortoiliac obstruction there will be bruit over aortoiliac region.
In iliac obstruction bruit can be identify over the iliac region
In femoropopliteal Unilateral claudication in the calf
Examination of a limb with claudication
Inspection:
Walking distance of the pain will give an idea of the severity.

Palpation;
Bilateral femoral and distal pulse will be absent in aortoiliac obstruction.
Unilateral femoral and distal
pulses will be absence in iliac obstruction.
In femoropopliteal obstruction femoral pulse will be palpable with absent
unilateral distal pulses.
Only ankle pulses will be absent with palpable femoral and popliteal pulses in a obstruction distal to femoropopliteal region.

Auscultation:
In aortoiliac obstruction there will be bruit over aortoiliac region.
In iliac obstruction bruit can be identify over the iliac region
In femoropopliteal Unilateral claudication in the calf
Examination of a limb with rest pain Inspection for,
The position of the patient (will hang down the legs). look for presence of skin discoloration (dry gangrene) and ulcers (examine the ulcer for site, surrounding, base, edges).
Tropical changes of the skin like loss of hair, sweating, So the skin will be dry.
Examine for amputation, and if present examine the stump (for healing, length of the stump, movements of the proximal joint, muscle strength of the proximal part, pulses). look for any evidence of infections (fever, inflammatory changes of the surrounding area, pus collection).

Palpation for,
the coldness of the leg. Sensation will be impaired and pulses will be absent according to the site of the obstuction.

Auscultation for,
Bruit over the limb. The bruit site will depend according to the site of the obstruction.
Examination of a limb with rest pain
Inspection for,
The position of the patient (will hang down the legs). look for presence of skin discoloration (dry gangrene) and ulcers (examine the ulcer for site, surrounding, base, edges).
Tropical changes of the skin like loss of hair, sweating, So the skin will be dry.
Examine for amputation, and if present examine the stump (for healing, length of the stump, movements of the proximal joint, muscle strength of the proximal part, pulses). look for any evidence of infections (fever, inflammatory changes of the surrounding area, pus collection).

Palpation for,
the coldness of the leg. Sensation will be impaired and pulses will be absent according to the site of the obstuction.

Auscultation for,
Bruit over the limb. The bruit site will depend according to the site of the obstruction.
Examination for bruits and presence of andominal aortic aneurysm. look for bruits in other sites like carotid, subclavian, brachial, renal. Abdominal aortic aneurysm will present as the pulsatile abdominal lump. Examination for bruits and presence of andominal aortic aneurysm.
look for bruits in other sites like carotid, subclavian, brachial, renal. Abdominal aortic aneurysm will present as the pulsatile abdominal lump.
Systemic signs of arterial occlusion With this condition arteries in all systems can affect causing various symptoms.
Eg:
Brain strokes can occur giving features of paralysis, paresthesia and cranial nerve palsy.
In spinal cord, features of infarction like limb paralysis, paresthesia, bladder/ bowel dysfunction.
In bones, ischemic pain at site of the joint/back pain and fractures following long bone infarction can be seen.
Myocardial infarctions can occur following hypoperfusion of the myocardium( chest pain, difficulty in breathing, dizziness).
In lungs there will be shortness of breath and pleuritic type chest pain.
In mesentry, acute abdominal pain will be the presentation.
In digits, painful fingers and toes with small bone infarction.
In kidneys infarction of medulla with papillary necrosis may lead to fail in concentrating urine causing high urine out put, dehydration and nocturnal enuresis.
Chronic liver failure with micro infarction giving signs of chronic liver failure like jaundice, ascites.
Splenic infarction leads to pallor, easy bruising and recurrent infections like upper/ lower respiratory tract infections and diarrheal illnessess.
Systemic signs of arterial occlusion
With this condition arteries in all systems can affect causing various symptoms.
Eg:
Brain strokes can occur giving features of paralysis, paresthesia and cranial nerve palsy.
In spinal cord, features of infarction like limb paralysis, paresthesia, bladder/ bowel dysfunction.
In bones, ischemic pain at site of the joint/back pain and fractures following long bone infarction can be seen.
Myocardial infarctions can occur following hypoperfusion of the myocardium( chest pain, difficulty in breathing, dizziness).
In lungs there will be shortness of breath and pleuritic type chest pain.
In mesentry, acute abdominal pain will be the presentation.
In digits, painful fingers and toes with small bone infarction.
In kidneys infarction of medulla with papillary necrosis may lead to fail in concentrating urine causing high urine out put, dehydration and nocturnal enuresis.
Chronic liver failure with micro infarction giving signs of chronic liver failure like jaundice, ascites.
Splenic infarction leads to pallor, easy bruising and recurrent infections like upper/ lower respiratory tract infections and diarrheal illnessess.
capillary nail-fold loops examination and observation of Raynaud’s phenomenon This can be done with an ophthalmoscope. It is helpful in distinguishing primary from secondary Raynaud's (loss of the normal loop pattern and capillary 'fallout' with haemorrhage and dots indicate underlying disease). Raynaud’s phenomenon can be observed while patient handling the cool water. capillary nail-fold loops examination and observation of Raynaud’s phenomenon
This can be done with an ophthalmoscope. It is helpful in distinguishing primary from secondary Raynaud's (loss of the normal loop pattern and capillary 'fallout' with haemorrhage and dots indicate underlying disease). Raynaud’s phenomenon can be observed while patient handling the cool water.
Signs of superficial thrombophlebitis There will be tender localized areas over the skin of the limb. This condition is often migratory. Signs of superficial thrombophlebitis
There will be tender localized areas over the skin of the limb. This condition is often migratory.
Signs of superficial thrombophlebitis Patient will develop swelling, redness and tenderness and warmth of the limbs. Signs of superficial thrombophlebitis
Patient will develop swelling, redness and tenderness and warmth of the limbs.
Signs suggestive of pulmonary embolism Patient will be dyspnoic,coughing, wheezing and there will be fine crepts on auscultation. Signs suggestive of pulmonary embolism
Patient will be dyspnoic,coughing, wheezing and there will be fine crepts on auscultation.

Investigations - Diagnosis

Fact Explanation
Doppler ultrasound blood flow detection Hand-held Doppler is a simple non invasive test use to assess the presence occlusive arterial disease.So this is useful in measurement of ankle-brachial pressure index (ABPI). Doppler ultrasound blood flow detection
Hand-held Doppler is a simple non invasive test use to assess the presence occlusive arterial disease.So this is useful in measurement of ankle-brachial pressure index (ABPI).
Duplex imaging This is a combined investigation of both doppler studies and ultrasound scanning. it assess the anatomy of the vessels and the extend of the disease condition. This also useful in excluding the associated deep vein thrombosis. Duplex imaging
This is a combined investigation of both doppler studies and ultrasound scanning. it assess the anatomy of the vessels and the extend of the disease condition. This also useful in excluding the associated deep vein thrombosis.
Colour-flow imaging In here the results of doppler studies are seen through the colour images. It is more sensitive in detecting small vascular disease. Colour-flow imaging
In here the results of doppler studies are seen through the colour images. It is more sensitive in detecting small vascular disease.
Angiography/ Computerised tomography angiography/ Magnetic resonance angiogram/ echocardiography These will show anatomy of the vascular tree via a contrast imaging with characteristic arteriograpic findings (peripheral multiple segmental occlusion, cock-screw collaterals) and are also used to exclude a proximal embolic source . Angiography/ Computerised tomography angiography/ Magnetic resonance angiogram/ echocardiography
These will show anatomy of the vascular tree via a contrast imaging with characteristic arteriograpic findings (peripheral multiple segmental occlusion, cock-screw collaterals) and are also used to exclude a proximal embolic source .
D dimer level D dimer level will be elevated in deep vein thrombosis. D dimer level
D dimer level will be elevated in deep vein thrombosis.
CT pulmonary angiography This is the first line imaging modality in diagnosing pulmonary embolism. CT pulmonary angiography
This is the first line imaging modality in diagnosing pulmonary embolism.

Investigations - Management

Fact Explanation
Swab from ulcers for culture and ABST This will be useful in excluing the presence of infection in a chronic ullcer associated with limb ischemia. Swab from ulcers for culture and ABST
This will be useful in excluing the presence of infection in a chronic ullcer associated with limb ischemia.
Ultrasound scan This is useful during follow up to assess the presence of abdominal aortic aneurysm. Ultrasound scan
This is useful during follow up to assess the presence of abdominal aortic aneurysm.
Investigations to exclude other causes of vasculitis like Antinuclear antibody, rheumatoid factor, complement level, anticentromere antibody, Scl-70 antibody, antiphospholipid antibodies These tests will be useful in excluding other causeds of systemic vasculitis like Systemic Lupus Erythematosus, antipospholipid antibody syndrome, rheumatoid arthritis. Investigations to exclude other causes of vasculitis like Antinuclear antibody, rheumatoid factor, complement level, anticentromere antibody, Scl-70 antibody, antiphospholipid antibodies
These tests will be useful in excluding other causeds of systemic vasculitis like Systemic Lupus Erythematosus, antipospholipid antibody syndrome, rheumatoid arthritis.
FBC This is useful in assessing the haemoglobin level, and the wBC and platelet counts before invasive procedures or surgeries. FBC
This is useful in assessing the haemoglobin level, and the wBC and platelet counts before invasive procedures or surgeries.
ESR/CRP This will assess the presence of any ongoing inflammation and important in excluding inflammatory vasculitis associated with various autoimmune conditions. ESR/CRP
This will assess the presence of any ongoing inflammation and important in excluding inflammatory vasculitis associated with various autoimmune conditions.
Fasting blood sugar This will assess the blood sugar levels and to identify the co existing diabetes mellitus which is a common acquired condition for macro vascular diseases finally resulting amputation. . Fasting blood sugar
This will assess the blood sugar levels and to identify the co existing diabetes mellitus which is a common acquired condition for macro vascular diseases finally resulting amputation. .
Renal function tests like serum electrolytes, serum creatinine, blood urea Renal function need to be assess before surgical procedures. Renal function tests like serum electrolytes, serum creatinine, blood urea
Renal function need to be assess before surgical procedures.
Liver function tests like AST, ALT Liver function also need to be assess before surgical procedures. Liver function tests like AST, ALT
Liver function also need to be assess before surgical procedures.
Clotting profile with PT/ INR, APTT This will give an idea about clotting status of the patient. Clotting profile with PT/ INR, APTT
This will give an idea about clotting status of the patient.
Blood grouping and crossed matching Before surgical procedure these test will useful in preserving blood for an emergency need. Blood grouping and crossed matching
Before surgical procedure these test will useful in preserving blood for an emergency need.
Lipid profile This will be useful in excluding any associated hyperlipidaemia and the presence of atherosclerotic occlusive arterial diseases. Lipid profile
This will be useful in excluding any associated hyperlipidaemia and the presence of atherosclerotic occlusive arterial diseases.
ECG This will be useful in assessing the cardiac function in pre operatively as these patients are at risk of developing cardiac complications as well.. ECG
This will be useful in assessing the cardiac function in pre operatively as these patients are at risk of developing cardiac complications as well..
Chest X ray This will assess the pulmonary suitability before a surgical procedure. Chest X ray
This will assess the pulmonary suitability before a surgical procedure.
Rutherford classification(staging system for clinical symptoms) Grade 0: Category 0 - Asymptomatic
Grade I: Category 1 - Mild claudication
Grade I: Category 2 - Moderate claudication
Grade I: Category 3 - Severe claudication
Grade II: Category 4 - Rest pain
Grade III: Category 5 - Ischemic ulcer not exceeding digits
Grade IV: Category 6 - Severe ischemic ulcer or gangrene .
Rutherford classification(staging system for clinical symptoms)
Grade 0: Category 0 - Asymptomatic
Grade I: Category 1 - Mild claudication
Grade I: Category 2 - Moderate claudication
Grade I: Category 3 - Severe claudication
Grade II: Category 4 - Rest pain
Grade III: Category 5 - Ischemic ulcer not exceeding digits
Grade IV: Category 6 - Severe ischemic ulcer or gangrene .
Leriche-fontaine classification (clinico-pathological classification) I; Asymptomatic or effort pain with Relative hypoxia ;Silent arteriopathy

II A: Effort pain/pain-free walking distance >200 m with Relative hypoxia: Stabilized arteriopathy, noninvalidant claudication

II B: Pain-free walking distance <200 m with Relative hypoxia: Instable arteriopathy, invalidant claudication

III A: Rest pain, ankle arterial pressure >50 mm Hg with Cutaneous hypoxia, tissue acidosis, ischemic neuritis: Instable arteriopathy, invalidant claudication

III B: Rest pain, ankle arterial pressure <50 mm Hg with Cutaneous hypoxia, tissue acidosis, ischemic neuritis: Instable arteriopathy, invalidant claudication

IV: Trophic lesions, necrosis or gangrene with Cutaneous hypoxia, tissue acidosis, necrosis: Evolutive arteriopathy
Leriche-fontaine classification (clinico-pathological classification)
I; Asymptomatic or effort pain with Relative hypoxia ;Silent arteriopathy

II A: Effort pain/pain-free walking distance >200 m with Relative hypoxia: Stabilized arteriopathy, noninvalidant claudication

II B: Pain-free walking distance <200 m with Relative hypoxia: Instable arteriopathy, invalidant claudication

III A: Rest pain, ankle arterial pressure >50 mm Hg with Cutaneous hypoxia, tissue acidosis, ischemic neuritis: Instable arteriopathy, invalidant claudication

III B: Rest pain, ankle arterial pressure <50 mm Hg with Cutaneous hypoxia, tissue acidosis, ischemic neuritis: Instable arteriopathy, invalidant claudication

IV: Trophic lesions, necrosis or gangrene with Cutaneous hypoxia, tissue acidosis, necrosis: Evolutive arteriopathy

Management - Supportive

Fact Explanation
Health education Patient should be educated regarding the disease, symptoms associated with, possible complications, investigations needed, available treatment options, predisposing factors for exacerbations and prognosis. Health education
Patient should be educated regarding the disease, symptoms associated with, possible complications, investigations needed, available treatment options, predisposing factors for exacerbations and prognosis.
Wound care This could classified as optimizing systemic and local factors. Regarding the systemic factors correction of haemoglobin level, glycaemic control, nutrition, high protein diet can be done. Regarding the local factors timely performed wound debridement, proper wound dressing, physio therapy and using antibiotics. The proper wound care will reduce the rate of amputation. Wound care
This could classified as optimizing systemic and local factors. Regarding the systemic factors correction of haemoglobin level, glycaemic control, nutrition, high protein diet can be done. Regarding the local factors timely performed wound debridement, proper wound dressing, physio therapy and using antibiotics. The proper wound care will reduce the rate of amputation.
Prevention Prevention is only by non smoking. Prevention
Prevention is only by non smoking.
Prevention of the complications Following measures would be beneficial in minimizing the complications
Avoiding injuries to the extremities by wearing properly fitting footwear and identifying risk activities and avoiding those.
Early treatment for the ulcers before becoming septic also important.
Avoiding exposure to cold water which will further impede the circulation.
Avoidance vasoconstrictive drugs.
Prevention of the complications
Following measures would be beneficial in minimizing the complications
Avoiding injuries to the extremities by wearing properly fitting footwear and identifying risk activities and avoiding those.
Early treatment for the ulcers before becoming septic also important.
Avoiding exposure to cold water which will further impede the circulation.
Avoidance vasoconstrictive drugs.

Management - Specific

Fact Explanation
Absolute cessation of smoking Cessation of smoking is the only proven action to slow or stop the disease progression. Smoking, chewing tobacco and even nicotin patch replacement should be avoided. Absolute cessation of smoking
Cessation of smoking is the only proven action to slow or stop the disease progression. Smoking, chewing tobacco and even nicotin patch replacement should be avoided.
Medical management A prostaglandin analogue called Intravenous iloprost not used much yet in current practice appears to be effective in improving symptoms, enhancing the resolution of distal-extremity trophic changes. It also reduces the rate of amputation in affected patients.

The use of thrombolytic agents seems to be effective but still no hard evidence.

Other pharmacological modalities such as antiplatelets, steroids, vasodilators, anticoagulants andcalcium channel blockers are generally being ineffective.
Medical management
A prostaglandin analogue called Intravenous iloprost not used much yet in current practice appears to be effective in improving symptoms, enhancing the resolution of distal-extremity trophic changes. It also reduces the rate of amputation in affected patients.

The use of thrombolytic agents seems to be effective but still no hard evidence.

Other pharmacological modalities such as antiplatelets, steroids, vasodilators, anticoagulants andcalcium channel blockers are generally being ineffective.
Pain management This could be pharmacological or non pharmacological. Nonsteroidal anti-Inflammatory drugs can be use to treat the pain which occurs with the limb ischemia. But usually the pain is not resolved by simple analgesics. So the most of the patients may require opioid analgesics such as tramadol and morphine. Tricyclic antidepressants such as amitriptyllin neuropathic pain drugs such as gabapentin and valporate also can be used.

In some patients the pain will be intractable and not controlled with analgesics. So in these cases invasive procedures may be needed. Non pharmacological
This could be either simple invasive procedures such as nerve infiltration or could be major interventions like sympathectomy.
Pain management This could be pharmacological or non pharmacological.
Nonsteroidal anti-Inflammatory drugs can be use to treat the pain which occurs with the limb ischemia. But usually the pain is not resolved by simple analgesics. So the most of the patients may require opioid analgesics such as tramadol and morphine. Tricyclic antidepressants such as amitriptyllin neuropathic pain drugs such as gabapentin and valporate also can be used.

In some patients the pain will be intractable and not controlled with analgesics. So in these cases invasive procedures may be needed. Non pharmacological
This could be either simple invasive procedures such as nerve infiltration or could be major interventions like sympathectomy.
Amputation of non viable and high risk extremities. In Thrombangitis oblitarans the arterial grafting can be rarely performed because unlike in atherosclerotic occlusive arterial disease medium and small vessels are also affected. So it is difficult find a patent distal vessels to act as a run off for the graft.
There fore other than for the pain management by invasive procedures the surgical options are towards timely amputation which prevent the occurrence of sepsis but the surgeon should try the minimum possible amputation.

Indications for amputation are dead limb, gangrene, deadly limb and severe rest pain.
Amputation of non viable and high risk extremities.
In Thrombangitis oblitarans the arterial grafting can be rarely performed because unlike in atherosclerotic occlusive arterial disease medium and small vessels are also affected. So it is difficult find a patent distal vessels to act as a run off for the graft.
There fore other than for the pain management by invasive procedures the surgical options are towards timely amputation which prevent the occurrence of sepsis but the surgeon should try the minimum possible amputation.

Indications for amputation are dead limb, gangrene, deadly limb and severe rest pain.

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