Article by Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
Buerger’s disease is a rare condition. It is a disease of arteries and veins present in the arms and legs. Buerger’s disease is an inflammation of small and medium sized blood vessels. The blood vessels can get swollen up and can get blocked with blood clots (thrombi). It can involve any artery but usually the blockages in this condition take place in the arteries of the feet and hands. This would lead to pain and tissue damage.
This condition is also called Thrombo-Angiitis-Obliterans (abbreviated as TAO).
Pathogenesis of Buerger’s Disease
This disease first manifests in the hands and feet. It will eventually affect larger areas of the arms and legs.
This disease causes inflammation and blocks in the blood vessels in the arms and legs. Due to this, the blood stops flowing which leads to formation of clots which affect the hands and feet.
Inflammation and swelling of small and medium sized blood vessels of arms and legs / hands and feet
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Blocks in the blood vessels in the arms and legs
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Blood stops flowing in the blocked blood vessels
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Clots (thrombi) are formed and block the blood vessels
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Damage and destruction of skin tissues
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Infection and gangrene
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Related symptoms like pain, weakness etc.
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Buerger’s Disease TAO OR Thrombo-Angiitis Obliterans
The tobacco connection
As already said, Buerger’s Disease or TAO is common in those who regularly use tobacco, (cigarettes, cigars, tobacco chewing and snuff) and is said to have no cure.
The main cause of this disease is ‘smoking cigarettes’. Almost everyone having this disease has smoked cigars or has used other forms of tobacco (like chewing tobacco).
To stop this disease, one needs to quit all forms of tobacco. When one quits using tobacco, it helps in easing or relieving the symptoms of the disease. On the other hand, those who keep using tobacco in one or the other form are at greater risk of suffering from severe tissue damage. As a result, one may lose fingers, toes or parts of limbs.
Amputation of all or part of a limb would become necessary for those who do not quit using tobacco.
Incidence
This disease is found worldwide. It can affect people of any age group or race. It is mainly found to affect Asian and Middle Eastern men. It is found to majorly affect men between 40 and 45 years of age, who heavily use or have used tobacco products. This also includes chewing tobacco.
Causes of Buerger’s Disease
The exact cause or causes of Buerger’s Disease are not clearly known.
Tobacco – Tobacco use has been considered to play a major role in the development of Buerger’s disease. One hypothetical understanding is that the chemicals in the tobacco may irritate the lining of the blood vessels. This will cause swelling in blood vessels. According to other opinions, the immune system, triggered by tobacco, attacks the blood vessels.
‘Heavily smoking’ is a habit known to increase the risk of developing Buerger’s disease. In spite of the exact reasons for tobacco increasing this risk being unknown, the correlation between tobacco smoke / habits and development of Buerger’s disease is well documented. ‘Almost everyone with Buerger’s disease uses tobacco’ – says Mayo Clinic.
Genes – Genes may play an important role in causation of Buerger’s Disease. It is also believed that some people might have genetic predisposition to the disease. There is also a possibility that it is caused by an autoimmune response.
Symptoms of Buerger’s Disease
Pain – is usually the first sign / symptom of Buerger’s disease. Pain occurs in hands or feet which spreads to the arms and legs. Many times, the pain is severe in nature. The pain can occur while one is active (claudication) or while resting. The pain can get worse when one is exposed to cold or is stressed.
Below mentioned are the signs (changes) in one’s hands and feet –
– Pain – in hands and feet / legs and arms – the pain may keep coming and going
– Weakness in the affected areas
– Cold, numb or tingling sensation
– Pale, red or bluish coloration
– Pallor – in cold temperatures, the toes or fingers become cold
– Skin becomes thin and shiny
– Having less hairs than usual
– Painful open sores on fingers and toes
– Fingers and toes turn pale when you are cold (Raynaud’s phenomenon)
– Swelling / inflammation along the course of a vein under the skin, usually a sign of blood clot (this should alert one to see the doctor immediately)
| Sl No | Category | Symptom / appearance / nature | Where? |
| 1 | Sensation | Feel of numbness or tingling | Hands or feet |
| 2 | Appearance | Pale, reddish or blue tint | Hands or feet |
| 3 | Pain & claudication | Comes and goes,Claudication – pain appears when you use your hands or feet and reduces / eases when you stop that activity or when you are at rest | Legs and feet orArms and hands |
| 4 | Inflammation | Inflammatory swelling along the vein below the surface of the skin | Along a vein, below the skin’s surface (possibly due to a blood clot in the vein) |
| 5 | Raynaud’s Phenomenon / Pallor | Appearance of pallor when exposed to cold – called Raynaud’s phenomenon | Fingers and toes |
| 6 | Sores | Appearance of painful sores | Fingers and toes |
What is the right time to see the doctor?
Anytime is quick time in Buerger’s Disease. You may take consultation with an expert physician when you think or know that you have signs and symptoms of this disease.
Risk Factors of Buerger’s Disease
Tobacco – Cigarette smoking is the greatest risk factor for the development of Buerger’s disease. On the other hand, this disease can also occur in those who use any form of tobacco. This includes cigars and chewing tobacco. Even among the tobacco users the below mentioned are at the highest risk of developing this disease –
– Smoking hand rolled cigarettes having raw tobacco
– Smoking more than one and half packet of cigarettes per day
Geography – The rates of this disease are highest in areas of Mediterranean, Asia and Middle East. In these regions heavy smoking is common.
Chronic disease of gums – Development of Buerger’s Disease is linked to long term infection of gums.
Sex – This disease is more common in males than in females. This could possibly be so because men smoke more than women.
Age – This is often seen to first manifest in people below 45 years of age.
Complications of Buerger’s Disease
In the worst stage of this disease there is decrease in blood flow to the arms and legs. This is because the blood doesn’t reach the finger and toe tips due to blockages in the blood vessels. The tissues deprived of blood supply are also deprived of oxygen and nutrients. This leads to the onset of gangrene (death of skin and tissues on the finger and toe tips).
Gangrene is marked by –
– Black or blue skin
– Loss of feeling / sensation in affected finger or toe
– Foul smell from the affected part
Gangrene – Gangrene is a serious condition. Gangrene is death of skin and tissue in the toes and fingers – is caused due to complete slowing down or stoppage of blood flow to the mentioned parts. The toes and fingers go numb and turn blue or black. Gangrene may need amputation of the affected finger or toe, many times. Stroke or heart attack can occur in rare cases.
Prevention of Buerger’s Disease
No behavior modification or vaccine can prevent one from developing Buerger’s Disease. The progression of the disease however can be prevented by quitting smoking.
One should quit all forms of tobacco usage.
One should take the help of a doctor if they are planning to quit smoking or planning to do so and not being able to do so.
Diagnosis of Buerger’s Disease
The doctor may first conduct thorough examination, elicit signs and symptoms and record detailed history to evaluate and diagnose Buerger’s disease.
There are no specific tests or confirmatory tests to determine that one has Buerger’s disease. Therefore, Buerger’s Disease is basically a clinical diagnosis.
The below mentioned tests may be recommended by your physician to rule out other conditions and also possibly conclude if the signs and symptoms that you are experiencing are those of Buerger’s disease.
Blood tests – These are recommended to rule out conditions like scleroderma, lupus, blood clotting disorders and diabetes which might cause similar signs and symptoms.
Allen’s Test – This test is done to find out blood flow through the arteries carrying blood to one’s hands. The patient is asked to make a tight fist. This forces the blood out of his hands. Now the doctor presses on his arteries at each side of the wrist. This would slow down the flow of blood into his hand and eventually make his hand lose its normal color. Now the patient is asked to open his hand. The doctor would release the pressure on one artery, then the other. The health of the arteries is determined on how quickly the color returns to his hand. When the blood flow into the hand is slow it might suggest problems like Buerger’s disease.
Imaging – Vascular ultrasound or an angiogram may be ordered if blood samples turn out to be negative.
Angiogram – It is an X-ray which checks for blocked blood vessels in arms and legs (A CT or MRI scan can also be used).
This will help in seeing the condition of the arteries. It may be done on both your arms and legs. Even if there are no signs and symptoms in other limbs wherein angiogram is done it may detect early signs of vessel damage.
Prognosis of Buerger’s Disease
The prognosis of Buerger’s disease depends on whether one quits tobacco or not. About 43% of those who keep using it might have an amputation within 8 years of diagnosis. The chances of getting an amputation comes down to 6% in those who quit. If diagnosed early, the percentage of amputation comes close to 0.
Lifestyle and home remedies
Below mentioned are some of the measures which might improve your symptoms.
Regular exercise – would help in easing the pain. Exercises should be taken very regularly, without missing out, on most days of the week, for at least half hour each day. The exercises should include moderate aerobic activity such as walking or biking.
Skin care – It is very much essential to take care of fingers and toes in patients with Buerger’s disease. One should regularly deep check for cuts and scrapes on the arms and legs. This is because if the sensation is lost, one may not feel if the cut or scrap happens. The fingers and toes should be protected and should not be exposed to cold.
Avoid places where you are exposed to passive smoking – One should give up smoking for sure. On the other hand, it is equally important to give up second hand or passive smoking which is equally harmful.
Gum care – Gums and teeth should be taken care of and their optimum health shall be maintained. One should also avoid gum diseases and take essential tips and suggestions from the dentist. In its chronic form, gum disease is linked to Buerger’s disease.
Preventing infections – Infections are common in the lower extremities when there is shortage of blood flow. Serious infections can occur when small cuts and scrapes are not addressed properly. Therefore, any cut shall be cleansed with soap and water, antibiotic ointment applied and covered with clean bandage. Cuts or scrapes shall be constantly observed to make sure that they are healing properly. Cuts and scrapes getting worse or not healing or healing slowly should alert one to go to the doctor and seek prompt intervention.
Treatment of Buerger’s Disease
Stop smoking – Stopping all tobacco products is the most effective way to stop worsening of the disease. It is the best way to limit the effects and reduce the symptoms of Buerger’s Disease. This is because even smoking a few cigarettes a day can worsen the disease. Stopping smoking can halt the swelling within your blood vessels. Residential smoking cessation programs are another effective option. This includes staying in a treatment facility to undergo treatment and counseling sessions and other activities which might help you to keep away from smoking and craving for the same.
Other treatment options
These options are less effective than quitting smoking but are often included in treating Buerger’s disease –
– Medicines – vasodilators to dilate blood vessels, improve blood flow or medicines to dissolve blood clots
– Intermittent compression of arms and legs (this would increase blood flow to the extremities)
– Spinal cord stimulation
– Amputation – in presence of (area of) infection or gangrene
Futuristic (potential) treatment approaches
Nerve surgery / surgical sympathectomy – to cut off the nerves to the affected area (so as to control pain and increase blood flow). It may be needed in rare cases wherein there is severe pain.
Growing new blood vessels / therapeutic angiogenesis
Bosentan / Tracleer – is a medication which has shown to improve blood flow in people with Buerger’s disease
Blood vessel procedure / endovascular therapy – to open up blood vessels and restore blood flow by threading thin catheter into the blood vessels
Exercise – Walking exercises should be done daily.
Growth factors – proteins which might help to speed healing and ease pain
Stem cells injections – to help the body to make new blood vessels
Keep away from cold – Avoiding cold weather and exposure to cold can help in pain control.
Hydration and activity – Some people have reported improvements in the symptoms by regularly drinking fluids and staying active. These approaches increase circulation.
Outlook
The symptoms may disappear even without need for treatment once the person suffering from Buerger’s disease stops using tobacco products.
Gangrene or circulation problems in other parts of the body cannot be avoided if the condition is severe. Limb amputation may be required in severe cases of gangrene.
Any possible complications related to Buerger’s disease may be avoided when one reports to the doctor with the onset of symptoms or when the symptoms of the disease are first noticed.
One study on ‘Stem Cell Therapy in Thromboangiitis Obliterans / Buerger’s Disease’ has shown that therapeutic angiogenesis and immunomodulatory approaches through the delivery of stem cells to target tissues are potential options for ischemic lesion treatment.
Another study emphasizes integrated care towards comprehensive treatment of Buerger’s Disease. It states – ‘To achieve better clinical results, integrated care in multidisciplinary and trans-sectoral teams with emphasis on smoking cessation, pain control, wound management, and social care by professionals, social workers and family members is necessary.
Ayurveda Understanding of Buerger’s Disease
Vatarakta – The closest correlation which can be made with Buerger’s Disease is Vatarakta. Vatarakta matches with Buerger’s Disease from the perspective of causes, pathogenesis, symptoms and complications.
Buerger’s disease is said to be caused by swelling and inflammation of blood vessels, leading to formation of clots therein, thus hampering the flow of blood to the limbs and other parts of the body. These events are responsible for the manifestation of pain and other symptoms of Buerger’s disease.
Similar sets of events are explained in the pathogenesis of vatarakta. In vatarakta, vata and rakta – blood is aggravated individually due to the consumption of or exposure to their respective etiological factors. Later the aggravated blood causes blockage of the movement of vata. The combination of aggravated vata and rakta are responsible for the manifestation of vatarakta.
The treatments and treatment principles explained in the context of Vatarakta – including therapies, medicines, diet and lifestyle changes, when administered in the treatment of Buerger’s Disease are found to yield appreciable results. Administration of Vasti – medicated enemas, Virechana – purgation, Raktamokshana – bloodletting and external therapies like showering the afflicted parts with milk processed with Dashamula and herbs like Guduchi – Tinospora cordifolia etc mentioned in the treatment of Vatarakta are highly beneficial in the treatment of Buerger’s Disease.
Related Reading – ‘Buerger’s Disease – Ayurveda Understanding’
