Buerger’s vs Atherosclerosis vs Ulcers😊

Buerger’s vs Atherosclerosis

Feature	Buerger’s Disease (Thromboangitis Obliterans)	Atherosclerosis
Gender	M > F	M = F
Age	3rd Decade → most important	≥ 5th Decade
Risk Factors	Smoking	Smoking, Alcohol, Type A Personality, Hyperlipidemia
Limbs Affected	Lower Limbs > Upper Limbs	Lower Limbs > Upper Limbs
Affected Structures	Artery, Vein, Nerve Small to Medium Arteries and veins  (totally obliterated). Never Affected: Lymphatics.	Arteries Large to Medium
Progression	Distal → Proximal	Proximal → Distal
Clinical Symptoms:	• Initial: Intermittent claudication, usually leg claudication (pain during walking). • Later: Pain at rest (due to nerve involvement).	ㅤ
Other Features	- Confirmatory Test: Muscle Biopsy → → Shows Neutrophilic microabcess - Imaging: Corkscrew Collaterals	-
Management	1. Stop Smoking 2. Pentoxyphylline 3. Conservative Amputation 4. Lumbar Sympathectomy → Only if Rest Pain Present → If B/L, Conserve L1 Ganglion on One Side to Prevent Impotence	1. Angioplasty (First line) 2. Bypass (Best) : Using grafts

Dry Gangrene

• Desiccated Tissue:
• Due to Gradual Slowing of Blood

• Good Line of Demarcation

• If Bone Involved: Conical Stump

 

Wet Gangrene

• Due to Venous Blockade or Superadded Infection

• Poor Line of Demarcation

• Can be Proximal Due to Extension of Infection

Sclerosis

• Definition: Something becoming stiff.

Hyaline Arteriolosclerosis

• Appearance: Blood vessel becomes very pink with a pink glassy appearance.

• Associated Diseases:
• Benign hypertension.
• Diabetes mellitus.

Hyperplastic Arteriolosclerosis

• Appearance: Shows an onion skinning pattern.
• Due to increase in smooth muscle and fibroblasts.

• Associated Disease: Seen in malignant hypertension.

Mönckeberg Arteriosclerosis
(Calcific Medial Degeneration - CMD)

• Pathology:
• Involves dystrophic calcification in tunica media (middle layer).

• Significance:
• Degenerative phenomenon seen in old age.
• Carries no clinical significance.

Atherosclerosis

• Causes:
• Infections: Chlamydia, Cytomegalovirus, Herpes.
• Chlamydia is very important.
• Mnemonic: CM (CMV) gets Heart attack while Chambing (Chlamydia) Her (Herpes)
• Lifestyle factors:
• Sedentary lifestyle, alcohol, smoking, obesity, high cholesterol.

• Lesions:
• First Lesion: 
• Fatty streak.
• Small, few millimeters.
• Next Lesion: 
• Atheromatous plaque.
• Location: Subintimal (below tunica intima).
• Composition: Lots of cholesterol and triglycerides.

• Microscopy:
• Contains foam cells 
• macrophages engulfing cholesterol/lipids
• aka lipid-laden macrophages
• Stain: Oil Red O positivity for lipids.

• Complications:
• Mnemonic: ACUTE
• A: Aneurysm formation.
• C: Calcification.
• U: Ulceration (plaque rupture).
• T: Thrombosis (blood clot).
• E: Embolism (spread of thrombosis).

• Most Common Vessels Affected (most to least common):
• Mnemonic: ACP of Delhi is cute



• A: Abdominal aorta.
• C: Coronary artery (e.g., left anterior descending).
• P: Popliteal artery.
• D: Descending thoracic branch of aorta.
• I: Internal carotid artery.
• C: Circle of Willis (least common).

Acute Arterial Occlusion

Features

• Most Common Cause: Embolus
• Source: Heart (Most common)
• History of Ischemic Heart Disease
• History of A-fib (Irregularly Irregular Heartbeat)

• No Collaterals Present

Clinical Features (6 Ps)

• Pain

• Pallor

• Paresthesia

• Poikilothermia (Cold Limbs)

• Pulselessness

• Paresis/Paralysis (Late Signs)

Imaging of Choice (IOC):

• Doppler/Duplex Scan

Management

• Patient within 6-8 Hours
• Angiogram: Embolectomy + Revascularization
• Using Fogarty's Balloon

• Gangrene Present:
• Amputation

Complication:

• Reperfusion Injury

• Muscle Swelling
• Management: Fasciotomy

Chronic Arterial Occlusion

Features

• Gradual Occlusion (Due to Thrombus)

• Formation of Collaterals

Clinical Features

• Intermittent Claudication
• Cramping Pain
• Felt after walking a certain distance called as claudication distance
• As disease progress → claudication distance ↓↓
• Progresses to Rest Pain
• Due to Substance P
• Pain is One Level Below Site of Occlusion

• Rest Pain
• Patient prefers to be in Seated position with legs hanging down
• Pain aggravates while lying down or elevating the leg

• Gangrene

Pain on First Step Differentials

1. Osteoarthritis
• Maximum Pain on First Step
• Pain in Affected Joint

2. Neurogenic Claudication
• Due to Lumbar Canal Stenosis
• Pain Varies with Posture
• Bending Forward: Relieved
• Relieved while climbing stairs
• Standing Straight: Aggravated

Boyd’s Classification

• Class 1: Pain on Walking, pain reduces as patient continues to walk
• due to washout of substance P

• Class 2: Pain on Walking, Able to Walk Despite Pain

• Class 3: Pain Forces Patient to Stop

• Class 4: Pain at Rest

• Mnemonic: Boy likes walking

Rutherford Classification for Chronic Limb Ischaemia

Peripheral Vessel Doppler/ Duplex

• 1st IOC
• POVD
• Aneurysm

Vessel	Flow	Notes
Peripheral artery	Triphasic waveform	Triphasic EEG → Hep Enceph
Visceral artery	Monophasic with pulsations	ㅤ
Veins	Monophasic with respiratory phasicity. without pulsations	ㅤ

Site of Obstruction

• Aortoiliac
• Buttock Claudication (Earliest)
• Pain in Thigh & Calves
• Bruit Over Aortoiliac Region
• Impotence in Males (Leriche Syndrome)

• Iliac:
• Thigh Pain
• May Thurner Syndrome → Left iliac Vein occlusion

• Femoropopliteal:
• Calf Pain

• Distal Obstruction:
• Ankle Pain

Investigations

• IOC:
• Doppler or Duplex Scan (Doppler + B-mode USG)

• ABPI (Ankle Brachial Pressure Index)
• Max Systolic BP at Ankle / Max Systolic BP at Brachial Artery
• Values & Inference

Value Range	Condition
> 1.4	Calcified Vessels (DM/CKD)
0.9 - 1.4	Normal
< 0.9	Intermittent Claudication
< 0.5	Twice as Likely to Deteriorate
< 0.4	Chronic Limb Threatening Ischemia
> 20% Drop After Exercise	Flow Limiting Arterial Disease

• Bailey Updates
• Gradually Decreasing ABPI:
• Sign of Imminent Limb Loss
• Every 0.1 ↓↓ in ABPI below 0.9
• 10% ↑ ↑ Risk of Cardiac Mortality

• CLTI (Chronic Limb Threatening Ischemia)
• Ischemic Rest Pain ± Ulceration/Gangrene
• Requires Urgent Assessment & Treatment

TBI (Toe Brachial Pressure Index)

• Used in DM Patients
• with ABPI > 1.4 (falsely high)

• More Reliable
• as Digital Arteries rarely affected by Sclerosis

• TBI < 0.6
• Indicates an Arterial Lesion

• Mnemonic: Ptosis → Toe 6

Digital Subtraction Angiography (DSA)

• Only if Intervention is Planned

• Provides Dynamic Arterial Flow + Anatomy of Vessels

• Complications
• Bleeding
• Dissection
• Thrombosis
• Renal Dysfunction
• Aneurysm

Management of Atherosclerosis:

1. Angioplasty & Stenting

• Complications
• Failure
• Hematoma
• Bleeding
• Thrombosis

• 1st Line Treatment

• Successful for Iliac & Femoropopliteal (Less Successful Below Knee)

2. Grafting

• Best Method

• Aorto-bifemoral

Aorto-Bifemoral:

• Dacron Graft (Best)

Infra-inguinal Graft:

• Reversed Saphenous Vein (GSV) → Best

• PTFE → Best Synthetic Graft

Indications for CABG

• Left main disease > 50%

• Three-vessel disease > 70%

• Two-vessel disease:
• LAD + one other major artery

• One-vessel disease > 70% in survivor of:
• Sudden cardiac death
• Due to ischemia-related ventricular tachycardia

CABG Grafts

1. Reversed great saphenous vein:
• m/c
• m/c complication: Saphenous nerve injury during Harvesting

2. LIMA-LAD
• Left internal mammary artery used for LAD
• Preferred d/t low risk of atheroscleorisis

3. RIMA – Right internal mammary artery

4. Radial artery

Raynaud’s Phenomenon

Causes

• Cold Weather

• History of Use of Drilling Equipment

• Dihydroergotamine can cause Raynauds

Features

• Vasospasm (Pain +)

• Colour Change: White → Blue → Red
• Blue → Pain +

Primary vs Secondary

Ulcers

Venous Ulcer

• Clinical Features:
• Shallow with sloping edges.
• Pale granulation tissue.
• Pigmented margins.

• Most Common Site: Medial malleolus / Gaiter’s area.

• Cause: Ambulatory venous hypertension.

Management:

• Bisgaard’s Regime:
• Education.
• Limb elevation.
• Elastic compression stockings.
• Dressings.

• Surgery (for underlying venous insufficiency).

• Medication: Pentoxyphylline (improves microvascular perfusion).

Marjolin's Ulcer

• Low-grade squamous cell carcinoma arising from:
• chronic venous ulcers (e.g., venous ulcer)
• Post-burn scar
• Chronic osteomyelitis
• Post-radiation ulcer

• Slow growing
• Due to being relatively avascular

• Painless
• Due to absence of nerves in scar tissue

• No secondary deposits
• Due to no lymphatics in scar tissue

• Radioresistant
• Due to avascularity

Management:

• Wedge biopsy

• Wide Local Excision (WLE).

Differential Diagnosis (D/D) of Leg Ulcers

General Ulcer Management:

• Debridement
• Except trophic ulcer

• VAC Dressing (-125 mmHg): 
• Contraindicated in osteomyelitis with DM.