New views on the nature and therapy of Burger's disease will be presented to the readers of "Doctor" by one of Bulgaria's leading specialists in the field of vascular surgery, Assoc. Dr. Dimitar Petkov, MD. He is the head of the Department of Vascular and Endovascular Surgery at Trakia Hospital in Stara Zagora and Associate Professor of Cardiovascular Surgery at the Faculty of Medicine of Trakia University. Associate Professor Petkov has a speci alty in "Surgery and Vascular Surgery", as well as a qualification in "He alth Management". Prof. Petkov is the author and co-author of over 90 scientific works, published and presented at scientific forums in Bulgaria and around the world, as well as publications in renowned Bulgarian and international journals. He is a member of the Bulgarian National Society of Angiology and Vascular Surgery; of the European Society of Vascular Surgery and the International College of Angiology in the USA
Prof. Petkov, has there been a change in recent years in the views of specialists regarding the essence and especially the therapy of Buerger's disease?
- The etiology of Buerger's disease remains unknown, although smoking is strongly implicated in the initiation of the disease. Also, the idea that it is an autoimmune disease continues to be worked on and research is being done in that direction. Overall, the spread remains the same. So far, there is no drastic leap and change in our views on the etiology and development of Buerger's disease. As well as about the reasons that provoke it and how it develops.
What are the main methods of diagnosis and treatment of Buerger's disease?
- The main diagnostic methods remain the same: Doppler sonography and angiography, with computed tomography angiography becoming more and more popular due to the ease of performance and high informativeness of the study. And, of course, histology as a diagnostic procedure, when there is an opportunity to take material from blood vessels when performing various operations. In terms of treatment, the principles remain the same, while the novelty is the increasingly active introduction of endovascular procedures, the so-called "bloodless operations" as a treatment method for the disease. In them, balloons are inserted through small holes in the blood vessels, which expand the blood vessels, after which, if necessary, stents are placed - devices that keep the blood vessel open and prevent the formation of new narrowings. I want to note that in Buerger's disease, the indications in this regard are more specific, because the disease is different from atherosclerosis.
That is why it is necessary to make a correct assessment of the treatment approach in advance. Worldwide, endovascular procedures in the treatment of Buerger's disease are becoming increasingly popular, but there is still a lack of sufficient experience to definitively prove that under certain conditions the endovascular technique is best, such as in atherosclerosis. Also important is the fact that Buerger's disease is spread only in certain geographical areas, therefore the data in the specialized literature are still less compared to those for atherosclerosis.
Prof. Petkov, what should people remember about this disease, what is most characteristic of it?
- Most often it concerns young people, under the age of 50, who complain of coldness, pain and numbness in the limbs. They complain of hair loss, the appearance of sores and gangrene - darkening of the ends of the fingers, in which the skin turns black. The development of gangrene is accompanied by an extremely severe pain syndrome. It is also typical that almost all patients are smokers. Approximately 90% of patients are men, but in recent years there has been a tendency to increase the number of affected women. This is most likely related to the increase in smoking among women as well.
It is probably redundant to ask you if self-medication is permissible?
- Categorically self-medication leads to only one thing - loss of limbs in this disease. We must emphasize that in the case of the generalized form affecting the blood vessels of the entire organism, it can lead to death in over 50% of cases.
How do people know that it is Buerger's disease? Have they read enough about the symptoms?
- The diagnosis is most easily made by a specialist - a vascular surgeon. I want to point out that cannabis arteritis - a disease with symptoms similar to Buerger's disease in patients who smoke cannabis - should also be discussed in the diagnostic plan.
Vascular surgeons deal with Buerger's disease, vascular diseases of the extremities, aneurysms of the aorta, narrowing of the carotid arteries and other diseases affecting blood vessels in the human body.
What is the treatment for Buerger's disease?
- I will repeat again that a qualified vascular surgeon should offer the optimal treatment for each patient. A characteristic feature of this disease is that only about 25% of patients are suitable for open surgical treatment. Currently, some of the procedures are endovascular, but we cannot yet say with certainty what percentage of interventions will be performed this way in the future. Unfortunately, about 50% of patients are in a condition that can only be treated medically due to the fact that the blood vessels of the patients have severe obliterations (blockages) that do not allow open surgery to be performed. To your question - since endovascular procedures can also dilate (widen) smaller blood vessels, it is believed that in this way we can have a positive effect on collateral blood circulation. This gives us hope that the results of endovascular treatment in the future will be satisfactory. At the moment, we are still working in this direction, and there are no large groups of patients on which to definitively draw conclusions.
Risk groups
Assoc. Petkov recalled that as the most easily applicable for diagnosing the disease, based on the clinical picture, the criteria of Sh. Shionoya prevailed. He assumes that if the following 5 symptoms are present, the diagnosis is certain. Here's who they are:
1. Men under the age of 50.
2. Smokers.
3. Presence of peripheral arterial blockages.
4. Presence of thrombophlebitis and involvement of the arteries of the upper limbs in the process.
5. Lack of risk factors for the development of atherosclerosis and diabetes.
"Effective treatment is related to a definite and final cessation of smoking" - Assoc. Prof. Dimitar Petkov emphasized again. He explained that the type of treatment is determined by the degree of the so-called chronic arterial insufficiency (HANC). "When the disease we are talking about is the cause of the development of HANK first and second degree, treatment is carried out with the so-called vasoactive medications, vasodilators, antiplatelet agents. Protection from cold effects and microtraumas of the affected limbs is part of the treatment program. Walking at a slower speed is recommended, as this helps the development of the so-called collateral circulation. When the patient begins to experience constant pain in the horizontal position of the limb and at night, when atonic wounds and gangrene appear, then we are talking about the third and fourth degree of chronic arterial insufficiency, and surgical treatment is discussed accordingly. The most commonly performed operation is a bypass, in which an artificial blood vessel (prosthesis) or own vein is used to bypass the blocked area and direct the blood under the affected arterial segment. Unfortunately, because of the diffuse and distal occlusions of the arteries, this operation is not suitable for a fairly large percentage of cases. Then medical treatment with prostaglandins is applied. And, of course, the increasingly active use of endovascular procedures as a new method of treatment.”
14 Bulgarians per 100,000 are sick
“Buerger's disease is believed to be a systemic, most likely autoimmune, chronic inflammatory disease of small and medium-sized arteries, primarily in the extremities. - explained associate professor Dr. Dimitar Petkov. - It is interesting that it has a characteristic geographical location - it mainly affects the population of the Balkan Peninsula, the Mediterranean and the Asian continent. In our country, the incidence is 14 people per 100 thousand population, and patients with Buerger's disease are 12.3 percent of the total number of patients with peripheral arterial occlusive diseases. As I have already said, the disease is considered to affect mostly male smokers under the age of 50, but the number of affected women is also constantly increasing worldwide. In Bulgaria, the male-female ratio is 11/1. I will remind you that the name is in honor of the discoverer of the disease - Dr. Leo Buerger, who in May 1908 at the meeting of the Association of American Physicians in Washington for the first time accurately described the clinical and pathoanatomical characteristics of the disease. Until his death in 1943, Dr. Bürger worked tirelessly on the observation, diagnosis, treatment and popularization of the disease and published his clinical observations and results incessantly. However, it was only in 1979 that the disease was officially recognized by medical circles worldwide, and then it received the name "Buerger's disease".
For the almost 100-year period during which the disease has been studied, various reasons for its development have been discussed. Cold trauma, infectious agents, allergies, nutritional deficiency, but without proving a definite connection with the initiation and progression of the pathological process. However, a relationship between the quality of life and the development of the disease has been established. Globally, there is a greater incidence among population groups with a low standard of living. In Bulgaria, interest is caused by the increase in the number of new patients in 1991 and the period 1995-1997. As a probable reason, the reduced quality of life in the country during these periods can be discussed. At the beginning of the 21st century, the opinion increasingly prevails that the cause of the disease is an autoimmune process affecting and damaging not only arterial but also venous vessels. As a result, stenoses (narrowings) and obturation (thrombosis) develop with subsequent acute or chronic arterial insufficiency of the limbs. However, it is an indisputable fact that all patients with Buerger's disease are smokers. It is now clear that the increase in the number of women affected is also associated with the increase in the number of female smokers. It is now accepted that smoking cessation results in clinical improvement and arrest of disease progression. While for those who continue to smoke, not only is the treatment ineffective, but the disease also begins to cover new areas of the blood vessels. And in the end, it most often leads to necrosis and gangrene of the fingers and limbs".
It is important to know that Buerger's disease comes in several forms. In the beginning, complaints of numbness and coldness of the fingers predominate, the hair begins to fall out, the brittleness of the nail edges increases. Gradually, the pain when walking is localized in the foot. Subsequently, unbearable pain occurs at rest and at night. If no measures are taken, gangrene and atonic wounds develop on the toes and feet. When arteries from other parts of the human body are involved in the disease process, then the corresponding symptoms develop: in the case of coronary arteries - heart attack; if the brain is affected - cerebral stroke; when affecting the abdominal - the so-called angina abdominalis. It is important to know that Buerger's disease occurs in the following forms:
• soft - after adequate treatment and cessation of smoking, necrosis and gangrene of the limbs do not develop;
• typical - the disease proceeds in waves with periodic worsening. Pain occurs at rest and atonic wounds and gangrene occur. This is followed by improvement of the clinical picture and control of symptoms with adequate treatment and, of course, without smoking;
• Pseudoembolic - at first glance, it begins suddenly and resembles the clinical picture of embolism with the development of acute arterial insufficiency. This means a sudden onset of unbearable pain, loss of sensitivity and varying degrees of limitation of the motor activity of the fingers;
• Generalized - with her, after the development of the initial symptoms, the disease progresses continuously with the involvement of the four limbs and the development of abdominal, brain and heart symptoms. Mortality in this form of the disease is high - over 50%;
• Combined - here on the arteries affected by Buerger's disease are superimposed changes due to atherosclerosis or diabetic macroangiopathy - most often in larger caliber arteries. As a result, the so-called mixed arterial decompensation.
