It is a well-known fact that smoking is hazardous to health, and the incidence of lung cancer, laryngeal cancer, coronary heart disease, circulatory system, and bronchitis are many times higher in long-term smokers than in non-smokers. Today, Dr. Xia is not here to be an ambassador to quit smoking, but today to share the clinical cases also related to smoking, but also to pick the young and strong smokers, let’s take a look.
Thrombo-occlusive vasculitis a blood case induced by smoking
I. Clinical definition
Thrombo-occlusive vasculitis (TAO) is a chronic, segmental, periodic episodes of non-suppurative inflammatory vascular damage disease involving mainly the distal middle arteries, small arteries and veins of the extremities, which can involve both veins and peripheral nerves. The inflammatory vascular lesions cause painful limb ischemia secondary to intraluminal thrombosis and luminal occlusion, which can lead to limb gangrene or even amputation if not treated promptly.
Figure 1. Patient’s limb amputation due to TAO
II. Epidemiology and etiology
The disease has a worldwide distribution, but there are obvious geographical differences in prevalence, mostly in the Middle East, the Far East, Eastern Europe and other regions, some data show that the prevalence of blacks is relatively low, and the incidence in the north of China is significantly higher than in the south.
The prevalence of TA0 is also high in young men aged 20-45 years with low social status and high psychological stress, and recently, with the increase of female smokers, the number of female patients has increased significantly, and the average age of onset of TAO has also increased.
Figure 2. Important factors of smoking history triggering TAO
The etiology of TAO is not completely clear, and is currently considered to be related to smoking (closely related); cold; humidity; surgery, injury, infection; male hormone disorders; genetic factors; autoimmune dysfunction; and blood hypercoagulable state.
Clinical manifestations and staging
The onset of TAO is insidious, and the course of the disease progresses slowly, with periodic episodes, and the disease gradually worsens only after a long period of time.
1.Clinical manifestations
(1) Pain: In the early stage of the disease, pain and other abnormal sensations appear in the affected limbs (toes and fingers) due to vasospasm and stimulation of the nerve endings in the vessel walls and surrounding tissues. With the development of the disease, the pain of the lower limbs gradually worsens, resulting in resting pain, and the patient often sits with his knees clasped, with the lower limbs hanging over the edge of the bed.
Figure 3. Patients “sitting on their knees” due to pain
(2) Chill: the skin temperature decreases the affected limbs are cold, cold, sensitive to external cold is a common early symptom of thrombo-occlusive vasculitis. As the disease progresses, the degree of chilliness increases and a decrease in skin temperature of the limb distal to the arterial occlusion may occur.
Figure 4. Skin temperature examination
(3) Skin color change: Ischemia of the affected limb makes the skin color pale, which is more obvious when the limb is elevated. In addition, some patients stimulated by cold or emotional fluctuations may develop Raynaud’s syndrome, which is manifested as intermittent changes in pale, cyanotic and flushed skin of the fingers (toes).
(4) Limb nutritional disorders: Ischemia of the affected limbs can cause limb nutritional disorders, often manifesting as dry, flaky and wrinkled skin; loss of sweat hair and reduced sweating; thickened, deformed and slow-growing toe (finger) nails; muscle atrophy and thinning limbs. In severe cases, ulcers and gangrene may occur.
Figure 5. Terminal finger and toe necrosis
(5) Weakness or disappearance of arterial pulsation in the limb: depending on the arteries involved in the lesion, there may be weakness or disappearance of arterial pulsation in the dorsalis pedis, posterior tibial artery, popliteal artery or ulnar artery, radial artery, brachial artery, etc.
2.Clinical stage
The disease starts insidiously, progresses slowly and has periodic episodes, and can be divided into three stages according to the degree of limb ischemia.
Phase I local ischemic phase: intermittent claudication, weakened posterior tibial artery pulsation in the dorsum of the foot, wandering thrombotic superficial phlebitis, and functional factors (spasm) are greater than organic factors (occlusion).
Phase II Dystrophic phase: resting pain, loss of dorsalis pedis posterior tibial artery pulsation, nutritional impairment of the affected limb, organic factors predominate, and the limb relies on collateral circulation for survival.
Phase III: ischemic ulceration, gangrene, and secondary infection symptoms. Pain is persistent, and the necrotic limb often detaches itself.
Figure 6. Finger lost due to vasculitis
Figure 7. Toe lost due to vasculitis
Four, auxiliary examination
1.General examination
(1) Whether claudication
To ask the history of patients whether they have claudication, ward aisle set distance markers, ask patients to walk back and forth in the ward aisle, determine the claudication distance and claudication time.
(2) Limb elevation test
Patients lying down, the affected limb elevated 45 °, 3 min later to observe the color change of the foot, test positive, the skin of the foot is pale or waxy yellow, especially the toes and the palm part, acupressure is more and more obvious, self-conscious numbness and pain, and then let the patient sit up, the lower limbs naturally hanging down on the side of the bed, the central skin color gradually appear flushed, patchy or cyanotic. A positive test indicates that the affected limb has a severe blood supply deficiency. This method requires doctor-patient cooperation, otherwise it is difficult for the patient to adhere to it.
Figure 8. Buerger test
2.Special examination
(1) Color Doppler ultrasound: mainly to detect the degree of arterial cavity lesions.
(2) Segmental arterial pressure measurement: It can determine where the lesion is located, and the pressure difference between the segmental healthy arteries is within 20 mmHg. If it exceeds 30 mmHg, it indicates significant stenosis of the distal artery.
(3) Arteriography DSA: The lesion can be seen in the distal vessels, and the artery is segmentally stenosed or occluded, while the proximal vessels are not abnormal.
(4) CTA: It can clearly show the vascular path, morphology and lumen thickness, and make an accurate judgment of the stenosis site with a sensitivity specificity of more than 90%, and the trunk can reach 100% and 98%. It can show the lesions of the vessel lumen and vessel wall, and no atherosclerotic plaque can be seen.
Figure 9. CT angiography
V. Clinical diagnosis
This disease has certain characteristics, and it is not difficult to diagnose. The main points of diagnosis include.
1. a history of long-term smoking with a high level of addiction, which is more common in young adults.
2, clinical manifestations of lower limb ischemia: coldness and fear of cold in the affected limbs, numbness and weakness, dotted and striped purplish red spots on the skin, and soreness and swelling of the lower limbs.
3.Weakness or disappearance of arterial pulsation: dorsalis pedis artery, posterior tibial artery, etc. are taught to be obvious.
VI. Treatment
1, general treatment: quit smoking, prevent cold and damp, keep the affected limb warm, moderate exercise, etc. Only appropriate exercise, the limb must not be hot-packed, not rubbed, these actions will make the lower limb oxygen demand, oxygen consumption increased, is not conducive to disease control.
Figure 10. not hot compress
2. Drug therapy: vasodilator drugs, circulation improvement drugs, anti-platelet drugs, antibiotics and analgesics. These drugs can avoid the formation of thrombus on the basis of vascular stenosis, and timely control of the inflammatory reaction of blood vessels, slowing down the progress of vascular lesions
3, hyperbaric oxygen therapy: the role is to increase the partial pressure of oxygen to increase blood oxygen tension and oxygen diffusion, improve tissue oxygen reserve, to improve tissue hypoxia, to promote local tissue repair and relieve resting pain is more effective.
4.Surgical therapy: including endovascular surgery, venous arterialization, arterial reconstruction, large omental graft with vascular tip, lumbar sympathectomy, etc.
Figure 11. Large omental graft with vascular tissues