RISK FACTORS:Smoking tobacco, Occasional cases is users of smokeless tobacco and
snuff
GENERAL MEASURES :
β’ Stop smoking (mandatory)
β’ Protect against trauma (poor fitting shoes)
β’ Protect against infections
β’ Protect against vasoconstriction from cold or drugs
β’ Eliminate exposure to thermal damage
β’ Eliminate exposure to chemical damage (iodine, carbolic acid, salicylic acid)
β’ Thrombolytic therapy of occlusive thrombus and angioplasty are experimental
SURGICAL MEASURES :
β’ Amputation for non-healing ulcers, gangrene or intractable pain. Should preserve as much limb as possible.
Rarely required.
β’ Omental autotransplantation has been successful in treating ulcers
β’ Infrainguinal bypass
β’ In severe disease, a lumbar sympathectomy to increase blood supply to the skin
β’ Spinal cord stimulator
β’ Direct revascularization of distal arteries is not practical. Distal target vessel is usually not available.
PATIENT EDUCATION
β’ Must stop smoking
β’ Remove possibilities of exposure to others in the environment who smoke
β’ Nicotine replacement may keep the disease active
β’ Use heel pads or foam rubber boots
DRUG(S) OF CHOICE :
β’ Medications are not a substitute for discontinuance of smoking
β’ Antibiotics for infected digital ulcers and osteomyelitis
β’ Iloprost, a prostacyclin analogue, promotes ulcer healing (available in Europe)
β’ Urokinase or streptokinase selectively infused into occluded artery
β’ Intramuscular endothelial growth factor gene therapy
β’ No form of medical treatment has been shown to be effective (including steroids, calcium channel blockers,
reserpine, pentoxifylline, vasodilators, antiplatelet drugs, anticoagulants)
PATIENT MONITORING : Frequent history and physical examinations
PREVENTION/AVOIDANCE : Never smoke
POSSIBLE COMPLICATIONS :
β’ Ulcerations
β’ Gangrene
β’ Need for amputation
β’ Rare occlusion of cerebral, coronary, renal, splenic, mesenteric, pulmonary, iliac arteries and aorta
EXPECTED COURSE/PROGNOSIS :
β’ Occasional remissions
β’ Unremitting progression if patient continues to smoke
β’ Death rare; normal survival curve