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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 130-136

Management of chronic case of Buerger’s disease through Ayurveda: A case report


Department of Panchakarma, All India Institute of Ayurveda, New Delhi, India

Date of Submission15-Apr-2020
Date of Decision26-May-2020
Date of Acceptance02-Jul-2020
Date of Web Publication07-Sep-2020

Correspondence Address:
Dr. Ram Lakhan Meena
Department of Panchakarma, All India Institute of Ayurveda, Sarita Vihar, New Delhi.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISM.JISM_29_20

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  Abstract 

Thromboangiitis obliterans (Buerger’s disease) is a non-atherosclerotic inflammatory disease of unknown etiology characterized by thrombosis and recanalization of the affected vessels, which has a strong association with tobacco. It usually affects small and medium-sized arteries and veins in distal upper and lower extremities. The onset of disease occurs between 40 and 45 years of age, and men are most commonly affected. The prevalence of the disease among all the patients with peripheral arterial disease varies from as low as 0.5%-5.6% in Western Europe to as high as 45%-63% in India. The present case study was on a patient who approached the OPD of All India Institute of Ayurveda, New Delhi, with chief complaints of pain and swelling in digits of the left foot for 1 year along with associated complaints of decreased sensation over left toe with bluish and blackish skin discoloration. The essential investigation such as ultrasound Doppler was done and diagnosed as a case of peripheral vascular disease (Buergers disease). Based on clinical presentation, sign, and symptoms, it was diagnosed as a case of Vatarakta (~occlusive peripheral vascular disease) according to Ayurveda. The treatment principle of Vatarakta mainly includes Virechana (~therapeutic purgation), Basti (~therapeutic enema), and Raktamokshana (~bloodletting by mean of leech application along with oral medications were advised. Patient showed significant improvement in the pain according to visual analog scale, skin discoloration, and other associated symptoms along with the positive changes in color Doppler of lower limbs. It shows that the therapeutic purgation with bloodletting therapy is an effective method for the management of thromboangiitis obliterans disease.

Keywords: Leech therapy, Thromboangiitis obliterans, Vatarakta, Virechana Karma


How to cite this article:
Bhatted SK, Meena RL. Management of chronic case of Buerger’s disease through Ayurveda: A case report. J Indian Sys Medicine 2020;8:130-6

How to cite this URL:
Bhatted SK, Meena RL. Management of chronic case of Buerger’s disease through Ayurveda: A case report. J Indian Sys Medicine [serial online] 2020 [cited 2020 Sep 23];8:130-6. Available from: http://www.joinsysmed.com/text.asp?2020/8/2/130/294430




  Introduction Top


Buerger’s disease (thromboangiitis obliterans [TAO]) is an inflammatory occlusive vascular disorder involving small and medium-sized arteries and veins in distal upper and lower extremities. It is a non-atherosclerotic inflammatory disease characterized by thrombosis and recanalization of the affected vessels. The onset of disease occurs between 40 and 45 years of age, and men are most commonly affected. Cause of this disease is not known, but smoking is strongly associated with disease course and progression.[1] The prevalence of the disease among all the patients with peripheral arterial disease varies from as low as 0.5%–5.6% in Western Europe to as high as 45%–63% in India.[2] Histologically there are inflammatory changes in the wall of arteries and veins leading to thrombosis. Thrombosis occurs in small to medium-sized arteries and veins with associated dense polymorphonuclear leukocyte aggregation, microabscesses, and multinucleated giant cells. The chronic phase of the disease shows a decrease in the hypercellularity and frequent recanalization of the vessel lumen. End-stage lesions show organized thrombus and blood vessel fibrosis.[3]

Symptoms may include claudication (cramp such as pain) of the feet, legs, hands, and arms. The pain typically begins in the extremities, but may radiate to other parts of the body. Other signs and symptoms of the disease may include numbness and/or tingling sensation in the limbs, loss of hairs of affected parts, skin discoloration, skin ulcerations, and gangrene of distal parts. Progression of the disease leads to calf claudication and eventually ischemic rest pain and ulcerations on the toes, feet, or fingers.[4]

In Ayurveda, there is involvement of aggravated Vata Dosha along with Rakta Dosha in Vatarakta where normal flow of Vata is obstructed by blood. On the basis of its clinical presentation and pathogenesis, it can be correlated with the disease occlusive peripheral vascular disease. In occlusive peripheral vascular disease, there is an obstruction to the normal flow of Vata by blood in blood vessels manifesting many clinical symptoms such as swelling, pricking pain, and blackish discoloration of skin starts mainly from distal part such as foot and hands.[5]

There is no specific treatment for the disease except abstinence from tobacco, regular exercise, and antiplatelet agents. In patients who are able to avoid smoking, disease remission is impressive and amputation avoidance is increased. The use of vasodilators, lumbar sympathectomy, and aspirin may hold the progression of the disease for a while but that is not the permanent solution. Surgical procedures are not having that promising results, as there is often no acceptable target vessel for bypass.[3] If gangrene sets then amputation is the choice of treatment. In Ayurveda, the treatment principle of Vatarakta disease mainly includes Therapeutic purgation, therapeutic enema, and bloodletting by leech therapy along with some oral medication which provides promising result in sign and symptoms of disease.


  Case Report Top


A 51-year-old male patient attended the OPD of Panchakarma (OPD No. 313640) at All India Institute of Ayurveda, New Delhi on April 26, 2019 with chief complaints of pain and swelling in digits of left foot since 1 year along with associated complaint of decreased sensation (numbness) over left toe with skin discoloration. He also had disturbed sleep in night because of pain. Patient had history of diabetes mellitus since 10 years with chronic smoking (more than six cigarettes per day since 3 years). He had no history of high blood pressure and hypo\hyperthyroidism. No history of any injury or surgery. His appetite was poor, bowel movement was irregular, and had frequent micturation.

On examination, pain was moderate (as per visual analog scale [VAS]) and nonradiating in nature. The skin was bluish and blackish in color, thinner inconsistency shown in [Figure 1]. There was no ulceration, discharge, and foul smelling present in left foot. He was taking nonsteroidal anti-inflammatory drugs (NSAIDs) regularly but there was no significant relief.
Figure 1: Image of affected leg before treatment

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  Clinical Examinations Top


Inspection: Flattening of terminal pulp of toes, nails become brittle, flattened, and ridged.

Palpation: Palpation of peripheral arteries was done and noted as femoral artery––three positive (+++), popliteal artery––two positive (++), posterior tibial artery––two positive (++), and dosralis pedis artery––two positive (++).[6]


  Investigation Top


Ultrasound Doppler (October 8, 2018)––left dorsalis pedis shows continuous diastolic flow suggestive of reduced PSV––sluggish flow. Left lower limb popliteal artery shows intimo medial thickening [Figure 2].
Figure 2: Image of color Doppler before treatment

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  Differential Diagnosis Top


Amavata is a disease in which vitiation of Vata Dosha and accumulation of Ama take place in joints. It starts from small joints of hands and spread to other parts of body, and it simulates rheumatoid arthritis (RA) at modern parlance. Sandhigata Vata is the most common form of the articular disorder. It is a type of Vatavyadhi which mainly occurs in Vriddhavastha due to Dhatukshaya, which limits everyday activities such as walking, dressing, and bathing. It mainly starts with weight-bearing large joints. In Ayurveda, there is involvement of aggravated Vata Dosha along with Rakta Dosha in Vatarakta where the normal flow of Vata is obstructed by blood. It starts from the end parts of hands and feet. On the basis of the above examination, patient was diagnosed as case of Vatarakta as per Ayurveda (~Buerger’s disease [TAO])


  Therapeutic Intervention Top


Before starting treatment, the written informed consent was obtained from the patient for publication of this case report and accompanying images.


  Panchakarma Procedure Adopted Top


Therapeutic purgation was carried out as per the classical method. Treatment was done as mentioned in [Table 1].
Table 1: Panchakarma procedures administered

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Figure 3: Image of affected leg during leech therapy

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Observation after Panchakarma procedures

Madhyama Shuddhi (~moderate cleansing) observed with 16 Vegas (bowel movements) by purgation. No any complications were observed.

After completion of Virechana Karma, following drugs were prescribed as mentioned in [Table 2].
Table 2: Oral medication administered

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  Observation and Results Top


After completion of 1 month of total Ayurveda therapy (Shodhana and Shamana Chikitsa), the patient got complete symptomatic relief in pain and swelling as shown in [Table 3]. Skin color and sensation were also improved as shown in [Figure 4]. He got a significant improvement in the peripheral pulsation of Dorselis pedis artery of left lower limb shown in [Table 4] and [Figure 5]. After completion of treatment, there was no any sign of intimo medial thickening of left lower limb popliteal artery in color Doppler as shown in [Figure 4]. There was significant relief in subjective symptoms such as fatigue and burning epigastrium. Appetite was increased and bowel became regular.
Table 3: Assessment parameters BT and AT

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Figure 4: Image of affected leg after treatment

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Table 4: Peripheral pulsation of left lower limb

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Figure 5: Image of color Doppler after treatment

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Color Doppler both lower limb (September 6, 2019): Both lower limb arteries show normal systolic flow velocity as shown in [Figure 5].


  Discussion Top


The present case was diagnosed case of Buerger’s disease having pain in left great toe with swelling, numbness, and blackish discoloration of skin of the great toe. Based on the clinical presentation in particular and all other findings in general it was diagnosed as a case of Vatarakta according to Ayurveda. Occlusive peripheral vascular disease caused due to Rakta Dushti (impure blood) and vitiation of Vata Dosha. Properties of blood are similar to Pitta. Therapeutic purgations considered best in treating Pitta and blood disorders. Therapeutic purgation specially indicated in the treatment of Raktavaha Shrotodushti and in the Chikitsasutra (~principle and treatment) of Vatarakta.[12] In this case, therapeutic purgation might have removed the obstruction in blood vessels and eliminated aggravated Pitta and clear the path for Vata Dosha. Thus, it reduced the pain and swelling, and improved the skin color. Maha Tiktaka Ghrita was used for internal oleation as it is specially indicated in Vatarakta. The contents of Maha Tiktaka Ghrita are Tikta Rasa Pradhana which are blood purifier and Pitta Shamaka.[13] Leeches sucks the blood where they applied and reduce the local pressure, so reduce pain and swelling. The saliva of Leech also contains various agents such as anticoagulants, anti-inflammatory, thrombolytic, anesthetic, and vasodilators, which affects positively in this disease to reduce inflammation and occlusion in the blood vessels. Bdellins and Eglins are the anti-inflammatory agents who subside local inflammatory process; hirudin and calin are the anticoagulant agents that effectively inhibit coagulation. Manjisthadikwatha is a blood purifier, immuno-modulator, and Vataraktahara.[14]Kaishorguggulu is drug of choice for Vatarakta. It is antibacterial, antimicrobial, anti-inflammatory, and Rakta Prasadaka in property; therefore, it corrects vitiation of blood.[15]Guduchi is Tikta, in Rasa, and Madhura Vipaka which helps in Pitta Shaman and is immune modulatory, antioxidant.[16]Amalaki and Mulethi are Pitta Shamaka in nature and both of the drugs are specially indicated for the treatment of Vatarakta.[17],[18] They also have rejuvenation properties, by which they improve the immune response of body. Cardorium plus is an effective herbal remedy for improving the blood circulation. It contains Arjuna (Terminelia arjuna) and Gokshura (Tribulus terrestris) which enhances the blood flow by disintegrating the blocks and strengthening the blood vessels of the heart and other blood vessels.

Various extracts of the stem bark of Arjuna have shown to possess many pharmacological properties including inotropic, antiischemic, antioxidant, blood pressure lowering, antiplatelet, hypolipidemic, antiatherogenic, and antihypertrophic. Hence, Arjuna is used as a potential cardioprotective agent.[19]

The main ingredient of KsheerbalaTaila is Balamool which is Madhura Rasa, Sheet Virya, and Pitta Shamaka; hence, it is specially indicated in Vatarakta Chikisa.[20]Amruthotharam Kashayam prepared with Haritaki (Terminalia chebula), Guduchi, and Shunthi (Zingiber officinale) which especially act on Ama Dosha. Due to its antiarthritic, antigout, anti-inflammatory, and immune-modulator properties, it is helpful in the treatment of occlusive peripheral vascular disease.[21]


  Conclusion Top


The results revealed that Buerger’s disease and other peripheral vascular diseases can be cured effectively with the collaborative approach of various Panchakarma procedures, including therapeutic purgation along with Leech therapy and Shamana Chikitsa. This case report is only an observation and based on the result, this case opens a new lead to conduct research with a large sample size with this intervention in the management of Buerger’s disease.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.



 
  References Top

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Trikamji Y, editor. Chikitsasthana. chapter 29, verse no. 11–12. In: Charakasamhita of Agnivesha with Commentary of Chakrapanidatta. Varanasi, India: Chaukhamba Surbharati Prakashan;2014. p. 628.  Back to cited text no. 5
    
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Sastri H, editor. Kalpasidhisthana, chapter 2, verse 9. In: Astangahrdaya of Vagbhata, Varanasi, India: Chaukhambha Surbharti Prakashana;2017. p. 742.  Back to cited text no. 9
    
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Sastri H, editor. Chikitsasthana, chapter 21, verse 58–61. In:Astangahrdaya of Vagbhata. Varanasi, India: Chaukhambha Surbharti Prakashana;2017. p. 726-7.  Back to cited text no. 10
    
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Trikamji Y, editor. Chikitsasthana; chapter 29, verse no. 41. In: Charakasamhita of Agnivesha with Commentary of Chakrapanidatta. Varanasi, India: Chaukhamba Surbharati Prakashan;2016. p. 629.  Back to cited text no. 12
    
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Trikamji Y, editor. Chikitsasthana; chapter 7, verse no. 148–150. In: Charakasamhita of Agnivesha with Commentary of Chakrapanidatta. Varanasi, India: Chaukhamba Surbharati Prakashan;2016. p. 457.  Back to cited text no. 13
    
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Tripathi B, editor. Madhyama Khanda, chapter 2, verse 137–142. In: Sharangadhar Samhita of Sarngadharacarya. Varanasi, India: Chaukhambha Surbharti Prakashana;2017. p. 102.  Back to cited text no. 14
    
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Tripathi B, editor. Madhyama Khanda. chapter 7, verse 70–80. In: Sharangadhar Samhita of Sarngadharacarya. Varanasi, India: Chaukhambha Surbharti Prakashana;2017. p. 136.  Back to cited text no. 15
    
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Dwivedi S, Chopra D. Revisiting terminalia arjuna: An ancient cardiovascular drug. J Tradit Complement Med 2014;4:224-31.  Back to cited text no. 19
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20.
Sastri H, editor, Chikitsasthana. chapter 22, verse 45–46. In: Astangahrdaya of Vagbhata. Varanasi, India: Chaukhambha Surbharti Prakashana;2017. p. 732.  Back to cited text no. 20
    
21.
Nishteswar K, Vidyanath R, editors. Kashaya Prakarana. In: Sahasrayogam. Varanasi, India: Chaukhambha Sanskrita Series Office;2017. p. 4.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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