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ESSENTIALS OF DIAGNOSIS

  • Active tobacco use, typically moderate to heavy.

  • Severe digital ischemia without evidence of internal organ involvement.

  • Angiography reveals segmental involvement of medium-sized arteries, with abrupt vascular cutoffs and corkscrew collaterals.

  • The major vessel involvement occurs at the levels of the ankle and wrist, but the biggest clinical impact is on the digits, with severe digital ischemia leading to tissue loss.

General Considerations

In thromboangiitis obliterans (TAO; also known as Buerger disease), the classic patient is a young male smoker. The mean age of onset is approximately 40 years, but the disease can occur in teenagers as well as in the elderly. Although the patients described initially were men, the disease may afflict women as well, probably in direct proportion to the number of women in any particular society who smoke. The precise mechanism underlying the relationship between TAO and cigarette smoking is unknown; autoimmune reactions to constituents of tobacco have been postulated. Cases may present several years after the start of smoking, but TAO does not occur in the absence of ongoing tobacco exposure.

There are four keys to the diagnosis of Buerger disease: (1) Recognition of clinical findings compatible with that condition, namely, digital ischemia that generally (and scrupulously) spares internal organs; (2) identification of the typical pattern of vascular involvement by angiography; (3) exclusion of diseases that may mimic TAO (Table 37–1); and (4) confirmation that the major risk factor, ongoing tobacco exposure, is present.

Table 37–1.Differential diagnosis of thromboangiitis obliterans.

Because of difficulty in accessing medium-sized vessels for biopsy, the diagnosis is rarely confirmed by biopsy. The exceptions to this rule are superficial thrombophlebitis, which seldom comes to medical attention, and amputation specimens, by which time medical attention is (at least in some sense) too late. When biopsy is possible, acute TAO is characterized by a highly inflammatory thrombus, composed of a variety of cell types: lymphocytes, neutrophils, giant cells, and occasional microabscesses. Inflammation is typically more intense within the clot itself than within the walls of affected blood vessels. Fibrinoid necrosis, a hallmark of most systemic vasculitides, is absent in Buerger disease.

CLINICAL FINDINGS

A. Symptoms and Signs

1. Extremities

A major hallmark of Buerger disease is its confinement to the extremities. The initial symptoms may be nonspecific pains in the calf, ...

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