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KEY FEATURES

Essentials of Diagnosis

  • Typically occurs in men who smoke cigarettes

  • Distal extremities involved with severe ischemia progressing to tissue loss

  • Thrombosis of the superficial veins may occur

  • Smoking cessation is essential to stop disease progression

General Considerations

  • Thromboangiitis obliterans (Buerger disease) is a segmental, inflammatory, and thrombotic process of the most distal arteries and occasionally veins of the extremities

  • Cause is unknown but condition is rarely seen in patients who do not smoke cigarettes

  • Pathologic examination reveals arteritis in affected vessels

  • Arteries most commonly affected are the plantar and digital vessels of the foot and lower leg

  • In advanced stages, the fingers and hands may become involved

  • Progression of disease seems to be intermittent with acute and dramatic episodes followed by some periods of remission

Demographics

  • Patients usually younger than 40 years old

  • Incidence has decreased dramatically

CLINICAL FINDINGS

Symptoms and Signs

  • Lesions on the toes in a patient < 40 years old

  • Superficial thrombophlebitis may aid in differentiating from atherosclerotic peripheral vascular disease (PVD)

  • Rest pain, particularly in the toes

  • Pain often progresses to tissue loss and amputation, unless patient stops smoking

  • Intermittent claudication is not common

Differential Diagnosis

  • PVD

    • Tissue ischemia tends to be less dramatic in PVD than in thromboangiitis obliterans

    • Also in PVD symptoms of proximal arterial involvement (eg, claudication) predominate

  • Raynaud disease

  • Repetitive atheroemboli

DIAGNOSIS

Imaging Studies

  • Magnetic resonance angiography or invasive angiography can demonstrate the obliteration of the distal arterial tree

  • Biopsy of a tender cord from migratory thrombophlebitis is no longer necessary

TREATMENT

Surgery

  • Sympathectomy is rarely effective

Therapeutic Procedures

  • Smoking cessation is mainstay of therapy and will halt disease in most cases

  • Revascularization is not often possible as the distal arterial tree is occluded

  • Intra-arterial infusion of prostacyclin analogs has been reported to improve ulcer healing in some cases

OUTCOME

Complications

  • Amputation may be required unless patient stops smoking

Prognosis

  • Prognosis dependent on smoking cessation

    • For patients who stop smoking, outlook may be better

    • For those who do not stop smoking, prognosis is poor with possible amputation of both lower and upper extremities

REFERENCES

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Cacione  DG  et al. Pharmacological treatment for Buerger's disease. Cochrane Database Syst Rev. 2020;5:CD011033.
[PubMed: 32364620]  
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Le Joncour  A  et al; French Buerger's ...

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