Updated: 5/22/2021

Thromboangiitis Obliterans (Buerger's disease)

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  • Introduction
    • A nonatherosclerotic, segmental, inflammatory disease in the small and medium-sized vessels of the hands and feet
      • occurs predominantly in smokers
  • Epidemiology
    • Incidence
      • 12.6 per 100,000 in the United States
    • Demographics
      • 3:1 male: female ratio
      • typically affects patients < 45 years old
    • Risk factors
      • smoking
      • chewing tobacco
  • Etiology
    • Pathophysiology
      • inflammation and clotting of the small vessels of hands and feet
      • 3 phases
        • acute
          • thrombus including neutrophils and giant cells occludes the vessel lumen while sparing the wall
        • subacute
          • progressive organization of the thrombus
        • chronic
          • inflammation has subsided
          • organized thrombus and vascular fibrosis remain
  • Presentation
    • Symptoms
      • early disease
        • intermittent claudication of feet, legs, hands or arms
        • numbness and/or tingling in the limbs
      • late disease
        • symptoms of critical limb ischemia
          • rest pain
    • Physical exam
      • inspection
        • ulcerations
        • large, erythematous, superficial blood vessels
        • necrotic distal digits in hands and feet
      • palpation
        • decreased temperature in hands and feet
      • neurovascular
        • diminished or absent pulses
        • sensory findings in up to 70% of patients
      • provocative tests
        • positive Allen test in young smoker with digital ischemia is suggestive of disease
  • Imaging
    • Arteriography
      • indications
        • useful for ruling-out other conditions that may mimic Buerger's disease
      • findings
        • "corkscrew" vessels
        • collateral circulation giving a "spider leg" appearance
  • Studies
    • Labs
      • used to exclude alternative diagnoses
    • Echocardiogram
      • used to exclude proximal source of emboli
  • Treatment
    • Nonoperative
      • smoking cessation and symptomatic treatment
        • indications
          • all patients with Buerger's disease that use tobacco
        • techniques
          • smoking cessation
            • patient education
            • pharmacotherapy
            • smoking cessation groups
          • symptomatic treatment
            • avoid exposure to cold
            • gentle exercise
            • daily aspirin
            • vasodilators
        • outcomes
          • smoking cessation is the only treatment known to decrease the risk of future amputation
    • Operative
      • surgical sympathectomy
        • indications (controversial)
          • refractory pain and digital ischemia
        • technique
          • cut nerves to the affected areas
      • amputation
        • indications
          • gangrene
          • non-healing ulcers
          • refractory pain
  • Prognosis
    • Depends on smoking status
      • 94% who quit smoking avoid amputation
      • 43% chance of amputation within 8 years if smoking is continued
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Questions (1)

(OBQ12.126) A 45-year-old male smoker presents with the clinical appearance shown in Figure A. Which of the following statements is true regarding his condition?

QID: 4486
FIGURES:
1

Treatment with aspirin has been shown to decrease the incidence of amputation

27%

(1653/6047)

2

Arteriography is useful in the diagnosis of his condition

44%

(2669/6047)

3

Prophylactic amputation of unaffected digits leads to improved patient outcomes

2%

(93/6047)

4

The condition is usually painless

23%

(1409/6047)

5

Involves proximal vessels first and distal vessels last

3%

(170/6047)

L 4 C

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