Updated: 10/5/2016

Thromboangiitis Obliterans (Buerger's disease)

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Questions
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Evidence
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https://upload.orthobullets.com/topic/6099/images/acute.jpg
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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
  • 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
  • Prognosis
    • depends on smoking status
      • 94% who quit smoking avoid amputation
      • 43% chance of amputation within 8 years if smoking is continued
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
 

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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? Review Topic | Tested Concept

QID: 4486
FIGURES:
1

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

28%

(1564/5672)

2

Arteriography is useful in the diagnosis of his condition

44%

(2480/5672)

3

Prophylactic amputation of unaffected digits leads to improved patient outcomes

1%

(85/5672)

4

The condition is usually painless

23%

(1331/5672)

5

Involves proximal vessels first and distal vessels last

3%

(163/5672)

L 4 C

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Evidences (2)
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