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Cover image: Thromboangiitis Obliterans or Buerger's disease is an arterial vascular disease associated with smoking. Note the blackened tips of middle and pinky fingers. | Image courtesy of Charlie Goldberg, M.D.
Thromboangiitis obliterans, also known as Buerger disease, is a recurring progressive inflammation and thrombosis (clotting) of small and medium arteries and veins of the hands and feet.
Etiology
- Tobacco
- Smoking and/or chewing
- Smoking index (SI) > 300 is a risk factor
- [No. of cigarettes per day X No. of years of smoking]
- Pack-years index (PYI) > 40 is a risk factor
- [No. of years of smoking] X [No. of cigarette packs per year\
- < 30 years
Pathophysiology
Segmental, progressive, occlusive, inflammatory disease of small & medium-sized vessels with superficial thrombophlebitis.
- Thromboembolism due to blood disorders
- (Nicotine) → Vasoconstriction → Arterial Occlusion → Necrosis
- Panarteritis is a common feature

Complications:
- Ulcerations
- Gangrene
- Autoamputation
Presentation
- Intermittent claudication: Progressing to pain, ulceration & gangrene
- Itching
Clinical subtypes:
- Type I: Upper limb TAO (rare)
- Type II: Involves legs & feet
- Type III: Femoropopliteal involvement
- Type IV: Aortofemoral involvement
- Type V: Generalised
Diagnosis
Olin (2000) diagnostic criteria
- 20–40 years old and male (although females have been diagnosed)
- Current (or recent) history of tobacco use
- Presence of distal extremity ischemia (indicated by claudication, pain at rest, ischemic ulcers or gangrene) documented by noninvasive vascular testing such as ultrasound
- Exclusion of other autoimmune diseases, hypercoagulable states, and diabetes mellitus by laboratory tests.
- Exclusion of a proximal source of emboli by echocardiography and arteriography.
- Consistent arteriographic findings in the clinically involved and noninvolved limbs
Allen test
Buerger’s test
- Elevation pallor: Vascular angle or Buerger’s angle is the angle to which the leg has to be raised before it becomes pale, whilst in supine decubitus
- Normal limb may not show pallor even at 90°
- Vascular angle < 20°: Severe ischemia
- Sunset foot: When patient shifts to sitting position, the leg will revert to the pink colour more slowly than normal and also pass through the normal pinkness to a red-orange colouring (rubor – redness)
- Rubor of dependency: Foot will return to its normal colour if descended
Imaging:
- Arterial Doppler & Duplex scan
- CT Angiography (Transfemoral retrograde angiogram)
- Narrowing of blood vessels
- Spiralling of blood vessels



Differential diagnosis:
- Atherosclerosis (build-up of cholesterol plaques in the arteries)
- Endocarditis (an infection of the lining of the heart)
- Other types of vasculitis
- Severe Raynaud’s phenomenon associated with connective tissue disorders (e.g., lupus or scleroderma)
- Clotting disorders of the blood
Management
Lifestyle changes
- Cessation of tobacco
Medical management (Acute cases):
- Vasodilation:
- Nifedipine
- Prostaglandins
- Hyperbaric oxygen
- Epidural anaesthesia
- Antithrombin:
- Low-dose aspirin
- Streptokinase
- Adjuvant
Surgical management (Chronic cases):
- Debridement of ulcers
- Sympathectomy
- Omentoplasty: Surgical procedure in which part of the greater omentum is used to cover or fill a defect, augment arterial or portal venous circulation, absorb effusions, or increase lymphatic drainage
- Profundoplasty: Surgical enlargement of the junction of the femoral artery and its deep branch, a common operation to relieve narrowing by atherosclerosis at this point
- Amputation (if required)
Buerger-Allen exercises
Specific exercises intended to improve circulation to the feet and legs
