eMedicine Specialties > Vascular Surgery > Medical Topics

Buerger Disease (Thromboangiitis Obliterans)

Author: Eric J Hanly, MD, Resident, Department of Surgery, The Johns Hopkins University School of Medicine; Fellow, Department of Surgery, The Johns Hopkins University School of Medicine
Coauthor(s): Ozanan R Meireles, MD, Resident Physician, Department of Surgery, Michigan State University College of Human Medicine; Research Fellow in Minimally Invasive Surgery, Department of Surgery, Johns Hopkins University School of Medicine; E Jerry Cohn Jr, MD, FACS, Vascular Surgeon, The Vein Center at Savannah Vascular Institute
Contributor Information and Disclosures

Updated: May 1, 2009

Introduction

Background

Buerger disease, a nonatherosclerotic vascular disease also known as thromboangiitis obliterans (TAO), is characterized by the absence or minimal presence of atheromas, segmental vascular inflammation, vasoocclusive phenomenon, and involvement of small- and medium-sized arteries and veins of the upper and lower extremities. The condition is strongly associated with heavy tobacco use, and progression of the disease is closely linked to continued use. The typical presentations are rest pain, unremitting ischemic ulcerations, and gangrene of the digits of hands and feet, and as the disease evolves, the patients may require several surgical amputations.1,2

The first reported case of thromboangiitis obliterans was described in Germany by von Winiwarter in an 1879 article titled "A strange form of endarteritis and endophlebitis with gangrene of the feet."3 A little more than a quarter of a century later, in Brookline, NY, Leo Buerger published a detailed description of the disease in which he referred to the clinical presentation of thromboangiitis obliterans as "presenile spontaneous gangrene."4 The paper discussed the pathological findings in 11 limbs amputated from Jewish patients with the disease.

The feet of a patient with Buerger disease. Note ...

The feet of a patient with Buerger disease. Note the ischemic ulcers on the distal portion of the left great, second, and fifth toes. Though the patient's right foot is normal in gross appearance, angiography demonstrated compromised arterial flow to both feet.

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The feet of a patient with Buerger disease. Note ...

The feet of a patient with Buerger disease. Note the ischemic ulcers on the distal portion of the left great, second, and fifth toes. Though the patient's right foot is normal in gross appearance, angiography demonstrated compromised arterial flow to both feet.


Pathophysiology

While the etiology of Buerger disease is unknown, exposure to tobacco is essential for both initiation and progression of the disease. The notion that the condition is linked to tobacco exposure is supported by the fact that the disease is more common in countries with heavy use of tobacco and is perhaps most common among natives of Bangladesh who smoke a specific type of cigarettes, homemade from raw tobacco, called "bidi." While the overwhelming majority of patients with Buerger disease smoke, a few cases have been reported in nonsmokers that have been attributed to the use of chewing tobacco.

The disease mechanism underlying Buerger disease remains unclear, but a few observations have led investigators to implicate an immunologic phenomenon that leads to vasodysfunction and inflammatory thrombi. Patients with the disease show hypersensitivity to intradermally injected tobacco extracts, have increased cellular sensitivity to types I and III collagen, have elevated serum anti–endothelial cell antibody titers, and have impaired peripheral vasculature endothelium-dependent vasorelaxation. Increased prevalence of HLA-A9, HLA-A54, and HLA-B5 is observed in these patients, which suggests a genetic component to the disease.

Frequency

United States

The prevalence of Buerger disease has decreased over the past half decade, partly because the prevalence of smoking has decreased, but also because the diagnostic criteria have become more stringent. In 1947, the prevalence of the disease in the United States was 104 cases per 100,000 population. More recently, prevalence has been estimated at 12.6-20 cases per 100,000 population.

Mortality/Morbidity

Death from Buerger disease is rare, but in patients with the disease who continue to smoke, 43% require 1 or more amputations in 7.6 years. Most recently, in a December 2004 CDC publication, the 2002 deaths report in the United States divided by cause of death, month, race, and sex (based on the International Classification of Diseases, Tenth Revision, 1992), reported a total of 9 deaths related to TAO, depicting male to female gender ratio of 2:1 and white to black ethnicity ratio of 8:1.

Race

Buerger disease is relatively less common in people of northern European descent. Natives of India, Korea, and Japan, and Israeli Jews of Ashkenazi descent, have the highest incidence of the disease.5

Sex

Though Buerger disease is more common in males (male-to-female ratio, 3:1), incidence is believed to be increasing among women, and this trend is postulated to be due to the increased prevalence of smoking among women.

Age

Most patients with Buerger disease are aged 20-45 years.

Clinical

History

  • Because a firm diagnosis of Buerger disease is difficult to establish, a number of different diagnostic criteria have been proposed.6 Olin asserts that the following criteria must be met for the diagnosis to be made with reasonable certainty:7
    • Age younger than 45 years
    • 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
    • Exclusion of 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
  • Most patients (70-80%) with Buerger disease present with distal ischemic rest pain and/or ischemic ulcerations on the toes, feet, or fingers, as depicted in the images below.8
The feet of a patient with Buerger disease. Note ...

The feet of a patient with Buerger disease. Note the ischemic ulcers on the distal portion of the left great, second, and fifth toes. Though the patient's right foot is normal in gross appearance, angiography demonstrated compromised arterial flow to both feet.

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The feet of a patient with Buerger disease. Note ...

The feet of a patient with Buerger disease. Note the ischemic ulcers on the distal portion of the left great, second, and fifth toes. Though the patient's right foot is normal in gross appearance, angiography demonstrated compromised arterial flow to both feet.


Superficial thrombophlebitis of the great toe in ...

Superficial thrombophlebitis of the great toe in a patient with Buerger disease.

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Superficial thrombophlebitis of the great toe in ...

Superficial thrombophlebitis of the great toe in a patient with Buerger disease.

  • Progression of the disease may lead to involvement of more proximal arteries, but involvement of large arteries is unusual.
  • Patients may also present with claudication of the feet, legs, hands, or arms and often describe the Raynaud phenomenon of sensitivity of the hands and fingers to cold.
  • Foot or arch claudication may be erroneously attributed to an orthopedic problem.
  • Patients who seek medical attention late in the course of their disease may present with foot infections and, occasionally, with florid sepsis.
  • Although classic Buerger disease affects the vessels of the extremities, a few cases of aortic, cerebral, coronary, iliac, mesenteric, pulmonary, and renal thromboangiitis obliterans have been reported.

Physical

  • Patients with Buerger disease develop painful ulcerations and/or frank gangrene of the digits.
  • The hands and feet of patients with the disease are usually cool and mildly edematous.
  • Superficial thrombophlebitis (often migratory) occurs in almost half of patients with Buerger disease.
  • Paresthesias (numbness, tingling, burning, hypoesthesia) of the feet and hands and impaired distal pulses in the presence of normal proximal pulses are usually found in patients with the disease.
  • More than 80% percent of patients present with involvement of 3-4 limbs.
  • More recently a point-scoring system has been proposed by Papa to support or contest the diagnosis of TAO using the following criteria.
    • Distal extremity (feet, toes, hands, fingers) involvement
    • Onset before age 45
    • Tobacco use
    • Exclusion of atherosclerosis or proximal source of emboli
    • Lack of hypercoagulable state
    • Lack of definable arteritis (ie, progressive systemic sclerosis, giant cell arteritis)
    • Classic arteriographic findings
    • Involvement of digital arteries of finger or toes
    • Segmental involvement (ie, "skip areas")
    • Corkscrew collaterals
    • No atherosclerotic changes
    • Classic histopathologic findings
    • Inflammatory cellular infiltrate within thrombus
    • Intact internal elastic lamina
    • Involvement of surrounding venous tissues

Table 1. Scoring system for the diagnosis of thromboangiitis obliterans (x)

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Table
Positive points
Age at onsetLess than 30 (+2)/30-40 years (+1)
Foot intermittent claudicationPresent (+2)/ by history (+1)
Upper extremitySymptomatic (+2)/ asymptomatic (+1)
Migrating superficial vein thrombosisPresent (+2)/ by history only (+1)
RaynaudPresent (+2)/ by history only (+1)
Angiography; biopsyIf typical both (+2)/ either(+1)
Negative points
Age at onset45-50 (-1)/more than 50 years (-2)
Sex, smokingFemale (-1)/ nonsmoker (-2)
LocationSingle limb (-1)/no LE involved (-2)
Absent pulsesBrachial (-1)/femoral (-2)
Arteriosclerosis, diabetes, hypertension, hyperlipidemiaDiscovered after diagnosis 5.1-10 years (-1)/2.1- 5 years later (-2)
Positive points
Age at onsetLess than 30 (+2)/30-40 years (+1)
Foot intermittent claudicationPresent (+2)/ by history (+1)
Upper extremitySymptomatic (+2)/ asymptomatic (+1)
Migrating superficial vein thrombosisPresent (+2)/ by history only (+1)
RaynaudPresent (+2)/ by history only (+1)
Angiography; biopsyIf typical both (+2)/ either(+1)
Negative points
Age at onset45-50 (-1)/more than 50 years (-2)
Sex, smokingFemale (-1)/ nonsmoker (-2)
LocationSingle limb (-1)/no LE involved (-2)
Absent pulsesBrachial (-1)/femoral (-2)
Arteriosclerosis, diabetes, hypertension, hyperlipidemiaDiscovered after diagnosis 5.1-10 years (-1)/2.1- 5 years later (-2)


Table 2. Sum of points defines the probability of the diagnosis of thromboangiitis obliterans

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Table
Number of pointsProbability of diagnosis
0-1Diagnostic excluded
2-3Suspected, low probability
4-5Probable, medium probability
6 or moreDefinite, high probability
Number of pointsProbability of diagnosis
0-1Diagnostic excluded
2-3Suspected, low probability
4-5Probable, medium probability
6 or moreDefinite, high probability

Causes

Propagating agents include cigarettes, as depicted in the image below, chewing tobacco, nicotine patches, and secondhand tobacco smoke (the latter two have been implicated as propagating agents of the disease only in former smokers).

The tobacco smoke–stained fingers of this p...

The tobacco smoke–stained fingers of this patient suggested the man's diagnosis (Buerger disease). The patient presented with small, painful ulcers on the tips of his thumb and ring finger.

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The tobacco smoke–stained fingers of this p...

The tobacco smoke–stained fingers of this patient suggested the man's diagnosis (Buerger disease). The patient presented with small, painful ulcers on the tips of his thumb and ring finger.


More on Buerger Disease (Thromboangiitis Obliterans)

Overview: Buerger Disease (Thromboangiitis Obliterans)
Differential Diagnoses & Workup: Buerger Disease (Thromboangiitis Obliterans)
Treatment & Medication: Buerger Disease (Thromboangiitis Obliterans)
Follow-up: Buerger Disease (Thromboangiitis Obliterans)
Multimedia: Buerger Disease (Thromboangiitis Obliterans)
References
Further Reading
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References

  1. Espinoza LR. Buerger's disease: thromboangiitis obliterans 100 years after the initial description. Am J Med Sci. Apr 2009;337(4):285-6. [Medline].

  2. Malecki R, Zdrojowy K, Adamiec R. Thromboangiitis obliterans in the 21st century-A new face of disease. Atherosclerosis. Feb 12 2009;[Medline].

  3. von Winiwarter F. Ueber eine eigenthumliche Form von Endarteriitis und Endophlebitis mit Gangran des Fusses. Arch Klin Chir. 1879;23:202-26.

  4. Buerger L. Thrombo-angiitis obliterans: a study of the vascular lesions leading to presenile spontaneous gangrene. Am J Med Sci. 1908;136:567-80.

  5. Salimi J, Tavakkoli H, Salimzadeh A, Ghadimi H, Habibi G, Masoumi AA. Clinical characteristics of Buerger's disease in Iran. J Coll Physicians Surg Pak. Aug 2008;18(8):502-5. [Medline].

  6. [Modern aspects of diagnostics and treatment for thromboangiitis obliterans]. Khirurgiia (Mosk). 2009;75-9. [Medline].

  7. Olin JW, Young JR, Graor RA, Ruschhaupt WF, Bartholomew JR. The changing clinical spectrum of thromboangiitis obliterans (Buerger's disease). Circulation. Nov 1990;82(5 Suppl):IV3-8. [Medline].

  8. Motukuru V, Suresh KR, Vivekanand V, Raj S, Girija KR. Therapeutic angiogenesis in Buerger's disease (thromboangiitis obliterans) patients with critical limb ischemia by autologous transplantation of bone marrow mononuclear cells. J Vasc Surg. Dec 2008;48(6 Suppl):53S-60S; discussion 60S. [Medline].

  9. Lawrence PF, Lund OI, Jimenez JC, Muttalib R. Substitution of smokeless tobacco for cigarettes in Buerger's disease does not prevent limb loss. J Vasc Surg. Jul 2008;48(1):210-2. [Medline].

  10. Tavakoli H, Salimi J, Rashidi A. Reply: "Treatment-of-choice for Buerger's disease (thromboangiitis obliterans): still an unresolved issue". Clin Rheumatol. Jun 2008;27(6):813. [Medline].

  11. Adar R, Papa MZ, Halpern Z, et al. Cellular sensitivity to collagen in thromboangiitis obliterans. N Engl J Med. May 12 1983;308(19):1113-6. [Medline].

  12. Allen EV. Thromboangiitis obliterans: methods of diagnosis of chronic occlusive arterial lesions distal to the wrist with illustrative cases. Am J Med Sci. 1929;178:237-44.

  13. Cabezas-Moya R, Dragstedt LR 2nd. An extreme example of Buerger's disease. Arch Surg. Nov 1970;101(5):632-4. [Medline].

  14. Cachovan M. Epidemiologie und geographisches Verteilungsmuster der Thromboangiitis obliterans. In: Heidrich H, ed. Thromboangiitis Obliterans Morbus Winiwarter-Buerger. Stuttgart, Germany:. Georg Thieme;1988:31-6.

  15. CDC. The Centers for Disease Control and Prevention Home Page. Available at: http://www.cdc.gov. Accessed June 9, 2006. [Full Text].

  16. Corelli F. Buerger's disease: cigarette smoker disease may always be cured by medical therapy alone. Uselessness of operative treatment. J Cardiovasc Surg (Torino). Jan-Feb 1973;14(1):28-36. [Medline].

  17. Cotran R, Kumar V, Robbins S, eds. Robbins pathologic basis of disease. 6th ed. Philadelphia:. WB Saunders Co;1999:523.

  18. Deitch EA, Sikkema WW. Intestinal manifestation of Buerger's disease: case report and literature review. Am Surg. Jul 1981;47(7):326-8. [Medline].

  19. Donatelli F, Triggiani M, Nascimbene S, et al. Thromboangiitis obliterans of coronary and internal thoracic arteries in a young woman. J Thorac Cardiovasc Surg. Apr 1997;113(4):800-2. [Medline].

  20. Eichhorn J, Sima D, Lindschau C, et al. Antiendothelial cell antibodies in thromboangiitis obliterans. Am J Med Sci. Jan 1998;315(1):17-23. [Medline].

  21. Fiessinger JN, Schafer M. Trial of iloprost versus aspirin treatment for critical limb ischaemia of thromboangiitis obliterans. The TAO Study. Lancet. Mar 10 1990;335(8689):555-7. [Medline].

  22. Gilbert DN, Dworkin RJ, Raber SR, Leggett JE. Outpatient parenteral antimicrobial-drug therapy. N Engl J Med. Sep 18 1997;337(12):829-38. [Medline].

  23. Goldman L, Bennett JC, eds. In: Cecil Textbook of Medicine. 21st ed. Philadelphia:. WB Saunders Co;2000:363-4.

  24. Grove WJ, Stansby GP. Buerger's disease and cigarette smoking in Bangladesh. Ann R Coll Surg Engl. Mar 1992;74(2):115-7; discussion 118. [Medline].

  25. Hussein EA, el Dorri A. Intra-arterial streptokinase as adjuvant therapy for complicated Buerger's disease: early trials. Int Surg. Jan-Mar 1993;78(1):54-8. [Medline].

  26. Isner JM, Baumgartner I, Rauh G, Schainfeld R, Blair R, Manor O, et al. Treatment of thromboangiitis obliterans (Buerger's disease) by intramuscular gene transfer of vascular endothelial growth factor: preliminary clinical results. J Vasc Surg. Dec 1998;28(6):964-73; discussion 73-5. [Medline].

  27. Iwai T. Buerger's disease with intestinal involvement. Int J Cardiol. Oct 1 1998;66 Suppl 1:S257-63; discussion S265. [Medline].

  28. Jaff M. Failure of acute-phase reactants to predict disease activity in Takayasu's arteritis. J Vasc Med Biol. 1994;4:223-227.

  29. Joyce JW. Buerger's disease (thromboangiitis obliterans). Rheum Dis Clin North Am. May 1990;16(2):463-70. [Medline].

  30. Kellerman R. Thromboangiitis obliterans (Buerger's disease). In: Dambro MR, Griffith JA, Winters R, et al, eds. Griffith's 5-Minute Clinical Consult. Philadelphia:. Lippincott Williams & Wilkins;1999:1062-3.

  31. Kubota Y, Kichikawa K, Uchida H, Nishimine K, Hirohashi R, Ohishi H. Superselective urokinase infusion therapy for dorsalis pedis artery occlusion in Buerger's disease. Cardiovasc Intervent Radiol. Sep-Oct 1997;20(5):380-2. [Medline].

  32. Lambeth JT, Yong NK. Arteriographic findings in thromboangiitis obliterans with emphasis on femoropopliteal involvement. Am J Roentgenol Radium Ther Nucl Med. Jul 1970;109(3):553-62. [Medline].

  33. Lau H, Cheng SW. Buerger's disease in Hong Kong: a review of 89 cases. Aust N Z J Surg. May 1997;67(5):264-9. [Medline].

  34. Lie JT. The rise and fall and resurgence of thromboangiitis obliterans (Buerger's disease). Acta Pathol Jpn. Mar 1989;39(3):153-8. [Medline].

  35. Lie JT. Thromboangiitis obliterans (Buerger's disease) and smokeless tobacco. Arthritis Rheum. Jun 1988;31(6):812-3. [Medline].

  36. Lie JT. Visceral intestinal Buerger's disease. Int J Cardiol. Oct 1 1998;66 Suppl 1:S249-56. [Medline].

  37. Makita S, Nakamura M, Murakami H, Komoda K, Kawazoe K, Hiramori K. Impaired endothelium-dependent vasorelaxation in peripheral vasculature of patients with thromboangiitis obliterans (Buerger's disease). Circulation. Nov 1 1996;94(9 Suppl):II211-5. [Medline].

  38. Matsushita M, Nishikimi N, Sakurai T, Nimura Y. Decrease in prevalence of Buerger's disease in Japan. Surgery. Sep 1998;124(3):498-502. [Medline].

  39. McKusick VA, Harris WS, Ottesen OE. The Buerger syndrome in the United States: arteriographic observations, with special reference to involvement of the upper extremities and the differentiation from atherosclerosis and embolism. Bull Johns Hopkins Hosp. 1962;110:145-76.

  40. Michail PO, Filis KA, Delladetsima JK, Koronarchis DN, Bastounis EA. Thromboangiitis obliterans (Buerger's disease) in visceral vessels confirmed by angiographic and histological findings. Eur J Vasc Endovasc Surg. Nov 1998;16(5):445-8. [Medline].

  41. Olin JW. Thromboangiitis obliterans (Buerger's disease). N Engl J Med. Sep 21 2000;343(12):864-9. [Medline].

  42. Olin JW. Thromboangiitis obliterans (Buerger's disease). In: Rutherford RB, ed, Vascular Surgery. 5th ed. Philadelphia:. WB Saunders Co;2000:350-64.

  43. Olin JW, Lie JT. Thromboangiitis obliterans (Buerger's disease). In: Loscalzo J, Creager MA, Dzau VJ, eds. Vascular Medicine. 2nd ed. Boston: Little Brown;1996:1033-49.

  44. Papa MZ, Rabi I, Adar R. A point scoring system for the clinical diagnosis of Buerger's disease. Eur J Vasc Endovasc Surg. Apr 1996;11(3):335-9. [Medline].

  45. Raad I. Intravascular-catheter-related infections. Lancet. Mar 21 1998;351(9106):893-8. [Medline].

  46. Rai M, Miyashita K, Oe H, Naritomi H. [Multiple brain infarctions in a young patient with Buerger''s disease. A case report of cerebral thromboangiitis obliterans]. Rinsho Shinkeigaku. Aug 2004;44(8):522-6. [Medline].

  47. Rosen N, Sommer I, Knobel B. Intestinal Buerger's disease. Arch Pathol Lab Med. Oct 1985;109(10):962-3. [Medline].

  48. Sasajima T, Kubo Y, Inaba M, Goh K, Azuma N. Role of infrainguinal bypass in Buerger's disease: an eighteen-year experience. Eur J Vasc Endovasc Surg. Feb 1997;13(2):186-92. [Medline].

  49. Sayin A, Bozkurt AK, Tuzun H, Vural FS, Erdog G, Ozer M. Surgical treatment of Buerger's disease: experience with 216 patients. Cardiovasc Surg. Aug 1993;1(4):377-80. [Medline].

  50. Shionoya S. Buerger's disease (thromboangiitis obliterans). In: Rutherford RB, ed, Vascular surgery. 3rd ed. Philadelphia:. WB Saunders Co;1989:207-17.

  51. Shionoya S, Ban I, Nakata Y, Matsubara J, Shinjo K. Diagnosis, pathology, and treatment of Buerger's disease. Surgery. May 1974;75(5):695-700. [Medline].

  52. Singh I, Ramteke VK. The role of omental transfer in Buerger's disease: New Delhi's experience. Aust N Z J Surg. Jun 1996;66(6):372-6. [Medline].

  53. Swigris JJ, Olin JW, Mekhail NA. Implantable spinal cord stimulator to treat the ischemic manifestations of thromboangiitis obliterans (Buerger's disease). J Vasc Surg. May 1999;29(5):928-35. [Medline].

  54. Talwar S, Jain S, Porwal R, Laddha BL, Prasad P. Free versus pedicled omental grafts for limb salvage in Buerger's disease. Aust N Z J Surg. Jan 1998;68(1):38-40. [Medline].

  55. Oral iloprost in the treatment of thromboangiitis obliterans (Buerger's disease): a double-blind, randomised, placebo-controlled trial. The European TAO Study Group. Eur J Vasc Endovasc Surg. Apr 1998;15(4):300-7. [Medline].

  56. Williams G. Recent views on Buerger's disease. J Clin Pathol. Sep 1969;22(5):573-8. [Medline].

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Further Reading

Clinical guidelines

Counseling to prevent tobacco use and tobacco-caused disease: recommendation statement.
 United States Preventive Services Task Force - Independent Expert Panel. 1996 (revised 2003 Nov). 13 pages. NGC:003268

Chronic wounds of the lower extremity.
American Society of Plastic Surgeons - Medical Specialty Society. 2007 May. 21 pages. NGC:005966

VA/DoD Clinical practice guideline for rehabilitation of lower limb amputation.
Department of Defense - Federal Government Agency [U.S.]
Department of Veterans Affairs - Federal Government Agency [U.S.]
Veterans Health Administration - Federal Government Agency [U.S.]. 2007 Aug. 163 pages. NGC:006060

Clinical trial

 TACT-NAGOYA: Therapeutic Angiogenesis Using Cell Transplantation

Related eMedicine topics
Digital Amputations

Atherosclerosis

Vascular Occlusive Syndromes of the Upper Extremity

Vascular Ulcers

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Keywords

Buerger disease, Buerger's disease, thromboangiitis obliterans, TAO, endarteritis, endophlebitis, vasoocclusive disease, presenile spontaneous gangrene, corkscrew collaterals, bidi, cigarette smoking, tobacco use, secondhand smoke, smoking cessation, distal ischemic rest pain, ischemic ulcerations, amputation

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Contributor Information and Disclosures

Author

Eric J Hanly, MD, Resident, Department of Surgery, The Johns Hopkins University School of Medicine; Fellow, Department of Surgery, The Johns Hopkins University School of Medicine
Eric J Hanly, MD is a member of the following medical societies: American Medical Association, Association of Military Surgeons of the US, MedChi, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Ozanan R Meireles, MD, Resident Physician, Department of Surgery, Michigan State University College of Human Medicine; Research Fellow in Minimally Invasive Surgery, Department of Surgery, Johns Hopkins University School of Medicine
Ozanan R Meireles, MD is a member of the following medical societies: American College of Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.

E Jerry Cohn Jr, MD, FACS, Vascular Surgeon, The Vein Center at Savannah Vascular Institute
E Jerry Cohn Jr, MD, FACS is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Richard M Stillman, MD, FACS, Honorary Medical Staff, Northwest Medical Center; Former Chief of Staff and Medical Director, Wound Healing Center, Department of Surgery, Northwest Medical Center
Richard M Stillman, MD, FACS is a member of the following medical societies: American College of Angiology, American College of Surgeons, Association for Academic Surgery, and Society of University Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Vincent Lopez Rowe, MD, Assistant Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center
Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, Association for Academic Surgery, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, and Society for Vascular Surgery
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

 
 
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