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Thromboangiitis Obliterans Treatment & Management

  • Author: Naiem Nassiri, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
 
Updated: Nov 19, 2015
 

Approach Considerations

Except for absolute tobacco avoidance, no forms of therapy are definitive for thromboangiitis obliterans (TAO), or Buerger disease. There is some support for a few pharmacologic approaches, but for the most part, such approaches are ineffective. Surgical or endovascular revascularization usually is not feasible, because of the lack of a distal target for revascularization. Patients may require one or more amputations.

Indications for hospital admission include the following:

  • Surgery
  • Parenteral pharmacologic treatment of infection or pain that is refractory to oral medical therapy
  • Intensive behavioral modification therapy for patients unable to achieve smoking cessation at home

No dietary restrictions are needed; diet has not been shown to affect the course of the disease. Cardiovascular exercise should be encouraged, restricted only by symptoms.

Consultations that may be considered include the following:

  • Rheumatologist
  • Hematologist
  • Vascular surgeon
  • Smoking cessation counselor

In the long term, outpatient management is generally appropriate for patients with TAO. Such management should include frequent follow-up examination by a physician or wound-care specialist.

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Cessation of Tobacco Use

Absolute discontinuance of tobacco use is the only strategy proven to prevent the progression of TAO. Smoking as few as one or two cigarettes daily, using chewing tobacco, or even using nicotine replacements may keep the disease active.[13] In the rare event that a pregnant woman presents with TAO, the treatment would remain recommendation of absolute cessation of tobacco use.

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Pharmacologic Therapy

Intravenous (IV) iloprost (a prostaglandin analogue), an expensive agent unavailable in the United States, appears to be somewhat effective in improving symptoms, accelerating resolution of distal-extremity trophic changes, and reducing the amputation rate among patients with TAO.[14] IV iloprost therapy is probably most useful for slowing progressive tissue loss and reducing the need for amputation in patients with critical limb ischemia during the period when they first discontinue cigarette smoking.

The use of thrombolytic agents to treat TAO has been proposed, but the data to support this proposal remain inconclusive, and the therapy is thus considered experimental. Isner et al reported that improved healing of ischemic ulcers and relief of rest pain was achieved in a small series of TAO patients by using intramuscular gene transfer of vascular endothelial growth factor (VEGF).[15]

Oral nonsteroidal anti-inflammatory drugs (NSAIDs) and narcotic analgesics can be administered to palliate ischemic pain, and appropriate oral antibiotics can be used to treat mild distal extremity ulcers.

Aside from the experimental use of iloprost and thrombolytics, the use of antibiotics to treat infected ulcers, and the palliative treatment of ischemic pain with NSAIDs and narcotics, all other forms of pharmacologic treatment have been generally ineffective in the treatment of TAO, including steroids, calcium-channel blockers, reserpine, pentoxifylline, vasodilators, antiplatelet drugs, and anticoagulants.

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Hyperbaric Oxygen Therapy

Hyperbaric oxygen therapy is now an accepted adjunctive measure that has been shown to provide significant clinical improvement in patients with diabetic wounds, refractory osteomyelitis, acute limb ischemia, or necrotizing soft-tissue infection. Its use in treating TOA patients without revascularization options remains experimental; the available data are extremely limited.[16] Hyperbaric oxygen therapy does, however, provide a promising alternative treatment option that is worth investigating on larger scales.

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Surgical Intervention

Because of the diffuse segmental nature of TAO and the disease’s predilection for small and medium-sized arteries, surgical revascularization for TAO is usually not feasible. Nevertheless, every effort should be made to improve distal arterial flow in patients with TAO, and autologous vein bypass of coexistent large-vessel atherosclerotic stenoses should be considered in patients with severe ischemia who have an acceptable distal target vessel.

Other proposed surgical treatments for TAO are as follows:

  • Sympathectomy
  • Intra-arterial infusion of reserpine
  • Spinal cord stimulator implantation

The ultimate surgical therapy for refractory TAO (in patients who continue smoking) is distal limb amputation for nonhealing ulcers, gangrene, or intractable pain. Amputation should be avoided whenever possible, but if it is necessary, it should be performed in a way that preserves as much of the limb as possible.

Autologous bone marrow – derived progenitor cell implantation into ischemic limbs for potentiation of angiogenesis has been performed as an experimental alternative option. Results have been satisfactory, with minimal complication rates. Larger-scale studies and longer follow-up are needed before any firm recommendations can be made about this particular therapeutic option.[9]

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Prevention

The following strategies are important for preventing complications from TAO:

  • Use of well-fitting protective footwear to prevent foot trauma and thermal or chemical injury
  • Early and aggressive treatment of extremity injuries to protect against infections
  • Avoidance of cold environments
  • Avoidance of drugs that lead to vasoconstriction
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Contributor Information and Disclosures
Author

Naiem Nassiri, MD RPVI, Instructor in Vascular Surgery, Rutgers Robert Wood Johnson Medical School; Founder and Director, Vascular Anomalies and Malformations Program, Vascular Center of New Jersey and Bristol Myers Squibb Children’s Hospital Center for Advanced Surgery

Naiem Nassiri, MD is a member of the following medical societies: American College of Surgeons, Society for Vascular Surgery, American Venous Forum, Society for Clinical Vascular Surgery, International Society for the Study of Vascular Anomalies

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Society for Vascular Surgery, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, Pacific Coast Surgical Association, Western Vascular Society

Disclosure: Nothing to disclose.

Acknowledgements

Matthew Carpenter, MD Program Director, Department of Internal Medicine, Department of Internal Medicine, Keesler Medical Center; Assistant Clinical Professor, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine

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.

Eric J Hanly, MD 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.

Ozanan R Meireles, MD Instructor in Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School

Ozanan R Meireles, MD is a member of the following medical societies: American College of Surgeons, American Society for Gastrointestinal Endoscopy, and Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Brian D Peyton, MD Chief of Vascular and General Surgery, Keesler Medical Center; Assistant Professor, Department of Surgery, Associate Program Director, Department of General Surgery, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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

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

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

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

  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. 2008 Aug. 18(8):502-5. [Medline].

  6. ICD10Data.com. 2014 ICD-10-CM Diagnosis Code I73.1. Available at http://www.icd10data.com/ICD10CM/Codes/I00-I99/I70-I79/I73-/I73.1. Accessed: May 2, 2014.

  7. Abyshov NS, Zakirdzhaev EA, Aliev ZM. [Modern aspects of diagnostics and treatment for thromboangiitis obliterans]. Khirurgiia (Mosk). 2009. 75-9. [Medline].

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

  9. 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. 2008 Dec. 48(6 Suppl):53S-60S; discussion 60S. [Medline].

  10. Kulkarni S, Kulkarni G, Shyam AK, Kulkarni M, Kulkarni R, Kulkarni V. Management of thromboangiitis obliterans using distraction osteogenesis: A retrospective study. Indian J Orthop. 2011 Sep. 45(5):459-64. [Medline]. [Full Text].

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

  12. Graziani L, Morelli L, Parini F, Franceschini L, Spano P, Calza S, et al. Clinical Outcome After Extended Endovascular Recanalization in Buerger's Disease in 20 Consecutive Cases. Ann Vasc Surg. 2012 Apr. 26(3):387-95. [Medline].

  13. 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. 2008 Jul. 48(1):210-2. [Medline].

  14. Melillo E, Grigoratos C, De Sanctis F, Spontoni P, Nuti M, Dell'Omodarme M, et al. Noninvasive Transcutaneous Monitoring in Long-Term Follow-Up of Patients With Thromboangiitis Obliterans Treated With Intravenous Iloprost. Angiology. 2014 Jul 8. [Medline].

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

  16. Saito S, Nishikawa K, Obata H, Goto F. Autologous bone marrow transplantation and hyperbaric oxygen therapy for patients with thromboangiitis obliterans. Angiology. 2007 Aug-Sep. 58(4):429-34. [Medline].

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Feet of patient with thromboangiitis obliterans (Buerger disease). Note ischemic ulcers on distal portion of left great, second, and fifth toes. Although patient's right foot is normal in gross appearance, angiography demonstrated compromised arterial flow to both feet.
Superficial thrombophlebitis of great toe in patient with thromboangiitis obliterans (Buerger disease).
Tobacco smoke stains on male patient's fingers suggest diagnosis of thromboangiitis obliterans (Buerger disease). Patient presented with small, painful ulcers on tips of thumb and ring finger.
Lower-extremity arteriogram of peroneal and tibial arteries of patient with thromboangiitis obliterans (Buerger disease) demonstrates classic findings of multiple small and medium-sized arterial occlusions with formation of compensatory "corkscrew collaterals."
Table 1. Scoring System for Diagnosis of Thromboangiitis Obliterans[11]
Positive Criterion Positive Points
Age at onset< 30 y (+2)



30-40 y (+1)



Foot intermittent claudicationPresent (+2)



By history only (+1)



Upper extremitySymptomatic (+2)



Asymptomatic (+1)



Migrating superficial thrombophlebitisPresent (+2)



By history only (+1)



Raynaud phenomenonPresent (+2)



By history only (+1)



Angiography; biopsyIf typical, both (+2)



Either(+1)



Negative CriterionNegative Points
Age at onset45-50 y (−1)



>50 y (−2)



Sex; smokingFemale (−1)



Nonsmoker (−2)



LocationSingle limb (−1)



No lower extremity involved (−2)



Absent pulsesBrachial (−1)



Femoral (−2)



Arteriosclerosis, diabetes, hypertension, hyperlipidemiaDiscovered 5.1-10 y after diagnosis (−1)



Discovered 2.1-5 y later (−2)



Table 2. Numerical Scores Defining Probability of Diagnosis of Thromboangiitis Obliterans
No. of PointsProbability of Diagnosis of Thromboangiitis Obliterans
0-1Diagnosis excluded
2-3Diagnosis suspected (low probability)
4-5Diagnosis probable (medium probability)
≥6Diagnosis definite (high probability)
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