Buerger Disease (Thromboangiitis Obliterans) Treatment & Management

  • Author: Eric J Hanly, MD; Chief Editor: Vincent Lopez Rowe, MD   more...
 
Updated: May 1, 2009
 

Medical Care

Absolute discontinuation of tobacco use is the only strategy proven to prevent the progression of Buerger disease. Smoking as few as 1 or 2 cigarettes daily, using chewing tobacco, or even using nicotine replacements may keep the disease active.[9]

Except for absolute tobacco avoidance, no forms of therapy are definitive. Treatment with intravenous iloprost (a prostaglandin analogue), an expensive therapy unavailable in the United States, has been shown to be somewhat effective in improving symptoms, accelerating resolution of distal extremity trophic changes, and reducing the amputation rate among patients with Buerger disease. Intravenous iloprost use is probably of greatest value in 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 therapy in the treatment of Buerger disease has been proposed, but the data for this treatment remain inconclusive and the treatment is thus considered experimental. Recently, Isner and colleagues reported improved healing of ischemic ulcers and relief of rest pain in a small series of patients with Buerger disease using intramuscular gene transfer of vascular endothelial growth factor.[10]

The following strategies are important in prevention of complications from Buerger disease:

  • 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
Next

Surgical Care

Given the diffuse segmental nature of thromboangiitis obliterans and the fact that the disease primarily affects small- and medium-sized arteries, surgical revascularization for Buerger disease is usually not feasible and is extremely rare in the United States. However, make every effort to improve distal arterial flow in patients with Buerger disease, and consider autologous vein bypass of coexistent large-vessel atherosclerotic stenoses in patients with severe ischemia who have an acceptable distal target vessel.

  • Other proposed surgical treatments for Buerger disease are as follows:
    • Omental transfer
    • Sympathectomy
    • Spinal cord stimulator implantation
  • Ultimate surgical therapy for refractory Buerger disease (in patients who continue smoking) is distal limb amputation for nonhealing ulcers, gangrene, or intractable pain. Avoid amputation when possible, but, if it is necessary, perform the operation in a way that preserves as much of the limb as possible.
Previous
Next

Consultations

  • Rheumatologists
  • Vascular surgeons
  • Smoking cessation counselors
Previous
Next

Diet

No dietary restrictions are needed. Diet has not been shown to affect the course of the disease.

Previous
Next

Activity

Encourage cardiovascular exercise. Activity should be restricted by symptoms only.

Previous
Proceed to Medication
 
 
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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Vincent Lopez Rowe, MD  Associate 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.

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

Vincent Lopez Rowe, MD  Associate 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.

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].

 
Previous
Next
 
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 a patient with Buerger disease.
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.
This lower extremity arteriogram of the peroneal and tibial arteries of a patient with Buerger disease demonstrates the classic findings of multiple small- and medium-sized arterial occlusions with formation of compensatory "corkscrew collaterals."
Table 1. Scoring system for the diagnosis of thromboangiitis obliterans (x)
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
Number of pointsProbability of diagnosis
0-1Diagnostic excluded
2-3Suspected, low probability
4-5Probable, medium probability
6 or moreDefinite, high probability
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.