Thromboangiitis Obliterans (Buerger Disease) Treatment & Management

Except for absolute tobacco avoidance, no forms of therapy are definitive for thromboangiitis obliterans (TAO; also known as Buerger disease). ^[13] There is some support for a few pharmacologic approaches, but for the most part, such approaches are ineffective. Surgical revascularization usually is not feasible, because of the lack of a distal target for revascularization. Endovascular options for treatment of occlusive lesions are growing in popularity. ^{[14, 15, 16, 17]} 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.

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.

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. ^[18] In the rare event that a pregnant woman presents with TAO, the treatment would remain recommendation of absolute cessation of tobacco use.

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. ^[19] 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). ^[20]

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.

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. ^[21] Hyperbaric oxygen therapy does, however, provide a promising alternative treatment option that is worth investigating on larger scales.

Because of the diffuse segmental nature of TAO and the disease’s predilection for small and medium-sized arteries, surgical revascularization for TAO usually is 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]

Endovascular options for treatment of occlusive lesions in TAO are becoming increasingly popular, with moderate- and long-term success seen in selected patients. ^{[14, 15, 16, 17, 22]}  Clinical outcomes appear to be improved when interventions are combined with smoking cessation.  

Rodoplu et al retrospectively investigated the efficacy of percutaneous transluminal angioplasty (PTA) for the treatment of critical limb ischemia (CLI) secondary to TAO in 24 patients (46 limbs). ^[23] Limb salvage was achieved in 21 (87.5%). Revascularization was achieved in 87.5% of the destination arteries at the primary intervention, and the overall technical success rate (including reinterventions) was 95.8%. After PTA, 22 patients showed a clinical response, and mean Rutherford category significantly improved (from 5.2 ± 0.74 to 1.6 ± 0.7). Complete wound healing was achieved in all patients with ischemic ulcers at 3.9 ± 2.6 months after revascularization. Six patients required reinterventions.

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

Consultations that may be considered include the following:

• Rheumatologist
• Hematologist
• Vascular surgeon
• Smoking cessation counselor