Cardiology > Thromboangiitis Obliterans 

Background

Thromboangiitis obliterans (TAO), also known as Buerger disease, is a non-atherosclerotic, segmental, inflammatory vasculitis that primarily affects the small- and medium-sized arteries and veins of the extremities. It leads to progressive vascular occlusion, ischemia, and tissue damage, often resulting in ulceration, gangrene, or amputation if untreated. It is strongly associated with tobacco use. 

II) Classification/Types

By Vessel Involvement: 

• • Arterial TAO: Most common; affects digital, tibial, radial, and ulnar arteries. 

• • Venous TAO: May present with superficial thrombophlebitis. 

• • Mixed: Both arterial and venous involvement. 

By Course: 

• • Acute/Inflammatory Phase: Vascular inflammation and thrombus formation. 

• • Chronic/Obliterative Phase: Fibrosis and vessel occlusion. 

III) Pathophysiology 

TAO involves a cell-mediated immune response, possibly triggered by tobacco or other toxins, leading to endothelial injury and segmental thrombosis without atherosclerotic changes. The thrombus typically contains inflammatory cells, sparing the internal elastic lamina early on. The inflammation leads to vascular occlusion and ischemic damage in distal extremities. 

IV) Epidemiology

• • Sex: Predominantly affects men, but incidence in women is rising with increased smoking. 

• • Age: Commonly occurs between 20 and 45 years. 

• • Geography: Higher prevalence in Middle East, South Asia, Eastern Europe, and other regions with high tobacco use. 

• • Comorbidities: Strongly linked to tobacco use; not associated with hyperlipidemia, hypertension, or diabetes as in atherosclerosis. 

Etiology

I) Causes

• • The exact cause is unknown, but tobacco use (including cigarettes, chewing tobacco, and vaping) is essential for disease initiation and progression. 

II) Risk Factors

• • Tobacco use (100%): Cigarette smoking, smokeless tobacco, marijuana. 

• • Male sex 

• • Age <50 years 

• • Low socioeconomic status 

• • Poor dental hygiene (possible contributing factor) 

Clinical Presentation

I) History (Symptoms)

• • Claudication in feet, hands, or calves 

• • Rest pain in distal extremities (fingers/toes) 

• • Ischemic ulcers or gangrene 

• • Raynaud phenomenon 

• • Migratory superficial thrombophlebitis 

• • Cold sensitivity or paresthesia 

II) Physical Exam (Signs)

Vascular: 

• • Diminished or absent distal pulses (especially dorsalis pedis, posterior tibial, radial, ulnar) 

• • Cold extremities 

• • Color changes: rubor, cyanosis, or pallor on elevation 

• • Dependent rubor in chronic ischemia 

Skin/Extremities: 

• • Ischemic ulcers on fingers or toes 

• • Digital gangrene 

• • Trophic changes (e.g., shiny skin, hair loss) 

• • Superficial thrombophlebitis with palpable cords 

Differential Diagnosis (DDx)

• • Atherosclerotic peripheral artery disease (PAD) 

• • Embolic disease (e.g., atrial fibrillation) 

• • Vasculitis (e.g., polyarteritis nodosa) 

• • Connective tissue diseases (e.g., systemic sclerosis) 

• • Raynaud disease 

• • Diabetic microvascular disease 

• • Thrombophilia (hypercoagulable states) 

Diagnostic Tests

Initial Tests: 

Ankle-Brachial Index (ABI): 

• • May be normal or mildly decreased (due to distal involvement) 

Doppler Ultrasound: 

• • Segmental arterial occlusion with preserved proximal flow 

• • Poor distal waveforms 

Arteriography (Gold Standard): 

• • Segmental occlusions with “corkscrew” collaterals 

• • Distal vessel involvement (especially below the knee or elbow) 

• • Absence of atherosclerotic plaques 

Laboratory Tests (to exclude other diseases): 

• • CBC, ESR/CRP (usually normal) 

• • ANA, RF, ANCA (to exclude systemic vasculitis) 

• • Hypercoagulable panel 

• • HbA1c, lipid panel (to rule out atherosclerosis) 

Treatment

I) Medical Management

Smoking Cessation (Most Critical): 

• • Complete and permanent abstinence from tobacco in any form is essential 

• • Counseling, nicotine replacement therapy, varenicline or bupropion may be used 

Wound Care: 

• • Local treatment for ulcers and infections 

• • Avoid trauma or cold exposure 

Pain Management: 

• • Analgesics for ischemic pain 

Vasodilators (limited efficacy): 

• • Calcium channel blockers (e.g., nifedipine) 

• • Iloprost (prostacyclin analog) for critical limb ischemia 

Antiplatelet agents: 

• • Aspirin or clopidogrel (may be used but not proven to reverse disease) 

II) Interventional/Surgical

Revascularization: 

• • Generally not feasible due to distal and segmental involvement 

Sympathectomy: 

• • Considered for pain relief in refractory ischemia 

Amputation: 

• • May be necessary in advanced cases with non-healing ulcers or gangrene 

Patient Education, Screening, Vaccines

Smoking Cessation: 

• • Absolute requirement for halting disease progression 

Foot and Hand Care: 

• • Avoid trauma, cold exposure, and infections 

• • Regular inspection for ulcers or color changes 

Avoid Vasoconstrictive Substances: 

• • Including nicotine, cocaine, amphetamines 

Vaccinations: 

• • Influenza 

• • Pneumococcal vaccine 

• • COVID-19 vaccine 

Consults

• • Vascular Surgery: For evaluation of revascularization, sympathectomy, or amputation 

• • Rheumatology: If vasculitis or autoimmune conditions are considered 

• • Pain Management: For ischemic pain control 

• • Wound Care: For ulcer management 

• • Smoking Cessation Program: Essential for all patients 

• • Primary Care: Ongoing monitoring and education 

Follow-Up

• • Frequent follow-up to monitor for: 

• • Tobacco relapse 

• • Progression of ischemia 

• • New ulcer formation 

• • ABI and Doppler studies to assess disease stability 

• • Reinforce foot care and smoking cessation 
  • Monitor psychological impact, especially if amputation is anticipated