Thromboangiitis obliterans

Background

• Also known as "Buerger's disease"
• Idiopathic inflammatory occlusive disease of the hands and feet (exact pathogenesis unknown)

Risk factors

• Tobacco use
  • Virtually all affected patients are smokers
• Male
• Middle Eastern

Vasculitis Syndrome Types

• Large vessel
  • Takayasu arteritis
  • Giant cell arteritis (temporal arteritis)
• Medium-vessel
  • Kawasaki disease
  • Polyarteritis nodosa
  • Thromboangiitis obliterans (Buerger's disease)
  • Primary angiitis of the central nervous system
• Small-vessel
  • Henoch-Schönlein purpura
  • ANCA-associated vasculitides
    • Granulomatosis with polyangiitis (Wegner's)
    • Eosinophilic granulomatosis with polyangiitis (Churg-Strauss)
    • Microscopic polyangiitis
  • Cutaneous leukocytoclastic angiitis (“hypersensitivity vasculitis”)
  • Essential cryoglobulinemia, cryoglobulinemic vasculitis due to hepatitis C
  • Behçet's disease]
• Secondary vasculitides and other/miscellaneous
  • Drug-induced vasculitis
  • Serum sickness
  • Vasculitis associated with other rheumatic diseases (e.g. SLE)

Clinical Features

Thromboangiitis obliterans of foot

• Red, tender nodules over peripheral arteries
  • May have diminished pulses
• In-step claudication
• Hand claudication
  • Often bilateral and symmetrical
  • May lead to ulceration
• Raynaud phenomenon
• Gangrene and autoamputation of digits in severe disease

Differential Diagnosis

Blue Digit

• Acute arterial ischemia
  • Atheroembolism (AKA Blue Toe Syndrome)
  • Arterial embolism
  • Arterial thrombosis
• Vasospastic Disorders
  • Raynaud’s disease
  • Primary erythromelalgia
• Autoimmune
  • Scleroderma
  • SLE
• Idiopathic
  • Thromboangiitis obliterans (Buerger's disease)
• Chronic peripheral artery disease
  • Atherosclerosis obliterans

Evaluation

• Clinical criteria for diagnosis (noninvasive testing not necessary)
  • History of smoking
  • Onset prior to <50 years old
  • Absence of atherosclerotic risk factors
  • Upper limb involvement
  • Infrapopliteal arterial occlusive lesions

Management

• Abstinence from tobacco
• Early symptoms with out threatened tissue loss: outpatient vascular
• Advanced disease: intra-arterial or intravenous PGE1, ASA, Heparin, arterial reconstruction, sympathectomy

Disposition

• Discharge with vascular follow-up if no evidence/threat of tissue loss
• Otherwise admit

See Also

• Peripheral artery disease