What is the treatment for Buerger's disease?

Treatment for Buerger's Disease

The most critical intervention for Buerger's disease is complete tobacco cessation, which remains the only proven method to stop disease progression and prevent amputations. 1, 2, 3, 4, 5

Disease Overview

Buerger's disease (thromboangiitis obliterans) is an inflammatory occlusive disorder affecting small and medium-sized arteries and veins, primarily in young male smokers. It is characterized by:

• Segmental inflammatory vascular disease
• Predominantly affects distal extremities
• Strong association with tobacco use (95% of patients are smokers)
• Typically occurs before age 50
• Can affect both upper and lower limbs

Treatment Algorithm

First-Line Treatment

1. Complete tobacco cessation

   • Must be absolute and permanent
   • Disease activity is strongly associated with continued tobacco use
   • Smoking cessation alone can halt disease progression 3, 4

2. Conservative management for early disease

   • Encourage walking for patients with claudication
   • Hospitalization with bed rest for critical limb ischemia 1
   • Regular, dosed physical exercise 2

Pharmacological Interventions

For patients with persistent symptoms despite tobacco cessation:

1. Vasodilators and anti-ischemic agents

   • Prostacyclin analogs (most evidence-supported pharmacological option) 2, 3
   • Calcium channel antagonists 2
   • Antiplatelets (aspirin, clopidogrel) 2
   • Anticoagulants (limited evidence) 2

2. Pain management

   • Non-opioid analgesics preferred
   • Neuropathic pain medications if indicated

Surgical Interventions

Reserved for cases with critical limb ischemia not responding to conservative treatment:

1. Revascularization options (limited applicability due to distal nature of disease)

   • Endovascular interventions when feasible
   • Bypass grafting (rarely an option due to lack of target vessels)
   • Reported bypass patency rates are suboptimal, but limb salvage rates may be satisfactory 1

2. Alternative surgical approaches

   • Arterialization of venous blood flow of the foot
   • Resection of posterior tibial veins
   • Transplantation of greater omentum onto the crus 2

Monitoring and Follow-up

• Regular vascular assessment
• Continued reinforcement of tobacco abstinence
• Vigilant foot care and wound monitoring
• Early intervention for skin ulcers or signs of critical ischemia

Important Considerations

• Bypass grafting is seldom an option due to the distal location of lesions and lack of target vessels 1
• Even short-term patent grafts may be sufficient to allow healing of ulcers 1
• Without tobacco cessation, amputation is a common outcome 5
• The disease typically becomes quiescent if smoking cessation is achieved 5

Diagnostic Criteria

Traditional diagnosis is based on five criteria:

1. Smoking history
2. Onset before age 50
3. Infrapopliteal arterial occlusive disease
4. Upper limb involvement or phlebitis migrans
5. Absence of atherosclerotic risk factors other than smoking 1

The key to successful management of Buerger's disease lies in early diagnosis, absolute tobacco cessation, and appropriate conservative management. Surgical interventions should be considered only when conservative approaches fail to prevent critical limb ischemia.