Treatment of Buerger's Disease (Thromboangiitis Obliterans)
Primary Treatment: Absolute Tobacco Cessation
Complete and permanent cessation of all tobacco use is the only definitive treatment that halts disease progression and prevents amputation in Buerger's disease. 1, 2, 3
- Tobacco abstinence generally results in disease quiescence and remains the cornerstone of all management strategies 3
- Continued smoking leads to relentless disease progression with high rates of amputation, while cessation typically stops advancement 2, 4
- Each clinician should advise patients to stop smoking and offer comprehensive cessation interventions including behavior modification therapy, nicotine replacement therapy, or bupropion 1
Initial Conservative Management
For Claudication (Non-Critical Ischemia)
- Encourage regular walking exercise to promote collateral development 2
- Initiate antiplatelet therapy to reduce risk of MI, stroke, or vascular death 1
For Critical Ischemia (Ulcers/Rest Pain)
- Admit for bed rest in hospital to minimize tissue oxygen demand 2
- Administer prostaglandin analogues for anti-ischemic effects 5
- Consider calcium channel antagonists, antiaggregants, and anticoagulants 5
Surgical/Interventional Considerations
Revascularization options are extremely limited and should only be attempted after conservative measures fail. 2
- Bypass grafting is rarely feasible because distal arterial occlusions leave few viable target vessels 2
- When performed, femorodistal bypasses show suboptimal patency rates but may achieve satisfactory limb salvage by allowing ulcer healing even with short-term graft patency 2
- Alternative surgical options include arterialization of venous blood flow of the foot, resection of posterior tibial veins, or omental transplantation onto the leg 5
- Endovascular interventions have not demonstrated efficacy comparable to other peripheral arterial diseases 5
Critical Diagnostic Confirmation
Before initiating treatment, confirm diagnosis by excluding:
- Atherosclerosis, diabetes mellitus, systemic connective tissue diseases, hypercoagulable states, and proximal embolic sources 3
- Verify patient age <45-50 years at onset, infrapopliteal arterial occlusions, and history of tobacco use 6, 3
Common Pitfalls
- Do not rely on revascularization as primary therapy—the distal, segmental nature of occlusions makes surgical options poor compared to tobacco cessation 2
- Do not underestimate the absolute requirement for tobacco cessation—even minimal continued tobacco use perpetuates disease activity 4
- Arteriographic findings ("corkscrew" or "spider legs" collaterals) are suggestive but not pathognomonic and should not be used alone for diagnosis 6, 2