Treatment of Buerger's Disease (Thromboangiitis Obliterans)
Primary Treatment: Absolute and Permanent Tobacco Cessation
Complete and permanent cessation of all tobacco products is the only definitive treatment that halts disease progression and prevents amputation in Buerger's disease. 1 This is non-negotiable and represents the cornerstone of management, as continued tobacco use invariably leads to disease progression, tissue loss, and major amputations. 2, 3
Comprehensive Smoking Cessation Strategy
- Every clinician encounter must include assessment of tobacco status and aggressive cessation counseling. 2
- Offer multimodal pharmacotherapy including one or more of the following (unless contraindicated): 2
- Combine pharmacotherapy with intensive behavioral modification therapy and individualized counseling. 2
- Monitor for neuropsychiatric side effects with varenicline and bupropion, including hostility, agitation, depressed mood, and suicidal ideation. 2
Critical caveat: Tobacco cessation interventions are particularly critical in thromboangiitis obliterans because tobacco components are presumed causative in disease pathogenesis, and continued use is associated with particularly adverse outcomes compared to other forms of peripheral artery disease. 2 The disease typically becomes quiescent only if smoking stops completely. 4, 3
Secondary Medical Management
Antiplatelet Therapy
- Initiate antiplatelet therapy to reduce cardiovascular event risk (myocardial infarction, stroke, vascular death). 1
- Aspirin or clopidogrel are appropriate first-line agents. 2
Anti-Ischemic Pharmacotherapy
When conservative management with tobacco cessation alone is insufficient for critical limb ischemia:
- Prostaglandin analogues (prostacyclins) are effective for critical limb ischemia in Buerger's disease. 5, 3
- Calcium channel antagonists may provide symptomatic relief. 5
- Anticoagulants can be considered in select cases. 5
Adjunctive Conservative Measures
- Regular, dosed physical exercise programs improve circulation. 5
- Induced hypervolemia combined with prostacyclins represents effective treatment for critical limb ischemia. 3
Surgical and Interventional Options
Indications for Revascularization
Revascularization should be considered only after failure of aggressive conservative management and only if the patient has achieved complete tobacco cessation. 5 Continued smoking renders any revascularization attempt futile.
Available Surgical Options (in order of consideration):
- Endovascular interventions (when anatomically feasible) 5
- Bypass reconstructive operations (limited by distal small vessel involvement) 5
- Arterialization of venous blood flow of the foot 5
- Resection of posterior tibial veins 5
- Omental transplantation onto the lower leg 5
Important limitation: Revascularization options are often severely limited in Buerger's disease due to the distal, small-vessel nature of the occlusive process. 5, 6 Most patients lack adequate distal targets for conventional bypass surgery.
Diagnostic Confirmation Requirements
Before initiating treatment, confirm the diagnosis by verifying:
- Patient age <45-50 years at symptom onset 1
- Infrapopliteal arterial occlusions on imaging 1
- Heavy tobacco use history 1, 6
- Exclusion of atherosclerosis, diabetes mellitus, autoimmune diseases, hypercoagulable states, and embolic sources 5, 6
Arteriography showing "corkscrew" or "spider legs" collaterals is suggestive but not pathognomonic and cannot be used alone for diagnosis. 1, 7
Prognosis and Expected Outcomes
- Disease spontaneously becomes quiescent with complete smoking cessation in most cases. 4, 3
- Continued smoking commonly results in amputation. 4
- Tissue loss and major amputations can generally be avoided by discontinuing tobacco. 3
Critical pitfall: Even minimal tobacco use (including secondhand smoke, smokeless tobacco, nicotine vaping) can perpetuate disease activity. Patients must understand that "cutting down" is insufficient—only complete and permanent cessation is effective. 2, 6