Workup for Buerger's Disease
The diagnostic workup for Buerger's disease requires confirming tobacco exposure, documenting distal arterial occlusions through imaging, and systematically excluding atherosclerotic disease and other vasculitides through laboratory testing. 1
Patient Demographics and Initial Assessment
- Age and tobacco history are critical: Buerger's disease almost exclusively affects patients under 45-50 years old who are heavy tobacco users (cigarettes or smokeless tobacco). 1, 2
- Document the Brinkman index (cigarettes per day × years of smoking) to quantify tobacco exposure; typical patients have indices around 780. 2
- Assess for characteristic clinical features: migratory superficial thrombophlebitis, paresthesias in digits, rest pain, intermittent claudication, and ischemic ulcers or gangrene of fingers/toes. 1, 2
- Look for upper extremity involvement (cyanosis, pallor, gangrene) which occurs in approximately 84% of cases and helps distinguish Buerger's from atherosclerotic disease. 2
Laboratory Evaluation
The primary purpose of laboratory testing is to exclude other conditions, as there are no specific diagnostic markers for Buerger's disease. 3, 4
- Complete blood count (CBC) to assess for hematologic abnormalities 5
- Comprehensive metabolic panel including renal and hepatic function 5
- Inflammatory markers: ESR and CRP to evaluate for systemic vasculitis 6
- Autoimmune screening: ANA, anti-dsDNA, anti-scl-70, anti-centromere antibodies to exclude connective tissue diseases like scleroderma 6
- Hypercoagulable panel when indicated to rule out thrombophilic disorders 6, 7
- Diabetes screening (fasting glucose, HbA1c) to exclude atherosclerotic risk factors 3
- Lipid panel to confirm absence of hyperlipidemia 3
Vascular Imaging Studies
Arteriography remains the gold standard for demonstrating the characteristic vascular findings of Buerger's disease. 1, 3
Digital subtraction angiography showing:
- Segmental occlusions of small and medium-sized arteries in distal extremities 1
- "Corkscrew," "spider legs," or "tree roots" collateral vessels representing pathologically dilated vasa vasorum—these are highly suggestive but not pathognomonic 1, 3
- Infrapopliteal arterial occlusions in lower extremities 2, 3
- Absence of atherosclerotic changes (no calcification, smooth vessel walls) 7
Non-invasive arterial studies as initial screening:
Additional Diagnostic Considerations
- Tissue biopsy (if accessible lesion available): Shows acute inflammation with preservation of vessel wall architecture, distinguishing it from atherosclerosis. However, biopsy is rarely practical given distal location of disease. 3, 4
- Echocardiography with bubble study if there is suspicion of cardiac source of emboli or shunt (to exclude other causes of digital ischemia). 6
- Periodontal examination: More than half of Buerger's patients have severe periodontitis (grades C-D), which may contribute to disease activity. 2
Diagnostic Criteria Application
The diagnosis requires the major criterion (tobacco use) plus four or more minor criteria, or definitive histopathology/angiography. 4
Major criterion:
Minor criteria (need ≥4):
- Disease onset before age 45 years 4
- Ischemic involvement of lower limbs 4
- Ischemic involvement of upper limbs 4
- Thrombophlebitis migrans 4
- Red-blue/purple discoloration of edematous digits 4
Critical Pitfalls to Avoid
- Do not accept smokeless tobacco substitution: Patients who switch from cigarettes to smokeless tobacco continue to experience disease progression and limb loss. 8
- Do not diagnose Buerger's in patients over 50 years old or with atherosclerotic risk factors beyond smoking—these patients likely have premature atherosclerosis. 3, 4
- Do not rely solely on angiographic findings: The "corkscrew" collaterals are suggestive but can occasionally be seen in other conditions; clinical criteria must be met. 3
- Do not overlook upper extremity examination: Failure to document upper limb involvement may lead to misdiagnosis as atherosclerotic disease. 2, 3