A Closer Look At Buerger’s Disease In The Lower Extremity

Buerger’s disease, which is also known as thromboangiitis obliterans, is a rare disease affecting the small and medium-sized vessels of the peripheral arterial and venous systems.^1,2 It is a nonatherosclerotic inflammatory disorder of unknown etiology.³ Smoking is the most important risk factor for Buerger’s disease.² The disease most often affects males under 45 with a history of tobacco use.⁴

The disease has a prevalence of 80 percent among Jews of Ashkenazi ancestry in Israel and between 45 and 63 percent in India.³ There is also an increased prevalence of 11 percent among females, which researchers attribute to the higher number of women smokers.⁴

Shionoya has described the most widely used criteria for diagnosing thromboangiitis obliterans.⁵ The Shionoya diagnostic criteria include a history of smoking, the onset of symptoms before the age of 50, infrapopliteal arterial occlusions, either arm involvement or phlebitis migrans, and the absence of atherosclerotic risk factors other than smoking.² The exclusion of arteriosclerosis or risk factors of other occlusive vasculopathies is the most important diagnostic criteria. Shionoya suggests that if a patient develops diabetes mellitus, hyperlipidemia or hypertension within a few years of the diagnosis of Buerger’s disease, one should reconsider the diagnosis.⁵

With Buerger’s disease, the lower extremities are involved in 100 percent of cases with upper extremity involvement only 44 percent of the time.² A podiatric patient may initially present with pain and claudication of the feet. With disease progression, patients may complain of calf claudication and rest pain. If left untreated, this can progress to ischemic ulcerations of the toes and feet.⁴ A thorough physical examination should also include inspection of the hands in addition to the feet.

In a study by Olin and colleagues, out of 112 patients, 85 presented with ischemic ulcerations, 91 presented with rest pain, 49 presented with Raynaud’s phenomenon and 43 had superficial thrombophlebitis.⁶

Imaging studies may demonstrate corkscrew-shaped collaterals. This is called Martorell’s sign. Although this is not pathognomonic for this disease, these collaterals are common arteriographic findings.³

Cessation of smoking is essential in the treatment of Buerger’s disease.  There is no other proven treatment to prevent the progression of the disease and amputation.⁴ Patients may require repeat smoking cessation, education and counseling. The correlation between smoking and thromboangiitis obliterans is extremely strong. If patients are successful in smoking cessation, reassure them that the disease will go into remission and they can avoid future amputations.⁴

References

1. Kröger K. Buerger's disease: What has the last decade taught us? Eur J Intern Med. 2006; 17(4):227-234.

2. Małecki R, Zdrojowy K, Adamiec R. Thromboangiitis obliterans in the 21st century—a new face of disease. Atherosclerosis. 2009; 206(2):328-334.

3. Rivera-Chavarría IJ, Brenes-Gutiérrez JD. Thromboangiitis obliterans (Buerger's disease). Ann Med Surg. 2016; 7(2):79-82.

4. Olin JW. Thromboangiitis obliterans (Buerger's disease). N Engl J Med. 2000; 343(12):864-869.

5. Shionoya S. Diagnostic criteria of Buerger's disease. Int J Cardiol. 1998; 66(Suppl1):S243-S245.

6. Olin JW, Young JR, Graor RA, et al. The changing clinical spectrum of thromboangiitis obliterans (Buerger's disease). Circulation. 1990; 82(5 Suppl):IV3-8.