Snapshot A 30-year-old man presents to his physician’s office for intermittent pain in his hands and feet and discoloration of 3 of his fingers, which he says is painful. He has had pain in his extremities for about 1 year now, but this is the first time he’s seen discoloration of his fingers. He has a 20-pack-year smoking history. Introduction Clinical definition an inflammatory vasculitis characterized by claudication from vaso-occlusion also known as thromboangiitis obliterans Associated conditions Raynaud phenomenon Epidemiology Demographics male > female 3:1 ratio common in adults < 40 years of age Risk factors smoking is the strongest risk factor ETIOLOGY Pathogenesis primarily a medium vessel vasculitis, but the disease can also affect the small vessels the disease is thought to be due to a combination of immunologic hypersensitivity to tobacco extracts, defects in endothelium-dependent vasodilation, and anti-endothelial cell antibodies Presentation Symptoms intermittent claudication and pain in the feet or hands numbness or tingling may have autoamputation of digits Raynaud phenomenon Physical exam superficial thrombophlebitis often migratory distended veins with redness and tenderness darkened or discolored skin gangrene cool extremities limb ischemia pain, paresthesia, pallor, mottling, pulselessness, and poikilothermia ischemic ulcers, especially in the toes or fingers Imaging Echocardiography indication for all patients to exclude another source of distal vessel occlusion Studies Laboratory evaluation should be used to exclude other autoimmune diseases Arteriography indication diagnostic findings non-atherosclerotic segmental occlusion of primarily medium-sized vessels, but also small-sized vessels corkscrew collaterals found around the area of occlusion Biopsy of involved vessels indication performed only if the diagnosis is uncertain Histology segmental thrombosing vasculitis Differential Raynaud phenomenon distinguishing factor typically does not result in ulcers, gangrene, or need for amputation Polyarteritis nodosa distinguishing factor often is accompanied by systemic symptoms such as fever or weight loss and is not associated with smoking DIAGNOSIS Making the diagnosis based on a history of current or recent tobacco use and clinical presentation Treatment Management approach Buerger disease and its progression are strongly associated with smoking use therefore, management is aimed at smoking cessation, and pharmacologic therapy is ineffective Conservative smoking cessation indication for all patients activities to increase circulation indication for all patients modalities apply warmth exercise Operative amputation indications nonhealing ulcers gangrene pain refractory to all other measures Complications Sepsis Need for amputation Prognosis Typically resolves with cessation of smoking Patients who do not stop smoking often eventually undergo amputation