In today's world, smoking is very common and it is considered as a status symbol. Use of different kinds of tobacco in cigarettes and cigars is becoming a fashion. But most of the people are unaware of its critical aspects that are directing towards cancerous ulcers. Almost five out of every 10 patients of Buerger's syndrome are smokers.  Buerger tried to find the root cause of the particular problem. Here are the facts and figures one should consider when smoking frequently.
Image: “Reeve 043536 Thromboangiitis obliterans
Selected by D. Rose.” by Otis Historical Archives National Museum of Health and Medicine. License: CC BY 2.0

Image: “Reeve 043536 Thromboangiitis obliterans Selected by D. Rose.” by Otis Historical Archives National Museum of Health and Medicine. License: CC BY 2.0

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In 1908, a unique disease was described by Buerger and a detailed analysis based on his pathologic conclusions was characterized in practice since today. Buerger’s disease is basically a chronic disease which occurs due to the severe inflammation and blood clotting phenomenon called as thrombosis, specifically in veins and arteries. The body parts that are most affected with this painful disease is the hands as well as feet. The biological terminology used for Buerger’s disease is named as thromboangiitis obliterans. So, this is a very unusual disease that interrupts blood circulation among the specific artery or vein of the legs and arms.

It is a common practice that usually the victims of Buerger’s disease either smoke too many cigarettes or consume other types of tobacco.

Definition of Buerger’s Disease

Buerger’s disease as inflammation of the blood vessels

Buerger's Disease (CT-angiogram)

Image: “Buerger’s Disease (CT-angiogram)” by Milorad Dimic MD. License: CC BY-SA 3.0

Buerger’s disease is persistent, illustrated by fragmental inflammation and a phenomenon of blood clotting known as thrombosis causing a severe damage of small to medium-sized arteries as well as veins eventually affecting the peripheral structure of lower and upper limbs.

Blood clotting inflames patients’ blood vessels consequently causing the swelling and blockage in the vascular structure of the body. Thrombi (blood clot) ultimately cause destruction and damage to the skin tissues leading to infectious gangrene. It starts from the tips and toes and then eventually spread towards the legs and arms of the patients.

Risk Factors of Buerger’s Disease

The attributed cause is indefinite but the consumption of tobacco is the main culprit in the growth and expansion of Buerger’s disease. Also, it is evident that autoimmune aspects may be concerned and therefore the pathophysiological factors that are thought to be involved are platelets, leukocytes, endothelial cells, and sensory neurons. Additionally, possible triggers that may be causing this disease are genetic factors, male gender, mental stress due to a social and economic crisis as well as the infectious agents. It is also important to note the cardiovascular menaces and glucose intolerance in diabetic patients.

Pathophysiology of Buerger’s Disease

The Buerger’s disease is considered as idiopathic but some of the affecters may have some genetic alterations resulting in Buerger’s disease.

Inflammatory endarteritis causing a vasculopathy inflammation in which a prothrombotic state is generated that will eventually lead to vaso-occlusive phenomena is a severe state of thromboangiitis obliterans (TAO) which is also known as Buerger’s disease. Initiation of the inflammation process is within the tunica intima. This medical condition is stoutly linked with intense use of tobacco and its permanence will lead to the promulgation in the peripheral structure.

Mild to severe claudication patients will fastly reach the critical limb ischemia attributing to tissue loss and rest pain. The appearance of sensitive limb ischemia includes paresthesia, poikilothermia, paresis, pallor, mottling and pulselessness.

Chief pathophysiology of this Buerger’s disease symptoms appears when the vessels start to get inflamed along with clot formation which may result in obstructed blood flow throughout the tissues of the body which may lead to the death of tissues due to lack of oxygen and nutrients. This ultimately produces vasculitis as well as ischemic changes in extremities or limbs.

This disease grasps the people who are likely to use 1–2 packs of cigarettes daily. TAOs’ patients are hypersensitive towards tobacco extracts that are injected into the skin layers, also they have amplified cellular kindliness towards peripheral endothelium-dependent vasorelaxation and collagen types I and III. Patients also indicate a complex frequency of leukocyte antigen (HLA)–A9, HLA-B5 and also HLA-A54, thus signifying a genetic element to the disease.

Clinical Features of Buerger’s Disease

Buerger’s disease commonly initiate with lethargy and pain in the particular areas which are affected. The symptoms may include:

  • Feeling of pain in hands, legs, and feet which are felt every now and then along with open sores on hands and feet
  • During cold temperature, pale fingers or toes
  • Swelled veins

Further signs and symptoms may appear resulting in the decreased blood supply as an outcome. 

  • Alteration in color of skin appears on lower and upper limbs (pallor skin with shininess or thickness)
  • Presence of weak pulses in leg and feet
  • Lack of blood flow causing death of tissues known as gangrene
  • Non-healing ulcers and wounds appearing on leg and feet
  • Reduction of growth of hair upon the lower limbs
  • Bluish toes
  • Severe burning sensation and pain in the toes
  • Pain and cramps in leg while patient is lying
  • Feeling of numbness and heaviness in legs and toes
  • Reddish blue color of lower limbs appear
  • Thick and opaque toenails

It is essential to notify the physician if the patient has experienced any signs and symptoms of Buerger’s disease. It should not be assumed that the signs are merely the consequences of aging.

Investigations and Diagnosis of Buerger’s Disease

The majority of patients affected with TAO is around 20–45 years old; this ailment does not arise in elderly or pediatric patients. Mostly males are affected by TAO, ratio of males and females patient is 3:1, yet the disease in women is assumed to be rising, most likely due to the growing trend of females smoking.

The signs and symptoms of Buerger’s disease might be lookalike those of many other diseases and a detailed assessment by a doctor is required to conclude the correct cause. There’s no authentic test to assess if someone is suffering from arterial’s disease but there are certain tests a physician can execute to exclude other diseases, for example, a simple blood sample test.

Additional assessment that a consultant may make is termed as Allen test, which is an intrusive test that involves a tightened fist whereas the consultant presses a pressure upon the artery of a hand. When the fist is opened the doctor will release the increased pressure from the artery and the hand should be turned from its original color to pale color. If the change in color occurs slowly than it signifies that it might be a sign of Buerger’s disease.

Overall, doctors practice five principles in assessing the diagnosis:

  • Use of tobacco
  • Pain during rest
  • Ulceration of feet and hand especially before the age of 50
  • Blockage of arteries
  • Blockage of artery or clot formation cause is not known

Analysis based on certain criteria has been recommended:

  • Age should be less than 50 years
  • Recent or present history of tobacco
  • Existence of infrapopliteal arterial occlusive ailment pointed by pain while resting,  claudication, gangrenes or ischaemic ulcers and recognized by a test known as non-invasive vascular
  • Either phlebitis migrans or upper-limb participation
  • Non-existence of atherosclerotic risk issues excluding smoking
  • Hypercoagulable states
  • Autoimmune diseases
  • Proximal source of emboli by echocardiography or arteriography
  • Diabetes mellitus

There is no particular investigation but the following might be employed in diagnosing the root cause.

Morbus Buerger, CT angiogram

Image: “Morbus Buerger, CT angiogram” by Milorad Dimic MD. License: Released under the GNU Free Documentation License.


It  is considered as the most common test for blockage of artery along with X-ray which is taken afterward the inoculation of dye.


There are no particular serological indicators to identify Buerger’s disease. Suggested tests to find out other reasons of vasculitis consist of LFTs, FBC, fasting glucose, renal function tests, CRP, ESR and autoantibodies.


Some angiographic characteristics are typical of Buerger’s disease (however not pathognomonic). These comprise of ‘corkscrew’ looking arteries resulting from damage of vascular, mainly the arteries in this area of the angle and wrists. Angiograms can also illustrate stenoses or occlusions in different areas of both the legs and arms. At times, it becomes necessary to do angiograms of the other parts of the patient’s body regions, similar to a mesenteric angiogram to get rid of other types of vasculitis that include vascular areas generally for the Buerger’s disease.

Doppler ultrasound

This could be helpful. Recently, to remove Buerger’s disease and other reasons of secondary Raynaud’s color Doppler are used.


This is necessary to eliminate a source of recurring emboli.


Due to the risk of cancerous elements sometimes biopsy in such areas that do not heal is required, but these skin biopsies are very rarely done.

Therapy of Buerger’s Disease

Treatment of Buerger’s disease

Pharmacologic therapy is usually ineffective; quitting tobacco is the only known measure to prevent TAO progression. The vessels medium and small sized arteritis, endovascular revascularization or surgical possibility chances are very low due to the lack of a distal objective for revascularization. With the evolution of the disease, the only possible option is amputation.

There is no satisfying treatment for Buerger’s disease yet. Nevertheless, the signs and symptoms of this disease can be controlled and treated by raising the blood flow, abandoning the habit of tobacco and its products, escaping cold climate and in certain situations, devising the affected nerves operated. The nerves are operated to cut down to abolish pain. This is all done via a surgical practice named as sympathectomy. You can raise the circulation by taking an inadequately amount of liquids and staying energetic.

Vascular surgery

Vascular surgery is a process in which a bypass of the blocked vein is done. A vein is taken from a different part of the patient’s body or an artificial grafting which is then connected to the affected vein. Thus, allowing the blood to bypass the constricted area. Avoid the deterioration of the signs and symptoms by abandoning smoking and residing away from some other secondhand smoke.

Review Questions

The correct answers can be found below the references.

1. What is the underlying pathophysiological process in Buerger’s disease?

  1. Inflammation process
  2. Allergic reaction
  3. Bacterial invasion                     
  4. Fungal infection

2. A 30 years old smoker complains of soreness on the fingertips. On examination, ulceration and gangrene are identified. What would be the possible diagnosis?

  1. Diabetes
  2. Cardiovascular Disease
  3. Buerger’s Disease
  4. Raynaud’s Disease

3. What should be the best possible diagnostic criteria for Buergers’ Disease?

  1. Existence of atherosclerotic
  2. Proximal Emboli
  3. Non-hypercoagulable state
  4. Diabetes insipidus
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