Thromboangiitis Obliterans (Buerger’s Disease)

Buerger’s disease; Smoker’s vasculitis; Segmental thromboangiitis

Thromboangiitis obliterans (TAO) is a rare, non-atherosclerotic, segmental inflammatory vasculitis of small- and medium-sized arteries and veins, predominantly affecting the distal extremities. It leads to progressive thrombotic occlusions and ischemia. The disease is strongly associated with nicotine use—traditionally tobacco smoking, but increasingly also other nicotine forms.

Rare. Most commonly affects men aged 20–45, but incidence among women is rising. Highest prevalence in Asia and the Mediterranean region. Almost exclusively occurs in current or recent nicotine users.

Primary systemic vasculitis affecting small- and medium-sized vessels, both arteries and veins. Must be distinguished from atherosclerosis, embolic disease, and connective tissue vasculitis.

Still unclear, but nicotine plays a central pathogenic role—regardless of the delivery form. The disease likely involves immune-mediated endothelial damage, thromboinflammation, and vasospasm. Contributing factors include:

• Endothelial dysfunction
• Segmental inflammatory thrombosis with microabscesses
• Genetic predisposition (e.g., HLA-B5, HLA-B54)
• Hypercoagulability (e.g., hyperhomocysteinemia)

New insights:
Case reports document TAO triggered not only by traditional tobacco use but also by:

• Exclusive use of e-cigarettes (vaping)
• Smokeless tobacco (snus, chewing tobacco)
• Nicotine patches or sprays (NRT)
• This supports the idea that nicotine itself—not just combustion byproducts—is a primary pathogenic factor.

• Intermittent claudication (feet, calves, hands)
• Nocturnal rest pain
• Coldness, pallor or cyanosis of toes/fingers
• Ischemic ulcers or dry gangrene of digits
• Migratory superficial thrombophlebitis
• Raynaud’s phenomenon
• No systemic symptoms (e.g., fever, organ involvement)

Primarily clinical. Shionoya criteria (modified):

• Age <50 years
• Current or recent nicotine use (any form)
• Distal extremity ischemia (clinically or angiographically)
• Segmental arterial occlusions and "corkscrew" collaterals on angiography
• Absence of other systemic or atherosclerotic diseases

Histopathology (optional)

• Segmental inflammatory occlusion of arteries and veins
• Microabscesses, multinucleated giant cells
• Preservation of vessel wall architecture
• No fibrinoid necrosis or immune complex deposition
   

Distal lower limbs (toes, plantar foot) > upper limbs (fingers). Often bilateral and asymmetrical.

Young adult with digital ischemia, painful ulcers, or necrosis; strong nicotine use history (smoking, vaping, snus); no conventional vascular risk factors.

Transmural vasculitis with thrombotic occlusion, granulomatous inflammation, and microabscesses. Venous involvement common. Diagnostic biopsy rarely required.

• Digital gangrene and amputations
• Chronic ischemic pain
• Superinfected ulcers
• Psychological burden, functional disability

Closely linked to nicotine cessation. Complete nicotine abstinence is the only known measure to halt progression. Continued nicotine use leads to high rates of tissue loss and amputation.

• Absolute nicotine cessation is essential (including vaping, snus, and NRT)
• Early recognition in young nicotine users with distal ulcers
• Prefer nicotine-free smoking cessation methods (e.g., varenicline, bupropion)

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2. Shibata T, et al. Buerger’s disease in a habitual e-cigarette user. Vasc Med. 2020;25(3):284–286.
3. Mark A, et al. TAO with smokeless tobacco use. BMJ Case Rep. 2015;2015:bcr2015210454.
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6. Bouaziz JD, et al. Dermatologic features of TAO. J Eur Acad Dermatol Venereol. 2013;27(1):11–16.
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9. Lau H, et al. Treatment strategies for TAO. J Vasc Surg. 2022;75(1):284–292.
10. Alihanoğlu YI, et al. Long-term outcomes in TAO. Vascular. 2018;26(1):21–27.