Thromboangiitis obliterans, also known as Buerger disease, is a vasculitis of small and medium-sized vessels involving the arteries, veins, and nerves of extremities resulting in limb ischemia.
Thromboangiitis obliterans includes thrombotic, segmental vasculitis of a chronic and inflammatory nature. Histologically, inflammatory thrombi affect arteries and can result in fibrotic casing of contiguous veins and nerves. Patients are often adult males between ages 25 and 50 with a history of long-term, heavy tobacco use. The condition is associated with a hypersensitivity reaction to intradermally injected tobacco extract.
As discussed by Santilli et al., thromboangiitis obliterans is an uncommon, but significant cause of chronic critical limb ischemia. While there is no definitive form of treatment, tobacco use cessation is the most widely accepted therapeutic measure.
While the exact pathogenesis of thromboangiitis obliterans is unknown, clinical studies reviewed by Paraskevas et al. have revealed that endothelium-dependent vasorelaxation is impaired and peripheral sympathetic outflow is decreased. Smoking is known to acutely increase sympathetic drive to muscle, blood vessels, skin, and the heart, and passive smoking impairs endothelium-dependent arterial and vein dilatation, perhaps exacerbating the presumed reaction to some component of tobacco.
Illustration A shows the typical ulcerations of the fingers of patient with thromboangiitis obliterans. As discussed before, the condition is highly associated with tobacco use.
Answer 1: Increased endothelial permeability is characteristic of atherosclerosis.
Answer 2: Necrotizing inflammation involving renal arteries is characteristic of polyarteritis nodosa.
Answer 4: Eosinophil-rich granulomatous inflammation is characteristic of Churg-Strauss syndrome (Eosinophilic Granulomatosis with Polyangiitis).
Answer 5: Concentric thickening of the arteriolar wall is an aspect of arteriosclerosis and giant cell arteritis.
Santilli JD, Santilli SM. Chronic critical limb ischemia: diagnosis, treatment and prognosis. Am Fam Physician. 1999 Apr 1;59(7):1899-908. Review. PubMed PMID: 10208708.
PMID:10208708 (Link to Abstract)
Paraskevas KI, Liapis CD, Briana DD, Mikhailidis DP. Thromboangiitis obliterans (Buerger's disease): searching for a therapeutic strategy. Angiology. 2007 Feb-Mar;58(1):75-84. Review. PubMed PMID: 17351161.
PMID:17351161 (Link to Abstract)
USMLE World Step 1 Qbank Question #451. Copyright © USMLEWorld, LLC 2012