Thromboangiitis obliterans, also called Buerger's disease, is a nonatherosclerotic, segmental, inflammatory disease that most commonly affects the small to medium-sized arteries and veins of the extremities [1-3]. Thromboangiitis obliterans is characterized by highly cellular and inflammatory occlusive thrombus with relative sparing of the blood vessel wall . Patients are young smokers who present with distal extremity ischemia, ischemic digit ulcers or digit gangrene . The disease is strongly associated with the use of tobacco products and smoking cessation is important to decrease the risk for amputation. The epidemiology, clinical manifestations, diagnosis, and treatment of thromboangiitis obliterans are reviewed here.
Thromboangiitis obliterans is more common in countries where tobacco is heavily used, especially among people who make homemade cigarettes from raw tobacco . As such, thromboangiitis obliterans is most prevalent in the Mediterranean, Middle East and Asia [7,8]. In North America, the prevalence of thromboangiitis obliterans has declined in the past 30 years due to a decline in smoking [8,9]. In other parts of the world, the prevalence of this disease among patients with arterial occlusive disease varies widely, ranging from 0.5 to 5.6 percent in Western Europe to as high as 45 to 63 percent in India. .
Men are more commonly affected than women and the typical age of onset is 40 to 45 years. Of patients diagnosed with thromboangiitis obliterans, 70 to 91 percent are male and 11 to 30 percent are female . However, there are reports of increasing prevalence of disease in women, possibly due to the increasing use of cigarettes among women [5,9,11-17].
The use of tobacco is essential for the initiation and progression of thromboangiitis obliterans [18-20]. Most patients are heavy cigarette smokers. In one study, patients diagnosed with thromboangiitis obliterans smoked an average of 23 years . Thromboangiitis obliterans has also been reported in cigar smokers, marijuana users and those who use smokeless tobacco such as chewing tobacco and snuff [4,5,21-24].
Chronic anaerobic periodontal infection may also play a role in the development of thromboangiitis obliterans [25,26]. Nearly two-thirds of patients with thromboangiitis obliterans have severe periodontal disease. In one study, DNA fragments associated with anaerobic bacteria were found within both the arterial lesions and oral cavities of patients with thromboangiitis obliterans . However, the prevalence of periodontal disease in smokers without thromboangiitis obliterans is similarly high and thus the association may be confounded.