• Clinical science

Thromboangiitis obliterans (Buerger disease)


Thromboangiitis obliterans (TAO, Buerger disease) is an inflammatory, non-atherosclerotic, vaso-occlusive disease of both small and medium-sized arteries as well as veins in the upper and lower limbs. TAO most commonly affects adult males with a significant history of cigarette smoking. In susceptible individuals, smoking causes inflammation of the tunica intima of small vessels by an unknown mechanism, which results in thrombotic occlusion of the vessel. Patients initially present with a classic triad of intermittent claudication, Raynaud phenomenon, and migratory thrombophlebitis. Eventually, critical limb ischemia develops and the patient presents with rest pain, absent pulse in the extremities, and/or digital gangrene. Ultrasonography and arteriography are used to localize the site of occlusion and differentiate TAO from other causes of peripheral artery disease. The most important therapeutic measure is the complete cessation of smoking. Additionally, prostaglandin analogs (e.g., iloprost) may be used to improve blood flow and decrease rest pain. Patients with TAO who develop digital gangrene require amputation.


  • Prevalence: 13–20 cases per 100,000 individuals
  • Sex: > (3:1)
  • Age of onset: 20–45 years
  • Ethnicity: Ashkenazi Jews, Indians, Koreans, Japanese


Epidemiological data refers to the US, unless otherwise specified.


  • Thromboangiitis obliterans is an inflammatory, non-atherosclerotic vasculitic disease that affects both small and medium-sized arteries as well as the veins.
  • Smoking is the single most important risk factor for TAO.
  • Stages of TAO
    1. Inflammation of the tunica intima with neutrophilic infiltration and microabscess formation (endarteritis)inflammation may also spread to the tunica media but the internal elastic lamina usually remains intact. Unlike in other forms of vasculitis, the rest of the vessel wall is usually relatively spared → development of cell-rich, inflammatory thrombi in the lumen → occlusion of the vessel
    2. Mononuclear cells, fibroblasts, and giant cells replace neutrophils
    3. Reorganization of the thrombus and perivascular fibrosis
    4. Contiguous extension of the inflammatory process to the adjacent vein and nerve, resulting in the encasement of the artery, vein, and nerve in a fibrous sheath
  • Disease localization: distal arteries of the upper and lower extremities


Clinical features

Patients may present with acute limb ischemia and/or symptoms of chronic peripheral artery disease (see “Clinical features” of peripheral artery disease).



  • Laboratory findings
  • Imaging
    • Doppler ultrasound (initial imaging): ankle-brachial index
    • Arteriography (imaging modality of choice): non-atherosclerotic, smooth, tapering, segmental lesions that occlude distal vessels of extremities with corkscrew-shaped collateral vessels around the site of occlusion
  • Although confirmation of the diagnosis requires excisional skin biopsy, biopsies are rarely performed.

ESR and CRP remain within normal limits!

Differential diagnoses

See “Differential diagnoses” in peripheral artery disease.

The differential diagnoses listed here are not exhaustive.



  • 1. Kumar V, Abbas AK, Aster JC. Robbins & Cotran Pathologic Basis of Disease. Philadelphia, PA: Elsevier Saunders; 2014.
  • 2. Olin JW. Thromboangiitis obliterans (Buerger's disease). In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/thromboangiitis-obliterans-buergers-disease. Last updated October 30, 2015. Accessed February 13, 2017.
  • 3. Nassiri N. Thromboangiitis Obliterans (Buerger Disease). In: Thromboangiitis Obliterans (Buerger Disease). New York, NY: WebMD. http://emedicine.medscape.com/article/460027. Updated December 19, 2016. Accessed February 13, 2017.
  • 4. Kasper DL, Fauci AS, Hauser SL, Longo DL, Lameson JL, Loscalzo J. Harrison's Principles of Internal Medicine. New York, NY: McGraw-Hill Education; 2015.
  • Herold G. Internal Medicine. Cologne, Germany: Herold G; 2014.
last updated 09/07/2020
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