Thromboangiitis obliterans (Burger's disease)

TAO is a disease of the small and medium size arterioles affecting the distal arms and legs and rarely, cerebrum, viscera, or veins. In the acute phase, there is endothelial proliferation, lymphocytes in the intima, and fibrinoid necrosis of the intima. Chronically there is recanalization and perivascular fibrosis. In brain, it has a predilection foer small artery occlusion without atherosclerosis, and the cerebral surface in the watershed region between the MCA and PCA territories. Fisher doubted cerebral involvement. Males predominate by 3-8:1. Median age is 35-45. It is seen almost exclusively in smokers and remits with smoking cessation. It is a CMI to certain collagen components, possibly due to a tobacco antigen, related to HLA Dr4.

Clinically it involves claudication in both legs, and to a lesser extent, both arms. It progresses distally to proximally. Raynauds, upper ext involvemnt, and superficial phlebitis (all about 35 %). 2 limbs in 16 %, 3 or 4 in 84 %. Leg and finger amputations occur in up to 20 %. Diagnosis requires exclusion of an ambolic source, AI disease, DM and hyperlipidemia, with normal arteriography to the level of the brachium/popliteal fossae and absent atheromatous disease fo the large vessels. Cessation of smoking will halt the disease progression. utility of immune suppression is unknown. Antiplatelet drugs and anticoagulants are not effective.