One of the diseases proven to be directly caused by tobacco use worldwide is Buerger's disease. This disease typically blocks blood flow in the leg arteries, causing pain and tissue damage over time. If left untreated, Buerger's disease can significantly reduce quality of life and lead to limb loss. This disease, caused by tobacco use, causes inflammation or swelling in the veins of the arms and legs, leading to atherosclerosis.

Buerger's disease is a disease that usually occurs in young people, particularly in medium- and small-sized vessels, for unknown reasons, and relapses after recovery. Research has revealed that the disease is associated with abnormalities in the immune system that lead to immunological vascular inflammation. This disease, commonly known as "pruning" or spontaneous amputation, was described in detail by Leo Buerger in 1908.

Causes of Buerger's disease

Tobacco use is a primary factor in the development of Buerger's disease. It is believed that the chemicals in tobacco irritate the lining of blood vessels, causing them to swell. Also known as thromboangiitis obliterans, Buerger's disease causes blood vessels to become inflamed, swollen, and blocked by blood clots (thrombi). However, the exact cause of Buerger's disease is unknown. It is also thought that some individuals have a genetic predisposition to the disease.

Buerger's disease symptoms

Symptoms of Buerger's disease usually appear during periods when the disease is active. These symptoms may include:

• Tenderness and pain in the affected vein area: The vein area affected by the disease may be painful and sensitive.
• General malaise, fatigue and fever: General malaise, fatigue, and sometimes fever may occur during the disease.
• Decrease or disappearance of foot sweating: The first symptom may be loss of sweating in the feet.
• Coldness and numbness in the fingers: Coldness and loss of sensation in the fingers may occur due to problems in the veins .
• Numbness in the feet: In some cases, numbness may be the first symptom instead of loss of sweating.
• Decrease in veins: A decrease in the fullness of the veins may be noticeable.
• Limping while walking: Over time, a limp while walking may develop, and pain may be evident, especially in the calf area.
• Bruising on the feet: As the disease progresses, bruising may begin on the feet.
• Night rest pain and sores on the fingers: Rest pain that increases at night and sores on the fingers may be observed.
• Risk of limb loss: If left untreated, gangrene can develop, leading to limb loss. It can initially begin in the fingers and progress upwards.

These symptoms can vary depending on the course and severity of the disease and may vary from person to person. Early diagnosis and treatment are crucial, as left untreated, limb loss is a risk.

Who gets Buerger's disease?

Buerger's disease is more common in young, smoker men between the ages of 25 and 40. In Türkiye, the prevalence of Buerger's disease among vascular diseases is generally between 7 and 10%. The incidence in women is approximately 2%.

One of the most significant causes of the disease is the hypersensitivity of vascular walls to the nicotine metabolite cotinine, which is formed in smokers when nicotine is converted into them in the body. Elevated homocysteine ​​levels, along with increased free oxygen radicals, may contribute to the development of the disease by making the vascular walls more vulnerable. Additionally, factors such as frequent exposure to cold, low socioeconomic status, poor nutrition, a history of hepatitis B, high fibrinogen levels, and a predisposition to clotting may also play a role in the development of the disease.

These specific risk factors may increase the likelihood of developing the disease, but the exact cause of the disease is still unknown. Smoking is one of the most prominent factors that significantly increases the risk of developing Buerger's disease.

How is Buerger's disease diagnosed?

Diagnosis of Buerger disease is generally based on clinical symptoms and a set of diagnostic criteria. Five main criteria, known as the Shionoya criteria, are the basis for clinical evaluation. These are:

• Smoking: The patient's smoking history is evaluated.
• Being under 50 years of age: Buerger's disease usually occurs in young individuals.
• Below-knee leg involvement: The distinct effects of the disease in the leg region are examined.
• Absence of atherosclerosis risk factors: The absence of risk factors typical for other vascular diseases is observed.
• Absence of upper extremity involvement: The upper extremities are usually not affected in Buerger disease.

The presence of four of these criteria may be sufficient for the diagnosis of Buerger disease.

Physicians perform an arterial examination to assess the patient's symptoms. Additionally, imaging studies such as ultrasound and Doppler ultrasound may be necessary to determine the location and extent of the blockage. Imaging methods such as tomographic angiography may also be used to obtain a more detailed map of the blockage in the arterial tree. This allows for the location, extent, and length of the blockage, the blood flow to the fingers, and, most importantly, the presence of collateral blood vessels. This information is crucial for treatment planning.

In some cases, conventional angiography may be requested for diagnostic and therapeutic purposes. This method can be used to directly visualize the vascular structure.

How is Buerger's disease treated?

Treating Buerger's disease is a challenging and multidisciplinary process. Treatment may include the following:

• Smoking should be stopped: The primary cause of Buerger's disease is smoking. The first step in treatment is for the patient to completely quit smoking. Most patients who quit smoking experience improvement, even if they have a foot injury.
• Regular exercise program: A sustainable and regular exercise program can help the treatment process by increasing blood circulation.
• Protection from cold: It is important to avoid cold temperatures and cold trauma. These factors can exacerbate symptoms.
• Medication: Painkillers, vasodilators, and clot-dissolving and blocking medications may be used. Regular and continuous use of these medications may be necessary.
• Wound treatment: Local treatment methods can be used for wounds if present. Ozone, high-pressure oxygen, PRP, and stem cell applications may be preferred in some cases.
• Pain management: Daily painkillers may not be enough. Specialists may try to manage the pain with stronger painkillers or methods such as an epidural.
• Surgical intervention: If treatment fails, angiography may be considered to open the artery. Additionally, reconstructive vascular surgery can be performed to widen the blood vessels supplying the patient's limb. However, in some cases, amputation may be necessary.

If the disease progresses or recurs, treatment can become more difficult. However, with regular medication use, regular checkups, and adopting habits that support vascular health, patients' clinical conditions can be stabilized and adverse outcomes can be avoided. This is a long-term process focused on improving the patient's lifestyle and vascular health.

How does Buerger's disease occur?

Buerger's disease primarily affects all layers of small and medium-sized arteries and veins. The disease follows a course with intact areas between affected areas. The disease generally progresses with remissions and relapses. With each relapse, the disease spreads further, affecting intact areas, and the veins can become fibrotic, becoming rigid like rope.

During recurrences, extensive swelling can occur in and around the walls of the affected veins, and fresh clots may form within them. During this period, microscopic inflammation occurs within the vein, creating a condition called a microabscess. Over time, the clots become persistent within the vein, while the swelling in the wall subsides and is replaced by a thickened vein wall. Consequently, the affected vein area may become blocked, ending the active phase of the disease.

In some relapses, surrounding nerves may be affected along with the vessels, and hardening may occur in the affected area. This process reflects the changes that occur during the active phases of Buerger's disease and the relapse process.

Is Buerger's disease related to other diseases?

Buerger's disease is a condition that can be seen in association with other diseases. It can also be associated with various connective tissue and rheumatic diseases. Some factors associated with Buerger's disease may be related to other diseases. However, Buerger's disease is a clinical entity with unique symptoms and specific criteria.

Buerger's disease is a completely different condition from atherosclerosis, which clogs arteries with calcium. It's important to make this distinction clearly. In Buerger's disease, blockages occur as a result of thickening and hardening of the arterial walls. In this case, plaques containing calcium deposits are usually absent.

Additionally, Buerger's disease can sometimes present with symptoms similar to Raynaud's phenomenon, a functional narrowing and widening of the arteries. This condition can also be considered an organic form of Buerger's disease. A thorough medical evaluation is necessary to distinguish these conditions.