Summary: A 32-year-old male presents with cold insensitivity involving his
Digital subtraction angiography (DSA) images of the bilateral
hands during the arterial phase of contrast material administration are
provided. Within the right hand (Figure 1) there is occlusion of the ulnar
artery with numerous corkscrew collateral vessels. Multiple corkscrew
collateral vessels are present surrounding the radial artery at the level of
the wrist as well as within multiple digital arteries. Within the left hand (Figure
2), there is occlusion of the radial artery, near occlusion of the ulnar
artery, and multiple digital artery occlusions with numerous corkscrew
collateral vessels. No improvement was seen with intra-arterial administration
Buerger Disease, also known as thromboangiitis obliterans,
is an obliterative vasculitis that affects the small- and medium-sized vessels
of the arms and legs. The disease occurs exclusively in smokers with greater
than 90% of patients being male. Patients almost always present with symptoms
before the age of 45. Patients most commonly present with intermittent
claudication involving their lower extremities, cold intolerance involving all
extremities, and ischemic ulcers involving their fingers and toes if they
present later in their disease course. Physical examination may reveal dampened
or absent pulses in the affected vessels with normal pulses involving the more
Angiography is the examination of choice for the diagnosis
of Buerger Disease. Angiography demonstrates normal proximal arteries without
significant atherosclerosis and multiple severe stenoses and segmental
occlusions involving the medium- and small-sized arteries. Extensive corkscrew
vessels are present around the occlusions. which represent collateral vessels
forming within the vasa vasorum of the arteries. Corkscrew vessels may
occasionally be seen in other diseases, including connective tissue disorders,
so the diagnosis also is dependant upon the patient’s age, gender, and smoking
history. Intra-arterial administration of vasodilators, such as nitroglycerin, has no effect on the stenoses and occlusions.
Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are
less commonly used for the diagnosis of Buerger Disease, but imaging sequences
such as contrast-enhanced time-resolved imaging of contrast kinetics (TRICKS) MRA
has been shown to represent a viable alternative means of diagnosis.
The treatment of Buerger Disease consists of smoking
cessation and appropriate hand and foot care for patients with ischemic ulcers.
The prognosis is directly related to tobacco use with progression to amputation
in patients who continue to smoke and avoidance of recurrences in patients who
- Swan JS, Carroll TJ, Kennell TW, et al.
Time-resolved three-dimensional contrast-enhanced MR angiography of the
peripheral vessels. Radiology. 2002;225:43-52.
- Olin JW. Thromboangiitis obliterans (Buerger disease). N Engl J Med. 2000;343: 86486-9.
- Stepansky F, Hecht EM, Rivera R, et-al. Dynamic MR angiography of upper extremity vascular
disease: Pictorial review. Radiographics.