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Health condition

Buerger's disease, a young smoker's vasculitis that responds only to complete cessation.

Thromboangiitis obliterans strips blood flow from the fingers and toes. The single intervention that changes the course is stopping tobacco in every form, backed by iloprost, wound care and a vascular team.

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A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Editorial team

    Written by our editorial team from the UK sources listed on each page.

  • 02

    Sourced from guidance

    Checked against vascular society standards and peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK vascular practice, including iloprost, wound care and the central role of smoking cessation.

Key facts

Buerger's disease at a glance.

The essentials, in plain English. What it is, who gets it and why tobacco cessation is the treatment that matters most.

  • What it is

    A segmental thrombotic and inflammatory vasculitis of the small and medium arteries and veins of the hands and feet.

  • Who it affects

    Predominantly young men aged 20 to 40, with a male-to-female ratio of roughly 3 to 8 to one. More common in Asian, Middle Eastern and Eastern European populations.

  • The driver

    A very strong association with tobacco of every form, plus cannabis, smokeless tobacco and secondhand smoke. A genetic and immune contribution is likely.

  • Classical feature

    Migratory superficial thrombophlebitis alongside distal ischaemia is close to pathognomonic.

  • Gold standard test

    Digital subtraction angiography showing corkscrew collaterals, segmental occlusion and normal proximal vessels.

  • Only proven treatment

    Complete and permanent tobacco cessation. Nothing else reliably prevents amputation.

Why this guide matters

One condition, one lever that changes the course.

Buerger's disease is uncommon, easily missed, and often treated late. Three points shape everything that follows on this page.

  • It is not atherosclerosis

    Young age, distal disease, migratory phlebitis and corkscrew collaterals set Buerger’s apart from age-related peripheral arterial disease.

  • Tobacco cessation is the treatment

    Every other therapy is supportive. Without complete cessation, iloprost and surgery buy time but not durable remission.

  • A vascular MDT changes outcomes

    Combined input from vascular, tissue viability, pain and cessation services reduces amputation risk and keeps quality of life better for longer.

How the diagnosis is made

From first cold toes to a confirmed diagnosis.

The Shionoya and Cleveland Clinic (Olin) criteria structure the workup. Investigations exclude mimics as much as they confirm Buerger's itself.

  1. 01

    Assessing

    History and pulse exam

    Age under 45 to 50, tobacco use in any form, distal ischaemic pain, preserved femoral and brachial pulses with reduced pedal, wrist and digital pulses.

  2. 02

    Assessing

    Rule out atherosclerosis

    Assess cardiovascular risk, lipids, glucose and HbA1c, plus carotid duplex and echocardiography to exclude a proximal atherosclerotic source.

  3. 03

    Assessing

    Autoimmune and clotting screen

    ANA, ANCA, RF, anti-CCP, complement, immunoglobulins and antiphospholipid antibodies, alongside a hypercoagulable screen (protein C, S, antithrombin, factor V Leiden, prothrombin, JAK2).

  4. 04

    Imaging

    ABPI and toe pressures

    Ankle-brachial pressure index and toe pressures document the level and severity of ischaemia, and give a baseline to track over time.

  5. 05

    Imaging

    Duplex and cross-sectional imaging

    Duplex ultrasound plus CT or MR angiography map the disease and check that proximal vessels are clean, in line with the Shionoya and Olin criteria.

  6. 06

    Confirming

    Digital subtraction angiography

    The definitive test. Corkscrew collaterals, tapering and abrupt segmental occlusion of small distal vessels with normal proximal arteries confirm the diagnosis.

  7. 07

    Confirming

    Biopsy and toxicology if needed

    Selective skin biopsy shows thrombosis with neutrophilic microabscesses and a preserved elastic lamina. Urine toxicology helps exclude cannabis and cocaine vasculopathy.

Typical timeline: from first vascular clinic visit to confirmed diagnosis in a few weeks.

Symptoms

What Buerger's actually looks like.

The mix of distal claudication, rest pain, digital ulcers and migratory thrombophlebitis is the giveaway, especially in a young smoker with preserved proximal pulses.

  • Foot and hand claudication

    Cramping pain in the instep, arch or hands with use, easing with rest. The instep and arch pattern is classical.

  • Rest pain and Raynaud’s

    Burning pain in the toes or fingers at rest, with colour change, pallor, cyanosis and mottling.

  • Digital ulcers and gangrene

    Painful non-healing ulcers on the tips of the toes and fingers, progressing to dry or wet gangrene without intervention.

  • Migratory thrombophlebitis

    Tender red cords under the skin that move location over weeks. Alongside distal ischaemia this pattern is close to pathognomonic.

  • Autonomic changes

    Hyperhidrosis, mottling and persistent cyanosis reflect autonomic and microvascular dysfunction.

  • Multi-limb involvement

    Around 40 per cent of people have more than three limbs affected at diagnosis, and disease often spreads if smoking continues.

  • Preserved proximal pulses

    Femoral and brachial pulses feel normal while pedal, wrist and digital pulses are weak or absent. That gap is a diagnostic clue.

  • Red flag - critical limb ischaemia

    Rest pain, spreading gangrene, wet gangrene with infection or systemic sepsis needs same-day vascular assessment.

Treatment

How Buerger's is treated in the UK.

Complete tobacco cessation first, iloprost and wound care to protect tissue, and selective sympathectomy or stem-cell therapy where medical treatment stalls.

  • Complete tobacco cessation

    The only intervention that reliably arrests disease and prevents amputation. Includes all tobacco, cannabis, smokeless products and secondhand exposure. Specialist cessation support, varenicline or bupropion, and lifelong vigilance.

  • Intravenous iloprost

    A prostacyclin analogue given as a three to five day infusion in a specialist vascular centre. Best evidence for healing digital ulcers, easing critical ischaemia and reducing amputation.

  • Analgesia ladder

    WHO analgesic ladder plus neuropathic agents such as gabapentin, pregabalin or amitriptyline. Spinal cord stimulation and selective sympathectomy are options for refractory pain.

  • Local wound care

    Meticulous hygiene, antiseptic and moist wound dressings led by tissue viability, with hyperbaric oxygen therapy in selected cases.

  • Antibiotics for infection

    Targeted antibiotics for infected ulcers or cellulitis, with tissue and swab cultures to guide choice and avoid unnecessary courses.

  • Vasodilators

    Nifedipine, pentoxifylline and cilostazol are sometimes used, with limited evidence. They complement, but do not replace, cessation and iloprost.

  • Sympathectomy

    Chemical or surgical sympathectomy can help critical ischaemia, rest pain and digital ulcers that do not settle with medical therapy.

  • Revascularisation and stem cells

    Bypass surgery is rarely feasible because of distal disease and poor target vessels. Endovascular options are limited. Autologous bone-marrow mononuclear cell therapy is under study in specialist centres.

What this guide is based on

The sources behind every claim on this page.

UK vascular society standards, international guidelines and the classical Shionoya and Olin diagnostic frameworks.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP or vascular consultant knows your limbs, your history and your imaging. They can tell you which parts of this guide apply to you. If in doubt, get seen.

  • Vascular Society of Great Britain and Ireland. Guidance on peripheral arterial disease and critical limb ischaemia.

  • European Society for Vascular Surgery (ESVS). Clinical practice guidelines on peripheral arterial disease and vasculitis of the limbs.

  • Olin JW. Thromboangiitis obliterans (Buerger’s disease). Cleveland Clinic diagnostic criteria and reviews.

  • Shionoya S. Diagnostic criteria for Buerger’s disease.

  • NICE. Smoking cessation guidance (NG209) and stop smoking interventions and services.

Red flags

When Buerger's needs urgent attention.

Some situations cannot wait for the next outpatient slot. These are the ones that should prompt same-day contact with vascular services or A&E.

  • Critical limb ischaemia

    Rest pain, non-healing ulcers or gangrene mean same-day vascular review. Delay costs tissue.

  • Wet gangrene or spreading infection

    A limb-threatening emergency needing urgent admission, antibiotics and surgical debridement or amputation.

  • Suspected acute limb ischaemia

    Sudden cold, pale, painful, pulseless, paraesthetic or paralysed limb needs immediate emergency vascular assessment.

  • Systemic sepsis

    Fever, tachycardia, hypotension or confusion with an infected ulcer needs emergency care and IV antibiotics.

  • Relapse after cessation

    Any return to tobacco, cannabis or nicotine risks rapid deterioration. Book urgent vascular and cessation review.

  • Suspected drug-induced vasculopathy

    Cannabis and cocaine can mimic Buerger’s. Fresh use with new ischaemia deserves toxicology and specialist review.

  • Mental health crisis

    Chronic pain, disability and repeated amputations carry a real risk of depression and suicidal thoughts. Seek urgent GP or crisis support.

  • Pregnancy considerations

    Several vasoactive drugs and imaging modalities need review in pregnancy. Ask for early specialist input.

  • Post-amputation deterioration

    New stump pain, redness, discharge or fresh ischaemia in the remaining limb needs prompt vascular reassessment.

Living with it

A serious condition, with one lever that matters most.

Four practical shifts that make the biggest difference day to day. Cessation, foot and hand care, a pain plan and staying under a vascular team.

A quiet reminder

Small daily habits beat the occasional heroic effort.

A consistent routine of checks, dressings and appointments keeps small problems small and prevents the crises that lead to amputation.

  1. 01 Cessation

    Stop, and stay stopped

    Every cigarette, vape, joint or chew resets the clock. Lifelong tobacco and nicotine avoidance is the single biggest protective act you can take.

  2. 02 Feet

    Daily foot and hand checks

    Look for new redness, ulcers, colour change or numbness. Warm socks, soft footwear and gentle nail care prevent small problems becoming big ones.

  3. 03 Pain

    Plan for pain, don’t chase it

    Regular analgesia, neuropathic agents and, where needed, pain-clinic input work better than escalating doses in a crisis.

  4. 04 Team

    Stay under a vascular team

    MDT input from vascular, tissue viability, pain management, physiotherapy, rehabilitation and cessation services keeps the plan joined up.

Frequently asked

Everything we get asked about Buerger's disease.

Quick answers on cessation, diagnosis, iloprost, surgery and long-term outlook.

  • What is Buerger’s disease?

    A segmental thrombotic and inflammatory vasculitis of the small and medium arteries and veins of the hands and feet, also called thromboangiitis obliterans. It causes ischaemia, ulcers and gangrene of the digits and is strongly linked to tobacco in every form.

  • Why is smoking so important?

    Tobacco exposure is the central driver. Complete and permanent cessation is the only intervention proven to arrest progression and prevent amputation. This includes cigarettes, cigars, pipes, roll-ups, vapes, smokeless tobacco, cannabis and secondhand smoke.

  • How is it different from ordinary peripheral arterial disease?

    Buerger’s tends to appear before age 45 to 50, spares the proximal arteries, involves veins as migratory thrombophlebitis, and shows corkscrew collaterals on angiography. Atherosclerosis is a disease of older adults with proximal calcified plaque.

  • What does the angiogram show?

    Digital subtraction angiography is the gold standard. It shows abrupt segmental occlusion of small distal arteries with tortuous corkscrew collaterals, and normal proximal vessels with no atheroma.

  • What treatments actually help?

    Complete tobacco cessation is by far the most important. Intravenous iloprost helps digital ulcers and critical ischaemia. Analgesia, meticulous wound care, selected sympathectomy and stem-cell trials in specialist centres round out the plan. Bypass surgery is rarely possible because the distal vessels are poor targets.

  • Will I lose a limb?

    Not inevitably. People who stop tobacco completely have a much lower risk of amputation. People who continue face progressive digital loss and repeat amputations. The decision about whether disease progresses sits largely with cessation, backed by a good vascular team.

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