Clinical Commander

All dossiers
cardio.dvt.thromboangiitis-obliterans.v1

DVT/VTE in thromboangiitis obliterans (Buerger's disease)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.dvt.core.v1 — narrowed to DVT/VTE complicating Buerger's disease (thromboangiitis obliterans), a non-atherosclerotic, segmental, occlusive inflammatory disease of small and medium-sized arteries AND veins of the extremities with an extraordinarily strong link to tobacco use. Inherits diagnostic arc and AC regimen from parent via routing; specializes for the combined AC + ABSOLUTE smoking cessation paradigm, the iloprost pathway for severe limb ischemia (Fiessinger Lancet 1990 PMID 1972973), and multidisciplinary vascular surgery + smoking cessation + wound care + pain management + psychiatry/addiction care. Manifest pointer reuses cardio.dvt.core.v1 manifest. Design-brief pointer reuses parent (Buerger-specific differences documented inline). Distinguishing features vs generic DVT: (1) SMOKING CESSATION is the single most effective intervention — anticoagulation alone cannot halt the underlying inflammatory thrombo-occlusive process while tobacco exposure continues (Olin NEJM 2000 PMID 10995864; Cooper JACC 2004 PMID 14736464); (2) demographics — young (<45) heavy smokers, often Bangladeshi/Indian/Korean/Middle Eastern/Eastern European; (3) Shionoya criteria (1989 PMID 9568200) require absence of atherosclerotic risk factors and exclusion of other vasculitides; (4) angiography shows corkscrew collaterals (Martorell sign) + segmental small-vessel occlusions sparing proximal vessels + no atheroma; (5) iloprost IV infusion (Fiessinger Lancet 1990 PMID 1972973) is first-line for severe limb ischemia; (6) bypass surgery rarely feasible due to small/medium-vessel disease with no acceptable distal target; (7) amputation common if continued smoking per Cooper JACC 2004; (8) AC duration tied to recurrence risk and smoking cessation success; sustained cessation may permit AC discontinuation after 6-12 mo. Severity triggers cover continued smoking despite intervention, critical limb ischemia + amputation decision, iloprost-induced hypotension, atypical presentation suggesting other vasculitis, recurrent VTE on AC with continued smoking. Multidisciplinary care: vascular surgery + smoking cessation + wound care + pain management + psychiatry/addiction medicine + rheumatology to confirm Shionoya/Olin criteria. Status INTEGRATED. Authored 2026-05-15 by shard-06-cardio-acute as Buerger's disease vascular DVT variant.

Entry points (5)

  • symptom
    DVT or migratory superficial thrombophlebitis in young (<45) heavy smoker without atherosclerotic risk factors → Buerger workup (Olin NEJM 2000 PMID 10995864; Shionoya 1989 PMID 9568200)
    distal_extremity_dvt_or_migratory_phlebitis_in_young_smoker
  • symptom
    Distal extremity rest pain, digital ulceration, gangrene + concurrent VTE in young smoker → Buerger arterial-venous overlap pathway
    distal_extremity_ischemia_with_concurrent_vte
  • history
    Recurrent DVT in patient with ongoing tobacco use + no atherosclerotic risk factors + segmental small-vessel involvement → consider Buerger
    recurrent_dvt_with_continued_smoking
  • imaging
    Angiography showing corkscrew collaterals (Martorell sign) + segmental small-vessel occlusions sparing proximal vessels + no atheromatous plaque (Olin 2000)
    angiography_with_corkscrew_collaterals_and_segmental_occlusions
  • history
    Bangladeshi, Indian, Korean, Middle Eastern, or Eastern European male <45 with distal VTE + heavy smoking → enriched epidemiologic background for Buerger
    asian_middle_eastern_eastern_european_smoker_with_distal_vte

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    Buerger typically <45 yr at onset; older onset prompts re-evaluation for atherosclerotic disease + other vasculitides (Shionoya criteria)
  • sexrequired
    demographic • used at CONTEXT
    Historically M:F 100:1; rising female incidence with female smoking patterns; informs but does not exclude diagnosis
  • tobacco_use_quantification_pack_years_and_current_statusrequired
    history • used at CONTEXT
    Pack-year quantification and current smoking status is THE defining etiologic + therapeutic variable — smoking cessation is the definitive intervention (Olin NEJM 2000 PMID 10995864; Cooper JACC 2004 PMID 14736464)
  • atherosclerotic_risk_factor_screenrequired
    history • used at CONTEXT
    Shionoya criteria require absence of atherosclerotic risk factors (DM, HTN, hyperlipidemia, advanced age) — screen for and document these to support diagnosis
  • other_vasculitis_exclusion_screenrequired
    history • used at BRANCHING_WORKUP
    Shionoya criteria + Olin require exclusion of other vasculitides (ANCA-associated, Behçet, polyarteritis nodosa, GCA), thrombophilia, and autoimmune disease before Buerger diagnosis
  • leg_swelling_or_extremity_painrequired
    symptom • used at ENTRY
    Cardinal symptom of DVT or distal ischemia in Buerger
  • compression_us_for_dvtrequired
    imaging • used at INITIAL_WORKUP
    Initial confirmation of DVT location (proximal vs distal vs small-vessel); Buerger typically affects distal segmental small/medium vessels
  • angiography_or_cta_for_buerger_featuresrequired
    imaging • used at BRANCHING_WORKUP
    CTA/MRA/conventional angiography to identify Buerger-specific findings (corkscrew collaterals, segmental occlusions sparing proximal vessels, no atheroma) supporting diagnosis (Olin NEJM 2000)
  • creatininerequired
    lab • used at TREATMENT
    eGFR for DOAC dosing + iloprost dose adjustment if used
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Baseline platelet for AC initiation; monitoring during therapy
  • vasculitis_thrombophilia_panelrequired
    lab • used at BRANCHING_WORKUP
    ANCA, ANA, anti-dsDNA, RF, anti-CCP, complement, cryoglobulins, antiphospholipid panel, factor V Leiden, prothrombin G20210A, protein C/S, antithrombin — required to exclude alternative diagnoses per Shionoya/Olin
  • bleed_riskrequired
    history • used at RED_FLAGS
    HAS-BLED + falls + GI bleed + ulcer/wound care complications inform AC intensity and duration decisions

12-phase flow (11)

  1. 1FRAME
    Buerger vascular phenotype: non-atherosclerotic segmental panvasculitis of small/medium arteries AND veins of the extremities; SMOKING CESSATION is the single most effective intervention — anticoagulation alone cannot halt the underlying inflammatory thrombo-occlusive process while tobacco exposure continues (Olin NEJM 2000 PMID 10995864; Cooper JACC 2004 PMID 14736464)
    inputs: leg_swelling_or_extremity_pain
    advance: Buerger pathophysiology framed
  2. 2ENTRY
    Wells DVT score + compression US; document tobacco use (pack-years + current); document distal-extremity ischemia symptoms (claudication, rest pain, ulceration, gangrene); document migratory superficial thrombophlebitis history; document atherosclerotic risk factor absence; identify ethnic background
    inputs: tobacco_use_quantification_pack_years_and_current_status
    advance: pretest probability for Buerger documented
  3. 3CONTEXT
    Age, sex, ethnicity, pack-years, current smoking, atherosclerotic risk factors (must be absent per Shionoya), prior VTE/ischemia history, comorbidities, social/psychiatric factors that may impede smoking cessation
    inputs: age, sex, atherosclerotic_risk_factor_screen
    advance: context complete
  4. 4RED_FLAGS
    Critical limb ischemia with impending tissue loss → vascular surgery + amputation decision; phlegmasia from massive proximal DVT (uncommon in Buerger but possible); concurrent acute MI/stroke (although unusual given young + non-atherosclerotic phenotype); active hemorrhage; absolute AC contraindication
    inputs: bleed_risk
    actions: acute_limb_ischemia, pe_full
    advance: critical features screened
  5. 5INITIAL_WORKUP
    Compression US (proximal vs distal vs small-vessel); CBC + BMP + INR/PTT + CRP; D-dimer if pretest probability borderline; ankle-brachial index + segmental pressures + toe pressures + transcutaneous oxygen for ischemia quantification
    inputs: compression_us_for_dvt, cbc, creatinine
    actions: panel.cardiac, panel.renal
    advance: imaging confirms VTE + ischemia quantified
  6. 6BRANCHING_WORKUP
    Angiography (CTA/MRA/conventional) for Buerger-specific findings (corkscrew collaterals, segmental occlusions, no atheroma); vasculitis + thrombophilia + autoimmune panel to exclude alternative diagnoses (ANCA, ANA, antiphospholipid, factor V Leiden, prothrombin G20210A); echocardiogram to exclude embolic source; biopsy of affected vessel only if diagnosis truly uncertain (typically not required if Shionoya criteria met)
    inputs: angiography_or_cta_for_buerger_features, vasculitis_thrombophilia_panel, other_vasculitis_exclusion_screen
    advance: Buerger diagnosis confirmed by Shionoya/Olin criteria + alternatives excluded
  7. 7RISK_STRATIFICATION
    Wells DVT, HAS-BLED, eGFR; severity of limb ischemia (Rutherford / Fontaine class); CAPRINI for surgical-context risk; identify amputation risk drivers (continued smoking, advanced ulceration, infection)
    inputs: bleed_risk
    actions: calc.wells_dvt, calc.has_bled
    advance: AC duration + smoking cessation intensity + ischemia management plan documented
  8. 8TREATMENT
    Co-administered ABSOLUTE smoking cessation + AC + ischemia therapy. (1) SMOKING CESSATION — definitive intervention; varenicline + behavioral support + nicotine replacement (NRT debated since nicotine itself may contribute but generally allowed if essential to cessation); (2) AC for acute DVT — DOAC (apixaban/rivaroxaban) or LMWH bridge per ACCP 2021 / ASH 2020; (3) ILOPROST IV for severe limb ischemia (Fiessinger Lancet 1990 PMID 1972973); (4) pentoxifylline + clopidogrel debated; (5) wound care + pain control; (6) bypass surgery rarely feasible (small-vessel disease, no distal target); (7) sympathectomy for refractory pain; (8) amputation if non-salvageable
    inputs: creatinine, bleed_risk
    advance: AC + smoking cessation + ischemia therapy bundle initiated
  9. 9DISPOSITION
    Outpatient for uncomplicated DVT with established smoking cessation pathway; admit if critical limb ischemia, amputation decision pending, severe pain control needs, iloprost initiation, or social barriers to smoking cessation
    advance: disposition + multidisciplinary handoff documented
  10. 10MONITORING
    Smoking cessation adherence (continued tobacco use is the single strongest predictor of disease progression and amputation per Cooper JACC 2004); CBC + BMP + bleed surveillance; serial wound + ischemia assessment; PTS Villalta at 3/6/12 mo; rheumatology + vascular surgery + ID follow-up if wound infection
    actions: panel.cardiac
    advance: monitoring schedule documented
  11. 11FOLLOWUP
    Long-term smoking cessation reinforcement + vascular + rheumatology follow-up; AC continuation tied to recurrence risk + ongoing disease activity; complete cessation generally arrests progression and may reverse ischemia (Cooper 2004); continued smoking → amputation common
    advance: multidisciplinary maintenance plan + smoking cessation support documented