Patient handout

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

PRODUCTION

1. Your condition

This handout is for dvt/vte in thromboangiitis obliterans (buerger's disease). Your care team identified this based on: 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).

Other reasons your team may use this plan: distal extremity rest pain, digital ulceration, gangrene + concurrent vte in young smoker → buerger arterial-venous overlap pathway; recurrent dvt in patient with ongoing tobacco use + no atherosclerotic risk factors + segmental small-vessel involvement → consider buerger; angiography showing corkscrew collaterals (martorell sign) + segmental small-vessel occlusions sparing proximal vessels + no atheromatous plaque (olin 2000).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
apixaban	10 mg BID × 7 d → 5 mg BID	PO	BID for ≥3 mo; reassess based on smoking cessation + recurrence risk	AMPLIFY (Agnelli NEJM 2013 PMID 23808982); ACCP 2021 (Stevens PMID 34352295); reasonable for Buerger-associated DVT but does NOT address underlying inflammatory vasculopathy — smoking cessation remains primary
rivaroxaban	15 mg BID × 21 d → 20 mg daily	PO	BID then daily for ≥3 mo	EINSTEIN-DVT (Bauersachs NEJM 2010 PMID 21128814)
enoxaparin	1 mg/kg SC BID; reduce to 1 mg/kg daily if CrCl <30	SC	BID	ASH 2020 (PMID 33007077); ACCP 2021 — bridge for inpatient stabilisation
warfarin	5 mg daily; INR target 2-3	PO	daily	Easier reversibility for procedural interruptions in wound care + amputation contexts
varenicline	0.5 mg PO daily × 3 d → 0.5 mg BID × 4 d → 1 mg BID × 12 wk minimum	PO	BID	USPSTF + ACC/AHA tobacco cessation — most effective single agent for cessation; combined with behavioral support; smoking cessation is THE definitive Buerger intervention (Olin NEJM 2000; Cooper JACC 2004)
nicotine	patch 21 mg daily + lozenge/gum prn cravings	transdermal + PO	daily + prn	NRT helps achieve cessation; nicotine itself is debated in Buerger but cessation outweighs nicotine concern when adjunctive to behavioral cessation
bupropion	150 mg daily × 3 d → 150 mg BID × 12 wk	PO	BID	USPSTF — combined with NRT for additive cessation efficacy
iloprost	0.5-2 ng/kg/min IV titrate × 6 hr daily for 2-4 wk	IV	daily × 2-4 wk	Fiessinger Lancet 1990 PMID 1972973 — placebo-RCT — iloprost superior to aspirin for ulcer healing + rest pain in Buerger; standard of care for severe ischemia per Olin NEJM 2000
pentoxifylline	400 mg PO TID with meals	PO	TID	Limited evidence in Buerger but used; may improve microcirculation
clopidogrel	75 mg PO daily	PO	daily	Debated in Buerger; sometimes used alongside AC for severe ischemia (combined antithrombotic risk acknowledged)
acetaminophen	650-1000 mg PO q6h scheduled	PO	q6h	Avoid NSAIDs due to bleed risk on AC; non-opioid baseline
gabapentin	300 mg PO TID titrate to 1800-3600 mg/day in divided doses	PO	TID	Neuropathic pain component in chronic ischemia + post-amputation phantom pain
morphine	2-4 mg IV q4h prn breakthrough pain	IV	q4h prn	Severe ischemic pain in critical limb ischemia or post-amputation; multidisciplinary pain control + chronic pain consult if prolonged

Plan: Buerger's disease VTE — ABSOLUTE smoking cessation + anticoagulation + iloprost for severe ischemia + wound care (Olin NEJM 2000 PMID 10995864; Cooper JACC 2004 PMID 14736464; Fiessinger Lancet 1990 PMID 1972973)

3. When to call your provider

Contact your care team if any of the following happen:

Recurrence on AC + continued smoking → escalate cessation effort (intensify pharmacotherapy + behavioral + psychiatry); reassess AC duration
New ischemia despite cessation → vascular surgery for revascularization assessment (rarely feasible due to small-vessel disease)
Wound deterioration → wound care + ID + vascular surgery
Major bleed → reverse, hold AC, reassess indefinite indication

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Patient continues active tobacco use despite cessation pharmacotherapy + behavioral support — single strongest predictor of disease progression and amputation in Buerger (Cooper JACC 2004 PMID 14736464)
Buerger patient with rest pain, digital ulceration, gangrene, or impending tissue loss → critical limb ischemia requiring iloprost + amputation decision; bypass surgery rarely feasible due to small-vessel disease (Olin NEJM 2000 PMID 10995864)(life-threatening)
During iloprost IV infusion for severe limb ischemia, patient develops hypotension, headache, flushing, or other prostacyclin-related side effects requiring dose reduction or discontinuation
Patient presenting as Buerger but with atypical features (proximal large-vessel involvement, ANCA positive, antiphospholipid positive, age >50, no smoking history, atherosclerotic risk factors present) → reconsider diagnosis; route to alternative vasculitis or thrombophilia engine
Buerger patient with recurrent DVT despite therapeutic AC and continued tobacco use — vasculitic vessel-wall inflammation continues to drive thrombus formation; smoking cessation is the definitive fix, NOT AC escalation

5. Follow-up

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

6. Sources

Guideline: Olin JW. Thromboangiitis obliterans (Buerger's disease). NEJM 2000 PMID 10995864 — definitive review anchoring diagnosis, smoking cessation as definitive intervention, and management framework. Cooper LT et al. JACC 2004 PMID 14736464 — long-term outcomes anchor (continued smoking → amputation). Shionoya 1989 PMID 9568200 — diagnostic criteria. Fiessinger Lancet 1990 PMID 1972973 — iloprost RCT for severe limb ischemia. Olin & Shih 2006 PMID 16344631 — Curr Opin Rheumatol management update. ESVS 2017 PAD guidelines + Buerger's subsection. ACR/Vasculitis Foundation 2021 vasculitis recommendations. ACCP/CHEST 2021 (Stevens PMID 34352295) for AC duration. ASH 2020 VTE Treatment (Ortel PMID 33007077) for DOAC choice.