A 26-year-old male smoker presents with painful ulcers on the tips of his right second and third toes. Angiography shows segmental occlusion of the tibial and digital arteries with corkscrew collaterals, and the proximal vessels are normal. Superficial migratory thrombophlebitis was noted two months ago. The single most important step to prevent amputation is:

• A Complete cessation of tobacco use ✓
• B Lifelong oral anticoagulation with warfarin
• C Prostaglandin E1 infusion for six weeks
• D Lumbar sympathectomy

Explanation

This is thromboangiitis obliterans (Buerger disease), an inflammatory, highly cellular thrombotic occlusion of small and medium distal arteries and veins, almost exclusively in heavy smokers. The only intervention that alters the natural history is absolute discontinuation of tobacco; continued smoking leads inexorably to ischemic ulceration and gangrene. Vasodilators, sympathectomy, and anticoagulation may ease symptoms but do not stop progression, so the best distractor, prostaglandin infusion, is adjunctive at most.

Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.