A 24-year-old male heavy smoker presents with recurrent episodes of claudication in the arch of the foot. Examination shows absent dorsalis pedis pulses with normal femoral and popliteal pulses. There is a healed ulcer on his great toe. Angiography shows segmental occlusions of the distal tibial and pedal arteries with corkscrew collaterals and a normal proximal arterial tree. What is the single most important step in management?

• A Lumbar sympathectomy
• B Lifelong oral anticoagulation with warfarin
• C Femoropopliteal bypass grafting
• D Complete cessation of tobacco use ✓

Explanation

The young age, male sex, heavy smoking, distal vessel involvement with spared proximal arteries, and corkscrew collaterals are classic for Buerger disease (thromboangiitis obliterans). Disease progression is inexorable if smoking continues, and complete abstinence is the only measure that alters the natural history; amputation rates fall dramatically with cessation. Sympathectomy may help rest pain but does not halt progression, and bypass is usually impossible because there is no suitable distal target vessel.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.