Failed Vascular Reconstructive Procedures with Profoundly Ischemic Limbs—Treated by Lumbar Sympathectomy

Abstract

The purpose of this study was to assess the impact of lumbar sympathectomy on limb loss in patients with prior reconstructive vascular surgery. One hundred and one patients underwent 118 lumbar sympathectomies. The 118 limbs were grouped presympathectomy into: rest pain (41), tissue breakdown (55), and gangrene (22). All vascular procedures were femoral-popliteal or femoral-distal bypass. No change in segmental Doppler pressures occurred after lumbar sympathectomy. Sixty-nine of 118 (58%) limbs underwent amputation following sympathectomy, a mean of two (range: one to twenty-two) months following the procedure. Of those limbs with an amputation (69/118), 14/69 (20%) had one reconstructive procedure, 41/69 (60%) had two reconstructive procedures, and 14/69 (20%) had three reconstructive procedures. Of those without an amputation (49/118 limbs), 27 had one vascular recon structive procedure, 9 had two reconstructive procedures, and 3 had three reconstructive procedures before sympathectomy. (continued on next page) Of the patients with diabetes (47), 44/47 (94%) underwent amputation, 35/44 (80%) with below-the-knee and 9/44 (20%) with above-the-knee amputation. Limb loss (69 limbs) by category was: rest pain, 21/41 (51%); nonhealing ulcers, 38/55 (69%); and gangrene, 10/12 (83%). Lumbar sympathectomy may be a useful procedure in very selected patients; diabetic patients who undergo reconstructive vascular surgery are not good candidates. Segmental Doppler pressures do not help predict successful or improved outcome following lumbar sympathectomy.