Management of Raynaud's syndrome: our twenty-year experience

Abstract

Purpose: 1) To review the long-term outcomes of a large group of patients who have undergone periarterial sympathectomy of the hand and 2) to describe the role of hand therapy in the evaluation and treatment of patients with Raynaud's syndrome. Method: We reviewed results on patients who had undergone periarterial sympathectomy (PAS) of the hand for recalcitrant ischemic pain, ulceration, and gangrene of digits from 1982 to the present. Data collection consisted of chart and operative review, and when possible follow-up telephone interview. Twenty-one (31 hands) had from two to 20 years of follow-up, ages at the time of initial procedure ranged from 21 to 87 years. Of these patients, three had suffered blunt trauma to the hand, four had mixed connective tissue disease, one had lupus, four had CREST (Calcinosis, Raynaud's phenomenon, esophageal involvement, sclerodactyly, and telangiectasia) or scleroderma, and the rest were idiopathic. Three main criteria—pain, ischemic ulceration, tissue loss (amputation)—were used to evaluate the success of treatment. We considered the initial procedure a success if the patient improved in one of the three main criteria. Patient satisfaction and changes in cold induced or Raynaud's attacks were also noted. The initial procedure was considered a failure if any of the criteria worsened or the patient required revision surgery or surgical amputation. When the result was rated as a failure, a critical review regarding the possible role of the surgical technique, disease progression, or both was considered. Not all Raynaud's syndrome patients require surgical intervention. A functional assessments algorithm aided our clinical decisionmaking regarding the choice of medical and/or surgical intervention. Evaluation baselines taken by the hand therapist included measurement of digital temperatures, cold recovery, tissue necrosis, sensibility, range of motion, and function. Repeat measures were used to evaluate the outcome of medical management or PAS. To complement medical management, the therapist discussed modification of risk factors, methods to reduce vasospastic episodes such as behavior and biofeedback techniques, and organized patient support groups. Results: Our first four patients had PAS of only the common volar vessels. To meet one of the three main criteria, all subsequent cases had PAS of the entire palmar arch, common volar digital arteries beyond the bifurcation into the digit, ulnar and radial artery. When necessary, vein grafts for arterial occlusion and primary amputation to the level of gangrenous tissue were performed. Conclusion: Treatment of severe digital ischemia can be a frustrating and unrewarding experience. In our 20-year experience we have found that a collaborative relationship between hand surgeon and hand therapist helps us to best serve our patients with Raynaud's syndrome. Information obtained in this organized approach aided our decisionmaking regarding medical and surgical management of this challenging group of patients.