Periarterial Sympathectomy Research Articles

Digital Sympathectomy in Patients With Scleroderma: An Overview of the Practice and Referral Patterns and Perceptions of Rheumatologists.

Periarterial sympathectomy is a treatment option for patients with systemic sclerosis (SSc) suffering from digital vasculopathy. Despite potential benefits of ulcer healing, pain improvement, and amputation prevention, this operation appears to be infrequently performed. The aims of our study are as follows: (1) to assess national digital sympathectomy rates in patients with SSc and (2) to improve our understanding of referring physicians' perceptions of operative management and access to hand surgeons. Our hypothesis is that rheumatologists' practices largely influence their referral patterns for digital sympathectomy. To determine the rates and demographics of hospitalized patients with SSc who had undergone digital sympathectomy, we queried the Nationwide Inpatient Sample from 2006 to 2010. Additionally, we mailed a self-administered survey to a national sample of 500 board-certified rheumatologists to elicit their practice patterns and perceptions of digital sympathectomy. Using logistic regression, we analyzed potential predictor variables associated with rheumatologists performing the following: (1) routinely counseling patients about digital sympathectomy and (2) expressing the desire to refer these patients for operative evaluation. Of 348,539 hospitalizations associated with a diagnosis of SSc, only 0.2% were for digital sympathectomy. Our questionnaire revealed that only 50% of rheumatologists routinely counseled, whereas 67% expressed the desire to refer. Factors associated with increased rheumatologists' interest in surgical management for patients with SSc included positive perception of the operation's efficacy, comfort with postoperative management, and interdisciplinary relationship with a hand surgeon. Critical components to increasing appropriate utilization of digital sympathectomy include enhancing rheumatologists' understanding of the operation, comfort with postoperative management, and promoting strong, interdisciplinary relationships with hand surgeons. Increasing education and awareness, as well as establishing a solid referral network of hand surgeons may thereby improve patient access to digital sympathectomy.

Two-Step Incision for Periarterial Sympathectomy of the Hand.

BackgroundSurgical scars on the palmar surface of the hand may lead to functional and also aesthetic and psychological consequences. The objective of this study was to introduce a new incision technique for periarterial sympathectomy of the hand and to compare the results of the new two-step incision technique with those of a Koman incision by using an objective questionnaire.MethodsA total of 40 patients (17 men and 23 women) with intractable Raynaud's disease or syndrome underwent surgery in our hospital, conducted by a single surgeon, between January 2008 and January 2013. Patients who had undergone extended sympathectomy or vessel graft were excluded. Clinical evaluation of postoperative scars was performed in both groups one year after surgery using the patient and observer scar assessment scale (POSAS) and the Wake Forest University rating scale.ResultsThe total patient score was 8.59 (range, 6-15) in the two-step incision group and 9.62 (range, 7-18) in the Koman incision group. A significant difference was found between the groups in the total PS score (P-value=0.034) but not in the total observer score. Our analysis found no significant difference in preoperative and postoperative Wake Forest University rating scale scores between the two-step and Koman incision groups. The time required for recovery prior to returning to work after surgery was shorter in the two-step incision group, with a mean of 29.48 days in the two-step incision group and 34.15 days in the Koman incision group (P=0.03).ConclusionsCompared to the Koman incision, the new two-step incision technique provides better aesthetic results, similar symptom improvement, and a reduction in the recovery time required before returning to work. Furthermore, this incision allows the surgeon to access a wide surgical field and a sufficient exposure of anatomical structures.

Digital periarterial sympathectomy in the management of post-traumatic Raynaud syndrome

Among Basque handball players, the repeated impact of a ball on the palms of their hands hundreds of thousands of times throughout their sporting careers produces Raynaud syndrome. Treating this patient group is complex. Our objective was to assess the efficacy of digital periarterial sympathectomy in this patient group. The study included all of the federated amateur and professional Basque handball patients who presented with Raynaud syndrome assessed in the vascular surgery service between January 2005 and December 2012. The postoperative assessment included a physical examination, basal photoplethysmography and photoplethysmography after heat hyperemia, and arteriography or magnetic resonance angiography. All 182 digital periarterial sympathectomies in the 114 fingers of 60 patients were in Porter functional class III or IV. All patients were discharged within the first 48 hours. Follow-up results, with a mean of 2 years ± 5 months, were 100%. All patients presented immediate pain remission, recovery of comfort, normal nail growth, rapid healing of all ulcers, distal anhidrosis, and return to active sport participation. The results remain steady in 58 patients (93.5%). Mean time until return to sports activity was 9.95 ± 1.61 weeks. Digital periarterial sympathectomy is a simple, relatively nonaggressive technique without adverse side effects and with excellent medium-term results. In patients with Raynaud syndrome refractory to medical treatment and with threat to the viability of one or several fingers, digital periarterial sympathectomy can be the first treatment option, especially in cases of arteritis associated with very severe spasms.

Vascular Conditions of the Hand

Treating vascular conditions of the hand requires a thorough understanding of the vascular anatomy of the hand and upper extremity. Treatment options include both operative and nonoperative modalities, and may involve a multidisciplinary team including vascular surgeons, hand surgeons, interventional radiologists, medical internists, and hand therapists. This review discusses the vascular anatomy, patient evaluation, and treatment of vascular conditions of the hand. Figures show the large blood vessels of the arm, locations of the bifurcation of the radial and ulnar arteries, the vascular branches of the arm, the vascular anatomy of the hand and wrist, the location of the superficial palmar arch, upper extremity angiography, the clinical appearance and venograms of phlegmasia cerulean dolens, a high-flow arteriovenous malformation involving the right long finger, images of a patient who experienced blunt trauma to his distal palm from a wood splinter, a 28-year-old male who developed forearm compartment syndrome, volar and dorsal appearance of the left hand of a 56-year-old male with Raynaud phenomenon secondary to scleroderma, and intraoperative images of a patient who underwent digital palmar sympathectomies. A video shows a periarterial digital sympathectomy. Tables list the distinction between Raynaud disease and Raynaud phenomenon, comparison of investigational modalities of vascular conditions, interpretation of segmental arterial pressures, Wake Forest classification of vasospastic and vaso-occlusive disease, and Jones classification of vein bypass graft configurations in upper extremity vascular reconstruction. This review contains 12 figures, 1 video, 5 tables, and 66 references.

Outcomes of Sympathectomy and Vascular Bypass for Digital Ischemia in Connective Tissue Disorders: Level 4 Evidence

Surgical treatment of digital ischemia in connective tissue disorders consists of periarterial sympathectomy alone (PS) or in conjunction with bypass graft (PSB) of the radial or ulnar artery. PSB may provide benefit compared to PS alone. Preoperative angiography may not accurately reflect the suitability of vessels for bypass.

Commentary on Murata et al. Long-term follow-up of periarterial sympathectomy for chronic digital ischaemia

Commentary on Murata et al. Long-term follow-up of periarterial sympathectomy for chronic digital ischaemia

Long-term follow-up of periarterial sympathectomy for chronic digital ischaemia

This study investigates long-term clinical results (> 10 years) of periarterial sympathectomy in chronic ischaemic digits compared with intermediate-term results (3 years). Periarterial sympathectomy via the palm and volar wrist was carried out on 11 hands of seven patients with digital ischaemia but no gangrene or severe ulceration. The aetiology of ischaemia was Buerger's disease in four hands, collagen disease in three hands, and repetitive digital trauma in four hands. Subjective symptoms were evaluated at a mean follow-up period of 12 years. The efficacy of surgery was assessed objectively using thermography and plethysmography. Although five of seven patients continued on oral vasodilators and antiplatelet agents until the final follow-up, improvement of symptoms was maintained in all patients between intermediate- and long-term evaluations. Our results suggest that periarterial sympathectomy via the palm and wrist could prevent long-term aggravation of symptoms of chronic digital ischaemia when combined with adequate postoperative drug therapy.

Alexis Carrel, Rene Leriche, Jean Kunlin, and the history of bypass surgery

Alexis Carrel, Rene Leriche, Jean Kunlin, and the history of bypass surgery

Long-Term Results of Periarterial Sympathectomy

Long-Term Results of Periarterial Sympathectomy

Long-Term Results of Periarterial Sympathectomy

To compare long-term results (minimum follow-up of 23 months) of periarterial sympathectomy for patients with digital vasospasm secondary to either an autoimmune disease or generalized atherosclerotic disease. Patients with posttraumatic or localized occlusive disease and vasospasm were not evaluated. Twenty-eight patients had periarterial sympathectomy at 1 hospital by 1 senior surgeon. Periarterial sympathectomy was targeted to the areas of ulceration. Twenty patients (with 24 involved extremities and 42 ulcerated digits) had a documented autoimmune disease; 17 patients had scleroderma or an undifferentiated mixed connective tissue disorder, 2 had systemic lupus erythematosus, and 1 had rheumatoid arthritis. Eight patients (with 9 involved extremities and 17 ulcerated digits) had atherosclerotic disease. The primary outcomes were complete healing of all ulcers, a decrease in the number of ulcers, and need for amputation by the end of follow-up. Statistical analysis was done using the Fischer exact t-test. The average follow-up for all patients was 96 months (90 months for the autoimmune group and 113 months for the atherosclerotic group). Fifteen of the 20 patients (28 of 42 digits) in the autoimmune group had complete healing or decrease in ulcer number. Conversely, only 1 of the 8 patients (2 of 17 digits) in the atherosclerotic group had complete healing or decrease in ulcer number. Eleven of the 42 (26%) digits treated in the autoimmune group required amputation. In contrast, 10 of the 17 (59%) digits treated in the atherosclerotic group ultimately required amputation. Periarterial sympathectomy can lead to complete healing and decrease in ulcer number in autoimmune disease patients with digital ischemia from vasospasm. However, our data suggest that periarterial sympathectomy may be of little or no benefit in patients with chronic digital ischemia and vasospasm secondary to severe atherosclerotic disease. Therapeutic III.

Periarterial Sympathectomy of the Foot for the Treatment of Necrotizing Raynaud's Phenomena

Patients with critical peripheral vascular disease and nonhealing toe ulcers secondary to collagen vascular disease often require toe amputation when nonsurgical measures fail to control their symptoms. The aim of this study was to evaluate the effectiveness of periarterial sympathectomy (PAS) of the foot/ankle in patients with unreconstructable vaso-occlusive disease and nonhealing digit ulcers unresponsive to nonsurgical measures. Five patients (seven feet and nine toe ulcers) were treated with PAS of their involved foot and followed for a minimal of 3 years (3 to 7 years). The technique included PAS of the dorsalis pedis, posterior tibial and anterior tibial arteries. Eight toe ulcers healed uneventfully within 3 months after surgery. Only one patient developed a new ulcer 5 years after PAS. The mean visual analog pain scale improved from 5.7 to 1 (P<0.03). The mean Wake Forest University (WFU) scale improved from 1.8 to 0.5 (P=0.07). There was no change in the WFU numbness score or the McCabe Cold sensitivity scale. The results suggest that foot/ankle PAS is a beneficial salvage treatment option for patients with non-reconstructable, vaso-occlusive disease that ameliorates foot symptoms, facilitates healing of toe ulcerations, and reduces the incidence of toe amputations.

Long-Term Successful Outcome of Severe Hand Ischemia Using Arterialization With Reversal of Venous Flow: Case Report

The management of unreconstructible vascular lesions in the hand is a challenge with limited options for treatment. After 22 years of hand ischemia, involving management with reverse interpositional vein grafting, periarterial sympathectomy, and partial finger amputations, a 62-year-old man underwent arterialization of the venous system of the hand for unreconstructible distal vascular lesions as a salvage procedure. At 7-year follow-up, the patient is pain-free with good functional and health-related quality of life outcomes and no further amputations. This procedure may be considered as a salvage alternative to prevent additional amputation in selected patients.

Peri-Arterial sympathectomy: An experimental investigation of the effects of this operation upon local circulation

Peri-Arterial sympathectomy: An experimental investigation of the effects of this operation upon local circulation

Peri-arterial sympathectomy with ligature of the femoral vein in the treatment of diabetic gangrene: A record of five cases

Journal Article Peri-arterial sympathectomy with ligature of the femoral vein in the treatment of diabetic gangrene: A record of five cases Get access Ralph Brooke Ralph Brooke Hon. Assistant Surgeon Royal West Sussex Hospital, Chichester Search for other works by this author on: Oxford Academic Google Scholar British Journal of Surgery, Volume 15, Issue 58, October 1927, Pages 286–290, https://doi.org/10.1002/bjs.1800155817 Published: 06 December 2005

The treatment of raynaud's disease by peri-arterial sympathectomy

The treatment of raynaud's disease by peri-arterial sympathectomy

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

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.

Periarterial sympathectomy in scleroderma patients: intermediate-term follow-up.

The use of periarterial sympathectomy (PAS) to manage chronic digital ischemia caused by scleroderma remains controversial. The duration of efficacy of PAS in managing scleroderma symptoms was evaluated by examining microvascular physiology, health-related quality of life, and patient satisfaction. Twenty-two patients (29 hands) with scleroderma, chronic vascular insufficiency, and a history of nonhealing digital ulcers unresponsive to nonsurgical treatment were evaluated. Isolated cold stress testing and laser Doppler fluxmetry measurements were used to evaluate microvascular perfusion before surgery and after a mean follow-up period of 31 months (range, 7-108 months). Digital temperatures did not change after surgery, but microvascular perfusion had increased significantly at a mean of 31 months in 22 hands. Health-related quality-of-life data were collected at a mean of 46 months (range, 11-108 months) after surgery. Subjective improvement (fewer ulcers, faster ulcer healing, and decreased pain) was reported for 18 of 22 patients (24 of 29 hands) at a mean follow-up period of 46 months; 6 patients remained ulcer free. Follow-up of scleroderma patients after PAS documented improved microvascular perfusion as evaluated by laser Doppler fluxmetry and by variable clinical results.

Chronic vascular disorders of the upper extremity

This article details the presentation and evaluation of occlusive, vasospastic, and mixed vascular disorders. Indications and techniques of nonoperative management and surgical techniques of vascular reconstruction and periarterial sympathectomy are presented. Copyright © 2001 by the American Society for Surgery of the Hand

Acute effects of periarterial sympathectomy on the cutaneous microcirculation.

The clinical effects of peripheral sympathectomy on patients with vaso-occlusive disease are often dramatic and include relief of pain, improved quality of life, and healing of ulcers. Peripheral periarterial sympathectomy is known to increase skin temperature and to maximize the nutritional component of peripheral blood flow, but the pathophysiology of vaso-occlusive disease and the physiologic mechanisms of this treatment are unknown. In this study, the acute effects of periarterial sympathectomy were directly observed in a rabbit ear model of digital microcirculation (arterioles, arteriovenous anastomoses, and venules). The effects of periarterial sympathectomy on cutaneous perfusion and total flow were also examined using laser Doppler perfusion imaging and digital temperature measurements. The central auricular artery became dilated (50-100%) immediately after sympathectomy; the arterioles, arteriovenous anastomoses, and venules dilated to 165, 156, and 223%, respectively, at 30 minutes and to 187, 174, and 204%, respectively, at 60 minutes, relative to their baseline diameters prior to sympathectomy. Laser Doppler perfusion imaging values and ear temperatures were noted to increase after sympathectomy (8.9%, 3 degrees C), although the core temperature of the rabbit did not change. Thus, acute periarterial sympathectomy can (a) effectively reduce the vascular tone of the distal microvasculature and (b) increase total microcirculatory perfusion-cutaneous and thermoregulatory-by both venular and arteriolar dilation. Periarterial sympathectomy has the clinical potential to increase nutritional blood flow, thereby ameliorating the signs and symptoms of ischemia associated with thermoregulatory abnormalities. Dilation of the arteriovenous anastomoses, with a subsequent reduction in vascular resistance, may contribute to the increased cutaneous temperature noted after sympathectomy.

Effect of deferoxamine and sympathectomy on vasospasm following subarachnoid hemorrhage.

We examined the effects of subarachnoid hemorrhage (SAH) and treatment with deferoxamine (DFO) or sympathectomy on vascular smooth muscle function, as well as the underlying mechanisms involved, by recording the responses to nor-adrenaline and serotonin in isolated carotid arteries in vitro. All studies were performed before and 7 days after SAH. An experimental subarachnoid hemorrhage model was created in rabbits by injecting autologous arterial blood into the subarachnoid space of the rabbits via cisterna magna punction. During the chronic stage of vasospasm following SAH deferoxamine (DFO) was given to the animals and cervical and periarterial sympathectomy was performed in the other groups of animals. In isolated carotid arteries noradrenaline (10(-8) to 10(-4) mol/l) and serotonin (10(-8) to 10(-4) mol/l) produced concentration-dependent contractions. These contractile responses were significantly enhanced in animals 7 days after SAH compared to controls and did not return to control values in carotid arteries obtained from animals treated with DFO or sympathectomy for 7 days after SAH. These results show that SAH causes supersensitivity in the carotid as well as cerebral arteries during the first week after SAH and could contribute to the development of cerebral vasospasm. Both treatment with DFO and sympathectomy after SAH did not reduce the contractile responses to noradrenaline and serotonin in the carotid arteries. In conclusion, treatment with DFO or sympathectomy during the chronic stage of vasospasm after SAH did not affect the vascular responses of the extradural part of the carotid artery to vasoactive substances.