Keywords
Chronic Digital Ischemia - Cervical sympathectomy - Extended Peripheral Periarterial
Sympathectomy
Introduction
Chronic digital ischemic pathology currently lacks solid scientific evidence to support
a specific treatment modality. In those patients who do not respond to medical treatment,
the surgical options available are very limited due to their complexity. Digital ischemia
can be the manifestation of numerous medical conditions, ranging from simple, such
as Raynaud's disease in response to cold weather, to more complex pathologies encompassing
a variety of vasculitis, peripheral vascular occlusive diseases, and autoimmune diseases,
collectively called “Raynaud's syndrome”.[1]
Depending on the degree of ischemia, patient complaints range from numbness, “pins
and needles,” and pain, to ulceration and gangrene, typically with Raynaud's syndrome.
([Fig. 1])
Fig. 1 Raynaud's phenomenon, 3 stages. (A) Paleness, due to vasospasm; (B) Cyanosis, due
to increased carboxyhemoglobin; (C) Erythema, due to reactive hyperemia.
The alpha-2 adrenergic receptors present in the tunica media of the digital arterioles
are the final link in the control of the sympathetic nervous system over digital blood
flow. These receptors play a fundamental role in developing of the pathologies, causing
vasoconstriction and decreased blood flow.[2]
To improve blood flow in patients resistant to medical therapy, both chemical and
surgical sympathectomies have been performed. The hypothesis behind these therapies
is that sympathetic hyperactivity, whether relative or absolute, is invariably involved
in pathogenesis. Moreover, the sympathetic pathways that reach the upper limb originate
from the ganglionic chain of the cervical sympathetic plexus at the central level
and through the adventitia of the arteries at the peripheral level.[3]
[4]
[5]
[6]
Lifestyle modification is the initial step of treatment. It is often enough to resolve
mild symptoms. This includes avoiding smoking, emotional stress, and low temperatures.
Medical therapy generally includes antiplatelet agents and vasodilators, in addition
to treatment of the primary pathology in cases of secondary Raynaud's. Aspirin and
calcium channel blockers are usually the first line of drug treatment.[6]
[7]
[8]
[9]
[10]
[11]
Capillaroscopy is essential to complement the etiological diagnosis as well as to try to predict
postoperative results and clinical evolution, understanding that those patients who
present capillaroscopy with autoimmune patterns usually present partial or incomplete
improvement with medical and/or surgical treatment ([Fig. 2]).
Fig. 2 Capillaroscopy and the different Scleroderma patterns. (A) Normal; (B) Early; (C)
Active; (D) Late.
The anatomical basis for periarterial digital sympathectomy of the hand was established
by Pick (1970), who pointed out that the brachial plexus does not receive its communicating
branches exclusively from the cervical-sympathetic trunk. The sinovertebral nerve,
carotid plexus, Kuntz nerve, and sympathetic ganglia in the spinal nerve roots divert
the sympathetic trunk to the brachial plexus without passing through the cervical
ganglia. These alternative pathways may explain residual sympathetic activity in the
upper limb after cervicothoracic sympathectomy.[8]
Mitchell (1953) demonstrated that sympathetic axons travel with peripheral nerves,
sending frequent branches to arteries along their path. These sympathetic axons are
located within the epineurium. In the arteries, sympathetic fibers do not penetrate
the vessel walls and are confined solely within the adventitia. Sympathetic innervation
of arteries is more prominent along the distribution of the median nerve than the
ulnar nerve. These anatomical concepts form the conceptual and technical foundation
of peri-arterial digital sympathectomy. The key point to consider regarding the sympathectomy
technique is that the adventitia must be completely resected along the entire treated
arterial segment (360°) since sympathetic fibers are distributed throughout the entire
arterial perimeter ([Fig. 3A]).[8]
Fig. 3 Surgical Technique. (B) Circumferential adventitectomy of the ulnar artery was performed.
In the background, the radial artery is visible with its landmark. The ulnar artery's
peri-arterial adventitia is circumferentially removed over 2 cm. (C) Common digital
artery. The collateral nerves are preserved, and 1 cm of the adventitia is resected.
Pick (1970) demonstrated that the distal third of the radial artery is innervated
by a branch of the superficial branch of the radial nerve and additional branches
from the lateral cutaneous nerve of the forearm. The distal third of the ulnar artery
receives three direct branches from the ulnar nerve (via Henle's nerve) and one branch
from the medial cutaneous nerve of the forearm, which typically runs along the volar
surface of the ulnar artery and can be visualized at the wrist level.[4]
[8]
Technically, distal periarterial sympathectomy can vary in extent. That is, from the
digital sympathectomy itself to additional sympathectomies of the common palmar digital
arteries, the superficial palmar arch, and combined with denervation of the radial
and ulnar arteries.[8]
[12]
The effectiveness of digital sympathectomy is determined by monitoring pain relief
and healing of digital ulcers and, more objectively, by assessing postoperative digital
blood pressure (POP) and oxygen saturation levels in comparison with preoperative
values.
The technique of peri-digital arterial sympathectomy, as originally described by Flatt
(1980), consisted of circumferentially removing the adventitia of the proper digital
arteries of more than 3 to 4 mm. Wilgis then performed a more extensive adventitial
detachment, 2 cm, from the common digital artery and extending beyond the bifurcation
to include 1 cm of the digital arteries. At the wrist, sympathectomy of the ulnar
artery and/or the radial artery and its dorsal branch was also performed.[7]
[8]
Objective
To evaluate the results of peripheral periarterial sympathectomy (PAS) in previously
selected patients with chronic digital ischemia refractory to medical treatment, objectively
evaluating the results in terms of remission of symptoms, ulcers, and improvement
of function and microvascular perfusion of the hand and fingers.
Materials and Methods
Retrospective, descriptive, and analytical study of a series of 14 patients (out of
a total of 21) treated in 3 different centers by the same team of hand surgeons (CH
& MC), between 2005 and 2021 with degree level of expertise grade IV-V according to
the Tang & Giddins criteria[13] ([Table 1])
Table 1
|
Patient
|
Sex
|
Age (years)
|
VAS (Visual Analog Scale) x/10
|
Compliance
|
Follow-up time (months)
|
Capillaroscopy
|
Number of fingers affected
|
|
Woman
|
Man
|
Pre-surgical
|
1
|
3
|
6
|
12
|
Autoimmune Disease
|
Scleriform Disease
|
1
|
2
|
3
|
|
1
|
*
|
|
61
|
7
|
2
|
1
|
1
|
1
|
Yes
|
12
|
*
|
|
*
|
|
|
|
2
|
*
|
|
57
|
9
|
6
|
4
|
4
|
3
|
Yes
|
123
|
|
*
|
|
*
|
|
|
3
|
|
*
|
28
|
10
|
7
|
3
|
3
|
2
|
Yes
|
196
|
*
|
|
|
|
*
|
|
4
|
*
|
|
41
|
9
|
1
|
1
|
1
|
1
|
Yes
|
141
|
*
|
|
*
|
|
|
|
5
|
*
|
|
53
|
9
|
2
|
2
|
2
|
2
|
Yes
|
110
|
*
|
|
|
*
|
|
|
6
|
*
|
|
63
|
8
|
2
|
2
|
2
|
1
|
Yes
|
70
|
|
*
|
*
|
|
|
|
7
|
|
*
|
30
|
9
|
5
|
4
|
4
|
2
|
Yes
|
53
|
|
*
|
|
|
*
|
|
8
|
*
|
|
42
|
9
|
4
|
4
|
4
|
2
|
Yes
|
48
|
*
|
|
|
*
|
|
|
9
|
|
*
|
31
|
9
|
5
|
3
|
3
|
2
|
Yes
|
105
|
*
|
|
|
*
|
|
|
10
|
*
|
|
55
|
8
|
6
|
4
|
4
|
3
|
Yes
|
24
|
|
*
|
|
|
*
|
|
11
|
*
|
|
51
|
9
|
3
|
2
|
2
|
2
|
Yes
|
33
|
*
|
|
|
*
|
|
|
12
|
*
|
|
49
|
8
|
4
|
3
|
3
|
1
|
Yes
|
22
|
*
|
|
|
*
|
|
|
13
|
*
|
|
52
|
9
|
1
|
1
|
1
|
1
|
Yes
|
18
|
*
|
|
|
*
|
|
|
14
|
*
|
|
60
|
9
|
1
|
1
|
1
|
1
|
Yes
|
53
|
|
*
|
*
|
|
|
|
Percentage
|
79%
|
21%
|
|
|
|
|
|
|
100%
|
|
64%
|
36%
|
30%
|
50%
|
21%
|
|
Average
|
|
|
48
|
9
|
4
|
3
|
3
|
2
|
|
72
|
|
|
|
|
|
Inclusion criteria
-
♢ Patients with pain due to cold intolerance, with digital ischemic disorders
-
♢ Patients with pain and distal digital ulcerations
-
♢ That do not respond adequately to pharmacological medical treatment.
Exclusion criteria
-
♢ Patients who did not comply with the minimum one-year postoperative follow-up
-
♢ Patients who did not continue with pharmacological treatment in the postoperative
period
-
♢ Patients who did not abandon, or reduced, their smoking habit (if applicable) after
the PAS.
According to these criteria, 14 patients out of a total of 21 were included in the
analysis.
Capillaroscopy was performed to determine whether the patient had a rheumatic disease
associated with discoloration of the hands (Raynaud's phenomenon) and/or to identify
those patients who may progress toward Sclerodermiform Syndrome ([Fig. 2]).
Pain assessment before and after the procedure was conducted using the Visual Analog
Scale (VAS), with records taken postoperatively at one, three, and six months, as
well as at one year. The methodology was applied in the clinic, using visual pain
scales where 0 represented no pain and 10 the maximum pain.
All patients continued with their underlying pharmacological treatment according to
their primary etiology, including antiplatelet agents and vasodilators, along with
treatment for the primary condition in cases of secondary Raynaud's phenomenon.
Surgical Technique
The procedure is performed under regional anesthesia using an ultrasound-guided plexus
block at the axillary level, followed by exsanguination by gravity, keeping the limb
elevated for three minutes before applying the tourniquet at 250 mmHg. The upper limb
is positioned on an accessory hand table. We systematically perform extensive SPA
using microsurgical techniques with 3.5x to 6x magnification through loupes or a microscope,
working from proximal to distal. Therefore, we recommend starting with an anterior,
longitudinal approach over the radial and ulnar arteries at the distal forearm, proximal
to the proximal wrist crease (separate approaches for each artery), resecting 1 to
2 cm of adventitia circumferentially at 360° ([Fig. 3B]). The procedure is then repeated on the intermetacarpal arteries of the affected
fingers, before their bifurcation. The digital arteries can be exposed through a Y-shaped
incision on the distal palm, over the bifurcation of the common digital artery, and
resecting up to 1 cm distal to the bifurcation. The digital arteries on the radial
side of the index finger and the ulnar side of the little finger are exposed through
zigzag medio-lateral incisions at the base of the digital flexion crease. A circumferential
adventitial debridement over a 2 cm distance must be ensured for the common digital
arteries, taking care to preserve all small arterial branches ([Fig. 3C]).
Results
According to the inclusion criteria, 14 patients were selected. The most affected
fingers were the index, middle, and ring fingers. In 70% of cases, sympathectomy was
performed on 2 or more fingers.
The results of the capillaroscopies showed that sclerodermiform patterns were evident in 5 cases, and autoimmune disease patterns in 9 cases.
The underlying etiologies in cases of secondary Raynaud's were:
According to sex, 11 (79%) were women and 3 (21%) were men, with an average age of
48 years (range: 28-63). The patients were evaluated over an average follow-up period
of 72 months (range: 12 to 192 months). Improvement or reduction in the number of
distal digital skin ulcers was observed in 11 out of 14 cases between the first and
third POP. ([Fig. 4])
Fig. 4 Improvement of lesions after extended periperipheral arterial sympathectomy.
In all cases, a clear decrease in pain was observed from the first postoperative day,
going from an average VAS score of 9/10 (7 to 10/10) in the preoperative period to
average values of 4, 3, and 2 after 1 month, 3 and 6 months and 1 year postoperatively
respectively. Two patients with atherosclerosis did not show objective improvement
of the lesions beyond the two-year follow-up, but they did show a reduction in pain
symptoms and did not require amputation.
All patients continued treatment with oral vasodilators and antiplatelet agents until
the end of follow-up. The improvement in symptoms was maintained in all patients until
the end of the evaluations ([Table 1]).
Discussion
The management of chronic digital ischemia characterized by pain is not well defined
in the reviewed literature. A lack of response to medical-pharmacological treatment
is frequently observed, with ischemic pain being the destabilizing factor that complicates
patient management. A group of patients were treated prospectively with extended peripheral
peri-arterial sympathectomy, showing encouraging results that persisted over time.
Kevin C. Chung and colleagues, after conducting a systematic review of the outcomes
of periarterial sympathectomy in patients with chronic digital ischemia, concluded
that due to the wide variety of surgical techniques and follow-up evaluation methods,
they were unable to establish clear parameters regarding the advantages of this method.[14]
When medical treatment for chronic ischemic disease is refractory, traditional cervical
sympathectomy is one of the options reported in the literature as a potential solution;
however, it often does not produce the desired results or is accompanied by secondary
side effects that frequently lead to patient rejection or resistance. Endoscopic cervical
sympathectomy may be associated with postoperative compensatory hyperhidrosis (recurrence).
Reports on the long-term effects of thoracic sympathectomy (TS), endoscopic thoracic
sympathectomy (ETS), or both, in the treatment of upper limb ischemia are inconsistent.
Some reports suggest that these outcomes significantly worsen over long-term follow-up
(> 5 years). In contrast, peripheral or digital sympathectomy, introduced by Flatt
in 1980, is technically much less demanding and can be performed under regional anesthesia.[12]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
Couveliers et al. in their bibliographic review, reported compensatory hyperhidrosis
in 45% to 98.6% of cases and Horner syndrome in 0% to 6.9%. The long-term effect of
TS and ETS in the management of Raynoud's disease is highly debated. All articles
reviewed reported a waning effect over time, with recurrence of symptoms in almost
all patients. The recurrence of symptoms generally begins 6 months after sympathectomy,
but despite this, all patients express their agreement with the result.[22]
Miller et al. have shown that after performing cervico-thoracic sympathectomy, blood
flow increases. However, in the long term, the results have generally been disappointing.
Relapse is very common and is attributed to incomplete denervation, regeneration of autonomic nerve fibers, and the reorganization and activation of
alternative pathways. Cervico-thoracic sympathectomy has also been shown to be relatively
more successful for the relief of hyperhidrosis than for the relief of vascular disease;
although the symptoms usually remit in the medium term according to the series consulted.[8]
Mohammad I Khan et al compared the effectiveness of TS versus conservative treatment
in patients who suffered severe Reynaud's disease after exposure to extreme temperatures
between 1999 and 2006. Of a total of 48 patients, 17 underwent TS and 31 were treated
conservatively. They found that the frequency of attacks and the duration between
them were reduced in all patients who underwent cervical sympathectomy (p < 0.05)
compared to conservative treatment. They concluded that TS is a very effective treatment
modality in patients with severe Raynaud's disease.[16]
Although the treatment of this pathology remains a topic of discussion without a defined
pattern, many authors consider that the outcomes in autoimmune diseases are unfavorable.
In our case series, all patients showed significant improvement in pain levels on
the pain scale during the immediate postoperative period, as this symptom is the main
factor that drastically affects the daily lives of these patients. Those with advanced
obstructive sclerotic arteriopathy did not evolve favorably regarding their ischemic
skin lesions, but they did show improvement in pain.
The use of the Visual Analog Scale (VAS) for measuring pain was in agreement with
numerous consulted series. Although some publications also used scores such as the
DASH and the WFUSS symptom rating scale, these are not evaluations we routinely conduct
in our service.
Balogh B et al. report on a series of 7 patients who were refractory to medical treatment
and underwent digital peri-arterial sympathectomy. All of them were asymptomatic after
surgery, with satisfactory healing of ulcers on the fingertips. None of them experienced
a relapse during the 1.5-year follow-up period.[5]
Ahmed A Elshabrawy et al. performed a prospective study in which they included 17
patients with chronic digital ischemia, between 2019 and 2020 and who underwent radial,
ulnar, and digital peripheral periarterial sympathectomy. They had 50% complete healing
of the ulcer at 1 month (p = 0.031) and 100% healing was complete at 6 months (p < 0.001).
Pain scores showed significant reductions at 1 month (p = 0.001) and 6 months (p < 0.001)
follow-up. They concluded that distal periarterial sympathectomy demonstrates high
success rates in terms of pain relief and ulcer healing in severe digital ischemia.[2]
The results obtained in our series indicate that extended peri-arterial sympathectomy,
in the upper limb, improves and/or stops the lesions of chronic digital ischemia,
when combined with adequate postoperative medical treatment. Compared with cervical
or central sympathectomy, the percentage of positive results is similar, but the adverse
effects are not.[8]
[12]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
[23] Considering the previously cited reports, which demonstrate a lower recurrence rate
and fewer complications, and given that it is a technically simpler and more cost-effective
procedure, we believe that extended peripheral periarterial sympathectomy is an excellent
alternative for treating these conditions. Although the benefits are limited in cases
dominated by obstructive arteriosclerotic pathology, the clinical improvement justifies
the procedure in these patients.
Since it is not possible to completely remove all adventitia at the digital level,
and given the significant sympathetic input the radial artery receives through the
superficial branch of the radial nerve and additional branches from the lateral cutaneous
nerve of the forearm, as well as the ulnar artery, which receives three direct branches
from the ulnar nerve (Henle's nerve) and one branch from the medial cutaneous nerve
of the forearm, adding adventitial removal from these major arteries at the wrist
increases the likelihood of complete interruption of sympathetic supply to the digital
arteries ([Fig. 3B] and [3C]).[1]
[4]
[7]
[8]
The main weaknesses of our study lie in its retrospective nature, the small sample
size, and the lack of a control group with a cervical/central technique. But the main
strengths, and in coincidence with some published series,[1]
[2]
[7]
[9]
[10]
[11]
[14]
[15] are the long-term follow-up of the patients and that they were all treated by the
same surgical team, with the same technique and evaluated with the same scales.
