Surgery for ischemic pain and Raynaud's' phenomenon in scleroderma: A description of treatment protocol and evaluation of results

Abstract

Although the literature suggests that palmar sympathectomy (PS) with or without vascular reconstruction may improve ischemic digital pain, fingertip ulceration, and cold intolerance in patients with scleroderma, the question regarding long-term efficacy still remains. This retrospective study of six patients (eight hands) operated on between 1995 and 1997 evaluates both early (6 months) and long-term (average, 2.5 years) outcome after PS in combination with decompression arteriolysis of the radial and ulnar arteries proximal to the wrist. When preoperative digital blood flow was inadequate based on noninvasive vascular studies and major inflow occlusion was present, vascular reconstruction was also performed when feasible. At early review, significant improvement in ischemic digital pain and moderate improvement in cold intolerance resulted in eight hands, and at final follow-up, this was sustained in seven hands. Preoperatively, digital ulcerations were present in six hands. After digital debridement and/or amputation, all wounds healed, but in one patient with bilateral disease who continued to smoke, ulcerations recurred without the need for subsequent surgery. Five of six patients were no longer dependent on narcotic analgesics, but use of vasodilator medication did not change. Five of six patients claimed significant improvement in the quality of life after surgery and reported that they would undergo the surgery again. PS in combination with radial and ulnar arteriolysis appears to be efficacious at both early and long-term review. When major inflow occlusion exists and digital blood flow is compromised, vascular reconstruction is recommended if possible. We review our treatment protocol in this complex population of patients.

Endovascular Revascularization in Secondary Raynaud’s Phenomenon

“…Surgical therapy includes arterial bypass, digital arterial reconstruction, sympathectomy (peripheral and digital) and amputation [12][13][14][15]. Recently botulinum toxin injection and local or intramuscular injection of mesenchymal stem cell have been used in the management of patients with digital ischemia due to secondary RP [16][17][18].…”

Treatment of Raynaud’s phenomenon: New insights and developments

“…Six of seven patients (and all four patients of this series who had scleroderma) experienced healing of digital ulcers after digital artery sympathectomy, performed as a salvage procedure to prevent amputation [46]. Long-term results (average length of follow-up 2.5 years, range 18 to 40 months) were recently reported in six patients with SSc who had undergone palmar sympathectomy in eight hands, and indications included increasing pain or Raynaud's phenomenon or non-healing digital ulceration [47]. Debridements, amputations, decompression arteriolysis of the radial and ulnar arteries proximal to the wrist, and vascular reconstruction were also performed at the same time, if indicated, reflecting the complexity of the surgical management issues [47].…”

“…Long-term results (average length of follow-up 2.5 years, range 18 to 40 months) were recently reported in six patients with SSc who had undergone palmar sympathectomy in eight hands, and indications included increasing pain or Raynaud's phenomenon or non-healing digital ulceration [47]. Debridements, amputations, decompression arteriolysis of the radial and ulnar arteries proximal to the wrist, and vascular reconstruction were also performed at the same time, if indicated, reflecting the complexity of the surgical management issues [47]. Five of the six patients were satisfied with the results [47].…”

“…There has been considerable recent interest in digital artery (palmar) sympathectomy in patients with scleroderma spectrum disorders [45][46][47]. It is likely that some of the benefit from this surgery comes from a mechanical decompression as opposed to from the sympathectomy itself.…”

Management of Raynaud’s Phenomenon in the Patient with Connective Tissue Disease

“…& Localized microsurgical digital sympathectomy has been claimed to be a successful yet safer alternative to conventional surgical sympathectomy, with relatively few complications [64,65]. However, a systematic review of the outcomes of digital sympathectomy revealed that the perioperative complication rate among scleroderma patients was 37% [66].…”