Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 228-230

Sympathectomy in postvascular surgical patients with severe pain in distal limb and/or small ulcers


1 Department of Cardio Thoracic and Vascular Surgery, RNT Medical College, Udaipur, Rajasthan, India
2 Department of General Surgery, RNT Medical College, Udaipur, Rajasthan, India

Date of Submission10-Jul-2020
Date of Decision07-Aug-2020
Date of Acceptance24-Sep-2020
Date of Web Publication6-Jul-2021

Correspondence Address:
Vinay Naithani
Department of Cardio Thoracic and Vascular Surgery, RNT Medical College, Udaipur, Rajasthan
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_95_20

Rights and Permissions
  Abstract 


Introduction: Sympathectomy is used principally in patients of inoperable peripheral vascular disease, small vessel disease, and vasospastic disease. It is useful to alleviate symptoms of rest pain and as an adjunct to heal ischemic ulcers. Aim and Objective: This is a clinical study to evaluate the role of sympathectomy in postvascular surgical patients with persistent pain in distal limb (causalgia) with or without ischemic ulcers on the foot or hand. Materials and Methods: This study was performed between February 2015 and February 2020. We did 823 arterial surgical interventions including embolectomies, endarterectomy with patch arterioplasty, and interposition grafting in upper or lower limb vessels. These patients were diagnosed on clinical bases and with investigational modalities such as arterial Doppler study and computed tomography angiography. All these patients had chronic vascular obstruction. Out of them, we selected 54 patients having persistent pain distal limb (causalgia) not relieved by medications. Besides causalgia, 24 patients had ischemic ulcers either on foot or hand. Postoperative arterial Doppler study was satisfactory in these patients. Their complaint persisted for 3–4 months in spite of all medications. Chemical sympathectomy was tried in 21 patients but was ineffective. We did thoracic sympathectomy in 28 patients and lumbar sympathectomy in 26 patients on side affected. Observation and Results: There were 46 males and 8 females. Majority of these patients were in active phase of life with a mean age of 35 (±2). Pain was relieved in all patients. Ischemic ulcers present in 24 patients also healed within 3–6 weeks. Conclusion: Although no clear guidance exists for the role of sympathectomy in postsurgical patients, we observe it is a boon for postvascular surgical patients with persistent pain and small ischemic ulcers.

Keywords: Peripheral artery disease, postvascular surgical patients, sympathectomy


How to cite this article:
Naithani V, Bhatia BP, Chanda DK, Sharma A. Sympathectomy in postvascular surgical patients with severe pain in distal limb and/or small ulcers. Indian J Vasc Endovasc Surg 2021;8:228-30

How to cite this URL:
Naithani V, Bhatia BP, Chanda DK, Sharma A. Sympathectomy in postvascular surgical patients with severe pain in distal limb and/or small ulcers. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Jul 25];8:228-30. Available from: https://www.indjvascsurg.org/text.asp?2021/8/3/228/320631




  Introduction Top


Peripheral arterial disease (PAD) refers to narrowing of the arteries of the limbs that restrict blood flow. In severe cases, PAD can cause pain at rest, ulcers, and gangrene. Open vascular surgical or endovascular interventions are the treatment of choice in all cases.

Sympathectomy was widely used in the management of peripheral vascular disease (PVD) before the era of vascular bypass and angioplasty. Nowadays, its indications are limited to cases, where surgical vascular intervention or angioplasty is not feasible or failed.[1] Other indications for sympathectomy include hyperhidrosis, causalgia, and neuropathic pain. Thoracoscopic and laparoscopic techniques are less invasive and have given more preference to open surgery.[2] However, many centers still prefer open surgery with a small incision. Chemical lumbar sympathectomy (LS) is another modality adopted by various pain clinics with variable results.[3]

Aim, objective, and methods

This is a clinical study to evaluate the role of sympathectomy in postvascular surgical patients with persistent pain in distal limb (causalgia) with or without ischemic ulcers on the foot or hand.

This study was conducted in the Cardiothoracic and Vascular Surgery Department, RNT Medical College, Udaipur, between February 2015 and February 2020.

During this 5-year interval, we did 823 arterial surgical interventions including embolectomies, endarterectomy with patch arterioplasty, and interposition grafting in upper or lower limb vessels. These patients were diagnosed on clinical bases and with investigational modalities such as arterial Doppler study and computed tomography angiography. These patients had chronic vascular obstruction. We selected 54 patients having persistent pain distal limb (causalgia) not relieved by medications. There Numerical rating Pain Scale and Wong-Baker Faces Pain Scale were around 6–8. Besides causalgia, 24 patients have ischemic ulcers on the foot or hand. The postoperative arterial Doppler study was satisfactory in these patients. Our policy is redo vascular surgery if we notice the recurrence of vascular block. In selected patients, complaints persisted for 3–4 months in spite of all medications. Chemical sympathectomy was tried in 21 patients but was ineffective. All these patients before vascular surgery were a smoker. They left smoking a few days before admission and continue to avoid smoking afterward. Patients with medium size vessel involvement and panarteritis seen during surgery were labeled as Buerger's disease, and those with the involvement of a big vessel considered atherosclerotic arterial disease. There were no comorbid conditions before sympathectomy, as comorbid cconditions such as anemia, hypoproteinemia, and infections were taken care before vascular surgery and during follow-up. None of these patients were diabetic. There were 46 males and 8 females. Majority of these patients were in active phase of life with a mean age of 35 (±2). We did thoracic sympathectomy in 28 patients and LS in 26 patients on side affected.

Surgical technique

Thoracic sympathectomy was done using the transaxillary approach under general anesthesia. With small incision exposure, T2–T4 segment of the thoracic sympathetic trunk was excised and sent for histopathology examination for confirmation.

LS was done using the small incision in the lumber area under general anesthesia; L2–L4 segment of the lumbar sympathetic trunk was excised and sent for histopathology examination.


  Results Top


Pain was relieved in all patients. Only four patients required analgesic for 2–3 weeks. These patients resume duties after 10–14 days.

Out of 54 patients, 24 patients had small ulcers on foot and fingers. Healing appeared within 1 week. The ulcers healed in a period of 3–4 weeks.

The patient's quality of life improved, and they started doing work without any assistance. Follow-up for a period of 1 year was satisfactory. There was no recurrence of clinical ischemic feature during follow-up.


  Discussion Top


PAD refers to a common condition of narrowing of the arteries of the lower limbs that restricts blood flow; in the most severe cases, PAD can cause pain at rest, ulcers, and gangrene. Amputation may be required in case if resistant pain or sepsis ensues. With the improvement in surgical techniques and medications, the incidence of amputations has reduced remarkably. We prefer vascular intervention in all vascular cases and even in cases of restenosis or thrombotic block following vascular surgery.

Sympathectomy is used principally in patients of inoperable PVD, small vessel disease, and vasospastic disease whereby nerves that stimulate constriction of arteries are destroyed.[1] It improves the blood circulation and tissue oxygenation of lower limbs and thus promotes early wound healing and alleviates pain. This can be done with open surgery or through endoscopic procedure.[2] Our preference is an open approach with a small incision. Chemical sympathectomy is another way adopted by various pain clinics with variable results.[3]

Complications of LS include ureteric injury, paralytic ileus, ejaculation disturbances, neuropathic complications, and rarely intestinal infarction.[4] Complications of thoracic sympathectomy[5] include pneumothorax, Horner's syndrome, hyperhidrosis, hemothorax, vascular, parenchymal injuries, and rarely chylothorax and skin depigmentation;[6] however, there are few reports in the literature on severe bronchospasm and excessive bronchial secretions postthoracic sympathectomy, resistant to theophylline and sympathomimetics (salbutamol).[7] With careful approach and good anatomical knowledge, complications are rare with experienced hands. In our series, we did not face any complications.

We did open sympathectomy with small incisions in all cases. We observed chemical sympathectomy has limitation, as observed in 21 of our patients. These patients later required open surgical intervention. Severe persistent pain, due to small vessel involvement and nerve ischemia, was relieved in all patients. Further, healing of small ulcers among 24 of our patients gave us a new hope in management of PVD. It took 3–6 weeks for complete recovery. The patient's quality of life improved. They become fruitful to family and society, and they started doing the routine light job without any assistance. Follow-up for a period of 1 year was satisfactory with no recurrence of symptoms.


  Conclusion Top


  1. Although no clear guidance exists for the role of sympathectomy in postvascular surgical patients, we observe sympathectomy is boon in postvascular surgical patients with severe pain in distal limb ± small ulcers
  2. Chemical sympathectomy has a limited role in these patients
  3. Quality of life improves after sympathectomy.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Govedarski V, Perov I, Zahariev T, Nachev G. The renaissance of lumbar sympathectomy. Khirurgiia (Sofiia) 2010;4-5:30-5.  Back to cited text no. 1
    
2.
Miminoshvili OI, Perepelitsa SV, Shapovalov IN. Comparative estimation of the results of open and endoscopic thoracic sympathectomy in the treatment of Raynaud's phenomenon. Klin Khir 2010;10:16-9.  Back to cited text no. 2
    
3.
Nesargikar PN, Ajit MK, Eyers PS, Nichols BJ, Chester JF. Lumbar chemical sympathectomy in peripheral vascular disease: Does it still have a role? Int J Surg 2009;7:145-9.  Back to cited text no. 3
    
4.
Rulli F, Galatà G, Micossi C, Dell'isola C. Massive intestinal infarction following retroperitoneoscopic right lumbar sympathectomy. J Minim Access Surg 2006;2:222-3.  Back to cited text no. 4
    
5.
Lin TS, Wang NP, Huang LC. Pitfalls and complication avoidance associated with transthoracic endoscopic sympathectomy for primary hyperhidrosis (analysis of 2200 cases). Int J Surg Investig 2001;2:377-85.  Back to cited text no. 5
    
6.
Westphal FL, de Campos JR, Ribas J, de Lima LC, Netto JC, da Silva MS, et al. Skin depigmentation: Could it be a complication caused by thoracic sympathectomy? Ann Thorac Surg 2009;88:e42-3.  Back to cited text no. 6
    
7.
Zeidan A, Nahle N, Baraka A. Does bilateral thoracic sympathectomy predispose to reflex bronchospasm following tracheal intubation? Can J Anaesth 2005;52:997-8.  Back to cited text no. 7
    




 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Results
  Discussion
  Conclusion
   References

 Article Access Statistics
    Viewed158    
    Printed0    
    Emailed0    
    PDF Downloaded16    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]