Extended Peripheral Periarterial Sympathectomy in Chronic Digital Ischemia

Abstract

Introduction In patients with chronic digital ischemia who do not respond to medical treatment, endoscopic cervical sympathectomy has its place but may be associated with postoperative compensatory hyperhidrosis. Peripheral or digital sympathectomy is technically less demanding and involves fewer complications than central or cervical sympathectomy.

Objective Evaluate the effects of extended peripheral periarterial sympathectomy in patients with chronic distal ischemia, refractory to medical treatment; and compare these results with the different reports in the literature.

Materials and Methods Retrospective, descriptive, and analytical study of a series of 14 patients treated between 2005 and 2021, who underwent extended peripheral arterial sympathectomy.

Results 11 women and 3 men with an average age of 48 years (28-63). In 11 of the 14 cases, an improvement and/or decrease in the number of ulcerated lesions was observed, and in all cases, an evident decrease in pain was observed from the first postoperative day.

Conclusions Extended peripheral periarterial sympathectomy improves and/or stops chronic digital ischemia lesions.

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:

• a) Autoimmune disorders.

• b) Arteriosclerotic disease.

• c) Buerger's disease.

• d) Sequelae of chemotherapy treatment for lymphoma.

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.

Conflict of Interest

Los autores no presentan conflicto de intereses.

Authors' contributions

The authors Caloia Martin and Ronconi Sergio participated similarly in the writing of the work. The author Caloia Hugo is credited with mentoring and collaborating in the correction of the manuscript. Drs Sofía Fernández and Mariana Muñoz participated in the field work collecting patient data and images.

• Bibliografía

• 1 Murata K, Omokawa S, Kobata Y, Tanaka Y, Yajima H, Tamai S. Long-term follow-up of periarterial sympathectomy for chronic digital ischaemia. J Hand Surg Eur Vol 2012; 37 (08) 788-793
• 2 Elshabrawy AA, Elkassaby M, Abdelgawad MS, Atif E, Megahed A, Regal S. Outcomes of periarterial sympathectomy in patients with digital ischemia. Vascular 2022; 30 (05) 859-866
• 3 Pace CS, Merritt WH. Extended Periarterial Sympathectomy: Evaluation of Long-term Outcomes. Hand (N Y) 2018; 13 (04) 395-402
• 4 Balogh B, Valencak J, Vesely M, Flammer M, Gruber H, Piza-Katzer H. The nerve of Henle: an anatomic and immunohistochemical study. J Hand Surg Am 1999; 24 (05) 1103-1108
• 5 Balogh B, Mayer W, Vesely M, Mayer S, Partsch H, Piza-Katzer H. Adventitial stripping of the radial and ulnar arteries in Raynaud's disease. J Hand Surg Am 2002; 27 (06) 1073-1080
• 6 Satteson ES, Chung MP, Chung LS, Chang J. Microsurgical distal sympathectomy in chronic vasospastic syndromes of the hand. J Scleroderma Relat Disord 2020; 5 (02) 130-136
• 7 Flatt AE. Digital artery sympathectomy. J Hand Surg Am 1980; 5 (06) 550-556
• 8 Miller LM, Morgan RF. Vasospastic disorders. Etiology, recognition, and treatment. Hand Clin 1993; 9 (01) 171-187
• 9 Koman LA, Smith BP, Pollock Jr FE, Smith TL, Pollock D, Russell GB. The microcirculatory effects of peripheral sympathectomy. J Hand Surg Am 1995; 20 (05) 709-717
• 10 Merritt WH. Role and rationale for extended periarterial sympathectomy in the management of severe Raynaud syndrome: techniques and results. Hand Clin 2015; 31 (01) 101-120
• 11 Rudolph M, Butler K, Prabhu S, Browne D, Koman LA, Li Z. Revision periarterial sympathectomy for recurrent digital ischaemia: a report with 11 patients. J Hand Surg Eur Vol 2021; 46 (08) 883-890
• 12 Coveliers HME, Hoexum F, Nederhoed JH, Wisselink W, Rauwerda JA. Thoracic sympathectomy for digital ischemia: a summary of evidence. J Vasc Surg 2011; 54 (01) 273-277
• 13 Tang JB, Giddins G. Why and how to report surgeons' levels of expertise. J Hand Surg Eur Vol 2016; 41 (04) 365-366
• 14 Kotsis SV, Chung KC. A systematic review of the outcomes of digital sympathectomy for treatment of chronic digital ischemia. J Rheumatol 2003; 30 (08) 1788-1792
• 15 Hartzell TL, Makhni EC, Sampson C. Long-term results of periarterial sympathectomy. J Hand Surg Am 2009; 34 (08) 1454-1460
• 16 Khan MI, Tariq M, Rehman A, Zafar A, Sheen SN. Efficacy of cervicothoracic sympathectomy versus conservative management in patients suffering from incapacitating Raynaud's syndrome after frost bite. J Ayub Med Coll Abbottabad 2008; 20 (02) 21-24
• 17 Karapolat S, Turkyilmaz A, Tekinbas C. Effects of Endoscopic Thoracic Sympathectomy on Raynaud's Disease. J Laparoendosc Adv Surg Tech A 2018; 28 (06) 726-729
• 18 Kamiya C, Kitaoka T, Yamamoto K, Matsumoto H, Deguchi J, Sato O. Acute palmer digital artery occlusion treated using endoscopic ablation of the thoracic sympathetic. Ann Vasc Dis 2010; 3 (01) 77-80
• 19 Cameron A. Endoscopic thoracic sympathectomy. Eur J Vasc Endovasc Surg 2002; 23 (06) 570
• 20 Moraites E, Vaughn OA, Hill S. Endoscopic thoracic sympathectomy. Dermatol Clin 2014; 32 (04) 541-548
• 21 Johnson JP, Obasi C, Hahn MS, Glatleider P. Endoscopic thoracic sympathectomy. J Neurosurg 1999; 91 (1, Suppl) 90-97
• 22 Coveliers H, Hoexum F, Rauwerda JA, Wisselink W. Endoscopic thoracic sympathectomy for upper limb ischemia. A 16 year follow-up in a single center. Surgeon 2016; 14 (05) 265-269
• 23 Lee KS, Chuang CL, Lin CL, Tsai LC, Hwang SL, Howng SL. Percutaneous CT-guided chemical thoracic sympathectomy for patients with palmar hyperhidrosis after transthoracic endoscopic sympathectomy. Surg Neurol 2004; 62 (06) 501-505 , discussion 505

Publication History

Received: 25 April 2023

Accepted: 06 September 2024

Article published online:
23 December 2024