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Maciejewska M, Sikora M, Maciejewski C, Alda-Malicka R, Czuwara J, Rudnicka L. Raynaud's Phenomenon with Focus on Systemic Sclerosis. J Clin Med 2022; 11:jcm11092490. [PMID: 35566614 PMCID: PMC9105786 DOI: 10.3390/jcm11092490] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 02/01/2023] Open
Abstract
Raynaud’s phenomenon is a painful vascular condition in which abnormal vasoconstriction of the digital arteries causes blanching of the skin. The treatment approach can vary depending on the underlying cause of disease. Raynaud’s phenomenon can present as a primary symptom, in which there is no evidence of underlying disease, or secondary to a range of medical conditions or therapies. Systemic sclerosis is one of the most frequent causes of secondary Raynaud’s phenomenon; its appearance may occur long before other signs and symptoms. Timely, accurate identification of secondary Raynaud’s phenomenon may accelerate a final diagnosis and positively alter prognosis. Capillaroscopy is fundamental in the diagnosis and differentiation of primary and secondary Raynaud’s phenomenon. It is helpful in the very early stages of systemic sclerosis, along with its role in disease monitoring. An extensive range of pharmacotherapies with various routes of administration are available for Raynaud’s phenomenon but a standardized therapeutic plan is still lacking. This review provides insight into recent advances in the understanding of Raynaud’s phenomenon pathophysiology, diagnostic methods, and treatment approaches.
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Affiliation(s)
- Magdalena Maciejewska
- Department of Dermatology, Medical University of Warsaw, Koszykowa 82A, 02-008 Warsaw, Poland; (M.M.); (R.A.-M.); (J.C.); (L.R.)
| | - Mariusz Sikora
- National Institute of Geriatrics, Rheumatology and Rehabilitation, Spartańska 1, 02-637 Warsaw, Poland
- Correspondence:
| | - Cezary Maciejewski
- 1st Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Rosanna Alda-Malicka
- Department of Dermatology, Medical University of Warsaw, Koszykowa 82A, 02-008 Warsaw, Poland; (M.M.); (R.A.-M.); (J.C.); (L.R.)
| | - Joanna Czuwara
- Department of Dermatology, Medical University of Warsaw, Koszykowa 82A, 02-008 Warsaw, Poland; (M.M.); (R.A.-M.); (J.C.); (L.R.)
| | - Lidia Rudnicka
- Department of Dermatology, Medical University of Warsaw, Koszykowa 82A, 02-008 Warsaw, Poland; (M.M.); (R.A.-M.); (J.C.); (L.R.)
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Ahn HC, Oh SW, Yoon JS, Park SO. Long-term results of ulnar and radial reconstruction with interpositional grafting using the deep inferior epigastric artery for chronic hand ischemia. Sci Rep 2021; 11:23185. [PMID: 34848789 PMCID: PMC8633384 DOI: 10.1038/s41598-021-02530-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/16/2021] [Indexed: 11/09/2022] Open
Abstract
Chronic hand ischemia causes cold intolerance, intractable pain, and digital ulceration. If ischemic symptoms persist despite pharmacologic treatments, surgical interventions should be considered. This retrospective study evaluated the long-term results after ulnar and radial reconstruction using an interpositional deep inferior epigastric artery (DIEA) graft combined with periarterial sympathectomy. Patients who underwent this surgery from March 2003 to February 2019 were included. To evaluate variables influencing recurrence after the procedure, patients were divided into the recurred and non-recurred groups and their data were compared. Overall, 62 cases involving 47 patients were analyzed (16 and 46 cases in the recurred and non-recurred groups, respectively). The median DIEA graft length was 8.5 cm. The rates of rheumatic disease and female patients were significantly higher in the recurred than in the non-recurred group, without significant between-group differences in postoperative complication rates. In the multivariate analysis, underlying rheumatic disease and graft length had significant effects on recurrence. In Kaplan-Meier analysis, the 5- and 10-year symptom-free rates were 81.3% and 68.0%, respectively, with lower rates for cases with rheumatic disease. Thus, arterial reconstruction using an interpositional DIEA graft provides long-term sustainable vascular supply in patients with chronic hand ischemia, especially in those without rheumatic disease.
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Affiliation(s)
- Hee Chang Ahn
- Department of Plastic and Reconstructive Surgery, CHA University Bundang Medical Center, Seongnam-si, Gyeonggi-do, Korea
| | - Se Won Oh
- Department of Plastic and Reconstructive Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Jung Soo Yoon
- Department of Plastic and Reconstructive Surgery, Dongguk University Medical Center, Goyang-si, Gyeonggi-do, Korea
| | - Seong Oh Park
- Department of Plastic and Reconstructive Surgery, Hanyang University College of Medicine, Seoul, Korea.
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Vegas DH, Fabiani MA, Gonzalez-Urquijo M, Bignotti A, Seré I, Salvadores P. Novel Combined Approach for Digital Necrosis Secondary to Raynaud's Phenomenon. Vasc Endovascular Surg 2021; 55:766-771. [PMID: 33866879 DOI: 10.1177/15385744211005663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The presence of severe Raynaud's Phenomenon (RP), with permanent pain or digital necrosis is a rare condition. Cervical sympathectomy or distal sympathectomy or A botulinum toxin have demonstrated efficacy after medical treatment failure. We report the case of a 38-year-old female patient with an acute onset of severe RP in both hands secondary to systemic sclerosis. Medical treatment failed, so a novel approach by a combination of a modified distal sympathectomy and injection of A botulinum toxin on digital neuromuscular bundles was performed. Remission of the pain occurred immediately after the procedure and 45 days later she had complete healing of the digital wounds and recovered full mobilization of both hands. The patient remained asymptomatic 6 month after the procedure, and a Doppler ultrasound showed tri-phasic flows distal to the surgical site. This novel technique is described, and a brief review of the literature is performed.
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Affiliation(s)
- Diego Herrera Vegas
- Centro de Estudios Médicos e Investigaciones Clínicas (C.E.M.I.C.), Buenos Aires, Argentina
| | - Mario Alejandro Fabiani
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Monterrey, Nuevo León, México
| | | | - Agustín Bignotti
- Centro de Estudios Médicos e Investigaciones Clínicas (C.E.M.I.C.), Buenos Aires, Argentina
| | - Ignacio Seré
- Centro de Estudios Médicos e Investigaciones Clínicas (C.E.M.I.C.), Buenos Aires, Argentina
| | - Pablo Salvadores
- Centro de Estudios Médicos e Investigaciones Clínicas (C.E.M.I.C.), Buenos Aires, Argentina
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Abstract
Raynaud's phenomenon, which is characterized by episodic digital pallor, cyanosis and rubor upon exposure to cold environment or to stress, is relatively common, although the prevalence depends on the climate. Still, it is under-diagnosed, under-treated, and often confused with other conditions. Primary Raynaud's phenomenon (i.e., Raynaud disease) must be distinguished from secondary Raynaud's phenomenon (i.e., Raynaud syndrome) as long-term morbidity and outcomes differ vastly between the two conditions. Additionally, the practitioner must differentiate between Raynaud's phenomenon and related vascular disorders, such as acrocyanosis, pernio, and livedo reticularis. In this article, we review differences between the conditions and suggest an approach to diagnosis and treatment strategy for these disorders.
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Affiliation(s)
- Eunjung Choi
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Stanislav Henkin
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Aljehani Y, Alhouri A, Turkistani A, ShahBahai R, AlQatari AA. Bilateral uniportal video-assisted thoracoscopic sympathectomy for managing secondary Raynaud's in CREST syndrome: A case report. Int J Surg Case Rep 2020; 75:203-206. [PMID: 32961460 PMCID: PMC7505751 DOI: 10.1016/j.ijscr.2020.08.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/25/2020] [Accepted: 08/25/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Secondary Raynaud's is a manifestation that can present in CREST syndrome as a variant of five different diseases: Calcinosis, Raynaud's phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasia. Secondary Raynaud's presents as a result of an imbalance between vasoconstriction and vasodilation potentially leading to tissue ischemia. The mainstay treatment is medical while surgery treatment preserved as a last resort. PRESENTATION OF CASE A 28-year-old female presented with secondary Raynaud's and was subsequently diagnosed with CREST syndrome. The patient failed to respond to medical treatment, and gangrene of the right fourth distal phalanx developed. Stellate ganglion block was successfully used as a bridge to surgery. Uniportal video-assisted thoracoscopic surgery (VATS) sympathectomy was performed via a 2-cm incision, the sympathetic ganglia were identified and transected by cauterization at the level of the 3rd, 4th, and 5th intercostal spaces extending for a distance of 5 cm to ensure that the nerve of Kuntz was transected. The postoperative outcome was satisfactory, and the condition of the patient improved in a few months. DISCUSSION Different management modalities have been used to relieve the symptoms of secondary Raynaud's. The treatment ranges from lifestyle modification, medical treatment, and lastly surgical intervention. Sympathectomy has been suggested for the management of refractive secondary Raynaud's owing to its considerable clinical response. CONCLUSION The use of uniportal VATS sympathectomy results in favorable cosmetic and clinical outcomes including reduced length of hospital stay and postoperative pain.
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Affiliation(s)
- Yasser Aljehani
- Division of Thoracic Surgery, Department of General Surgery, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
| | - Atteia Alhouri
- Division of Rheumatology, Department of Internal Medicine, Qatif Central Hospital, AlQatif, Saudi Arabia
| | - Alaa Turkistani
- Division of Thoracic Surgery, Department of General Surgery, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Rahma ShahBahai
- Department of General Surgery, Airbase Hospital, Dhahran, Saudi Arabia
| | - Abdullah A AlQatari
- Division of Thoracic Surgery, Department of General Surgery, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Abstract
Purpose of review Multiple classes of medications have been studied for the treatment of Raynaud's phenomenon (RP) with or without digital ischemia. The goal of this review is to discuss the outcomes of recent studies and to report on our approach to the management of RP in light of the available evidence. Recent findings Comparing treatments for RP remains a challenge as efficacy endpoint vary widely among trials. While calcium channel blockers are used first-line in the pharmacologic management of RP, phosphodiesterase 5 inhibitors have also been shown to be beneficial in reducing symptoms. In the setting of digital ischemia, administration of intravenous prostanoids is the standard of care. Bosentan has shown benefit in the prevention of future ulcers in patients with scleroderma. Botulinum toxin therapy was ineffective in a clinical trial involving scleroderma patients; more controlled studies are needed in other subsets of patients. Digital sympathectomy may be beneficial in cases of critical digital ischemia, though recurrence of symptoms is common. Summary Comparative effectiveness studies are needed to determine which therapeutic interventions are most beneficial in patients with RP. Based on the available evidence, we start with CCBs and add a phosphodiesterase inhibitor if symptoms are not controlled, or intravenous prostacyclin in the setting of severe critical digital ischemia. We may additionally add an endothelial receptor antagonist in cases of recurrent digital ulcers. A surgical sympathectomy may be used in refractory cases of digital ischemia. A digital block may also be a less invasive, but temporary, intervention allowing for titration of medical therapy.
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Affiliation(s)
- Alicia M Hinze
- Division of Rheumatology, Johns Hopkins University, 5200 Eastern Avenue, MFL Building, Center Tower Ste. 4100, Baltimore, MD, 21224
| | - Fredrick M Wigley
- Division of Rheumatology, Johns Hopkins University, 5200 Eastern Avenue, MFL Building, Center Tower Ste. 4100, Baltimore, MD, 21224
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Abstract
Raynaud's phenomenon (RP) is a transient, acral, vasospastic phenomenon that manifests with characteristic color changes. This vasospasm, classically triggered by cold temperatures, may also be driven by shifts in temperature, climate, or emotional state. Primary RP (PRP) is a common condition without severe sequelae. Secondary RP (SRP), which may be driven by vascular, autoimmune, hematologic, or endocrine etiologies, can result in digital ulceration, irreversible ischemia and necrosis, and secondary infection. This review delineates the clinical manifestations of both primary and secondary RP, as well as the current understanding of RP epidemiology and pathogenesis. Proper examination, including nailfold capillary microscopy, and laboratory workup for secondary causes of RP are also discussed. The traditional armamentarium of therapies used for RP, as well as newer medical and surgical options, is also summarized with particular regard to the clinical evidence for their efficacy.
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Affiliation(s)
- Thomas Stringer
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York, USA
| | - Alisa N Femia
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York, USA.
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Zheng Z, Wan Y, Liu Y, Zhu L, Tang J, Huang W, Cheng B. Lumbar sympathectomy regulates vascular cell turnover in rat hindfoot plantar skin. Clin Hemorheol Microcirc 2018; 67:149-157. [PMID: 28759961 DOI: 10.3233/ch-170257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Sympathetic denervation and impaired angiogenesis cause skin diseases. However, the relationship between the sympathetic nervous system and vascular cell turnover in normal skin remains unclear. OBJECTIVE To determine the effects of sympathetic denervation on vascular cell turnover in normal skin. METHODS Rats underwent bilateral L2-4 sympathetic trunk resection (sympathectomy group) or sham operation (control). Hindfoot plantar skin was analyzed 2 weeks and 3 months postoperatively. RESULTS Mural cell marker (α-smooth muscle actin; p < 0.001, and desmin; p = 0.047) expression decreased 2 weeks after sympathectomy, but recovered 3 months after sympathectomy (p > 0.05). CD31 levels were lower in the experimental group than in the control group at 2 weeks (p = 0.009), but not at 3 months. Von Willebrand factor, vascular endothelial growth factor, and angiopoietin-2 expression were not significantly different between the groups (p > 0.05). Angiopoietin-1 expression levels were higher in the experimental group than in the control group at 2 weeks (p = 0.035), but not at 3 months. CONCLUSIONS Lumbar sympathectomy regulates vascular cell turnover in rat hindfoot plantar skin by inhibiting mural cell proliferation and increasing angiopoietin-1 expression. Sympathetic nerves therefore play an important role in plantar skin vascular cell turnover.
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Affiliation(s)
- Zhifang Zheng
- Southern Medical University, Guangzhou, China.,Department of Plastic Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China.,Department of Anatomy, School of Basic Medicine Sciences, Southern Medical University, Guangzhou, China
| | - Yu Wan
- Southern Medical University, Guangzhou, China.,Department of Plastic Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China
| | - Yishu Liu
- Department of Plastic Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China.,The Graduate School of Third Military Medical University, Chongqing, China
| | - Lulu Zhu
- Department of Plastic Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China
| | - Jianbing Tang
- Department of Plastic Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China
| | - Wenhua Huang
- Southern Medical University, Guangzhou, China.,Department of Anatomy, School of Basic Medicine Sciences, Southern Medical University, Guangzhou, China
| | - Biao Cheng
- Southern Medical University, Guangzhou, China.,Department of Plastic Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China.,The Graduate School of Third Military Medical University, Chongqing, China.,Center of Wound Treatment, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China.,The Key Laboratory of Trauma Treatment & Tissue Repair of Tropical Area, PLA, Guangzhou, China
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Abstract
INTRODUCTION Raynaud's disease is a disorder that is characterized by attacks of pain, cyanosis, redness, and numbness in the upper extremities caused by vasospasm of digital arteries due to cold or emotional stress. We aimed at demonstrating our experiences with endoscopic thoracic sympathectomy (ETS) in the treatment of Raynaud's disease. METHODS From 48 patients who underwent ETS for various reasons at our department between January 2014 and January 2015, we reviewed 9 patients with Raynaud's disease (18.7%) with respect to their demographic characteristics such as gender and age, postoperative complications, short-term results, side effects, recurrence of symptoms, and long-terms results. RESULTS The symptoms and findings reappeared and the number and dosage of the drugs used returned to their preoperative levels in 66.6% of the patients at month 6, and in all patients except 1 at the end of the 1st year. CONCLUSION ETS should be considered an ultimate choice for patients with Raynaud's disease who have treatment-resistant severe symptoms and serious complications, disturbed social and daily lives, and impaired quality of life, and all patients should be properly informed before the surgery about the possibility of a high rate of recurrence.
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Affiliation(s)
- Sami Karapolat
- Department of Thoracic Surgery, Karadeniz Technical University Medical School , Trabzon, Turkey
| | - Atila Turkyilmaz
- Department of Thoracic Surgery, Karadeniz Technical University Medical School , Trabzon, Turkey
| | - Celal Tekinbas
- Department of Thoracic Surgery, Karadeniz Technical University Medical School , Trabzon, Turkey
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Wilson A, Ronnekleiv-Kelly SM, Pawlik TM. Regret in Surgical Decision Making: A Systematic Review of Patient and Physician Perspectives. World J Surg 2017; 41:1454-65. [PMID: 28243695 DOI: 10.1007/s00268-017-3895-9] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Regret is a powerful motivating factor in medical decision making among patients and surgeons. Regret can be particularly important for surgical decisions, which often carry significant risk and may have uncertain outcomes. We performed a systematic review of the literature focused on patient and physician regret in the surgical setting. METHODS A search of the English literature between 1986 and 2016 that examined patient and physician self-reported decisional regret was carried out using the MEDLINE/PubMed and Web of Science databases. Clinical studies performed in patients and physicians participating in elective surgical treatment were included. RESULTS Of 889 studies identified, 73 patient studies and 6 physician studies met inclusion criteria. Among the 73 patient studies, 57.5% examined patients with a cancer diagnosis, with breast (26.0%) and prostate (28.8%) cancers being most common. Interestingly, self-reported patient regret was relatively uncommon with an average prevalence across studies of 14.4%. Factors most often associated with regret included type of surgery, disease-specific quality of life, and shared decision making. Only 6 studies were identified that focused on physician regret; 2 pertained to surgical decision making. These studies primarily measured regret of omission and commission using hypothetical case scenarios and used the results to develop decision curve analysis tools. CONCLUSION Self-reported decisional regret was present in about 1 in 7 surgical patients. Factors associated with regret were both patient- and procedure related. While most studies focused on patient regret, little data exist on how physician regret affects shared decision making.
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Zheng ZF, Liu YS, Min X, Tang JB, Liu HW, Cheng B. Recovery of sympathetic nerve function after lumbar sympathectomy is slower in the hind limbs than in the torso. Neural Regen Res 2017; 12:1177-1185. [PMID: 28852403 PMCID: PMC5558500 DOI: 10.4103/1673-5374.211200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Local sympathetic denervation by surgical sympathectomy is used in the treatment of lower limb ulcers and ischemia, but the restoration of cutaneous sympathetic nerve functions is less clear. This study aims to explore the recovery of cutaneous sympathetic functions after bilateral L2–4 sympathectomy. The skin temperature of the left feet, using a point monitoring thermometer, increased intraoperatively after sympathectomy. The cytoplasm of sympathetic neurons contained tyrosine hydroxylase and dopamine β-hydroxylase, visualized by immunofluorescence, indicated the accuracy of sympathectomy. Iodine starch test results suggested that the sweating function of the hind feet plantar skin decreased 2 and 7 weeks after lumbar sympathectomy but had recovered by 3 months. Immunofluorescence and western blot assay results revealed that norepinephrine and dopamine β-hydroxylase expression in the skin from the sacrococcygeal region and hind feet decreased in the sympathectomized group at 2 weeks. Transmission electron microscopy results showed that perinuclear space and axon demyelination in sympathetic cells in the L5 sympathetic trunks were found in the sympathectomized group 3 months after sympathectomy. Although sympathetic denervation occurred in the sacrococcygeal region and hind feet skin 2 weeks after lumbar sympathectomy, the skin functions recovered gradually over 7 weeks to 3 months. In conclusion, sympathetic functional recovery may account for the recurrence of hyperhidrosis after sympathectomy and the normalization of sympathetic nerve trunks after incomplete injury. The recovery of sympathetic nerve function was slower in the limbs than in the torso after bilateral L2–4 sympathectomy.
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Affiliation(s)
- Zhi-Fang Zheng
- The Graduate School of Southern Medical University, Guangzhou, Guangdong Province, China.,Department of Plastic Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, China
| | - Yi-Shu Liu
- Department of Plastic Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, China.,The Graduate School of Third Military Medical University, Chongqing, China
| | - Xuan Min
- Department of Plastic Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, China
| | - Jian-Bing Tang
- Department of Plastic Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, China
| | - Hong-Wei Liu
- Department of Plastic Surgery, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
| | - Biao Cheng
- The Graduate School of Southern Medical University, Guangzhou, Guangdong Province, China.,Department of Plastic Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, China.,The Graduate School of Third Military Medical University, Chongqing, China.,Center of Wound Treatment, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, China.,The Key Laboratory of Trauma Treatment & Tissue Repair of Tropical Area of Chinese PLA, Guangzhou, Guangdong Province, China
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12
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Burbelko M, Wagner HJ, Gutberlet M, Grothoff M. [Image-guided pain therapy. Sympathicolysis]. Radiologe 2015; 55:462-9. [PMID: 26063075 DOI: 10.1007/s00117-014-2802-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND In the autonomic nerve system most sympathetic neurons synapse peripherally in the ganglia of the sympathetic trunk. A reduction in sympathicotonia by partial elimination of these ganglia is a therapeutic approach that has been used for more than 100 years. In the early 1920s the first attempts at percutaneous sympathicolysis (SL) were carried out. Nowadays, minimally invasive image-guided SL has become an integral part of interventional radiology. Established indications for SL are hyperhidrosis, critical limb ischemia and the complex regional pain syndrome. METHODS The standard imaging guidance modality in SL is computed tomography (CT) which allows the exact placement of the puncture needle in the target area under visualization of the surrounding structures. Ethanol is normally used for chemical lysis, which predominantly eliminates the unmyelinated autonomic axons. In order to visualize the distribution of the ethanol during application, iodine-containing contrast medium is added. RESULTS The sympathetic nervous system (SNS) controls sweat secretion via the efferent neurons; therefore, effective therapy of idiopathic palmar, axillary and plantar hyperhidrosis can be achieved when SL is performed at the corresponding level of the sympathetic trunk. Furthermore, due to the vasomotor innervation of most blood vessels, by reduction of the sympathicotonus an atony of the smooth muscles and therefore vasodilatation occurs, which is used as a palliative therapeutic option in patients with critical limb ischemia. By elimination of the afferent sensory fibers this also results in pain relief. This principle is also used in the SL therapy of the complex regional pain syndrome. CONCLUSION After the introduction of CT guidance, major complications have become rare events. In addition to the usual risks of percutaneous interventions there are, however, a number of specific complications, such as syncope caused by irritation of cardiac sympathetic nerves in thoracic SL and ureteral injury in lumbar SL.
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Affiliation(s)
- M Burbelko
- Institut für Radiologie und Interventionelle Therapie, Vivantes Klinikum im Friedrichshain, Landsberger Allee 49, 10249, Berlin, Deutschland,
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Gabrhelik T, Stehlik D, Adamus M, Zalesak B, Michalek P. Radiofrequency upper thoracic sympathectomy in the treatment of critical upper limb ischemia--a case series. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2011; 157:202-8. [PMID: 22660208 DOI: 10.5507/bp.2011.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2011] [Accepted: 10/19/2011] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Patients with significant medical and social problems resulting from impaired perfusion of the upper limbs caused by micro- or macro-angiopathy are now frequent in clinical practice. Vasospastic disease of the upper limbs of combined origin is a difficult condition to treat by conservative methods and therapeutic strategies are usually multidisciplinary. In addition to standard pharmacotherapy, treatment may involve regional anaesthesia, thoracoscopic or radiofrequency sympathectomy and surgical treatment of defects, including plastic surgery. METHODS This paper describes our successful work in the treatment of upper limb critical ischemia using radiofrequency upper thoracic sympathectomy. RESULTS In three case reports we present the results of radiofrequency thermolysis applied to treat patients with chronic defects of the hand and fingers. These patients were diagnosed with upper limb critical ischemia of combined origin, standard conservative treatment methods failed and surgical intervention was originally not indicated, however, radiofrequency thermolysis proved to be beneficial. CONCLUSIONS Radiofrequency thoracic sympathectomy could improve peripheral perfusion of the upper limbs and thereby contribute to healing of chronic defects, reduction of pain and improvement in the quality of life of the patients.
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Affiliation(s)
- Tomas Gabrhelik
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic.
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Coveliers HM, Hoexum F, Nederhoed JH, Wisselink W, Rauwerda JA. Thoracic sympathectomy for digital ischemia: A summary of evidence. J Vasc Surg 2011; 54:273-7. [DOI: 10.1016/j.jvs.2011.01.069] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Revised: 01/19/2011] [Accepted: 01/25/2011] [Indexed: 10/18/2022]
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Devulder J, van Suijlekom H, van Dongen R, Diwan S, Mekhail N, van Kleef M, Huygen F. 25. Ischemic Pain in the Extremities and Raynaud’s Phenomenon. Pain Pract 2011; 11:483-91. [DOI: 10.1111/j.1533-2500.2011.00460.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Lee R, Lomas O, Handa A. Severe Raynaud's phenomenon-A streamlined approach to acute management. Int J Surg Case Rep 2011; 2:61-3. [PMID: 26902555 DOI: 10.1016/j.ijscr.2011.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Revised: 01/31/2011] [Accepted: 02/03/2011] [Indexed: 10/18/2022] Open
Abstract
Raynaud's phenomenon is an exaggerated vasospastic response to cold or emotional stress which not only may cause the patient severe pain but also critical ischaemia and necrosis of the digits. We report the case of a 69-year-old woman who presented with rest pain, impending ulceration and necrosis of finger tips due to an episode of left-sided Raynaud's phenomenon. Intravenous prostacyclin was administered successfully as a bridge to endoscopic thoracic sympathectomy. Vascular surgery units are ideally positioned for the acute management of severe Raynaud's phenomenon to provide continuity of care to patients with profound digital ischaemia and impending tissue loss.
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Affiliation(s)
- Regent Lee
- Department of Vascular Surgery, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, United Kingdom.
| | - Oliver Lomas
- Department of Vascular Surgery, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, United Kingdom
| | - Ashok Handa
- Department of Vascular Surgery, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, United Kingdom
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Wasserman A, Brahn E. Systemic sclerosis: bilateral improvement of Raynaud's phenomenon with unilateral digital sympathectomy. Semin Arthritis Rheum 2009; 40:137-46. [PMID: 19878974 DOI: 10.1016/j.semarthrit.2009.08.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2009] [Revised: 08/10/2009] [Accepted: 08/24/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To demonstrate that unilateral digital sympathectomy, in patients with Raynaud's phenomenon (RP) and systemic sclerosis (SSc), may result in bilateral resolution of RP and digital ulcerations. METHODS We report a case of SSc and RP that had bilateral benefits from unilateral digital sympathectomy. A computer-assisted Medline/PubMed search of the medical literature was performed for 1960 through June 2009 using the keywords sympathectomy, Raynaud's phenomenon, systemic sclerosis, CREST, and digital ulcers. These searches were also combined with text words unilateral, ipsilateral, bilateral, digital sympathectomy, selective sympathectomy, autonomic nervous system, hyperhidrosis, etiology, pathogenesis, hypothesis, and treatment. Only pertinent literature, primarily in the English language, was included. RESULTS The majority of patients with SSc have RP and many suffer from digital ulcerations. Medical and behavioral management may have limited benefit and surgical intervention can be considered in recalcitrant cases, although efficacy data are sparse. We describe a man with limited SSc who underwent unilateral digital sympathectomy but manifested bilateral benefit. To our knowledge, this is the first published report of contralateral response with this procedure. The patient ultimately demonstrated these digital benefits when stressed with extreme cold and hypoxia while mountaineering. Despite the onset of high-altitude sickness and cerebral edema, his fingers remained unaffected while other mountaineers sustained severe frostbite or died of hypothermia. CONCLUSIONS Selective unilateral sympathectomy in SSc, for RP with digital ulcerations, can result in bilateral benefits despite intense challenge with cold and hypoxia.
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Affiliation(s)
- Amy Wasserman
- Division of Rheumatology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA 90095-1670, USA
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Gabrhelik T, Michalek P, Adamus M, Berta E. Percutaneous Upper Thoracic Radiofrequency Sympathectomy in Raynaud Phenomenon: A Comparison of T2/T3 Procedure Versus T2 Lesion With Phenol Application. Reg Anesth Pain Med 2009; 34:425-9. [DOI: 10.1097/aap.0b013e3181b48f9a] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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