Ultrasound-guided digital sympathectomy using botulinum toxin

Ultrasound-guided Sympathetic Block of the Radial Artery with Botulinum Toxin to Treat Vasospasm

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Vasospastic disorders in the hand have been treated with surgical sympathectomy and recently with botulinum toxin A (BTX) injections in the palm. The purpose of this study was to evaluate if it is possible to obtain precise administration of BTX around the radial artery using a single ultrasound-guided injection. We present a novel technique using 1 single ultrasound-guided BTX injection around the radial artery to treat vasospastic symptoms. Ten patients were included in a pilot study. All patients were referred by a rheumatologist after been diagnosed with primary or secondary Raynaud. Under ultrasound guidance, BTX was injected around the radial artery and its comitant veins 3–5 cm proximal to the wrist. Ultrasound-guided injection of BTX allowed for a precise distribution of BTX into the perivascular space of the radial artery and its comitant veins. Intravascular injection could easily be excluded. One patient reported temporary reduced grip strength, most likely due to leakage of BTX to the flexor pollicis longus muscle. No other complications were registered. All patients reported reduced number of vasospastic episodes, warmer hands, and reduced pain. Ultrasound-guided injection enables precise administration of BTX in the space surrounding the radial artery and its comitant veins. This novel approach could be a promising treatment for vasospastic disorders of the hands in patients with primary and secondary Raynaud.

The Role of Botulinum Toxin A in the Treatment of Raynaud Phenomenon

Raynaud phenomenon (RP) is a transient digital ischemia that occurs after exposure to cold temperature or emotional distress. It presents with a triphasic course: the initial white phase is followed by cyanotic discoloration and, subsequently, erythema. The attacks may be associated with pain, paresthesia, and complicate with nonhealing ulceration often leading to amputation. To date, there are no clear-cut therapeutic guidelines and many medications are used off-label. Encouraging results were reported with the use of botulinum neurotoxin-A (BoNT-A). However, there is still ongoing debate regarding indications, contraindications, best injection technique, and mechanism of action. The aim of this study was to address these issues by providing an up-to-date and detailed overview of the use of BoNT-A in RP.A PubMed database search was conducted. The available studies and techniques were evaluated and compared.The search yielded a total of 29 studies. Ten papers, published between 2004 and 2014, were considered relevant. A total of 128 patients underwent BoNT-A injections. Seventy-five percent to 100 % of the patients reported pain reduction after treatment. Healing of ulcers was reported in 75% to 100% of the affected patients. The most common complication was temporary hand weakness, with an average incidence of 14.1%. Injections targeting the neurovascular bundle at or slightly proximal to the A1 pulley were the most commonly performed.Botulinum neurotoxin-A injection proved to be a valid approach in both primary and secondary RP. The available evidence shows the achievement of both symptomatic and functional improvements in this debilitating condition. However, the patient should be adequately informed about the risk of transient hand weakness.

Therapeutic implications from the pathogenesis of Raynaud's phenomenon

INTRODUCTION

Raynaud's phenomenon (RP) can be either primary (idiopathic) or secondary to a number of different diseases/conditions, when vasopasm can be superimposed upon structural vascular abnormality or a hyperviscosity state and may then lead to severe ischaemia with tissue damage. Treatment must be tailored to the individual. Areas covered: This review discusses how increased understanding of the pathogenesis of RP has driven and is driving new approaches to therapy, and how we are now better able to predict which patients presenting with RP are likely to have an underlying disease requiring specific intervention. Medline searches (1946 to August 2016) were conducted for 'Raynaud's' in combination with relevant terms including different drugs. All papers identified were English language, with abstracts. Expert commentary: Randomised controlled trials of RP present particular challenges. The major aim must continue to be development of safe, effective treatments for patients across the spectrum of RP.