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The use of digital artery sympathectomy as a salvage procedure for severe ischemia of Raynaud's disease and phenomenon
The Use of Digital Artery Sympathectomy as a Salvage Procedure for Severe Ischemia of Raynaud’s Disease and Phenomenon Tracy E. McCall, MD, Springfield, IL, David P. Petersen, MD, Leslie B. Wong, MD, Grand Rapids, MI
We retrospectively reviewed the effectiveness of digital artery sympathectomy as a last resort to prevent amputation in severe cases of Raynaud’s disease and phenomenon. Seven patients underwent digital artery sympathectomy as a salvage procedure to prevent amputation. The patients developed cold intolerance secondary to atherosclerosis or collagen vascular disease. The results were analyzed using the criteria of ulcer healing and the prevention of amputation. In 6 of the 7 patients, the digital ulcers healed and amputation was avoided. (J Hand Surg 1999;24A:173–177. Copyright © 1999 by the American Society for Surgery of the Hand.)
Chronic ischemic disease in the upper extremity results in cool pale fingers, cold intolerance, ulcerations, and gangrenous changes. It is a difficult problem that is currently treated by conservative therapy, such as smoking cessation, cold avoidance, biofeedback techniques, and nifedipine therapy.1–3 Not uncommonly, the disease necessitates amputation. According to Poiseuille’s law, blood flow is directly proportional to the fourth power of the vessel’s radius. Thus, a small change in the vessel’s radius will cause a very large change in the blood flow. Eliminating the sympathetic innervation and subsequent
From the Division of Plastic Surgery, Southern Illinois University School of Medicine, Springfield, IL; and the Department of Surgery, Michigan State University, Grand Rapids, MI. Received for publication September 30, 1997; accepted in revised form June 26, 1998. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Address correspondence to: Tracy E. McCall, MD, 135 Ocean Parkway #11C, Brooklyn, NY 11218. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A01-0025$3.00/0
vessel dilatation must be considered as a point of intervention in digital ischemia. Conventional cervical sympathectomy is often unsuccessful because this preganglionic sectioning does not remove all the sympathetic stimulation to the hand.4,5 Additional sympathetic fibers innervate the hand through the sinuvertebral nerve, the carotid plexus, and the nerve of Kuntz.6 The sympathetic fibers are located in the epineurium of the peripheral nerves and pass to the vessel adventitia through multiple small branches as the nerves and vessels travel distally into the arm.7 To overcome this problem, distal sympathectomy was introduced with some success.4 The technique for digital artery sympathectomy involves stripping the adventitia from the digital arteries for a distance of a few millimeters to several centimeters.4,8 –10 The results for digital artery sympathectomy in the treatment of Raynaud’s phenomenon have been much more successful than those for cervical sympathectomy.4 Sympathectomy is performed for 3 basic causes of chronic digital ischemia: atherosclerotic disease, collagen vascular disease, and posttraumatic cold sensitivity. This is a moderately large series that assesses digital The Journal of Hand Surgery 173
174 McCall, Petersen, and Wong / Digital Artery Sympathectomy
artery sympathectomy as a salvage procedure for the treatment of severe chronic ischemia in terms of digital ulcer healing and the prevention of amputation.
Materials and Methods A retrospective analysis of all digital artery sympathectomies performed in a hand surgery practice in Western Michigan was performed. Data were collected by chart review. Seven patients representing 23 fingers underwent digital artery sympathectomies for severe intractable Raynaud’s phenomenon during a 12-year period. All patients had nonhealing ulcers failing conservative therapy with impending gangrene on at least 1 finger before surgery. The patients showed worsening ischemia and progressive ulcer formation while receiving conservative therapy. Digital artery sympathectomy was only considered as a last resort before digital amputation. Conservative therapy included calcium channel blockers, smoking cessation, cold avoidance, and the recommendation to spend at least 2 to 3 weeks of the winter in a warmer climate. Preoperative sympathetic block and cold stress testing, as recommended by Wilgis,10 were not used in this study. Digital artery sympathectomy, as described by Flatt4 or Wilgis,3,9 is a relatively easy procedure to perform. The common digital arteries are approached through a palmar incision. With the aid of loupe magnification, the adventitia is stripped circumferentially for a distance of 1 to 2 cm. The wound is then closed with interrupted nylon sutures. Healing of digital tip ulcers was graded objectively by physician observation during regularly scheduled postoperative evaluations. Time to ulcer healing represents the time between the operation and the first postoperative visit recording the ulcer as completely healed. The records were also reviewed for subsequent amputations of the involved digits and recurrence of ulcerations.
The etiology of the digital ischemia was Raynaud’s phenomenon secondary to scleroderma in 4 patients (16 fingers), atherosclerosis in 2 patients (3 fingers), and an undiagnosed cause (Raynaud’s disease) in 1 patient (4 fingers) (Table 1). One of the scleroderma patients had undergone previous successful sympathectomy and repeat sympathectomy at another location; this patient’s procedure was a repeat sympathectomy (1 finger). Two patients were smokers at the time of initial consult, 2 were nonsmokers, and 1 was an ex-smoker; the smoking history of 2 patients was not available. Smoking cessation was required before surgical therapy was considered. The follow-up period averaged 2 years (range, 1 month to 6 years 4 months).
Results Six of the 7 patients, representing 22 of the 23 digits, healed sufficiently to prevent amputation (Table 2). All 23 digits presented with impending gangrene and ulcerations. Ulcerations healed after sympathectomy in 22 of the 23 digits. The average time to ulcer healing was 14 weeks (range, 4 weeks to 7 months). Two patients developed a recurrent ulceration after initial healing. These recurrent ulcerations followed traumatic events and healed with conservative treatment. One patient developed a recurrent ulceration 2 years after the digital artery sympathectomy and the ulcer healed with 3 weeks of local wound care. Another patient developed a very small ulcer after sustaining trauma to the finger. Due to the diminutive size of this ulcer, the patient was instructed to perform local wound care and follow-up on an as-needed basis. Another patient developed recurrent infections 4 years after the sympathectomy but healed with antibiotics and local wound care. One patient required amputation of the involved digit following sympathectomy of 1 finger for atherosclerosis; it eventually progressed to amputation
Table 1. Etiology of the Digital Ischemia Patient No. 1 2 3 4 5 6 7
Age (yr)*
Gender
Diagnosis
Other Diagnosis and Procedures
Smoker
67 58 43 42 38 42 71
M M F F F F F
Atherosclerosis Atherosclerosis Scleroderma Scleroderma Scleroderma Scleroderma Raynaud’s disease
CABG, excision BL thrombosed ulnar arteries PVD, diabetes, renal transplant
Ex (17 yr) No Yes No Yes Unknown Unknown
Hypertension
* Average age, 51.5 years. CABG, coronary artery bypass grafting; BL, bilateral; PVD, peripheral vascular disease.
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 175
Table 2. Results Following Digital Artery Sympathectomy Patient No.
Time to Healing
Follow-up
4 5 6
2 1 4 4 1 2 4
12 wk NA 16 wk 24 wk 12 wk 4 wk 5 wk
11 mo 7 mo 74 mo 76 mo 12 wk 4 wk 28 mo
7
1 4
9 wk 4 wk, 3 digits
16 mo 7 mo
Average
3
7 mo, 1 digit 14 wk*
34 mo*
1 2 3
No. of Digits
Results No ulcers 1 cold intolerance below 5°C Amputation No ulcers 1 cold intolerance; recurrent infections after 4 yr No ulcers 1 cold intolerance No ulcers, unknown cold intolerance Cold intolerance, ulcers healed, recurrent ulcer 2 yr after surgery healed with 3 wk of conservative measures Ulcers healed, 1 recurrent ulcer 8 mo after surgery, unknown cold intolerance
NA, not available. * Averages are per digit.
at the mid-middle phalanx level 7 months after the procedure. While the digit initially appeared to be healing, evidence of vascular insufficiency began to recur after 3 months.
Discussion Few options exist for the patient with nonhealing digital ulcers once conservative measures have failed. Fingertip amputation has been previously used; however, often several digits will become involved, and this treatment can lead to increasing cosmetic and functional impairment. The results of cervical sympathectomy have been generally disappointing.4 Flatt4 originally advocated digital artery sympathectomy for the treatment of Raynaud’s phenomenon and disease. His technique has been modified by Wiglis,3,9 who increased the length of adventitial stripping from 3 to 4 mm to 2 cm. Egloff et al11 stripped the adventitia from the common digital artery and the proximal part of the digital artery for 5 to 10 mm. El-Gammal and Blair12 modified Wiglis’ technique by also stripping the adventitia from the radial and ulnar arteries at the wrist. Jones13 proposed a much more extensive modification in 1991. In this extended digital artery sympathectomy, the adventitia is stripped from the superficial palmar arch; the radial digital artery to the index finger; the common digital artery and ulnar and radial digital arteries to the second, third, and fourth web spaces; and the ulnar digital artery to the little finger out to the level of the web spaces. Jones13 also recommends stripping the adventitia to the level of the proximal
interphalangeal joints in severely involved digits and performing microvascular reconstruction of the palmar arch when there is angiographic evidence of distal radial and ulnar artery involvement in a symptomatic patient. Koman et al14 have shown that distal sympathectomy, including adventitial stripping of the radial and ulnar arteries for a distance of 2 cm, combined with stripping of the common digital arteries for a distance of 1.5 cm is effective in treating digital ischemia in patients with combined vasospastic disease secondary to scleroderma and 2-level unreconstructable occlusive disease. Thrombosed digital arteries should be resected.15 In this study, adventitial stripping for a length of 1 to 2 cm was sufficient to achieve adequate circulation to heal the digital ulcers in 22 of 23 digits. However, in certain instances, a more proximal sympathectomy may be indicated. There is a high incidence of distal ulnar artery involvement in scleroderma (50%), and in this case adventitial stripping of the distal ulnar artery may be indicated.1,8,14 Arterial sympathectomy has been studied in the rabbit ear. The circulation of both the rabbit ear and the human digit are controlled mostly by the sympathetic nervous system, which can increase perfusion as the body core temperature rises. The microcirculation of both the rabbit ear and the human digit has 2 components: arteriovenous anastomoses for thermoregulatory control and capillaries for nutritional blood flow. In the rabbit ear, acute periarterial sympathectomy effectively reduced the sympathetic tone of the distal vasculature, increased cutaneous perfu-
176 McCall, Petersen, and Wong / Digital Artery Sympathectomy
sion and total flow, and increased auricular temperature.16 Long-term studies of sympathectomy in the rabbit ear also have shown no consistent reinnervation of the artery and a persistent elevation in temperature.17 Several others have shown an increase in digital temperature after digital artery sympathectomy.4,9,12,18 Koman et al14 found no significant difference in digital temperatures between patients and controls both before and after digital artery sympathectomy; however, a significant improvement in the response to cold stress testing was found after sympathectomy. These investigators showed that sympathectomy of the human digit in patients with scleroderma and unreconstructable occlusive disease could improve cutaneous perfusion sufficiently to heal ulcers and theorized that this indicated an increase in nutritional blood flow to the fingers rather than an increase in arteriovenous shunting. A poor response to preoperative cold stress testing with sympathetic blockade has been previously cited as a contraindication to digital artery sympathectomy.1,3,5,9,10,18 This is appropriate when excessive sympathetic activity is the sole cause of the digital ischemia. Recently, a dual cause of vessel constriction has been proposed.19 The narrowing of the vessel lumen is often a combination of sympathetic activity and external compression caused by a thickened adventitia or contraction of the tissues surrounding the arteries. A thickened adventitia is often seen with chronic vasculitis.10 Theoretically, this explains the common recurrence of digital ischemia found in patients with scleroderma; as the disease progresses, the tissues surrounding the vessels contract and create increasing external compression. Repeat sympathectomy was successful in 1 patient with scleroderma. It has been shown that sympathetic fibers in the adventitia do not regenerate extensively.17 This patient’s response is most likely due to a release of constricting scar tissue around the digital arteries.13 The patient had undergone several repeat sympathectomies, with good results after each procedure. Digital artery sympathectomy has been performed for chronic digital ischemia caused by a wide range of different conditions, with varying degrees of success. Reisman18 has reported prolonged healing after sympathectomy in patients taking steroids and in patients with scleroderma.18 In El-Gammal and Blair’s12 series of 3 patients, complete pain relief after digital artery sympathectomy was achieved in 2 patients with CREST syndrome and Raynaud’s disease. One patient with traumatic ulnar artery thrombosis achieved partial relief; however, the throm-
bosed ulnar artery itself was not addressed surgically.12 Flatt’s4 original report included 3 patients with frostbite, 2 patients with a history of trauma (crush injury), 2 patients with connective tissue disorders, and 1 patient with Raynaud’s phenomenon. The frostbite patients were all able to handle contents of domestic refrigerators without difficulty. Two of the patients returned to farming, but 1 was required to quit a job that entailed handling frozen turkeys for 8 hours a day. The patients with posttraumatic sympathectomies did not have complete relief of their symptoms; however, they could still retrieve beverages from their refrigerators without difficulty. The 2 patients with connective tissue disorders had improvement in their pain; however, 1 patient’s ulcers did not heal. The patient with Raynaud’s phenomenon had complete relief of pain and the return of normal nails. Jones et al8 performed digital artery sympathectomies on 7 patients and found good results in the majority of patients on short-term follow-up; however, these investigators found recurrent digital ulcerations at long-term follow-up predominantly in patients with connective tissue disease and the combination of renal vascular disease and diabetes.13 Ward and Van Moore2 presented 7 patients with scleroderma who underwent digital artery sympathectomy. These patients healed their digital ulcers in an average of 3.7 weeks; however, 3 patients developed recurrent ulcers after healing. Wilgis9 reported the poorest response in patients with scleroderma, with an excellent response in postfrostbite patients and the best results in young patients with vasculitis and primary vasospastic disorders. Egloff et al11 performed digital artery sympathectomies on 13 patients: 9 posttraumatic patients and 4 with idiopathic cold intolerance. All the patients’ symptoms were improved after sympathectomy, with 2 patients (1 posttraumatic and 1 idiopathic) becoming asymptomatic after the procedure. Yee et al19 reviewed the records of 9 patients undergoing digital artery sympathectomy for chronic ischemia caused by collagen vascular disorders. Six patients had scleroderma and 3 patients had undifferentiated rheumatic disorders. All the patients were reported as asymptomatic after surgery; however, loss of the distal tip occurred in 4 patients. It is clear that digital artery sympathectomy works very well in post-frostbite cold intolerance. While the procedure is likely to help cold intolerance caused by other conditions, no conclusions can be drawn regarding which diseases will obtain better results. The results presented here are similar to those of
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 177
several previous works2,4,8,9,11 in that most patients were not asymptomatic after the procedure. The average time to ulcer healing was longer than has been previously reported.2 While scleroderma has previously been shown to have varying results with digital sympathectomy,2,9,18,19 all patients with scleroderma in this study had healed ulcers and avoided amputation. Of particular importance is the improvement noted in 1 patient with scleroderma undergoing repeat digital artery sympathectomy. The usefulness of this procedure has been theorized19 but not documented in the literature. This lends support to the dual compression of the vessels by sympathetic activity and external compression by the surrounding tissues, in this case scar tissue compounded by scleroderma. While digital artery sympathectomy is effective in preventing amputation, the digits do not regain a normal tolerance to cold and trauma. Digital trauma can lead to recurrent ulceration, as evidenced by the 2 recurrent digital ulcerations in this study. These patients must avoid situations likely to induce injury to their hands and must practice good wound care when hand injuries occur. Cold tolerance is usually diminished following digital artery sympathectomy but is still present to some degree. Most patients reported difficulties with pain at temperatures below 5°C to 10°C. Subjectively, the patients have reported an improved ability to tolerate the duration of the winter when given a period of relief from the intensely cold weather; therefore, we routinely recommend a 2- to 3-week period in a warmer climate. Theoretically, this period of warmth breaks the cycle of pain and ischemia inherent in longer winters. In general, cold exposure should be avoided. Digital artery sympathectomy is a simple and effective technique with which to preserve the digits in a patient with chronic digital ischemia. The surgery should be performed in conjunction with continued smoking cessation and cold avoidance.
References 1. Miller LM, Morgan RF. Vasospastic disorders: etiology, recognition, and treatment. Hand Clin 1993;9:171–187.
2. Ward WA, Van Moore A. Management of finger ulcers in scleroderma. J Hand Surg 1995;20A:868 – 872. 3. Wilgis EFS. Evaluation and treatment of chronic digital ischemia. Ann Surg 1981;193:693– 698. 4. Flatt AE. Digital artery sympathectomy. J Hand Surg 1980; 5:550 –556. 5. Gahhos F, Ariyan S, Frazier WH, Cuono CB. Management of sclerodermal finger ulcers. J Hand Surg 1984;9A:320 – 327. 6. Pick J. The autonomic nervous system. Philadelphia: JB Lippincott, 1970:341–349. 7. Morgan RF, Reisman NR, Wilgis EFS. Anatomic localization of sympathetic nerves in the hand. J Hand Surg 1983; 8:283–288. 8. Jones NF, Imbriglia JE, Steen VD, Medsger TA. Surgery for scleroderma of the hand. J Hand Surg 1987;12A:391– 400. 9. Wilgis EFS. Digital sympathectomy for vascular insufficiency. Hand Clin 1985;1:361–367. 10. Wilgis EFS. Digital periarterial sympathectomy. In: Blair WF, Steyers CM, eds. Techniques in hand surgery. Baltimore: Williams & Wilkins, 1996:1164 –1169. 11. Egloff DV, Mifsud RP, Verdan C. Superselective digital sympathectomy in Raynaud’s phenomenon. Hand 1982; 15:110 –114. 12. El-Gammal TA, Blair WF. Digital periarterial sympathectomy for ischaemic digital pain and ulcers. J Hand Surg 1991;16B:382–385. 13. Jones NF. Acute and chronic ischemia of the hand: pathophysiology, treatment, and prognosis. J Hand Surg 1991; 16A:1074 –1083. 14. Koman LA, Smith BP, Pollock FE Jr, Smith TL, Pollock D, Russell GB. The microcirculatory effects of peripheral sympathectomy. J Hand Surg 1995;20A:709 –717. 15. Zook EG, Kleinert HE, Van Beek AL. Treatment of the ischemic finger secondary to digital artery occlusion. Plast Reconstr Surg 1978;62:229 –234. 16. Pollock DC, Li Z, Rosencrance E, Krome J, Koman LA, Smith TL. Acute effects of periarterial sympathectomy on the cutaneous microcirculation. J Orthop Res 1997;15: 408 – 413. 17. Morgan RF, Wilgis EFS. Thermal changes in a rabbit ear model after sympathectomy. J Hand Surg 1986;11A:120 – 124. 18. Reisman NR. Surgical management of Raynaud’s phenomenon. Tex Med 1984;80:44 – 49. 19. Yee AMF, Hotchkiss RN, Paget SA. Adventitial stripping: a digit saving procedure in refractory Raynaud’s phenomenon. J Rheumatol 1998;25:269 –276.
We retrospectively reviewed the effectiveness of digital artery sympathectomy as a last resort to prevent amputation in severe cases of Raynaud’s disease and phenomenon. Seven patients underwent digital artery sympathectomy as a salvage procedure to prevent amputation. The patients developed cold intolerance secondary to atherosclerosis or collagen vascular disease. The results were analyzed using the criteria of ulcer healing and the prevention of amputation. In 6 of the 7 patients, the digital ulcers healed and amputation was avoided. (J Hand Surg 1999;24A:173–177. Copyright © 1999 by the American Society for Surgery of the Hand.)
Chronic ischemic disease in the upper extremity results in cool pale fingers, cold intolerance, ulcerations, and gangrenous changes. It is a difficult problem that is currently treated by conservative therapy, such as smoking cessation, cold avoidance, biofeedback techniques, and nifedipine therapy.1–3 Not uncommonly, the disease necessitates amputation. According to Poiseuille’s law, blood flow is directly proportional to the fourth power of the vessel’s radius. Thus, a small change in the vessel’s radius will cause a very large change in the blood flow. Eliminating the sympathetic innervation and subsequent
From the Division of Plastic Surgery, Southern Illinois University School of Medicine, Springfield, IL; and the Department of Surgery, Michigan State University, Grand Rapids, MI. Received for publication September 30, 1997; accepted in revised form June 26, 1998. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Address correspondence to: Tracy E. McCall, MD, 135 Ocean Parkway #11C, Brooklyn, NY 11218. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A01-0025$3.00/0
vessel dilatation must be considered as a point of intervention in digital ischemia. Conventional cervical sympathectomy is often unsuccessful because this preganglionic sectioning does not remove all the sympathetic stimulation to the hand.4,5 Additional sympathetic fibers innervate the hand through the sinuvertebral nerve, the carotid plexus, and the nerve of Kuntz.6 The sympathetic fibers are located in the epineurium of the peripheral nerves and pass to the vessel adventitia through multiple small branches as the nerves and vessels travel distally into the arm.7 To overcome this problem, distal sympathectomy was introduced with some success.4 The technique for digital artery sympathectomy involves stripping the adventitia from the digital arteries for a distance of a few millimeters to several centimeters.4,8 –10 The results for digital artery sympathectomy in the treatment of Raynaud’s phenomenon have been much more successful than those for cervical sympathectomy.4 Sympathectomy is performed for 3 basic causes of chronic digital ischemia: atherosclerotic disease, collagen vascular disease, and posttraumatic cold sensitivity. This is a moderately large series that assesses digital The Journal of Hand Surgery 173
174 McCall, Petersen, and Wong / Digital Artery Sympathectomy
artery sympathectomy as a salvage procedure for the treatment of severe chronic ischemia in terms of digital ulcer healing and the prevention of amputation.
Materials and Methods A retrospective analysis of all digital artery sympathectomies performed in a hand surgery practice in Western Michigan was performed. Data were collected by chart review. Seven patients representing 23 fingers underwent digital artery sympathectomies for severe intractable Raynaud’s phenomenon during a 12-year period. All patients had nonhealing ulcers failing conservative therapy with impending gangrene on at least 1 finger before surgery. The patients showed worsening ischemia and progressive ulcer formation while receiving conservative therapy. Digital artery sympathectomy was only considered as a last resort before digital amputation. Conservative therapy included calcium channel blockers, smoking cessation, cold avoidance, and the recommendation to spend at least 2 to 3 weeks of the winter in a warmer climate. Preoperative sympathetic block and cold stress testing, as recommended by Wilgis,10 were not used in this study. Digital artery sympathectomy, as described by Flatt4 or Wilgis,3,9 is a relatively easy procedure to perform. The common digital arteries are approached through a palmar incision. With the aid of loupe magnification, the adventitia is stripped circumferentially for a distance of 1 to 2 cm. The wound is then closed with interrupted nylon sutures. Healing of digital tip ulcers was graded objectively by physician observation during regularly scheduled postoperative evaluations. Time to ulcer healing represents the time between the operation and the first postoperative visit recording the ulcer as completely healed. The records were also reviewed for subsequent amputations of the involved digits and recurrence of ulcerations.
The etiology of the digital ischemia was Raynaud’s phenomenon secondary to scleroderma in 4 patients (16 fingers), atherosclerosis in 2 patients (3 fingers), and an undiagnosed cause (Raynaud’s disease) in 1 patient (4 fingers) (Table 1). One of the scleroderma patients had undergone previous successful sympathectomy and repeat sympathectomy at another location; this patient’s procedure was a repeat sympathectomy (1 finger). Two patients were smokers at the time of initial consult, 2 were nonsmokers, and 1 was an ex-smoker; the smoking history of 2 patients was not available. Smoking cessation was required before surgical therapy was considered. The follow-up period averaged 2 years (range, 1 month to 6 years 4 months).
Results Six of the 7 patients, representing 22 of the 23 digits, healed sufficiently to prevent amputation (Table 2). All 23 digits presented with impending gangrene and ulcerations. Ulcerations healed after sympathectomy in 22 of the 23 digits. The average time to ulcer healing was 14 weeks (range, 4 weeks to 7 months). Two patients developed a recurrent ulceration after initial healing. These recurrent ulcerations followed traumatic events and healed with conservative treatment. One patient developed a recurrent ulceration 2 years after the digital artery sympathectomy and the ulcer healed with 3 weeks of local wound care. Another patient developed a very small ulcer after sustaining trauma to the finger. Due to the diminutive size of this ulcer, the patient was instructed to perform local wound care and follow-up on an as-needed basis. Another patient developed recurrent infections 4 years after the sympathectomy but healed with antibiotics and local wound care. One patient required amputation of the involved digit following sympathectomy of 1 finger for atherosclerosis; it eventually progressed to amputation
Table 1. Etiology of the Digital Ischemia Patient No. 1 2 3 4 5 6 7
Age (yr)*
Gender
Diagnosis
Other Diagnosis and Procedures
Smoker
67 58 43 42 38 42 71
M M F F F F F
Atherosclerosis Atherosclerosis Scleroderma Scleroderma Scleroderma Scleroderma Raynaud’s disease
CABG, excision BL thrombosed ulnar arteries PVD, diabetes, renal transplant
Ex (17 yr) No Yes No Yes Unknown Unknown
Hypertension
* Average age, 51.5 years. CABG, coronary artery bypass grafting; BL, bilateral; PVD, peripheral vascular disease.
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 175
Table 2. Results Following Digital Artery Sympathectomy Patient No.
Time to Healing
Follow-up
4 5 6
2 1 4 4 1 2 4
12 wk NA 16 wk 24 wk 12 wk 4 wk 5 wk
11 mo 7 mo 74 mo 76 mo 12 wk 4 wk 28 mo
7
1 4
9 wk 4 wk, 3 digits
16 mo 7 mo
Average
3
7 mo, 1 digit 14 wk*
34 mo*
1 2 3
No. of Digits
Results No ulcers 1 cold intolerance below 5°C Amputation No ulcers 1 cold intolerance; recurrent infections after 4 yr No ulcers 1 cold intolerance No ulcers, unknown cold intolerance Cold intolerance, ulcers healed, recurrent ulcer 2 yr after surgery healed with 3 wk of conservative measures Ulcers healed, 1 recurrent ulcer 8 mo after surgery, unknown cold intolerance
NA, not available. * Averages are per digit.
at the mid-middle phalanx level 7 months after the procedure. While the digit initially appeared to be healing, evidence of vascular insufficiency began to recur after 3 months.
Discussion Few options exist for the patient with nonhealing digital ulcers once conservative measures have failed. Fingertip amputation has been previously used; however, often several digits will become involved, and this treatment can lead to increasing cosmetic and functional impairment. The results of cervical sympathectomy have been generally disappointing.4 Flatt4 originally advocated digital artery sympathectomy for the treatment of Raynaud’s phenomenon and disease. His technique has been modified by Wiglis,3,9 who increased the length of adventitial stripping from 3 to 4 mm to 2 cm. Egloff et al11 stripped the adventitia from the common digital artery and the proximal part of the digital artery for 5 to 10 mm. El-Gammal and Blair12 modified Wiglis’ technique by also stripping the adventitia from the radial and ulnar arteries at the wrist. Jones13 proposed a much more extensive modification in 1991. In this extended digital artery sympathectomy, the adventitia is stripped from the superficial palmar arch; the radial digital artery to the index finger; the common digital artery and ulnar and radial digital arteries to the second, third, and fourth web spaces; and the ulnar digital artery to the little finger out to the level of the web spaces. Jones13 also recommends stripping the adventitia to the level of the proximal
interphalangeal joints in severely involved digits and performing microvascular reconstruction of the palmar arch when there is angiographic evidence of distal radial and ulnar artery involvement in a symptomatic patient. Koman et al14 have shown that distal sympathectomy, including adventitial stripping of the radial and ulnar arteries for a distance of 2 cm, combined with stripping of the common digital arteries for a distance of 1.5 cm is effective in treating digital ischemia in patients with combined vasospastic disease secondary to scleroderma and 2-level unreconstructable occlusive disease. Thrombosed digital arteries should be resected.15 In this study, adventitial stripping for a length of 1 to 2 cm was sufficient to achieve adequate circulation to heal the digital ulcers in 22 of 23 digits. However, in certain instances, a more proximal sympathectomy may be indicated. There is a high incidence of distal ulnar artery involvement in scleroderma (50%), and in this case adventitial stripping of the distal ulnar artery may be indicated.1,8,14 Arterial sympathectomy has been studied in the rabbit ear. The circulation of both the rabbit ear and the human digit are controlled mostly by the sympathetic nervous system, which can increase perfusion as the body core temperature rises. The microcirculation of both the rabbit ear and the human digit has 2 components: arteriovenous anastomoses for thermoregulatory control and capillaries for nutritional blood flow. In the rabbit ear, acute periarterial sympathectomy effectively reduced the sympathetic tone of the distal vasculature, increased cutaneous perfu-
176 McCall, Petersen, and Wong / Digital Artery Sympathectomy
sion and total flow, and increased auricular temperature.16 Long-term studies of sympathectomy in the rabbit ear also have shown no consistent reinnervation of the artery and a persistent elevation in temperature.17 Several others have shown an increase in digital temperature after digital artery sympathectomy.4,9,12,18 Koman et al14 found no significant difference in digital temperatures between patients and controls both before and after digital artery sympathectomy; however, a significant improvement in the response to cold stress testing was found after sympathectomy. These investigators showed that sympathectomy of the human digit in patients with scleroderma and unreconstructable occlusive disease could improve cutaneous perfusion sufficiently to heal ulcers and theorized that this indicated an increase in nutritional blood flow to the fingers rather than an increase in arteriovenous shunting. A poor response to preoperative cold stress testing with sympathetic blockade has been previously cited as a contraindication to digital artery sympathectomy.1,3,5,9,10,18 This is appropriate when excessive sympathetic activity is the sole cause of the digital ischemia. Recently, a dual cause of vessel constriction has been proposed.19 The narrowing of the vessel lumen is often a combination of sympathetic activity and external compression caused by a thickened adventitia or contraction of the tissues surrounding the arteries. A thickened adventitia is often seen with chronic vasculitis.10 Theoretically, this explains the common recurrence of digital ischemia found in patients with scleroderma; as the disease progresses, the tissues surrounding the vessels contract and create increasing external compression. Repeat sympathectomy was successful in 1 patient with scleroderma. It has been shown that sympathetic fibers in the adventitia do not regenerate extensively.17 This patient’s response is most likely due to a release of constricting scar tissue around the digital arteries.13 The patient had undergone several repeat sympathectomies, with good results after each procedure. Digital artery sympathectomy has been performed for chronic digital ischemia caused by a wide range of different conditions, with varying degrees of success. Reisman18 has reported prolonged healing after sympathectomy in patients taking steroids and in patients with scleroderma.18 In El-Gammal and Blair’s12 series of 3 patients, complete pain relief after digital artery sympathectomy was achieved in 2 patients with CREST syndrome and Raynaud’s disease. One patient with traumatic ulnar artery thrombosis achieved partial relief; however, the throm-
bosed ulnar artery itself was not addressed surgically.12 Flatt’s4 original report included 3 patients with frostbite, 2 patients with a history of trauma (crush injury), 2 patients with connective tissue disorders, and 1 patient with Raynaud’s phenomenon. The frostbite patients were all able to handle contents of domestic refrigerators without difficulty. Two of the patients returned to farming, but 1 was required to quit a job that entailed handling frozen turkeys for 8 hours a day. The patients with posttraumatic sympathectomies did not have complete relief of their symptoms; however, they could still retrieve beverages from their refrigerators without difficulty. The 2 patients with connective tissue disorders had improvement in their pain; however, 1 patient’s ulcers did not heal. The patient with Raynaud’s phenomenon had complete relief of pain and the return of normal nails. Jones et al8 performed digital artery sympathectomies on 7 patients and found good results in the majority of patients on short-term follow-up; however, these investigators found recurrent digital ulcerations at long-term follow-up predominantly in patients with connective tissue disease and the combination of renal vascular disease and diabetes.13 Ward and Van Moore2 presented 7 patients with scleroderma who underwent digital artery sympathectomy. These patients healed their digital ulcers in an average of 3.7 weeks; however, 3 patients developed recurrent ulcers after healing. Wilgis9 reported the poorest response in patients with scleroderma, with an excellent response in postfrostbite patients and the best results in young patients with vasculitis and primary vasospastic disorders. Egloff et al11 performed digital artery sympathectomies on 13 patients: 9 posttraumatic patients and 4 with idiopathic cold intolerance. All the patients’ symptoms were improved after sympathectomy, with 2 patients (1 posttraumatic and 1 idiopathic) becoming asymptomatic after the procedure. Yee et al19 reviewed the records of 9 patients undergoing digital artery sympathectomy for chronic ischemia caused by collagen vascular disorders. Six patients had scleroderma and 3 patients had undifferentiated rheumatic disorders. All the patients were reported as asymptomatic after surgery; however, loss of the distal tip occurred in 4 patients. It is clear that digital artery sympathectomy works very well in post-frostbite cold intolerance. While the procedure is likely to help cold intolerance caused by other conditions, no conclusions can be drawn regarding which diseases will obtain better results. The results presented here are similar to those of
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 177
several previous works2,4,8,9,11 in that most patients were not asymptomatic after the procedure. The average time to ulcer healing was longer than has been previously reported.2 While scleroderma has previously been shown to have varying results with digital sympathectomy,2,9,18,19 all patients with scleroderma in this study had healed ulcers and avoided amputation. Of particular importance is the improvement noted in 1 patient with scleroderma undergoing repeat digital artery sympathectomy. The usefulness of this procedure has been theorized19 but not documented in the literature. This lends support to the dual compression of the vessels by sympathetic activity and external compression by the surrounding tissues, in this case scar tissue compounded by scleroderma. While digital artery sympathectomy is effective in preventing amputation, the digits do not regain a normal tolerance to cold and trauma. Digital trauma can lead to recurrent ulceration, as evidenced by the 2 recurrent digital ulcerations in this study. These patients must avoid situations likely to induce injury to their hands and must practice good wound care when hand injuries occur. Cold tolerance is usually diminished following digital artery sympathectomy but is still present to some degree. Most patients reported difficulties with pain at temperatures below 5°C to 10°C. Subjectively, the patients have reported an improved ability to tolerate the duration of the winter when given a period of relief from the intensely cold weather; therefore, we routinely recommend a 2- to 3-week period in a warmer climate. Theoretically, this period of warmth breaks the cycle of pain and ischemia inherent in longer winters. In general, cold exposure should be avoided. Digital artery sympathectomy is a simple and effective technique with which to preserve the digits in a patient with chronic digital ischemia. The surgery should be performed in conjunction with continued smoking cessation and cold avoidance.
References 1. Miller LM, Morgan RF. Vasospastic disorders: etiology, recognition, and treatment. Hand Clin 1993;9:171–187.
2. Ward WA, Van Moore A. Management of finger ulcers in scleroderma. J Hand Surg 1995;20A:868 – 872. 3. Wilgis EFS. Evaluation and treatment of chronic digital ischemia. Ann Surg 1981;193:693– 698. 4. Flatt AE. Digital artery sympathectomy. J Hand Surg 1980; 5:550 –556. 5. Gahhos F, Ariyan S, Frazier WH, Cuono CB. Management of sclerodermal finger ulcers. J Hand Surg 1984;9A:320 – 327. 6. Pick J. The autonomic nervous system. Philadelphia: JB Lippincott, 1970:341–349. 7. Morgan RF, Reisman NR, Wilgis EFS. Anatomic localization of sympathetic nerves in the hand. J Hand Surg 1983; 8:283–288. 8. Jones NF, Imbriglia JE, Steen VD, Medsger TA. Surgery for scleroderma of the hand. J Hand Surg 1987;12A:391– 400. 9. Wilgis EFS. Digital sympathectomy for vascular insufficiency. Hand Clin 1985;1:361–367. 10. Wilgis EFS. Digital periarterial sympathectomy. In: Blair WF, Steyers CM, eds. Techniques in hand surgery. Baltimore: Williams & Wilkins, 1996:1164 –1169. 11. Egloff DV, Mifsud RP, Verdan C. Superselective digital sympathectomy in Raynaud’s phenomenon. Hand 1982; 15:110 –114. 12. El-Gammal TA, Blair WF. Digital periarterial sympathectomy for ischaemic digital pain and ulcers. J Hand Surg 1991;16B:382–385. 13. Jones NF. Acute and chronic ischemia of the hand: pathophysiology, treatment, and prognosis. J Hand Surg 1991; 16A:1074 –1083. 14. Koman LA, Smith BP, Pollock FE Jr, Smith TL, Pollock D, Russell GB. The microcirculatory effects of peripheral sympathectomy. J Hand Surg 1995;20A:709 –717. 15. Zook EG, Kleinert HE, Van Beek AL. Treatment of the ischemic finger secondary to digital artery occlusion. Plast Reconstr Surg 1978;62:229 –234. 16. Pollock DC, Li Z, Rosencrance E, Krome J, Koman LA, Smith TL. Acute effects of periarterial sympathectomy on the cutaneous microcirculation. J Orthop Res 1997;15: 408 – 413. 17. Morgan RF, Wilgis EFS. Thermal changes in a rabbit ear model after sympathectomy. J Hand Surg 1986;11A:120 – 124. 18. Reisman NR. Surgical management of Raynaud’s phenomenon. Tex Med 1984;80:44 – 49. 19. Yee AMF, Hotchkiss RN, Paget SA. Adventitial stripping: a digit saving procedure in refractory Raynaud’s phenomenon. J Rheumatol 1998;25:269 –276.