VINTAGE TECHNIQUE IN VASCULAR SURGERY: LUMBAR SYMPATHECTOMY IN CRITICAL LIMB ISCHEMIA
Keywords:Critical limb ischemia, Buerguer's disease, Lumbar sympathectomy
Introduction: Tromboangiitis Obliterans or Buerguer's disease is one of the expresions of the peripheral arterial disease; its main feauture is the absence of average distal outflow that precludes direct revascularization surgery; lumbar sympathectomy was carried out to treat this condition with acceptable results but nowadays this technique is described as obsolete; many young vascular surgeons have not even heard about it and most of them have never seen a lumbar sympathectomy for the treatment of patients with critical limb ischemia.
Case report: A 39-year-old woman admitted with critical limb ischemia due to popliteal artery occlusion without average distal outflow, treated by a lumbar sympathectomy as a resource technique.
Discussion: Today, endovascular treatment is the first option for the critical limb ischemia in most cases; althoug tromboangiitis obliterans is less frequent nowadays, exists, and this is one of the situations where endovascular treatment does not work; what's more, direct surgery is also not possible.
Conclusions: Lumbar sympathectomy can work not only in this scenary of Buerguer's disease; it can be used as resource technique when the first approach with direct surgery has failed and there is not more options to limb salvage; thus, lumbar sympathectomy should be part of the therapeutic arsenal of any vascular surgeon.
2. Freeman N.E., Leeds F.H., Gardner R.E. Sympathectomy for obliterative arterial disease. Indications and contraindications. Annals of Surgery, 1947; 126(6):873-895.
3. Imparato A.M. Lumbar sympathectomy. Role in the treatment of occlusive arterial disease in the lower extremities. Surgical Clinics of North America, 1979; 59(4):719-735.
4. Erichsen HG. Lumbar sympathectomy in obliterative arteriosclerosis. Should it still be performed? Scand Cardiovasc J. 1979;13(3):333-337. doi:10.3109/14017437909100574
5. Dalessandri K.M., Carson S.N., Tillman P., Talken L., Wong H.N. Effect of lumbar sympathectomy in distal arterial obstruction. Arch. Surg. 1.983; 118:1157-1160.
6. van der Stricht JP. Effect of lumbar sympathectomy on the lower extremity. J Cardiovasc Surg (Torino). 1979;20(3):301‐311.
7. Sanni A. Is sympathectomy of benefit in critical leg ischaemia not amenable to revascularisation? Interact Cardiovasc Thorac Surg. 2005;4(5):478-483. doi:10.1510/icvts.2005.115410
8. Fulton RL, Blakeley WR. Lumbar sympathectomy: A procedure of questionable value in the treatment of arteriosclerosis obliterans of the legs. Am J Surg. 1968;116(5):735-744. doi:10.1016/0002-9610(68)90359-0
9. Gordon A, Zechmeister K, Collin J. The role of sympathectomy in current surgical practice. Eur J Vasc Surg. 1994;8(2):129-137. doi:10.1016/S0950-821X(05)80447-5
10. Pratesi Franco. Microcirculazione e microangiologia. Edizione Minerva Médica (Torino). 1990; 3-118.
11. Friedman S.A., Frieberg P., Colton J. Vasomotor tone in diabetic neuropathy. Ann. Intern. Med. 1972; 77:353-355.
12. Cid Dos Santos J. The diagnosis and treatment of vascular obstruction. Gaz Med Port. 1948;1(3):631‐643.
13. Menzoian JO, Koshar AL, Rodrigues N. Alexis Carrel, Rene Leriche, Jean Kunlin, and the history of bypass surgery. J Vasc Surg. 2011;54(2):571‐574. doi:10.1016/j.jvs.2011.04.028
14. Karanth VKL, Karanth TK, Karanth L. Lumbar sympathectomy techniques for critical lower limb ischaemia due to non-reconstructable peripheral arterial disease. Cochrane Database Syst Rev. 2016;2016(12). doi:10.1002/14651858.CD011519.pub2
15. Qadura M, Terenzi DC, Verma S, Al-Omran M, Hess DA. Concise Review: Cell Therapy for Critical Limb Ischemia: An Integrated Review of Preclinical and Clinical Studies. Stem Cells. 2018;36(2):161‐171. doi:10.1002/stem.2751