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The Impact of Etiology on Periarterial Sympathectomy: A Long-Term Assessment
Megan Rudolph, MD¹, Katherine Butler, MD², Shamit Prabhu, BS¹, Zhongyu Li, MD, PhD³ and Donald Tracey Browne, MD⁴, (1)Wake Forest Baptist Medical Center, winston salem, NC, (2)Wake Forest Baptist Medical Center, winston-salem, NC, (3)Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, (4)Wake Forest Medical Center, winston-salem, NC

 

Introduction:

Digital ischemia due to vasospastic or occlusive disorders can be treated with periarterial sympathectomy, which reduces sympathetic tone and increases nutrient flow to the fingertips. The procedure remains controversial due to small and heterogeneous patient populations. We sought to perform a long-term analysis of surgical outcomes among different vasospastic and occlusive diseases.

 

Materials and Methods:

A retrospective review of patients undergoing periarterial sympathectomy from 1999-2018 was performed. Demographic information, angiography, surgical procedures and outcomes were recorded. Patients were divided into three subgroups including autoimmune disease, peripheral vascular disease (PVD) and vascular occlusion including hypothenar hammer syndrome and aneurysm. Descriptive statistics, chi-squared test and odds ratio were used for analysis.

 

Results:

There were 102 patients identified, with 35 having bilateral surgery (137 hands). Mean follow-up time was 17.9 months. Co-morbidities included scleroderma (N=35), lupus (N=8), cardiovascular disease (N=8) and rheumatoid arthritis (N=7). Hypothenar hammer syndrome and aneurysm were diagnosed in 20 hands (14.5%), respectively. On presentation, 55% had digital ulcers. Periarterial sympathectomy was performed alone in 70% of hands and in combination with arterial bypass in 29%. Simultaneous digital amputation was performed in 19 hands (14%).

 

There were 76 hands (55%) with autoimmune diseases, 36 hands (26%) with vascular occlusion and 14 hands (10%) with PVD. Subgroup treatment and outcomes detailed in Table 1. There is a relationship between subgroup and postoperative amputation (p=0.0003); PVD patients were over eight times as likely to require a postoperative amputation (OR 8.6, 95% CI 2.4-30.2).  There is an association between subgroups and development of new ulcers (p=0.008), with autoimmune patients three times as likely to develop new ulcers (OR 3.2, 95% CI 1.1-9.2). There was no association between subgroup and ulcer healing or infection. Overall, there was no association between simultaneous amputation and sympathectomy on postoperative infection (p=0.6)

 

Conclusion:

While the majority patients with autoimmune diseases heal ulcers postoperatively, they are most likely to have progression of disease as they are three times as likely to develop new digital ulcers. Patients with PVD were eight times as likely to have an amputation despite periarterial sympathectomy. Isolated vascular occlusion is associated with the best postoperative outcomes. These outcomes can be utilized for pre-operative patient counselling and risk stratification. Simultaneous digital amputation and periarterial sympathectomy does not increase infection risk.