Cath Lab Digest

Introduction
Digital ischemia in the upper extremity, with ulceration and gangrene due to primary or secondary Raynaud’s phenomenon, may be a difficult problem for the hand surgeon to solve. Ischemic pain, numbness, cold intolerance and disabling symptoms of the hands may be the early manifestations of the Raynaud’s phenomenon, but patients are usually referred to hand surgeons in later stages of the disease, when they have developed refractory ulcers and necroses at the fingers.

Many conventional therapies have been used. Behavioral therapy such as cessation of smoking, avoidance of cold exposure, avoidance of caffeinated beverages, use of gloves (preferably mittens) and biofeedback therapy are important initial interventions.^1,2 A variety of vasodilating and antiplatelet agents such as calcium channel blockers, a2 adrenergic antagonists, warfarin, plasminogen activator or iloprost, a prostacyclin analog have shown promising effectiveness in reducing morbidity.^3–6 Medical treatment is ineffective in many severe cases, causing partial or total loss of the finger. In cases refractory to medical treatment, cervical sympathectomy has been used with either poor long-term results, as preganglionic sectioning does not remove all the sympathetic stimulation to the hand, or unpleasant side effects such as postoperative compensatory hyperidrosis.^7–10 The results for digital artery sympathectomy have been much more successful than those for cervical sympathectomy. Digital sympathectomy, first described by Flatt, involves stripping the adventitial layer from the affected common and proper digital arteries. Digital sympathectomy may be the only alternative to amputation when medical therapy has failed.¹¹

The aim of this study is to evaluate the effect of peripheral periarterial sympathectomy on digital ulceration, severity of ischemic pain and cold intolerance of the digits in patients suffering from Raynaud’s syndrome.
Materials and Methods

A retrospective analysis of all digital artery sympathectomy performed in our Hand Surgery Clinic between February 1998 and May 2004 was performed. Five patients representing 16 affected digits underwent peripheral periarterial sympathectomy for severe Raynaud’s phenomenon. Three of them were females and 2 were males, and their ages ranged from 28 to 60 years (average age, 42 yrs). Four of the patients were heavy smokers (one and a half pack per day, for an average of 15 years of smoking). All the patients showed chronic ischemia with worsening ischemic pain, especially during their work, cold intolerance and numbness (Table 1). Progressive ulcer formation was present in three patients. There were three ulcers in the middle finger (Figure 1), 3 in the ring, 1 in the small, and 1 in the index finger. Gangrene on the middle and ring fingers was developed in one patient (Figure 2). Preoperative conservative treatment included pharmacological agents, such as calcium channel blockers, angiotensin converting-enzyme inhibitors, serotonin receptors antagonists, and behavioral modifications such as cessation of smoking, avoidance of caffeinated beverages, and avoidance of cold exposure and use of gloves. Diagnosis was based on a history of repeated or vibrational injuries, the number of attacks, blood dyscrasia, drug use, smoking, and the degree of incapacitation. Patients were also evaluated for capillary refill, skin integrity, and the presence or absence of ulcers or necrotic areas, peripheral pulses and an Allen test. Preoperative blockade was used in two patients, with lack of response and progression of ischemic symptoms. Doppler studies were performed in 2 patients and showed good pulsations to the distal tufts of their fingers. Conventional angiography was employed for the evaluation of digital ischemia to all patients (Figure 3). Cold stress testing, as recommended by Wilgis,¹² was not used in this study.

The etiology of the digital ischemia was Raynaud’s phenomenon secondary to collagen disease (scleroderma) in 4 patients and Raynaud’s disease in one patient (Table 1). One patient had undergone sympathectomy with incomplete response and a recurrent ulceration after initial healing. That patient also underwent a repeat sympathectomy.

Under axillary block anesthesia and after exsanguinations of the affected limb, a zigzag type incision was made at the base of the affected finger extending into the palm. The incision was extended distally to the crease of the proximal phalanx. Under operating microscope, the common digital artery was first separated from the adjacent digital nerve and then stripped of the adventitia from the superficial arch distally, as the artery advanced into the proximal phalanx (Figures 4A and 4B).

The patients were asked to complete a questionnaire where they scored digital pain pre- and post-surgery, complications of surgery and the overall impact of surgery. Disability of the upper extremity was measured with the Disabilities of the Arm, Shoulder and Hand Questionnaire.¹³ The postoperative rehabilitation program included recommendation for immediate mobilization and continuation of drug use. The follow-up time averaged 45 months (range 24–80).