Comprehensive Management Of Raynaud’S Syndrome

Neurectomy of the Nerve of Henle Associated with Periarterial Sympathectomy for Management of Intractable Raynaud Phenomenon

BACKGROUND

In periarterial sympathectomy for intractable Raynaud phenomenon, the extent of adventitectomy and postoperative outcomes and hand perfusion assessment tools remain debatable. The authors evaluated the outcome of neurectomy of the nerve of Henle combined with ulnar tunnel release and periarterial adventitectomy in the treatment of refractory Raynaud phenomenon using objective measurements and patient-reported outcomes.

METHODS

Nineteen patients with 20 affected hands were prospectively enrolled and underwent the proposed procedures from 2015 to 2021. Relevant data, including Michigan Hand Outcomes Questionnaire and 36-Item Short Form health questionnaire scores, were documented for analysis during a 3-year follow-up.

RESULTS

The average ingress value of the three measured fingers (index, long, and ring) on indocyanine green angiography increased after surgery ( P = 0.02). The median number of ulcers decreased ( P < 0.001), and the median digital skin temperature increased ( P < 0.001). Questionnaire scores showed improvement in physical aspects, such as overall hand function ( P ≤ 0.001), activities of daily living ( P = 0.001), work performance ( P = 0.02), pain ( P < 0.001), physical function ( P = 0.053), and general health ( P = 0.048), and mental aspects, such as patient satisfaction ( P < 0.001) and mental health ( P = 0.001). The average indocyanine green ingress value of the three measured fingers significantly correlated with the patient-reported outcomes, including overall hand function ( r = 0.46, P = 0.04), work performance ( r = 0.68, P = 0.001), physical function ( r = 0.51, P = 0.02), and patient satisfaction ( r = 0.35, P= 0.03).

CONCLUSIONS

The proposed surgical procedures provided satisfactory outcomes, both subjectively and objectively, over a follow-up period of up to 3 years. Indocyanine green angiography may provide rapid and quantitative measurements for perioperative hand perfusion assessment.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Long-term results of ulnar and radial reconstruction with interpositional grafting using the deep inferior epigastric artery for chronic hand ischemia

Chronic hand ischemia causes cold intolerance, intractable pain, and digital ulceration. If ischemic symptoms persist despite pharmacologic treatments, surgical interventions should be considered. This retrospective study evaluated the long-term results after ulnar and radial reconstruction using an interpositional deep inferior epigastric artery (DIEA) graft combined with periarterial sympathectomy. Patients who underwent this surgery from March 2003 to February 2019 were included. To evaluate variables influencing recurrence after the procedure, patients were divided into the recurred and non-recurred groups and their data were compared. Overall, 62 cases involving 47 patients were analyzed (16 and 46 cases in the recurred and non-recurred groups, respectively). The median DIEA graft length was 8.5 cm. The rates of rheumatic disease and female patients were significantly higher in the recurred than in the non-recurred group, without significant between-group differences in postoperative complication rates. In the multivariate analysis, underlying rheumatic disease and graft length had significant effects on recurrence. In Kaplan-Meier analysis, the 5- and 10-year symptom-free rates were 81.3% and 68.0%, respectively, with lower rates for cases with rheumatic disease. Thus, arterial reconstruction using an interpositional DIEA graft provides long-term sustainable vascular supply in patients with chronic hand ischemia, especially in those without rheumatic disease.

Extended Periarterial Sympathectomy: Evaluation of Long-term Outcomes

BACKGROUND

Periarterial sympathectomy is a proposed surgical treatment for patients with refractory Raynaud syndrome; however, there is debate regarding the indications and extent of dissection. Due to the segmental arterial sympathetic innervation, we favor an extended sympathectomy in concert with vein graft reconstruction of occluded vessels when necessary. The purpose of this study is to examine outcomes of extended periarterial sympathectomy in our patients.

METHODS

A retrospective chart review was performed on 46 patients who underwent 58 periarterial sympathectomies (12 bilateral) since 1981. The data collected include demographics, comorbidities, previous therapy, operative details, and surgical outcomes. In addition, we contacted available patients for a phone survey.

RESULTS

Of 58 cases, 68.9% were female, 29.3% were current smokers, and 58.6% had known connective tissue disease. Thirty-three vein graft reconstructions were performed with a long-term patency of 77.4%. Sustained improvement of ischemic pain was reported in 94.8% of cases, and 78% of patients with ulcers completely healed. For the most symptomatic fingertip, mean Semmes-Weinstein monofilament measurements improved from 4.15 preoperatively to 3.29 postoperatively ( P ≤ .05). Mean follow-up was 3.97 years. Of 10 patients contacted by telephone, all reported a decrease in frequency and severity of Raynaud attacks, while 9 reported a long-term decrease in pain an average of 11.6 years after surgery.

CONCLUSIONS

Extended periarterial sympathectomy is an effective and safe procedure for patients with refractory Raynaud syndrome. Our data demonstrate long-term improvement in ischemic pain and sensibility, along with a high rate of ulcer healing and patient satisfaction.

Digital Sympathectomy in Patients With Scleroderma: An Overview of the Practice and Referral Patterns and Perceptions of Rheumatologists

PURPOSE

Periarterial sympathectomy is a treatment option for patients with systemic sclerosis (SSc) suffering from digital vasculopathy. Despite potential benefits of ulcer healing, pain improvement, and amputation prevention, this operation appears to be infrequently performed. The aims of our study are as follows: (1) to assess national digital sympathectomy rates in patients with SSc and (2) to improve our understanding of referring physicians' perceptions of operative management and access to hand surgeons. Our hypothesis is that rheumatologists' practices largely influence their referral patterns for digital sympathectomy.

METHODS

To determine the rates and demographics of hospitalized patients with SSc who had undergone digital sympathectomy, we queried the Nationwide Inpatient Sample from 2006 to 2010. Additionally, we mailed a self-administered survey to a national sample of 500 board-certified rheumatologists to elicit their practice patterns and perceptions of digital sympathectomy. Using logistic regression, we analyzed potential predictor variables associated with rheumatologists performing the following: (1) routinely counseling patients about digital sympathectomy and (2) expressing the desire to refer these patients for operative evaluation.

RESULTS

Of 348,539 hospitalizations associated with a diagnosis of SSc, only 0.2% were for digital sympathectomy. Our questionnaire revealed that only 50% of rheumatologists routinely counseled, whereas 67% expressed the desire to refer. Factors associated with increased rheumatologists' interest in surgical management for patients with SSc included positive perception of the operation's efficacy, comfort with postoperative management, and interdisciplinary relationship with a hand surgeon.

DISCUSSION

Critical components to increasing appropriate utilization of digital sympathectomy include enhancing rheumatologists' understanding of the operation, comfort with postoperative management, and promoting strong, interdisciplinary relationships with hand surgeons. Increasing education and awareness, as well as establishing a solid referral network of hand surgeons may thereby improve patient access to digital sympathectomy.

Role and rationale for extended periarterial sympathectomy in the management of severe Raynaud syndrome: techniques and results

There is no consensus regarding etiology or best surgical technique for severe Raynaud syndrome in patients with connective tissue disease. Observations after 30 years' experience in more than 100 cases led to the conclusion that an extended periarterial sympathectomy (with or without vein-graft reconstruction) and adjunctive use of Botox topically will offer benefits that exceed palliation and reduce recurrent ulcerations. In this article the rationale for this approach is reviewed, techniques and results are outlined, and a hypothesis for the mechanism of Raynaud attacks is offered.

Reconstruction of the ischemic hand

Ischemia of the hand remains an uncommon condition, but problems with arterial perfusion of the hand can arise from trauma (open and closed), thrombosis, or arteriovascular disease. Certain identifiable patterns are seen with hand ischemia, usually discernable according to which one of the major arteries (radial or ulnar) are involved. This article discusses the origin and management of ischemic hand conditions, with an emphasis on recognizing the patterns of ischemia that are commonly seen.

Botulinum toxin A treatment of Raynaud's phenomenon: a review

OBJECTIVES

Botulinum toxin A has conventionally been used in the upper extremity to treat spasticity resulting from stroke, paraplegia, and dystonia. Recently, it has been used to relieve symptoms of vasospasm in Raynaud's phenomenon. This review summarizes the current literature on botulinum toxin A in the treatment of Raynaud's phenomenon and examines the proposed mechanisms of action, suggested techniques of administration, and clinical efficacy.

METHODS

An Ovid MEDLINE search from 1950 to September 2010 was performed to identify any reports on the use of Botulinum toxin in the treatment of Raynaud's disease or associated vasoconstrictive disorders. All studies pertaining to "Raynaud's disease," "Raynaud's," or "vasoconstriction" were queried and meshed with a secondary search of studies pertaining to "botox" or "botulinum toxin type A." These reports were meshed and subsequently limited to human studies. All studies that met criteria were included and their outcomes evaluated and summarized.

RESULTS

Since 2004, there have been 5 studies that have evaluated the use of Botulinum Toxin A for the treatment of Raynaud's. In each study, patients received a range of botulinum toxin injections (10-100 units) in their fingers and hands. The studies have many limitations (lack of controls, variable severity of disease, variability of dosing) but all report favorable clinical results. All showed overall improvement in patient pain as well as a reduction in soft tissue ulceration.

CONCLUSIONS

Initial reports on the use of botulinum toxin A for Raynaud's phenomenon are promising. Larger controlled trials with improved study design are warranted. A better understanding of the mechanism of action, appropriate dose and dose frequency, and the efficacy relative to other medical and surgical treatments requires investigation.

The Challenge to Manage Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome

The challenge to understand reflex sympathetic dystrophy/complex regional pain syndrome may require a better understanding of the complex relationship between the central and peripheral nervous systems. There is no comprehensive hypothesis that clearly explains the etiology and no uniformly successful treatment method. This brief summary of the challenge reviews some of what is known, hypothesizes a possible etiologic mechanism, and proposes 10 common-sense principles for management that recognizes the handicap of limited knowledge.

Medical and surgical considerations in patients with vasculitis and Raynaud's syndrome

Vascular problems in the foot are certainly common when one considers only arteriosclerosis on the macrovascular scale. The primary cause of ischemia of the foot undoubtedly is primary arteriosclerosis, whether related to smoking, diabetes, renal failure, or other causes. Vasculitis and vasospasm, in their many forms, are distinctly unusual as a cause of ischemia of the foot. These entities, nonetheless, can cause significant problems from the standpoint of symptoms and even ulceration or gangrene of the foot. This article addresses the pathophysiology of vasculitis and vasospastic problems in the foot and their management.