Radical microarteriolysis in the treatment of vasospastic disorders of the hand, especially scleroderma

Surgical Treatment of Chronic Hand Ischemia: A Systematic Review and Case Series

Background: Chronic hand ischemia refers to progressive, non-acute ischemic symptoms such as cold intolerance, rest pain, ulceration, tissue necrosis, and digit loss and poses a significant challenge in management. Conservative treatment begins with medical optimization and pharmacologic therapy, but when symptoms persist, surgical intervention may be required. Various operations exist to improve circulation including sympathectomy, arterial bypass, or venous arterialization. The purpose of this study is to systematically review published outcomes and present our experience with each surgical technique.

Methods: A systematic review of literature regarding surgical treatment of chronic hand ischemia published between 1990 and 2016 was conducted using PRISMA guidelines. A retrospective-review of surgical interventions for chronic hand ischemia from 2010 to 2016 was then conducted. Primary outcomes included improvement in pain, wound-healing, and development of new ulcerations.

Results: The review included 38 eight studies, showing all three techniques were effective in treating chronic hand ischemia. Sympathectomy had the lowest rate of new ulcerations (0.8%); bypass had the highest rate of healing existing ulcerations (89%). Arterialization was associated with consistent pain improvement pain (100%) but more complications (30.8%). Our series included 18 patients with 21 affected hands, 18 sympathectomies, 6 ulnar artery bypasses, and 1 arterialization. Most hands had improvement of wounds (89.5%) and pain (78.9%). No patients developed new ulcerations, but one required secondary amputation.

Conclusions: When conservative measures fail to improve chronic hand ischemia, surgical intervention is an effective last line treatment. An algorithmic approach can determine the best operation for patients with chronic hand ischemia.

Acupuncture Point "Hegu" (LI4) Is Close to the Vascular Branch from the Superficial Branch of the Radial Nerve

The acupuncture point “Hegu” (LI4) has been used for treating peripheral circulatory failure, which is located in the area covered by the superficial branch of the radial nerve (SBRN). SBRN has branches reaching arteries, so-called vascular branches (VBs), which are thought to be involved in the arterial constriction. The distribution areas of the VBs from the SBRN have been reported, but the positional relationship between these distribution areas and the acupuncture points are not known. To examine the positional relationship between LI4 and VBs from the SBRN, forty hands were examined to assess the positional relationship between the acupuncture points “Erjian” (LI2), “Sanjian” (LI3), LI4, and “Yangxi” (LI5) in the Yangming Large Intestine Meridian of Hand, which are located in the area covered by SBRN, and the VBs from the SBRN. After the VBs were identified, the distances from the acupuncture points (LI2, LI3, LI4, and LI5) to the point where the VBs reached the radial artery or the first dorsal metacarpal artery were measured. VBs reaching the radial arteries were observed in all specimens. The mean distances from LI2, LI3, LI4, and LI5 to the point where the VBs reached the radial artery were 64.2 ± 8.2 mm, 42.0 ± 7.5 mm, 4.3 ± 4.3 mm, and 33.0 ± 4.8 mm, respectively. LI4 was significantly closer than the other acupuncture points (P<0.01). The nerve fibers of the VBs adjacent to the radial artery were confirmed using hematoxylin and eosin staining. Our findings provide anatomical evidence that stimulation at LI4 is used for treating peripheral circulatory failure such as Raynaud's disease. LI4 is significant because it is located at a source point, making it clinically important.

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.

Vascular branches from cutaneous nerve of the forearm and hand: Application to better understanding raynaud's disease

Cutaneous nerves have branches called vascular branches (VBs) that reach arteries. VBs are thought to be involved in arterial constriction, and this is the rationale for periarterial sympathectomy as a treatment option for Raynaud's disease. However, the branching patterns and distribution areas of the VBs remain largely unclear. The aim of the present study was to investigate the anatomical structures of the VBs of the cutaneous nerves. Forty hands and forearms were examined to assess the branching patterns and distribution areas of the VBs of the superficial branch of the radial nerve (SBRN), the lateral antebrachial cutaneous nerve (LACN), the medial antebrachial cutaneous nerve (MACN), and the palmar cutaneous branch of the ulnar nerve (PCUN). VBs reaching the radial and ulnar arteries were observed in all specimens. The branching patterns were classified into six types. The mean distance between the radial styloid process and the point where the VBs reached the radial artery was 34.3 ± 4.8 mm in the SBRN and 38.5 ± 15.8 mm in the LACN. The mean distance between the ulnar styloid process and the point where the VBs reached the ulnar artery was 60.3 ± 25.9 mm in the MACN and 43.8 ± 26.0 mm in the PCUN. This study showed that the VBs of the cutaneous nerves have diverse branching patterns. The VBs of the SBRN had a more limited distribution areas than those of the other nerves. Clin. Anat. 31:734-741, 2018. © 2017 Wiley Periodicals, Inc.

Calcinosis of the Hand in Scleroderma: A Case Report

Calcinosis associated with scleroderma is a well recognized phenomenon. Fifteen to 44% of patients with systemic scleroderma and associated CREST (calcifications, raynaud's phenomenon, esophageal motility disorder, sclerodactyly and telangiectasias) syndrome have deposition of calcium in the fingers and hands. The tumourous effect may limit motion, cause neuropraxia, compound microangiopathy or present as calcific ulcers. This report describes the case of a patient with scleroderma and CREST syndrome in whom calcinosis in the hand resulted in severe, debilitating pain necessitating surgical evacuation of the deposits. The patient had complete pain relief in the postopertive period. A further surgical extirpation of calcium was required for recurring pain at six months after surgery. The patient has remained symptom free since that time. The rare occurence of excruciating pain prompted this report and literature review.

Use of Intermittent Pneumatic Compression for Treatment of Upper Extremity Vascular Ulcers

Ischemic vascular ulcerations of the upper extremities are an uncommon and frequently painful condition most often associated with scleroderma and small vessel inflammatory diseases. Digital amputation has been advocated as primary therapy because of the poor outcome with medical care. Intermittent pneumatic compression (IPC) pump therapy can improve ulcer healing in lower extremity ischemic ulcerations; however, the value of this treatment in upper extremity ischemic ulcerations is not known. This observational pilot study consisted of a consecutive series of 26 patients with 27 upper extremity ischemic vascular ulcers seen at the Mayo Gonda Vascular Center from 1996 to 2003. Inclusion criteria were documented index of ulcer size and follow-up ulcer size and use of the IPC pump as adjunctive wound treatment. Twenty-six of 27 ulcers (96%) healed with the use of the IPC pump. Mean baseline ulcer size was 1.0 cm2 (SD=0.3 cm2) and scleroderma was the underlying disease in 65% (17/26) of cases. Laser Doppler blood flow in the affected digit was 7 flux units (normal greater than 100). The mean ulcer duration before IPC treatment was 31 weeks. The average pump use was 5 hours per day. The mean time to wound healing was 25 weeks. Twenty-five of 26 patients reported an improvement in wound pain with pump use. Intensive IPC pump use is feasible and associated with a high rate of healing in upper extremity ischemic ulcers. A prospective, randomized, sham-controlled study of IPC is needed to determine whether IPC treatment improves wound healing compared to standard medical care.

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.

Minimally invasive treatment of Raynaud phenomenon: the role of botulinum type A

Although the mechanism is unknown, Btx-A injection may be an effective, localized, nonsurgical treatment option without addictive properties or systemic side effects for the treatment of ischemic digits. Clinical research supports the safety and efficacy of injection of Btx-A for the treatment of Raynaud phenomenon.

Long-term follow-up of periarterial sympathectomy for chronic digital ischaemia

This study investigates long-term clinical results (> 10 years) of periarterial sympathectomy in chronic ischaemic digits compared with intermediate-term results (3 years). Periarterial sympathectomy via the palm and volar wrist was carried out on 11 hands of seven patients with digital ischaemia but no gangrene or severe ulceration. The aetiology of ischaemia was Buerger's disease in four hands, collagen disease in three hands, and repetitive digital trauma in four hands. Subjective symptoms were evaluated at a mean follow-up period of 12 years. The efficacy of surgery was assessed objectively using thermography and plethysmography. Although five of seven patients continued on oral vasodilators and antiplatelet agents until the final follow-up, improvement of symptoms was maintained in all patients between intermediate- and long-term evaluations. Our results suggest that periarterial sympathectomy via the palm and wrist could prevent long-term aggravation of symptoms of chronic digital ischaemia when combined with adequate postoperative drug therapy.

Management of Raynaud's phenomenon and digital ischemic lesions in scleroderma

Raynaud's phenomenon is a challenging problem in patients who have scleroderma. It causes a great deal of morbidity with recurrent painful attacks and frequent digital ischemic lesions. The strategy to treat the vascular disease must consider treatment for the vasospasm and the intrinsic vascular disease with intimal proliferation and vessel occlusion. Vasodilator therapy remains the main method to treat Raynaud's phenomenon, but new understanding of the pathobiology of scleroderma vascular disease is providing novel treatment options. We need more investigations into these vasoactive drugs before routine use can be recommended. Critical ischemia can cause deep tissue injury and digital loss. An aggressive approach to reversing an ischemic crisis is essential for preventing these severe events.

Adventitial stripping of the radial and ulnar arteries in Raynaud's disease

Adventitial stripping of the palmar arch, the palmar common digital arteries, or the proper digital arteries is a last resort in the treatment of refractory primary or secondary Raynaud's phenomenon. Seven patients who had adventitial stripping of the ulnar and radial arteries proximal to the wrist and resection of the nerve of Henle, if identifiable, are presented. All of them were evaluated by telethermography, acral rheography, and a questionnaire before and after surgery. All were asymptomatic after surgery with satisfactory healing of the ulcers at the fingertips. None of them relapsed during the follow-up time of 1.5 years.

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.

Surgery for ischemic pain and Raynaud's' phenomenon in scleroderma: a description of treatment protocol and evaluation of results

Although the literature suggests that palmar sympathectomy (PS) with or without vascular reconstruction may improve ischemic digital pain, fingertip ulceration, and cold intolerance in patients with scleroderma, the question regarding long-term efficacy still remains. This retrospective study of six patients (eight hands) operated on between 1995 and 1997 evaluates both early (6 months) and long-term (average, 2.5 years) outcome after PS in combination with decompression arteriolysis of the radial and ulnar arteries proximal to the wrist. When preoperative digital blood flow was inadequate based on noninvasive vascular studies and major inflow occlusion was present, vascular reconstruction was also performed when feasible. At early review, significant improvement in ischemic digital pain and moderate improvement in cold intolerance resulted in eight hands, and at final follow-up, this was sustained in seven hands. Preoperatively, digital ulcerations were present in six hands. After digital debridement and/or amputation, all wounds healed, but in one patient with bilateral disease who continued to smoke, ulcerations recurred without the need for subsequent surgery. Five of six patients were no longer dependent on narcotic analgesics, but use of vasodilator medication did not change. Five of six patients claimed significant improvement in the quality of life after surgery and reported that they would undergo the surgery again. PS in combination with radial and ulnar arteriolysis appears to be efficacious at both early and long-term review. When major inflow occlusion exists and digital blood flow is compromised, vascular reconstruction is recommended if possible. We review our treatment protocol in this complex population of patients.

Digital arterial occlusion in scleroderma: is there a role for digital arterial reconstruction?

A 47-year-old patient with Raynaud's phenomenon secondary to scleroderma developed long finger ischaemic pain. This was successfully treated with a palmar sympathectomy and a long finger digital artery reconstruction using a reversed small calibre vein graft between a perforator from the deep palmar arch and the radial digital artery at the level of the distal interphalangeal joint.

Raynaud's Phenomenon

Raynaud's phenomenon may be primary (idiopathic) or secondary. Primary Raynaud's phenomenon is very common in young women, especially in cool climates. Treatment of patients with primary disease is usually much more successful than treatment of patients with secondary disease. Most patients respond to conservative measures. Reassurance that they will not lose digits or limbs is helpful. They should avoid instigating vasospastic attacks, which are usually caused by cold plus pressure on the digits. Reflex sympathetic vasoconstriction can be avoided by wearing warm clothing, including hats. Mittens are more protective than gloves, which separate the fingers. Many patients find chemical hand and foot warmers very useful. Pavlovian conditioning and biofeedback may be helpful if the patient is willing to spend the time. Underlying disease should be treated or instigating causes avoided in secondary Raynaud's phenomenon. In the more severe cases of primary Raynaud's phenomenon as well as in secondary cases, drug therapy is often beneficial. Calcium entry blockers have yielded the best results. Forms of nifedipine with extended action should be prescribed; felodipine or isradipine can be tried if nifedipine cannot be tolerated owing to frequent side effects. When these drugs fail or are not tolerated, sympatholytic drugs (eg, prazosin, reserpine, guanethidine) have benefited some patients. We have not found nitroglycerin preparations to be of benefit. In severe digital ischemia that does not respond to drug therapy, digital artery sympathectomy may help heal digital ulcers. Cervicodorsal sympathectomy is not recommended for upper extremity symptoms, but lumbosacral sympathectomy will often cure vasospastic attacks of the toes.

Prazosin for Raynaud's phenomenon in progressive systemic sclerosis

OBJECTIVES

To determine the effects and toxicity of prazosin versus placebo proposed for the treatment of Raynaud's phenomenon (RP) in scleroderma.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register, and Medline up to December 1996 using the Cochrane Collaboration search strategy developed by Dickersin et al.(1994). Key words included: Raynaud's or vasospasm, scleroderma or progressive systemic sclerosis or connective tissue disease or autoimmune disease. Current Contents were searched up to and including April 7, 1997. All bibliographies of articles retrieved were searched and key experts in the area were contacted for additional and unpublished data. The initial search strategy included all languages.

SELECTION CRITERIA

Randomized controlled trials comparing prazosin versus placebo were eligible if they reported clinical outcomes from the start of therapy. Trials with a greater than 35% dropout were excluded. Trials were included if patients with diffuse or limited scleroderma were the subjects. If patients with other connective tissue diseases or primary Raynaud's were included, the trial was used if the data on the scleroderma patients could be extracted from the paper.

DATA COLLECTION AND ANALYSIS

All data were abstracted by two independent and trained reviewers (DF, AT), and verified by a third reviewer (JP). Each trial was assessed independently by the same two reviewers for its quality using a validated quality assessment tool (Jadad 1996). Peto's odds ratios were calculated for all dichotomous outcomes and a weighted mean difference was carried out on all continuous outcomes. Fixed effects and random effects model were used if the data was homogeneous or heterogeneous, respectively.

MAIN RESULTS

Two trials with a total of 40 patients were included. Prazosin has been found in two randomized controlled cross-over trials to be more effective than placebo in the treatment of Raynaud's secondary to scleroderma. However, the positive response is modest and side effects are not rare in those taking prazosin.

REVIEWER'S CONCLUSIONS

Prazosin is modestly effective in the treatment of Raynaud's phenomenon secondary to scleroderma.

Limited microsurgical arteriolysis for complications of digital vasospasm

Twenty-two digits in seven patients with chronic digital vasospasm were surgically treated after failed medical management. All patients complained of severe ischaemic pain. Chronic digital tip ulceration was present in seven digits and dry gangrene in one. Following surgical microarteriolysis all digital ulcers healed completely. Severe digital ischaemic pain was significantly improved in all digits and completely resolved in 19 of 22 digits.

Raynaud's phenomenon

Raynaud's phenomenon is a common clinical problem occurring in 3% to 5% of the general population. The first symptom of scleroderma is often Raynaud's phenomenon, which is associated with a diffuse small vessel vasculopathy and ischemia and reperfusion injury to skin and other organs targeted in this disease. Current studies support the concept that Raynaud's phenomenon is secondary to a local defect in the regulation of regional blood flow. New evidence demonstrates that there is a profound sensitivity to alpha 2-adrenoceptors mediated vasoconstriction in scleroderma vessels. Traditional treatment of Raynaud's phenomenon is cold avoidance and the use of vasodilators. Oral prostaglandins have shown promise as therapeutic agents.

The role of sympathectomy in current surgical practice

Historically sympathectomy has been employed in the treatment of a variety of disparate disorders but in most there is little if any objective clinical evidence of its efficacy. Review of the literature confirms that sympathectomy provides an effective and permanent cure for hyperhidrosis of the hands and feet, and at present palmar hyperhidrosis is the major indication for its regular use. Sympathetic denervation of the hands is currently most easily achieved with minimal morbidity by thoracoscopic ablation of the second thoracic ganglion. Some evidence testifies to the efficacy of sympathectomy in the rare patients with true major causalgia. Clinical experience suggests that Raynaud's phenomenon in the feet can be usefully ameliorated by sympathectomy but in the hands any benefit is short lived and there is no effect on the prognosis of the disease. A weak case can be made for sympathectomy for ischaemic rest pain when arterial surgery is impractical but there is no reliable evidence to support its use in Buerger's disease, intermittent claudication, diabetic vascular disease or ischaemic ulceration or gangrene.