SIR 2024
Arterial Interventions and Peripheral Arterial Disease (PAD)
Sasicha Manupipatpong, MD (she/her/hers)
Integrated Diagnostic and Interventional Radiology Resident
Johns Hopkins University
Financial relationships: Full list of relationships is listed on the CME information page.
Mark L. Lessne, MD, FSIR
Vascular and Interventional Radiologist
Charlotte Radiology
Financial relationships: Full list of relationships is listed on the CME information page.
To review the mechanism of action and indications for lumbar and thoracic sympathectomy. To discuss the key technical elements of CT-guided lumbar and thoracic sympathectomy, including possible complications and strategies to minimize them.
Background:
Critical limb-threatening ischemia is the most severe form of peripheral arterial disease (PAD) for which surgical revascularization is the gold standard of treatment. However, in patients for whom this is not an option and in whom other modalities of treatment have failed, lumbar sympathectomy is an important treatment modality that can help relieve ischemic rest pain and avoid progression to amputation. {1} Further, patients with ischemia of the upper extremities, as in advanced scleroderma or Raynaud’s, may similarly benefit from CT-guided thoracic sympathectomy.
Clinical Findings/Procedure Details:
The mechanism of action in CT-guided sympathectomy is to provide targeted ablation of the sympathetic ganglia in either the lumbar or thoracic spine, with the goal to decrease vasomotor tone and afferent pain signals, thereby leading to vasodilation and symptomatic relief.
Although indications vary by institution, generally, patients considered for CT-guided lumbar sympathectomy are those with severe ischemic rest pain and non-reconstructable PAD. {3} As complications can include genitofemoral neuralgia, renal injury, and paralysis, we will discuss careful technique and the rationale for each step, as well as choice of neurolytic agent. Success rates described in literature range from 30-87%. {4}
CT- guided thoracic sympathectomy is not as well established, but has recently gained popularity for the treatment of dysautonomia and hyperhidrosis. {5} Surgical thoracic sympathectomy has long been used in Raynaud’s syndrome to preserve tissue and avoid amputation. {6} Institutionally, we have used CT-guided thoracic sympathectomy in patients with digital ischemia in the setting of vasculitis as well as advanced scleroderma, and for palmar hyperhidrosis.
Conclusion and/or Teaching Points:
Percutaneous CT-guided sympathectomy to promote vasodilation in the setting of distal limb ischemia is an important treatment to consider for patients in whom conservative, surgical, and/or endovascular treatments are not possible or have failed, with reported complication rates of less than 1%. {4}