Introduction

Lumbar sympathectomy was introduced by the Argentinian professor Julio Díez almost a century ago, for the treatment of Tromboangiitis Obliterans in the lower extremities¹.

This surgical technique was widely accepted and enjoyed diffusion among all surgical schools from the second third of the twentieth century, due to the absence of other alternative therapies for patients with peripheral artery diseases with risk of limb loss^2-6; its practice was generalized for several decades, based on two fundamental premises: its undeniable hyperemiant action⁷ and the absence of other alternative therapies for patients with peripheral artery diseases, when amputation was considered the only surgical alternative to sympathectomy.

The advent and developement of reconstructive arterial surgery made lumbar sympathectomy fall into disuse^8,9; nowadays this technique is practically abandoned and even it's unknown for mostly of young vascular surgeons.

Case report

A female, thirty-nine year-old, was admitted at the emergency department of our hospital due to a five month clinical onset of gemelar claudication, coldness, tightness in the sole and paraesthesia in the toes of the left foot; the patient had been previously diagnosed as Morton's Neuroma and had been treated with corticoid infiltrations by the Ortopedic Department of her local hospital without improvement.

At the time of her admission into our service, she presented a necrotic lesion on the first toe, and an interdigital lesion between first and second toes of the left foot with lymphangitis (Figure 1a); she had not temperature, but referred rest pain.

Figure 1a Ischemich foot at time of admission. 

Vascular examination showed a weak left popliteal pulse and absence of distal pulses in this extremity, while were present in the right lower extremity. There was also, no Doppler signal in the left foot, all it in the context of critical limb ischemia Rutherford 6.

Medical treatment was initiated with low molecular weight heparin at full dose and intravenous prostaglandin E1 (three week cycle), analgesia, suspension of hormone treatment and debridement on the foot wound.

After ruling out other causes of ischemia (embolic and auto-immune), a selective angiography of the left femoropopliteal sector was carried out; an occlusion was identified at the level of the second portion of the popliteal artery, without average distal outflow, but with abundant colateral circulation in this leg (Figure 1b). Intra-arterial fibrinolytic therapy with urokinase was tried without any success.

Figure 1b Selective angiography of the left femoropopliteal sector: occlusion at the second portion of the popliteal artery, abundant colateral circulation in the leg without a a adecuate vessel of distal outflow. 

The evolution of the ischemia lesions were unfavourable despite vasodilatory and debridement treatment, and due to the impossibilty of carrying out direct revascularization surgery, a left lumbar sympathectomy was done; the patient soon experienced a local improvement in the temperature of the foot, relief the rest pain and the foot wounds also slowly started to improve (Figure 2a). Now, at seven years of follow-up, the patient is asymptomatic, without claudication (Figure 2b).

Figure 2a Left foot currently healed without signs of critical ischemia. 

Figure 2b Improvement of the foot wounds after lumbar sympathectomy. 

Discussion

Since the discovery of the vasomotor nerves by Claude Bernard in 1851, the idea of sympathetic denervation in order to treat ischemia in extremities stimulating arterial vasodilatation was an objective pursued by all the angiologists of the time. The first to try it was René Leriche, who proposed a periarterial sympathectomy in 1913, but with bad results. The Argentinian Julio Díez carried out the first lumbar ganglionectomy with good clinical results in 1924, and he continued treating diverse patients with this technique, until 1931, when he published his results in the Journal de Chirurgie¹.

It is estimated that the total length of all the microvessels of a man can reach 100.000 km and a total surface area of about 6.500 m ; around 20% of the total correponds to the lower extremities, based on Burton's studies¹⁰; for this reason, lumbar sympathectomy can be used as an alternative route to vascularize the ischemic tissues, especially in patients who aren't affected by medical diabetes, in whom the very metabolic neuropathy limits the vasodilatory response to sympathetic denervation¹¹.

For several decades, Diez's sympathectomy was the only tool for management of limb ischemia until the advent of direct arterial surgery; Cid Dos Santos described thromboendarterectomy in 1946¹² and two years later Jean Kunlin advocated derivative surgery¹³, so hyperemiant surgery was forgotten until the point reached today, when it's an obsolete technique, unknown by mostly of young vascular surgeons and those in training.

One main weakness of lumbar sympathectomy is the absense of solid trials because it's decline coincided with the boom of Based Evidence Medicine¹⁴; with the advent of new compassive treatments to approach the critical ischemia like stemcell technique¹⁵ and the poor knowledge of lumbar sympathectomy, it's difficult that new evidence will be published in the future. However, lumbar sympathectomy can have a role in few patients where revascularization is not viable.

Conclusions

Lumbar sympathectomy is a feasible technique with low risk of complications; it can be done in specific scenaries of critical limb ischemia and can be resolutive in expertal hands as a resource technique, when standard techiques or other compassive procedures had been discarted. The knowledge of this technique can mean the difference between patient limb salvage or not, so lumbar sympathectomy should be on mind of any vascular surgeon.