Revisiting Lumbar Sympathectomy in Unreconstructable Peripheral Artery Disease
Jason E. Cohen, M.D., Nadia Awad, M.D., Evan Deutsch, M.D., Rashad Choudry, M.D..
Albert Einstein Medical Center, Philadelphia, PA, USA.
OBJECTIVES: Treatment of advanced peripheral artery disease (PAD) is predicated on endovascular and surgical revascularization. Certain lesions may be unreconstructable due to anatomic factors, extent of disease, or medical comorbidities. In such cases, lumbar sympathectomy may slow disease progression and improve symptoms. Our study reviews outcomes of patients with unreconstructable PAD treated with chemical lumbar sympathectomy.
METHODS: In this single-center, retrospective study, the electronic medical record (EMR) was queried for patients with confirmed PAD that underwent chemical lumbar sympathectomy from September 2017 to September 2018. Baseline demographic, medical, and surgical characteristics were tabulated. Evaluations based on our institutional protocol for PAD (Figure 1), which includes baseline symptomatology, ambulatory status, surgical risk assessment, and radiologic findings, were reviewed for each patient. Finally, clinical outcomes, including level of pain, narcotic requirements, and complications within one month, were assessed post-procedure.
RESULTS: Three patients, two men and one woman, were identified. Amongst the three patients, mean age was 65.3 years (59-69), and mean BMI was 19.2 (17.5-22.2). All patients had a history of smoking and hypertension. Other co-morbidities included end-stage renal disease, cardiomyopathy, chronic obstructive pulmonary disease (COPD), and atrial fibrillation. One patient had previous common femoral to popliteal arterial bypass of the affected limb. One patient had multiple previous endovascular angioplasty procedures and common femoral to popliteal arterial bypass of the affected limb. All three patients presented with unilateral rest pain, were ambulatory at baseline, but were considered non-candidates for re-vascularization based on CT-angiography (CTA) and formal angiographic findings. After chemical lumbar sympathectomy, all patients initially reported improvement in pain. One patient reported recurrent rest pain and subsequently underwent above the knee amputation within one month post-procedure. All three patients had a reduction in narcotic use post-procedure.
CONCLUSIONS: Lumbar sympathectomy may improve symptoms and reduce narcotic requirements in patients with unreconstructable PAD. Future studies should focus on longer-term follow-up and delineate which specific factors may be associated with improved outcomes after lumbar sympathectomy. 
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