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When should a digital sympathectomy be considered in patients with Raynaud phenomenon, and what are the benefits and risks of the procedure?

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The first reports of digital sympathectomy, used for the treatment of a variety of ischemic conditions involving the hands and feet (most notably Raynaud phenomenon), appeared in the early 1980s. The procedure involves removing the adventitial tissue around the culprit digital arteries using microscopic surgical techniques, and it is best done by expert hand surgeons, such as those who perform the procedure here at Hospital for Special Surgery.

Sympathetic nerve fibers that can cause vasospasm of the digital arteries course through the adventitial layer of the vessels. The term digital sympathectomy itself was coined to describe the disruption of sympathetic innervation that results from removal of this tissue. However, recent research done here at HSS suggests that this is only one effect of the procedure. We believe that the removal of fibrotic adventitial tissue that mechanically constricts the vessel itself is a more important benefit. Accordingly, we call the procedure by the more descriptive term adventitial stripping.

Digital sympathectomies/advential strippings are salvage procedures that should be considered only when more conservative therapies for Raynaud phenomenon - such as behavioral modification (especially smoking discontinuation), vasodilators, anticoagulants, and other non-invasive interventions - have been tried and failed or when there is a particular digit that appears to be imminently at risk for loss of tissue. Even after surgery, these therapies should continue to be employed.

Raynaud phenomenon is usually a benign condition that only rarely becomes severe enough to warrant adventitial stripping. Only those with scleroderma and other collagen vascular diseases will typically develop the degree of ischemia that would require this type of procedure.

The benefits of adventitial stripping are the re-establishment of perfusion to the ischemic digit(s) and the preservation of tissue at risk.

The most common adverse effects are occasional numbness and post-surgical pain, which usually resolve after several weeks to months. Further risks include failure of the procedure to provide benefit, post-operative infection and poor wound healing that are inherent in this population, and severing the blood vessel. When the procedure fails, sometimes ischemia becomes so severe that it requires amputation of part of the digit.

No controlled studies of the outcomes of adventitial stripping or digital sympathectomy have been performed. In general, our patients who have undergone the procedure have done well over the course of months to years, although patients with illnesses such as scleroderma or other collagen vascular diseases may have recurrences due to continued underlying disease.


Headshot of Arthur M. F. Yee, MD, PhD
Arthur M. F. Yee, MD, PhD
Assistant Attending Physician, Hospital for Special Surgery
Assistant Professor of Medicine, Weill Cornell Medical College

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