Endoscopic thoracic sympathectomy in the treatment of severe Raynaud's disease

To evaluate the results of endoscopic thoracic sympathectomy in severe cases of Raynaud's disease after medical treatment failure, with particular reference to the complications, safety and the effectiveness. We performed 22 endoscopic thoracic sympathectomies in 16 patients [12 males and 4 females] with severe Raynaud's disease after medical treatment failure. Their ages varies between 23 to 41 years. 10 patients underwent a unilateral endoscopic thoracic sympathectomy procedures, whereas 6 patients with bilateral symptoms underwent staged endoscopic thoracic procedures several weeks a part. Of the total 22 affected hands: 4 [18.18%] had severe intractable hand pain; 10 [45.45%] had trophic ulcers associated with terminal digital necrosis and 8 [36.36%] had gangrene of finger tips. All patients were evaluated clinically by history taking and physical examination as well as routine laboratory and radiological screening tests. All patients were carefully counseled on the potential complications of the procedure. We performed 22 endoscopic thoracic sympathectomy procedures [10 unilateral and 6 bilateral]. The mean post operative hospital stay was 1 day. The post-operative follow up ranged between 3 and 12 months with a mean of 6 months as regard to pain relief, healing of ulcers and spontaneous separation of gangrenous parts. There was no mortality and no serious morbidity detected in this study. The 4 hands [18.18%] with severe intractable hand pain were improved completely. Of the 10 hands [45.45%] with trophic ulcers associated with terminal digital necrosis, complete healing of ulcers as well as trophic lesions occurred in 8 of them [36.36%] while no healing detected in the remaining 2 hands [9%]. Of the 8 hands [36.36%] with gangrene of finger tips complete improvement of lesions and clear demarcation of the gangrenous parts occurred in 6 hands [27.27%] and the remaining 2 hands [9%] required later amputation at one or more distal inter-phalyngeal joint. Horner's syndrome occurred in 2 patients [12.5%] resolved in the first patient at 4 weeks and in the second patient at 4 months. Intercostal neuralgia detected in 2 patients. In one of them it appeared immediately after the operation, but in the 2nd it appeared 3 weeks later. The postoperative chest radiograms showed only a slight residual pneumothorax in one patient [6.25%] and non in the remaining cases. Endoscopic thoracic sympathectomy is safe-easy, reliable and effective way in the treatment of patients with severe Raynaud's disease after medical treatment failure

Outcome after distal revascularization and interval ligation [DRIL] for the tratment of dialysis-associated steal synrome

The purpose of this study was to determine the efficacy and durability of the distal revascularization and interval ligation [DRIL] procedure in relieving hand ischemia and in maintianing access patency in the setting of hemodialysis access-induced ischemia. The traditional operative treatment for ischemic steal intervention syndrome related to a functioning dialysis access arterio-venous fistula [A/V fistula] usually result in inconsistent limb salvage, loss of access function or both. This study describes the "DRIL" technique for correction of ischemic steal syndrome occurring as a complication of A/V fistulas. The study was conducted on 20 patients with a functioning upper extremity A/V fistulas associated with ischemic steal syndrome and treated by "DRIL" procedure at El Hussein University Hospital, Vascular Surgical Unit. The indications for surgery were ischemic hand pain in 9 patients [45%], tissue loss in 7 patients [35%], loss of neurologic function in 2 patients [10%] and pain during hemodialysis in 2 patients [10%]. The surgical technique used consisted of ligation of the brachial artery distal to the inflow anastomosis to the fistula and bypass graft from the brachial artery 5cm above the fistula by end to side anastomosis to a point just distal to the A/V anastomosis. The bypass material used in these patients was synthetic polytetrafluroethylene grafts [PTFE grafts] 6 mm in diameter. Of total 20 patients with ischemic steal syndrome affecting the upper extremities occurred after A/V fistulas treated by "DRIL" procedure, their ischemic symptoms improved immediately after surgery in 18 patients [90%]. The primary patency of the brachial artery bypass was 90% and the patency of A/V fistulas was 85% at 1 year. The "DRIL" technique is effective in alleviating symptoms of ischemic steal syndrome and preserving the hemodialysis access. It is considered as: the procedure of choice for correction of ischemic steal syndrome induced by A/V fistulas