Lumbar chemical sympathectomy in peripheral vascular disease: does it still have a role?

INTRODUCTION: Lumbar chemical sympathectomy (LCS) is used principally in inoperable peripheral vascular disease (PVD) to alleviate symptoms of rest pain and as an adjunct to other treatments for ulcers. No guidelines currently exist in the UK for its use in PVD. The aim of this study was to evaluate the role of LCS with regard to indications and outcomes in the UK and Irish vascular surgical practice. METHODS: Specifically designed questionnaires were sent to Vascular Surgical Society members. The questions related to their current use of LCS including indications, outcome parameters, use in diabetics and complications encountered. RESULTS: Four hundred and ninety postal questionnaires were sent out and 242 responses (49%) were received. Seventy five percent of the respondents (n=183) felt that LCS had a role in current practice. Seventy eight percent (n=144) performed less than 10 procedures per year and 3% (n=5) more than 20 per year. Eighty percent (n=145) were performed by anaesthetists, 12% (n=23) by radiologists and 8% (n=15) by surgeons. Inoperable peripheral vascular disease with rest pain was the main indication in over 80% of responses with 27% using it for the treatment of ulcers. Only 21% used LCS in diabetics. Clinical improvement was used to assess the outcome following LCS in 96% of responses. Complications included neuralgia, ureteric damage and paraplegia following inadvertent extradural injection. CONCLUSION: Although no clear guidance exists for the use of LCS in PVD, the majority of respondents continue to use it. Indications and outcomes are documented in this study of UK and Irish vascular surgical practice.

Surgical treatment of varicose veins: effect of rationing.

INTRODUCTION: A substantial part of vascular surgical workload is devoted to the treatment of varicose veins. To control demand for cosmetic venous surgery, primary care trusts in Somerset introduced clinical criteria in 2000 for the referral and treatment of varicose veins based on the presence of skin change or ulceration, a history of bleeding, or two or more episodes of thrombophlebitis. PATIENTS AND METHODS: A comparison of workload and case mix for the referral and treatment of new patients presenting with varicose veins to the Taunton and Somerset Hospital was carried out over two 6-month periods, before and after the introduction of clinically based assessment criteria. RESULTS: A total of 134 operations for varicose veins were carried out in 2000 and 85 such operations in 2002/03 after the introduction of new referral criteria (P = 0.001). Of these, 69% (92/134) were day-case procedures in 2000 compared to only 48% (41/85) in 2002/03 (P = 0.004). There was no significant difference in the type of cases (e.g. single, bilateral or recurrent surgery) performed as a day-case (P = 0.34) or as an in-patient (P = 0.43) over the two periods. There was, however, a significant difference (P = 0.007) in the mean ages of patients in the two periods (48.5 years in period 1; 57.8 years in period 2) and in the average ASA grade (1.15 in period 1; 1.42 in period 2; P = 0.0002). CONCLUSION: The introduction of clinical criteria for the referral and treatment of varicose veins reduced workload by 37%.