What surgical options can be performed for patients who are refractory to standard therapy?
Chemical sympathectomy via a digital lidocaine block can be performed promptly in the office for patients with acute episodes of ischemia and pain; this may provide lasting benefit beyond the temporary relief of the anesthetic. Chemical sympathectomy with botulinum toxin A has been described as well, but data on efficacy is conflicting. Recently, a small randomized trial failed to show clear benefit.
Surgical sympathectomy may be considered in patients in whom more conservative measures have failed and who are at high risk for digital necrosis and other ischemic complications. It is commonly performed at either the superficial palmar arch, the common digital arteries, or the radial and ulnar arteries. Sympathectomy may not provide long-lasting benefit.
The majority of patients with secondary RP due to SSc have vascular disease that is prominent at the level of the palmar arch and distal digital arteries. However, a small subset may have proximal vessel compromise that is discovered by an abnormal Allen’s test. In this setting, angiography to identify occult disease at the ulnar artery (or less commonly the radial artery) should be performed to determine if the patient would benefit from surgical revascularization.
In patients presenting with dry gangrene of a digit, it is preferable to avoid surgery if possible and allow the necrotic area to clearly demarcate from viable tissue proximally. Allowing the digit to autoamputate preserves the greatest length possible of the involved finger and avoids surgery at a site with compromised blood flow. Surgical resection may be required in some patients with concern for infection and/or intractable pain.
