Articles - Research relating to ETS

thromboangitis, lupus erythematosus, dermatomyositis), trauma, iatrogenic, and others [14] When ischemia be comes severe and causes constant pain and loss of tissue, appropriate treatment is necessary. Medical treatment and local tissue care are usually unsuccessful, and in this subset of patients, sympathectomy can represent an effective procedure to control pain, to help ulcer healing, and to prevent or delay amputation. Before the advent of VAT, thoracic sympathectomy was performed only in highly selected patients because of its invasiveness, and often sympathectomy for upper limb disorders was accomplished by the anterior cervical route. Thoracic sympathectomy has been substantially improved with the use of VAT, which offers better exposure and visualization of the anatomical structures with less surgical trauma. Unlike Raynaud’s disease, that usually relapses after sympathectomy, secondary Raynaud’s phenomenon and ischemia, both due to arterial occlusion, improve significantly after thoracic sympathectomy [15]. Pain control, ulcer healing, and demarcation of necrosis appear to be much more related to post surgical correction of abnormal arteriovenous shunting and to improved nutritional blood flow to ischemic areas than to the increase of total blood flow [9]. Thoracoscopic sympathectomy is considered in most cases as the last resort to prevent extensive amputation. In our experience, the results in terms of symptoms improvement, ulcer healing, and prevention or delay of amputation were satisfactory, with a low rate of complications even in patients with higher surgical risk. Thoracoscopic sympathectomy, after unsuccessful medical treatment, proved effective even in 3 patients who developed severe acute ischemia due to intra-arterial injection of illicit substances. In these cases, peripheral ischemia is due to the direct toxicity of the injected drug to the vascular endothelium [16], particulate emboli altered pH with crystal formation [17, 18], increased platelet aggregation, thromboxane release, and vasospasm sympathetic mediated [19]. The combination of these effects can lead to irreversible tissue destruction. Sympathectomy in these cases proved to be helpful, and even when amputation is necessary, it may be delayed until a clear demarcation of necrosis is obtained, allowing the preservation of the maximal viable tissue.

In conclusion, we believe that thoracoscopic sympathectomy in patients with severe ischemia of upper limb extremities permits optimal symptom control and maximum tissue salvage. Because the procedure is minimally invasive, safe, and associated with a low rate of complications, it should be considered earlier in the natural course of this disease.