Lumbar sympathectomy (LS), whether performed surgically, laparoscopically, or through image-guided chemical neurolysis, was historically used to relieve pain and improve distal perfusion in patients with peripheral arterial occlusive disease (PAOD) who were not candidates for revascularization. With the advent of advanced endovascular and surgical revascularization techniques, the role of LS has narrowed considerably. This narrative review explores the historical evolution, mechanisms of action, various techniques, contemporary evidence, current indications, clinical outcomes, complications, and guideline recommendations regarding LS in the management of PAOD. High-quality randomized evidence supporting the use of LS, particularly in chronic limb-threatening ischemia (CLTI), is lacking. A Cochrane review found no eligible randomized controlled trials (RCTs) comparing LS with no treatment or among different LS techniques, while another found low-quality evidence favoring prostanoids over open LS in Buerger’s disease. However, recent retrospective studies on computed tomography-guided chemical LS and laparoscopic LS report meaningful relief of rest pain and short-term limb salvage in carefully selected, non-reconstructable patients, with low peri-procedural morbidity. Current guidelines do not advocate routine use of LS but recognize its palliative role in “no-option” CLTI. LS today is best considered an adjunctive, palliative measure for patients with CLTI who lack revascularization options, including those with Buerger’s disease, to relieve rest pain, promote minor ulcer healing, and potentially delay, or reduce the extent of amputation. Image-guided chemical or minimally invasive approaches are preferred . Prospective studies with standardized outcomes are needed to better define its role.
Pai et al. (Wed,) studied this question.