FAILED VASCULAR RECONSTRUCTIVE PROCEDURES WITH PROFOUNDLY ISCHEMIC LIMBS - TREATED BY LUMBAR SYMPATHECTOMY

The purpose of this study was to assess the impact of lumbar sympathec tomy on limb loss in patients with prior reconstructive vascular surge ry. One hundred and one patients underwent 118 lumbar sympathectomies. The 118 limbs were grouped presympathectomy into: rest pain (41), tis sue breakdown (55), and gangrene (22). All vascular procedures were fe moral-popliteal or femoral-distal bypass. No change in segmental Doppl er pressures occurred after lumbar sympathectomy. Sixty-nine of 118 (5 8%) limbs underwent amputation following sympathectomy, a mean of two (range: one to twenty-two) months following the procedure. Of those li mbs with an amputation (69/118), 14/69 (20%) had one reconstructive pr ocedure, 41/69 (60%) had two reconstructive procedures, and 14/69 (20% ) had three reconstructive procedures. Of those without an amputation (49/118 limbs), 27 had one vascular reconstructive procedure, 9 had tw o reconstructive procedures, and 3 had three reconstructive procedures before sympathectomy. Of the patients with diabetes (47), 44/47 (94%) underwent amputation, 35/44 (80%) with below-the-knee and 9/44 (20%) with above-the-knee amputation. Limb loss (69 limbs) by category was: rest pain, 21/41 (51%); nonhealing ulcers, 38/55 (69%); and gangrene, 10/12 (83%). Lumbar sympathectomy may be a useful procedure in very se lected patients; diabetic patients who undergo reconstructive vascular surgery are not good candidates. Segmental Doppler pressures do not h elp predict successful or improved outcome following lumbar sympathect omy.