Peripheral Arterial Disease (PAD) Expert Forum
Is Sympathetic Nerve Block advisable for PAD induced by vasculitis?
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Is Sympathetic Nerve Block advisable for PAD induced by vasculitis?

I have been diagnosed with Polyarteritis Nodosa, and have had an aortagram done which shows chronic damage to the two rear arteries from the knee to the foot (they are "gone") on both legs, and the anterior artery in my left lower leg seems to stop at the ankle.  I have neuropathy in the left foot, very poor circulation - apparently it is being fed only by collateral vessels.  There is numbness, tingling, burning, pain in the toes that comes and goes; it is colder then the other foot, sometimes white, although it turns purplish when standing.  In a horizontal position, it remains more pink to red and pain is lessened.  The interventional radiologist who did the aortagram said there was nothing he could do to reopen the blocked arteries, saying they were probably now scar tissue.  The aortagram was done about 1.5 weeks after I first noticed symptoms in the foot.  I have been advised by two vascular surgeons, both of whom are against surgery saying the risk of losing the foot from surgery is not currently justified, since the foot is still viable.

However, one of the vascular surgeons offered to do a lumbar sympathetic nerve block to see if circulation to the foot improves.  If so, he would repeat several times to confirm, then cut the sympathetic nerve so the leg artery is always wide open.  But, the other vascular surgeon advised against this saying that the effects are temporary, that the body somehow finds another way to reestablish the sympathetic nerve function, and this procedure is now frowned upon.  Is this correct?  My feeling is that even if the effect is temporary, it may improve circulation enough to help new collateral vessels form or enlarge.  Is there any significant downside to trying this?  Is it a bad idea?

Also, if the nerve is cut, what are the unwanted consequences?  Would the whole sympathetic chain be severed, or only the part that controls the target arteries?

Thanks for your help.  Hoping to save my foot.
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Hello
First let me say that medicine is an art not a science. The arteriogram is a roadmap study. It provides information about the pathways that are open.It it usually preceded by a test called arterial doppler, pvr or abi. These test provide more information about the severity of blockages and the physioloic consequences. The test in combination along with your symptoms help the doctors determine how severe your problem is.

Intermittent numbness tingling and burning can be caused by nerve problems or poor circulation. either, or and sometimes both in combination. Do you have diabetes and are you a smoker

There are two indications for sympathectomy. A small toe ulcer when no bypass or other way to improve circulation is possible or when someone has persistent pain in the foot from poor circulation

Sympathectomy is usually not recommended for diabetic patients, because there nerves have already been reduced in function by the diabetes.

Both surgeons have a point. One option would be to try a pharmacologic block to see if there was improvement in your symptoms followed by surgical nerve block. On the other hand the symptom improvement after sympathectomy can sometime be short lived.

the sympathectomy does not help create new collateral form. in theory it allows your current vessels to dilate and permit and incremental increase in blood flow

the key is to assess how severe your circulation is impaired. Discuss the options with your doctors, ask a lot of questions and come to a good understanding of the treatment pros and cons. Good luck
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Lee Kirksey, MDBlank
The Cleveland Clinic Foundation
cleveland, OH
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