Effect of lumbar sympathectomy on the lower extremity.

1. Lumbar sympathectomy creates a state of vasodilatation equivalent to physiological vasodilatation of daily living; however, after sympathectomy, vasodilatation is permanent and irreversible. 2. This vasodilatation is characterized at rest by a preferred distribution of blood to the skin and to subcutaneous cellular tissue of the lower extremity, foot and toes. 3. This vasodilatation, although permanent, does not interfere with increased output to muscles at work. They benefit by a particular mechanism of metabolic vasodilatation (Fig. 6). 4. Lumbar sympathectomy has a beneficial effect on the collateral compensatory circulation of an obliterated large artery. This effect is induced by suppression of the peripheral resistance, and thus, by increasing the pressure gradient. 5. The vasodilatation obtained by intravenous injection of pentothal is qualitatively the same as that which follows a lumbar sympathectomy. The test with pentothal, because of this action, is an excellent method for prognosis and control of lumbar sympathectomy effects.

Lumbar sympathectomy in occlusive diseases.

To assess the real value of Lumbar Sympathectomy it is of prime importance to be aware of both the mechanisms of the neurogenic vasomotricity in a normal limb, and the effect of a sympathetic interruption on a normal and arteriopathetic limb. These mechanisms are studied and discussed by means of different vascular functional tests and results of operative procedure. It leads to identify the patients who are likely to respond well to sympathectomy either for distal skin troubles, or for claudication.

The sclerosing therapy in congenital vascular defects.

In most of the cases of angiodysplasias sclerotherapy is a palliative treatment. Its aim is to alleviate some disgracious consequences of secondary venous insufficiency caused by the primary malformation. Nevertheless sclerotherapy can be proposed to cure some primary malformation radically such as small venous angiomas or to reduce extensive angiomas before a surgical procedure.

[Indications for venous thrombectomy]. / Indications de la thrombectomie veineuse.

Thrombectomy has a place in the treatment of acute venous thrombosis. However, this is only the case in certain conditions. Its use is indisputable in true blue venous thrombosis which is a rarely occurring pathology. It may be proposed and discussed for recent thrombosis, of a known and correctable cause, blocking one or several important venous channels in a patient likely to develop an invalidating postthrombotic syndrome.

[Velocimetry and sympathectomy]. / Vélocimétrie et sympathectomie.

In a previous work, the writers have described the influence of vasomotoricity on the shape of the ultrasonic velocimetric curves (Doppler). A vasodilatation induced by an anaesthesia of the sympathetic chain or by a general anaesthesia by penthotal produces a raising of the whole curve above the basic line. The writers have studied in the present work the shape of the velocimetric curves after a lumbar sympathectomy and have compared them with the variations of the cutaneous thermometry and with the clinical results. A correlation has been found in 86.3% of the 124 studied limbs. The study shows that the raising of the curve due to the phenomenon of vasodilatation appears only at the extremity of the limb. The profile of the curve remains unchanged at the root. A velocimetric curve above the basic line may occur apart from any vasomotoric modification. In this case it is the sign of an up-stream obliteration combined with a drop of the index of perfusion (less than the unit).

[False aneurysm appearing 20 years after repair of a subisthmic stenosis of the thoracic aorta (author's transl)]. / Faux anévrisme, vingt ans après correction d'une sténose sous-isthmique de l'aorte thoracique.

A patient with atypical subisthmic stenosis of the thoracic aorta was treated by resection of the constriction and reconstruction with a Dacron prosthesis. Clinical recovery lasted for 20 years but the appearance of a false aneurysm required further operative intervention. The etiology of atypical stenoses, the resisting properties of Dacron prostheses, and the formation of false aneurisms are discussed.

[Complications of lumbar sympathectomy. Retrospective study of 791 patients]. / Les complications de la sympathectomie lombaire. Etude rétrospective de 791 malades

The purpose of this paper is to define the nature and the frequency of post-lumbar sympathectomy complications and to reappreciate their importance in the evaluation of operative indication. The non specific miscellaneous complications are no more frequent than after any other lombotomy. The specific complications occur in less than 10%; they are almost always transient. Prolonged paralytic ileus is related to post-operative hematoma in retroperitoneal space. Ejaculation disturbances are produced either by bilateral resection of one of the two first lumbar ganglian or by section of the intermesenteric plexus, the presacral nerves or the hypogastric nerves during associated dissection of the aortic bifurcaiton. Late neuralgia is probably induced by retroperitoneal hematoma; its size increases gradually during the postoperative period by transference of tissue fluids. In conclusion, the morbidity and the morbidity rates of lumbar sympathectomy are remarkably low; these are not arguments against the lumbar sympathectomy.

[Forecasting of the effects of lumbar sympathectomy by the radiothermometry with pentothal (author's transl)]. / Prévision des effets de la sympathectomie lombaire par le test radiothermométrique au pentothal

This test has been previously described and is used routinely by the authors since 1960. The method is based on the alternate arterial blood distribution between skin and muscle of a limb, depending on modifications in the vasomotor tone. Skin temperature, arteriography and progression speed of the contrast medium are measured simultaneously. The test shows the morphology of the arterial lesion. It measures vasomotor reserve by these parameters, especially the skin temperature, before and after administration of pentothal. Results are rated as good, average and poor. The authors have compared this test, performed before surgery, to the results of lumbar sympathectomy and found an excellent correlation. Late result of lumbar sympathectomy can thus be foreseen by means of this test provided no new organic lesion interferes with the hemodynamics of the limb.