CT-Guided Chemical Thoracic Sympathectomy versus Botulinum Toxin Type A Injection for Palmar Hyperhidrosis.

BACKGROUND: The present study aimed to evaluate and compare the efficacy of botulinum toxin type A (BTX-A) injection versus thoracic sympathectomy for idiopathic palmar hyperhidrosis. METHODS: Fifty-one patients with idiopathic palmar hyperhidrosis were treated with either BTX-A injection or thoracic sympathectomy between March 2013 and April 2016. The severity of palmar hyperhidrosis was qualitatively measured via the Hyperhidrosis Disease Severity Scale (HDSS). All patients completed a questionnaire that detailed the time taken for the treatment to work, local or systemic adverse effects, and pre- and post-treatment severity of hyperhidrosis. The efficacy and adverse effects of the two treatments were compared and analyzed. RESULTS: Hyperhidrosis-related quality of life improved quickly and significantly in the BTX-A group (26 patients) and the sympathectomy group (25 patients). Compared with pre-treatment, the HDSS score significantly reduced after treatment in both groups (p < 0.05). All patients in the sympathectomy group had cessation of sweating of the hands after treatment, and this curative effect lasted for 12 months. In contrast, the treatment took more time to work in the BTX-A group, and the curative effect lasted for a much shorter period (3 months). The sympathectomy group had a significantly lesser mean HDSS score than the BTX-A group at 1 week, 3 months, 6 months, 9 months, and 12 months after treatment (p < 0.05). The sympathectomy group experienced more complications than the BTX-A group. CONCLUSION: For palmar hyperhidrosis, thoracic sympathectomy is more effective and has a longer lasting curative effect than BTX-A injection, but thoracic sympathectomy has more complications.

Chemical lumbar sympathectomy in the treatment of recalcitrant erythromelalgia.

OBJECTIVE: Erythromelalgia is highly disabling and treatment is often very challenging. There have been solitary case reports that it might benefit from sympathectomy. This study sought to evaluate the short-term and long-term efficacy of chemical lumbar sympathectomy (CLS) for treatment of recalcitrant erythromelalgia and try to identify a CLS-responsive subset. METHODS: Patients with recalcitrant erythromelalgia were recruited from a tertiary hospital over a 10-year period. L3 to L4 CLS was performed using 5% phenol. The pain intensity score (visual analog scale [VAS] 0-10) was assessed before CLS and at 1 day, 1 week, 3 months, 6 months, 1 year, and 2 years after CLS. A VAS decrease of 90%-100% is defined as complete response, 60%-89% as major partial response. Relapse was defined by a return of a VAS score of 5 or higher. SCN9A gene mutations were screened. RESULTS: Thirteen patients were enrolled, with a median age of 15 years. The mean follow-up was 6.2 ± 3.8 years. SCN9A gene mutation was identified in five patients having family histories. The VAS was 8.2 ± 2.0 at baseline; it decreased to 4.9 ± 2.7 at 1 day and 1.9 ± 3.0 at 1 week after CLS. Nine patients (69.2%) achieved complete response at 1 week after CLS, including three patients with SCN9A gene mutation. Among the three complete response patients having the gene mutation, two reverted to major partial response and one relapsed at 2 years after CLS. Among the six complete response patients without mutation, five maintained complete response and one relapsed. Among the four patients who did not achieve complete response, one patient died at 3.5 months and one patient had an amputation performed at 4 months after CLS. CONCLUSIONS: CLS provides a valid option for the treatment of recalcitrant erythromelalgia. It takes about 1 week to achieve full efficacy. Relapse may occur, especially in patients with an SCN9A gene mutation.

Treatment of compensatory hyperhidrosis after sympathectomy with botulinum toxin and anticholinergics.

PURPOSE: Compensatory hyperhidrosis (CH) is the most common adverse complication of sympathectomy. It often has a major negative impact on life quality. No efficient treatment of CH is available. We report nine cases of CH after sympathectomy, which were treated with botulinum toxin A/B (BTX) and anticholinergics. METHODS: The patients responded to a dermatology life quality index (DLQI) questionnaire before injections with BTX and 3 weeks after treatment. At the follow-up visit, the participants also ranked the effect of the treatment on a five-grade scale. Three patients had residual sweating after BTX treatment, and received additional anticholinergics at the follow-up visit. Those subjects eventually had a third evaluation with the DLQI. RESULTS: The DLQI score was, on average, 16.4 before treatment and decreased to 4.8 after BTX injections. Eight out of nine patients were satisfied with the treatment. The average DLQI score decreased to 2.2 when the patients with residual sweating (n = 3) received additional anticholinergics. Adverse events from BTX were mild and temporary, but dry mouth was substantial in one patient using anticholinergics. CONCLUSIONS: A combination of BTX A/B and anticholinergics alleviated the hyperhidrosis with minor side-effects. We consider this treatment safe, effective, and well tolerated.

Denervation of capsaicin-sensitive C fibers increases pulmonary inflammation induced by ischemia-reperfusion in rabbits.

BACKGROUND: Capsaicin-sensitive C fibers (CapsCF) are abundantly distributed in the respiratory tract. Inflammation is one of the main contributors to lung ischemia-reperfusion (IR) injury. This study was designed to investigate the role of CapsCF in lung IR-induced inflammatory response. METHODS: Thirty-two male rabbits were randomized into four groups as follows: sham group (S), IR group (IR), large dose of capsaicin plus sham group (CS), and large dose of capsaicin plus IR group (CIR). The CS and CIR groups were pretreated with capsaicin (100 mg/kg) to induce functional ablation of CapsCF. The IR and CIR groups were subjected to 1 h lung ischemia and 3 h reperfusion. Thereafter, blood and lung tissue samples were obtained for blood gas and biochemical analyses. Levels of substance P and calcitonin gene-related peptide (CGRP), lung wet-to-dry weight ratio, and histopathologic changes as well as neutrophil counts in bronchoalveolar lavage fluids were also assessed. RESULTS: Capsaicin pretreatment in the CIR group resulted in increased lung wet-to-dry ratio, neutrophil counts in bronchoalveolar lavage fluids, and lung pathologic lesions, along with higher levels of plasma tumor necrosis factor α and interleukin 8 and lower level of interleukin 10 (P < 0.05 versus IR), although capsaicin did not alter the above variables in the CS group (P > 0.05 versus S). Lung tissue CGRP was elevated more than 2-fold in the IR group (P < 0.05 versus S), but it did not significantly change in the CIR group. CONCLUSION: Denervation of CapsCF aggravated lung IR-induced inflammation, probably by depleting the CGRP content of CapsCF. CapsCF may protect against lung IR-induced inflammation and injury.

Renal Sympathetic Denervation by Image-Guided Percutaneous Ethanol Injection - Histopathologic Characteristics, Efficacy and Safety.

PURPOSE: Evaluation of the efficacy and safety of chemical renal denervation by image-guided periarterial ethanol injection in pigs with emphasis on histopathological characteristics. MATERIALS AND METHODS: Unilateral renal periarterial ethanol injection under general anesthesia was performed in 16 animals with the contralateral kidney serving as the control. All interventions were performed in an open MRI system under real-time multiplanar guidance. In 10 pigs an ethanol-carbostesin contrast agent mixture was injected with amounts of 5 ml (6 animals, group I) and 10 ml (4 animals, group II). 6 pigs (group III) were treated with 10 ml of an ethanol-polyacrylic (2 %) mixture. Four weeks after treatment, all animals underwent MRI including MRA. After euthanasia, macroscopic and histologic examination of the kidneys, renal arteries and periarterial tissue was performed to assess nerve injury and potential side effects. Furthermore, the norepinephrine concentration (RTNEC) in the renal tissue was determined as a surrogate parameter of efficacy. RESULTS: Histologic signs of nerval degeneration with various degrees of severity and circumferential distribution were found in all groups. Injury depths ranged up to 7.6 mm. In groups II and III the nerve count was significantly lower on the treated side. Renal artery stenosis was not observed in any pig. In all pigs of group II treatment resulted in neural degeneration with a mean RTNEC reduction of 53 % (p < 0.02). In groups I and III significant changes in RTNEC were not observed. CONCLUSION: Image-guided percutaneous periarterial ethanol injection was efficient and safe for renal denervation. The detected variations in histologic outcome underlined the importance of the preclinical optimization of the technique in order to maximize treatment effects in humans. KEY POINTS: · Renal denervation by percutaneous periarterial ethanol injection is an effective and potentially safe procedure.. · The percutaneous approach is less prone to anatomical and procedural limitations compared to catheter-based procedures.. · The achievable nerve injury depth lies beyond those of current RFA-probes.. · Efficacy depends on amount, concentration, viscosity and periarterial distribution of the ethanol-mixture.. · Establishing an optimal balance between these parameters is mandatory for a maximum treatment effect at minimum risk for sensitive adjacent structures.. CITATION FORMAT: · Freyhardt P, Haage P, Walter A et al. Renal Sympathetic Denervation by Image-Guided Percutaneous Ethanol Injection - Histopathologic Characteristics, Efficacy and Safety. Fortschr Röntgenstr 2020; 192: 549 - 560.

Complication rates of EUS-guided celiac plexus blockade and neurolysis: results of a large case series.

BACKGROUND AND STUDY AIMS: Complication rates for EUS-guided celiac plexus blockade (CPB) and celiac plexus neurolysis (CPN) have been largely derived from studies utilizing percutaneous or surgical techniques, with few studies specifically examining rates for EUS-guided CPB and CPN. This study aims to further describe the complication rates of EUS-guided CPB and CPN. PATIENTS AND METHODS: In a retrospective analysis of a prospectively collected EUS database, tracking patients and complications for a single endosonographer at a tertiary-care teaching hospital, data for consecutive patients between August 2003 and March 2008 undergoing either EUS-guided CPB or CPN were analyzed for indications, methods, and complications. Excellent follow-up data were available for all patients. RESULTS: 189 EUS-CPB and 31 EUS-CPN procedures were done in 128 and 30 patients, respectively (60 men, 98 women). Indications for blockades included chronic pancreatitis (122), relapsing pancreatitis with chronic pain (28), upper abdominal pain of suspected pancreatic origin (37), and suspected (yet unproven) pancreatic cancer with pain (2). Neurolyses were performed for refractory pain from cancer (21) or chronic pancreatitis (10). No prophylactic antibiotics were administered. Acid suppression was not withheld. Complications were defined as procedural side effects treated with anything beyond standard observation. Four complications were observed during clinical follow-up (three after CPB, one after CPN), giving an overall complication rate of 1.8 % (CPB 1.6 %, CPN 3.2 %). Complications included asymptomatic hypotension after neurolysis, retroperitoneal abscess after CPB, and severe self-limited postprocedural pain in two patients after CPB. CONCLUSIONS: EUS-guided CPB and CPN are reasonably safe procedures with tolerable side-effect profiles and low overall complication rates.

Chemical Sympathectomy Impairs Peri-implant Osseointegration in Mice: Role of the Sympathetic Nervous System in Osseointegration.

PURPOSE: The possibility that the sympathetic nervous system (SNS) controls bone remodeling has been raised; however, the actual function of the SNS in osseointegration is still unknown. This study aimed to investigate the effect of chemical sympathectomy on peri-implant osseointegration in adult mice. MATERIALS AND METHODS: Forty C57BL/6J mice (8-week-old) were divided into two groups: a sympathectomy group and a control group, which were administered 6-hydroxydopamine and saline, respectively, by intraperitoneal injection for 5 days. Then, the mice were exposed to implant surgery. Analyses of serum chemistry, microcomputed tomography, biomechanical test, and bone histomorphometry were employed at 2 and 4 weeks. RESULTS: Compared with the control, the chemical sympathectomy group had a higher serum level of C-terminal collagen I cross-links but lower serum osteocalcin. After 4 weeks, peri-implant trabecular microstructure, including trabecular volume, trabecular thickness, the percentage of osseointegration, and bone-to-implant contact, was lower; however, the trabecular separation was higher in the sympathectomy group mice in comparison with the control group. In addition, the strength of bone-titanium integration measured by the biomechanical resistance test was lower. Furthermore, histomorphologic evidence revealed that the osteoclast counts were higher in the sympathectomy group, while the mineral apposition rate and the bone formation rate per bone surface were significantly lower. CONCLUSION: Within the limitations of this experimental study, the data showed that chemical sympathectomy has a negative effect in peri-implant osseointegration, suggesting that the SNS may need to be taken into consideration in terms of peri-implant bone healing.

Chemical sympathectomy increases susceptibility to ocular herpes simplex virus type 1 infection.

The cornea is one of the most highly innervated tissues in the mammalian host. We hypothesized changes to cornea innervation through chemical sympathectomy would significantly alter the host response to the neurotropic viral pathogen, herpes simplex virus type 1 (HSV-1) following ocular infection. Mice treated with 6-hydroxydopamine hydrobromide displayed reduced tyrosine hydroxylase-positive fibers residing in the cornea. Sympathectomized mice were also found to show a transient rise in virus recovered in infected tissues and succumbed to infection in greater numbers. Whereas there were no differences in infiltrating leukocyte populations including HSV-1-specific cytotoxic T lymphocytes in the infected tissue, an increase in substance P and a decrease in IFN-gamma levels in the trigeminal ganglion but not brain stem of sympathectomized mice were noted. Sympathectomized mice treated with the neurokinin-1 receptor antagonist L703,606 had delayed mortality implicating the involvement of substance P in HSV-1-mediated death.

[Experience in treatment of Raynaud's syndrome by chemical sympathectomy: 97 cases].

OBJECTIVE: To summarize the curative effect in treatment of Raynaud's syndrome with chemical thoracic sympathectomy (CTS) guided by X-ray since 2001. METHODS: From March 2001 to August 2007, 97 patients with Raynaud's syndrome (186 limbs) were treated by CTS. Guided by X-ray, a needle was punctured through the back skin to the second thoracic sympathetic ganglion beside the thoracic vertebrae and 2 mL of 5% (v/v) phenol was injected. RESULTS: The first CTS treatment produced a good effect on 146 limbs with an effective rate of 78.5% (146/186). The same treatment was performed on the limbs with no effect 1-2 days after the first treatment and produced good effect on 13 limbs with an effective rate of 32.5% (13/40). The total effective rate of the patients who were hospitalized for the first time was 85.5% (159/186). Of the 97 patients, 78 patients (80.4%) were followed up for 47 months on an average with an effective rate of 69.5%. And the rate of complications was 11.4% for pheumothorax, and 3.9% for hydrothorax. Hyperalgesia on axillary region and anterior chest wall; Horner syndrome and sinus bradycardia were rare. CONCLUSION: CTS is minimally invasive and effective in treatment of Raynaud's syndrome.

[Infiltrations, blocks and neurolysis in musculoskeletal pathology]. / Infiltrations, blocs et neurolyses en pathologie ostéo-articulaire.

Computed Tomography fluoroscopy for blocks and neurolysis provides a minimally-invasive, accurate and rapid alternative to surgery. Spinal and peri-spinal ultrasound-guided procedures, excluding peripheral procedures, will be discussed as well. The imaging-guided procedures discussed are performed using small needles. These percutaneous procedures must be performed with maximum patient comfort and cause as little complications as possible. These procedures should be performed by an experienced radiologist after discussion with the treating clinician.

Lumbar Sympathetic Neurolysis: How to and When to Use?

Lumbar sympathectomy was historically a mainstay of treatment for arterial occlusive disease and other vasospastic disorders, before the development of contemporary arterial reconstructive procedures either by surgical or endovascular means. Today, percutaneous methods of sympathetic blockade are possible using chemical neurolytic or ablative modalities. Lumbar sympathetic neurolysis is generally reserved for those patients with ischemic rest pain in the setting of nonreconstructable arterial occlusive disease, although patients with complex regional pain syndrome, peripheral neuralgia, vasospastic disorders, and various other disease states such as plantar hyperhydrosis may also benefit. A working knowledge of procedural anatomy and physiology, accompanied by appropriate patient selection, serve to maximize procedural success and minimize complications, which although infrequent may cause significant morbidity. A review of technique with a focus on traditional fluoroscopy is described, with attention drawn to intraprocedural and immediate postprocedural findings, as well as discussion of expected outcomes.

Prevention of exercise-induced cardiac hypertrophy in rats by chemical sympathectomy (guanethidine treatment).

The effect of 'chemical sympathectomy', produced by daily intraperitoneal injections of guanethidine sulphate for six weeks, was studied in sedentary rats and in rats chronically exercised by swimming. The guanethidine-treatment itself caused the following changes. There was a reduction in the rate of weight gain resulting in a 7% lower final body weight. Organ content of noradrenaline was decreased by 90% in spleen and submandibular glands and by 83% in the heart. Urinary excretion of noradrenaline was also decreased, but to a lesser degree, both during rest (45% lower) and after acute exercise (46% lower), while the urinary excretion of adrenaline was no different from that of controls. There was a compensatory adrenal hypertrophy in the guanethidine-treated rats, with a significant increase in adrenal catecholamine levels that was more pronounced for noradrenaline (+45%) than for adrenaline (+11%). Chronic physical exercise produced the expected degree of cardiac hypertrophy in untreated rats, but this adaptive cardiac hypertrophy was completely absent in the exercised guanethidine-treated rats. The results indicate, firstly that a good degree of chemical sympathectomy was obtained and that the persistence of a considerable urinary excretion of catecholamines in the guanethidine-treated rats was due to a compensatory increase in the secretory activity of the adrenal medulla. Secondly, it is suggested that the adaptive cardiac hypertrophy produced by chronic exercise is not caused by a direct effect of the increased work load on the cardiac muscle cell, but is instead mediated by release of a trophic factor from cardiac sympathetic nerves, probably noradrenaline itself but possibly a secretory protein.

Relationships between striatal dopamine denervation and frontal executive tests in Parkinson's disease.

Indirect evidence from human and monkey investigations supports the idea that impaired frontal tasks in Parkinson's disease (PD) may result from striato-frontal disruption caused by dopamine (DA) denervation of the caudate nucleus. To directly investigate this hypothesis, we used PET with 11C-S-Nomifensine (11C-S-NMF), a sensitive marker of striatal DA denervation, in 10 non-demented PD patients in whom two frontal executive tests, the object alternation (OA) and the conditional associative learning (CAL) tasks, thought to reflect mainly set-shifting/inhibition and planning, respectively, were given. In addition, the central executive function of verbal working memory was assessed with the Brown Peterson paradigm (BPP). We found a highly significant correlation between right caudate 11C-S-NMF specific binding and OA performance, less significant and reverse-direction correlations between CAL performance and putamen 11C-S-NMF binding, and no significant correlation with BPP performance. Thus, caudate DA denervation may subtend poor set-shifting/inhibition process in PD. Our results also point to distinct and complex relationships between striatal DA and specific frontal tasks.

Percutaneous epidural and nerve root block and percutaneous lumbar sympatholysis.

Epidural steroid injections and selective nerve root blocks currently are considered standard techniques in the diagnosis and treatment of back pain. The targeted epidural and perineural steroid injection with nerve block is a new technique that combines an epidural steroid injection and a nerve block. Radiologists are best suited for performing these procedures because of their training and skills in fluoroscopy and needle procedures.

Ingrowth of sympathetic innervation occurs concomitantly with a decrease of ANP in the growing rat cardiac ventricles.

The relationship between the immunohistochemical expression of atrial natriuretic peptide and the occurrence of sympathetic nerve fibres, as visualized by staining for tyrosine hydroxylase, in the growing rat heart was evaluated. Rats were investigated at four different stages from birth to 21 days postnatally. The effects of chemical destruction of sympathetic nerve terminals in neonatal rats on the cardiac atrial natriuretic peptide content were furthermore examined by use of radioimmunoassay. There was in principle a reciprocal pattern of immunoreaction for atrial natriuretic peptide and tyrosine hydroxylase positive innervation in the ventricular myocardium, atrial natriuretic peptide reaction becoming less and less pronounced with the ingrowth of innervation positive for tyrosine hydroxylase. Furthermore, in the peripheral Purkinje fibre network, there was a marked atrial natriuretic peptide immunoexpression and scarce or no nerve fibres throughout the examination period. The radioimmunoassay measurements showed that chemical sympathectomy lead to elevated cardiac levels of atrial natriuretic peptide. The study shows that sympathetic innervation grows into the ventricular parts concomitantly with the occurrence of a decline in atrial natriuretic peptide expression during development of the heart. Furthermore, it is shown that a reversion of the in growth of sympathetic innervation by destruction of cardiac sympathetic nerves at an early stage leads to increased levels of atrial natriuretic peptide in the heart. The results give new evidence to the phenomenon that the atrial natriuretic peptide levels in the ventricular myocardium and the peripheral parts of the conduction system are under influence of the presence of sympathetic innervation.

Palmar hyperhidrosis CT guided chemical percutaneous thoracic sympathectomy.

Palmar hyperhidrosis or excessive sweating of the hands causes, to those affected, emotional and physical disturbance and impediment in professional and social life. The cause is unknown. Sweat glands are innervated by the sympathetic chain of the autonomous nervous system. The center of sympathetic regulation of the upper extremities is located between the segments of D.2-D.9 of the spinal cord. Accepted treatment consists of surgery aimed to excise the third thoracic sympathetic ganglion. Besides the surgical procedure as such, and its complications, there are complications inherent to the excision of the ganglion. These are Horner's syndrome, compensatory sweating in other parts of the body, and recurrence of sweating. CT guided chemical percutaneous thoracic sympathectomy presents an alternative, which in the event of failure does not prevent ensuing surgery. The preliminary experience with this procedure in 50 patients is presented and discussed.

Chemical sympathectomy blocks androgen biosynthesis during prepuberty.

Twenty-one-day old male Wistar rats were injected subcutaneously with guanethidine (GUA) at doses of 5 and 10 mg kg-1 day-1 for 20 days. Animals were sacrificed by decapitation during the prepubertal (41 days of age) and early-pubertal (51 days of age) periods of sexual development. The testes were collected, frozen in liquid N2 and stored at -70 degrees C until determination of testicular progesterone (P), androstenedione (A) and testosterone (T). Higher levels of P (2.18 +/- 0.24 ng/g, control = 1.24 +/- 0.16 ng/g) associated with decreased levels of androgens (A = 0.26 +/- 0.06 ng/g and T = 2.05 +/- 0.19 ng/g; control = 1.86 +/- 0.76 ng/g and 8.48 +/- 1.16 ng/g, respectively) were observed in 10 mg GUA-treated rats of prepubertal age, while only P levels (3.12 +/- 0.51 ng/g, control = 1.73 +/- 0.27 ng/g) were increased in rats of early pubertal age. It is important to note that in 41-day old male rats both 5 and 10 mg were effective in decreasing testicular concentration of testosterone. These results suggest that the sympathetic innervation of the testis is involved in the modulation of androgen biosynthesis, acting through a selective step in the steroid biochemical pathway during the pubertal process and that under the conditions employed the blockage in androgen biosynthesis in the prepubertal stage of sexual maturation in dependent on the dose of GUA.

Vestibulo-ocular reflex deficits to rapid head turns following intratympanic gentamicin instillation.

The response of the vestibulo-ocular reflex following unilateral vestibular deafferentation by gentamicin ablation was studied using transient stimuli. The response to these rapid passive head turns showed a strong asymmetry with permanent, reduced gains toward the side of lesion. These gain reductions have large variation (gains of 0.26 to 0.83), which may result from preferential sparing of regularly firing afferent fibers following gentamicin ablation. Based on the size and nature of the nonlinearity, an explanation based on Ewald's second law was discounted.

Botulinum toxin chemo-denervation for strabismus in infants and children.

Fifteen children and five infants with short follow-up show chemo-denervation with botulinum toxin to be a safe and effective alternative to surgery.

[Lumbar sympathectomy in the aged subject: surgery or phenolization? Prospective study of early results]. / Sympathectomie lombaire chez le sujet âgé chirurgie ou phénolisation? Etude prospective des résultats précoces.

Lumbar sympathectomy, which is usually indicated in the arteritic patient in cases of severe ischemia and occlusion of leg arteries when bypass surgery is not feasible, can be performed surgically or by scanner-guided phenolization. Surgical sympathectomy was performed by resection of the 2nd, 3rd, 4th and 5th lumbar ganglia under general anesthesia by a retroperitoneal route. Chemical sympathectomy involved scanner-guided injection of phenol diluted 6.7% into the sympathetic nervous system at L3 and L4 level. This act, performed on outpatients, required no anesthesia. Prospective study of the early results (within one month) obtained with these two techniques in 428 patients indicates that rates of death, amputation and noteworthy complications for those less than 70 yr (table IV, VI and VIII) were respectively 4.7%, 8.5% and 7.4% for surgery, and 2.5%, 5% and 0% for phenolization; for those greater than 70 yr the rates were respectively 12%, 11% and 10% for surgery, and 10%, 9% and 8% for phenolization. It may be concluded that phenolization of the sympathetic nervous system provides the same results as surgical sympathectomy but has the advantage of lower morbidity and shorter hospitalization (24 h vs 10 days). The results of these two techniques in terms of limb conservation are disappointing and markedly poorer than those of distal bypass surgery.