Sympathetic blockade

Sympathectomies were first tried in 1964, when Apthorp et al.54 reported that they relieved the angina pain in about 75 percent patients. Sympathetic blockade can be achieved by thoracic epidural, paravertebral block, sym-pathectomy, or stellate ganglion blockade.

Local anesthetic stellate ganglion blocks are reported to provide repeated benefit47 for some patients, although the overall improvement only lasted a mean of 3.48 weeks.48 In our own practice, the number of patients who experience a benefit longer than one month is low, but it can be used for acute exacerbations. It has a proven effect on symptoms, but not on ischemia.36'37[III] Thoracic paravertebral block are reported to provide satisfactory analgesia for a mean duration of 2.8 weeks with a follow up of up to two years, with a complication rate of 3

percent.48

There has been some interest in endoscopic thoracic sympathectomies,49 despite the promising results shown by one study20[III] as the number of patients included was small and the follow up was limited to six months. One case series looked at percutaneous radiofrequency thoracic sympathectomy as a less invasive technique with good results,50 but further randomized evidence is lacking. High thoracic epidural anesthesia (HTEA) was initially described as a low-risk alternative to surgical thoracic sympathectomy.46 Employing an indwelling catheter with intermittent boluses or continuous infusions that allowed the patients to be discharged from hospital, HTEA has an effect both on symptoms and on ischemia.46[III] The evidence relates mainly to its use in acute unstable angina pectoris. Its use in a chronic setting is limited by the fact that it is usually administered via an infusion pump.

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