Perioperative Management of Patients with Rheumatic Disease by Brian F. Mandell

Author:Brian F. Mandell
Language: eng
Format: epub
Publisher: Springer New York, New York, NY

Calcium channel blockers – e.g., amlodipine and nifedipine

Topical nitroglycerin (applied to the web spaces between digits)

Alpha-1 antagonists – e.g., prazosin

Phosphodiesterase inhibitors – e.g., sildenafil and pentoxifylline

Statins

Angiotensin receptor inhibitors – e.g., losartan

Prostaglandins both oral and parenteral

Endothelin receptor antagonists (ERA) – e.g., bosentan and ambrisentan

Since increased sympathetic tone is thought to play in a role in the pathogenesis of Raynaud phenomenon, sympathectomy is sometimes used when digital ulcers/ischemia are refractory to medical management. The goals are to reverse vasoconstriction and to relieve pain. A temporary chemical sympathectomy may be tried initially by infiltration of a local anesthetic (lidocaine or bupivacaine without epinephrine) locally (e.g., digital or wrist block), regionally, or near the appropriate cervical or lumbar sympathetic ganglia. The anesthetic can be delivered by repeated injections or by placement of a catheter into the region of the cervical or lumbar sympathetic ganglia. Some studies have reported that cervical sympathectomy may be more useful in patients with primary Raynaud phenomenon compared to those with the secondary form; however, in our experience, individuals with primary Raynaud phenomenon rarely if ever require such intervention [3, 5–7].

Surgical sympathectomy may be either proximal or distal and should only be considered in cases of severe, refractory Raynaud phenomenon when irreversible ischemia threatens the involved fingers/toes. One or more of the medications listed above and a trial of a chemical sympathectomy should be tried first.

Vascular reconstruction may be an option for some patients who suffer from refractory ischemia. Surgical revascularization of the hand and arterial reconstruction may improve digital perfusion and hasten the healing of digital ulcers when there is bypassable proximal artery occlusion associated with digital artery vasospasm. Ulnar artery occlusion is common in systemic sclerosis, and revascularization of ulnar artery occlusive disease in this setting may improve Raynaud phenomenon and help to heal digital ulcers [8]. Surgical amputation of the involved digits is a last resort and should only be done in the settings of wet gangrene (infection) and/or intractable pain. In the absence of such surgical indications, autoamputation usually results in less tissue loss and greater preservation of function.

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