Sympathectomy Has Two-Decade Prominence in Treating Peripheral Arterial Disease

In 1924, Australian surgeon Norman D. Royale, MD delivered the keynote john B. Murphy Oration in Surgery at the ACS Clinical Congress on an unfamiliar topic—sympathectomy.

Along with his colleague John I. Hunter, MD, Dr. Royale proposed severing the sympathetic nerve bundle as it exited the vertebral column to treat spastic paralysis.¹ The presentation inspired William J. Mayo, MD, FACS, and ACS founder Franklin H. Martin, MD, FACS, to visit Australia, learn the intricacies of the new technique, and bring it back to the US, where The New York Times announced hope for a cure of this intractable condition. In disproving its efficacy against paralysis, physicians discovered its utility in redressing peripheral arterial disease (PAD), where it flourished as a mainstay of treatment for the next 20 years. 

Physicians had conceived a very rough equivalent of the autonomic nervous system since at least the Middle Ages, with anatomical investigations in the 16th century further defining their course. Anatomist Jacques B. Winslow—credited with first documenting the existence of the foramen that bears this name—called them “sympathetic” in 1752. 

In 1851, French physiologist Claude Bernard reported that severing a sympathetic nerve resulted in the dilation of blood vessels. His countryman, surgeon Mathieu Jaboulay, performed the first known sympathectomy when he extirpated pelvic rami to relieve pain in a patient’s lower urinary system. Dr. Jaboulay’s student, vascular surgeon and physiologist René Leriche, conducted the first sympathectomy for peripheral vascular disease in 1913.² Dr. Leriche’s work, however, remained confined to France; while later seen as inspiring and revelatory, it initially had only local effect. 

Peripheral vascular disease at the time had few therapeutic options. Scottish surgeon John Hunter had demonstrated the value of ligation, but that therapy was appropriate only for aneurysms and carried a significant risk of amputation. What we now call atherosclerotic vascular disease was becoming increasingly common in 20th century America as deaths from infectious etiologies, such as cholera and tuberculosis, fell and lifestyle changes led to calcified vessels throughout the body. Surgeons and other physicians quickly learned to diagnose the condition but lacked drugs or interventions to remedy it. 

Drs. Martin and Mayo brought sympathectomy back to Chicago, Illinois, and Rochester, Minnesota, respectively, where surgeons quickly demonstrated its futility in curing paralysis. But Mayo Clinic physician George E. Brown, MD, had observed experiments by neurosurgeon Alfred W. Adson, MD, and noted that while paralysis remain unchanged, the limb on the side where Dr. Adson operated was markedly warmer than the contralateral extremity. Dr. Brown, already interested in PAD, hypothesized that the operation might benefit those patients instead, and performed a number of controlled experiments on animals to test this theory. In March 1925, Drs. Brown and Adson performed the first sympathectomy for vascular disease in a patient suffering from Raynaud’s disease, curing him (see Figure 1, below).³

As the operation spread, techniques changed. Dr. Adson initially made a midline laparotomy, accessing the spinal column anteriorly. W. McKay Craig, MD, another neurosurgeon at the Mayo Clinic, modified the exposure, approaching the spinal column posteriorly, which is a much less invasive intervention. James White, MD, and Paul G. Flothow, MD, both surgical residents at Mayo at the time, recognized the possibility of chemically interrupting the sympathetic chain with injections of ethanol.

Indications also broadened widely. Physicians recommended applying sympathectomies for conditions as varied as migraines, menstrual cramps, constipation, and epilepsy. Ultimately, research proved its inefficacy for most of these pathologies, but repeated studies, including those using recently invented angiography, consistently demonstrated benefit for patients suffering from PAD. 

The operation gained widespread attention. The surgical literature featured hundreds of articles describing technical modifications, indications, and outcomes. The operation was featured as the topic for both the presidential address to the American Surgical Association in 1932 and the Hunterian Lecture at the Royal College of Surgeons in 1933 in London. 

The Mayo Clinic was performing more than 200 sympathectomies per year by the late 1930s. In fact, the procedure received a “royal endorsement” when, in 1949, King George VI of England asked Scottish surgeon James R. Learmonth to treat his Buerger’s disease. Dr. Learmonth performed a lumbar sympathectomy, sparing the king an amputation.⁴ 

While the operation proved most successful in treating spastic diseases like Buerger’s and Raynaud’s, surgeons applied it to every vascular condition, including aneurysms and trauma. In an era when arterial ligation predominated as the treatment of choice, surgeons—and patients—depended upon collateral circulation to preserve their extremities.  Dilating those vessels promised to increase the success of ligation and avoid limb loss.  

Mims Gage, MD, a surgeon at Tulane University in New Orleans, Louisiana, who had apprenticed with Rudolph Matas, MD, FACS, first proposed applying the technique for aneurysms. In 1934, Dr. Gage ligated the iliac artery while simultaneously performing a sympathectomy, treating a patient’s iliac aneurysm while avoiding amputation. The combination approach quickly gained favor. 

Based on these outcomes from civilian experiences, the Office of the Surgeon General insisted that military surgeons perform ligation plus sympathectomy for traumatically injured arteries during World War II (see Figure 2, above).⁵  

The Inter-Allied Surgery Conference continued to call for “more general use…of sympathetic blocks in an attempt to improve collateral circulation,” demonstrating its perceived effectiveness. Actual use seemed to vary by unit. The 95th Evacuation Hospital reported performing sympathetic blocks in “nearly most every” case. In their 487 vascular cases, the 3rd Auxiliary Surgical Group applied sympathetic blocks in 340 patients—and in 94% of the ones requiring ligation.

Other hospitals reported far less frequent use. Both contemporary and retrospective data failed to demonstrate significant benefit of sympathectomy in the trauma population, likely due to wound patterns annihilating whatever collateral circulation might benefit from vasodilation. Despite the statistical ambivalence, most American surgeons remained convinced of the importance of the technique and regularly credited sympathectomy for saving limbs. 

Importantly, World War II also provided preliminary data on the efficacy of repairing injured blood vessels through arteriorrhaphy, end to end anastomoses, and venous bypass grafts. While it would ultimately require another war, the Korean War, for these techniques to establish themselves as standard of care, they quickly overtook sympathectomies in the 1950s.

Sympathectomy retained a selective role for some vasospastic conditions like Raynaud’s, but otherwise largely faded from use. For 2 decades, however, it represented one of the only physiologically sound surgical treatments for vascular disease. 

Dr. Justin Barr is a fellow in transplant and hepato-pancreato-biliary surgery at the University of Toronto in Canada. He also chairs the program subcommittee of the ACS History and Archives Committee.

References

1. Royle ND. A new operative procedure in the treatment of spastic paralysis and its experimental basis. Med J Aust. 1924;1(4):77-86.
2. Leriche R. De la Sympathectomie Perí-Artérielle et de ses Résaltats. Presse Médical. 1919;25:513-515. Translation: Halsted WS. A striking elevation of the temperature of the hand and forearm following the excision of a subclavian aneurysm and ligations of the left subclavian and axillary arteries. Bull Johns Hopkins Hosp. 1920;31:219-224.
3. Brown GE, Adson AW. Calorimetric studies of the extremities following lumbar sympathetic ramisection and ganglionectomy. Am J M Sc. 1925;170:232-240.
4. Ellis H. James Learmonth: Distinguished academic surgeon who operated on King George VI. Br J Hosp Med (London). 2017;78(9):529.
5. Barr J, Cherry K, Rich ND. Vascular surgery in World War II. Ann Surg. 2016;263(3):615-620.