Van Beek Allen L, Lim Paul K, Gear Andrew J L, Pritzker Marc R
Minneapolis, Minn. From the Division of Plastic Surgery, Department of Cardiology, and Division of Heart Failure, Transplantation, and Investigational Therapeutics, Minneapolis Heart Institute Foundation, and Section of Cardiology, Department of Medicine, University of Minnesota.
Plast Reconstr Surg. 2007 Jan;119(1):217-226. doi: 10.1097/01.prs.0000244860.00674.57.
Surgical digital artery sympathectomy is indicated when medical management has failed to control rest pain, impending infarction of digits, or healing of ischemic ulcerations caused by profound vasospasm that is associated with other systemic diseases. After digital artery sympathectomy, recurrence or persistence of vasospasm may compromise hand function and ultimately result in amputation of all or portions of both lower and upper extremities.
The authors present a case series of 11 patients with vasospasm producing intractable rest pain, digital ulcerations, and digit infarctions that failed aggressive medical therapy and that were then treated by perivascular injections of botulinum toxin A (Botox). Before Botox injection, the level of pain, cutaneous temperatures, color, and ulcerations and infarctions were documented
The authors' longest follow-up was 30 months. All patients reported highly significant pain reduction, 10 of 10 to 0 to 2 of 10, within 24 to 48 hours after injection, persisting for months after the injection. Nine of 11 patients with nonhealing ulcers spontaneously healed small ulcers and areas of infarction after surgical debridement. Two cases required small skin grafts. Nine of 11 patients reported decreased severity and frequency of vasospastic episodes.
Hand injection of botulinum toxin A appears to be an effective treatment for intractable digital ulcerations and rest pain in patients with severe vasospastic disorders. Because of the complexity of surgical digital artery sympathectomy along with its associated high risk of persistent symptoms, the authors conclude that the therapeutic use of botulinum toxin A injections represents an attractive alternative therapy.
当药物治疗未能控制静息痛、即将发生的手指梗死或由与其他全身性疾病相关的严重血管痉挛引起的缺血性溃疡愈合时，需进行手术性指动脉交感神经切除术。指动脉交感神经切除术后，血管痉挛的复发或持续可能会损害手部功能，并最终导致上下肢全部或部分截肢。
作者介绍了一组11例血管痉挛患者的病例系列，这些患者产生顽固性静息痛、手指溃疡和手指梗死，积极药物治疗无效，随后接受了血管周围注射A型肉毒杆菌毒素（保妥适）治疗。在注射保妥适之前，记录疼痛程度、皮肤温度、颜色以及溃疡和梗死情况。
作者的最长随访时间为30个月。所有患者均报告注射后24至48小时内疼痛显著减轻，从10分制的10分降至0至2分，并在注射后持续数月。11例有不愈合溃疡的患者中有9例在手术清创后小溃疡和梗死区域自发愈合。2例需要进行小面积皮肤移植。11例患者中有9例报告血管痉挛发作的严重程度和频率降低。
手部注射A型肉毒杆菌毒素似乎是治疗严重血管痉挛性疾病患者顽固性手指溃疡和静息痛的有效方法。由于手术性指动脉交感神经切除术的复杂性及其伴随的持续症状高风险，作者得出结论，注射A型肉毒杆菌毒素的治疗用途是一种有吸引力的替代疗法。
