Digital Sympathectomy for Critical Digital Ischaemia — SCE Palliative Medicine MCQ

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HardNon-Malignant Palliative CareDigital Sympathectomy for Critical Digital IschaemiaSCE Palliative Medicine

A 65-year-old woman with advanced systemic sclerosis has severe digital ischaemia with rest pain and early tissue loss in her fingertips despite oral calcium channel blockers and intravenous iloprost. What emergency intervention may prevent amputation?

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Correct answer: B — Digital sympathectomy – surgical removal of sympathetic fibres around digital arteries to improve blood flow

In this patient with systemic sclerosis whose digital ischaemia has failed first-line medical therapy (calcium channel blocker and IV iloprost), digital sympathectomy offers a targeted surgical emergency option. It interrupts sympathetic-mediated vasoconstriction overlaying fixed vasculopathy and can restore critical blood flow, alleviating rest pain and preventing progression to gangrene or amputation. Peer-reviewed UK-based case reports and reviews affirm its role in refractory cases. The other options lack evidence in this scenario: hyperbaric oxygen has no established role; high‑dose steroids risk precipitating scleroderma renal crisis; IV immunoglobulin and plasma exchange are not indicated for fixed ischaemic vasculopathy.

Reference: Stratton R et al. Digital sympathectomy for ischaemia in scleroderma. Br J Rheumatol 1997;36(12):1338–9. and Sharp CA et al. Differential diagnosis of critical digital ischemia in systemic sclerosis. Semin Arthritis Rheum 2016;46(2):209–16. https://pubmed.ncbi.nlm.nih.gov/9448600/