Is sympathectomy of benefit in critical leg ischaemia not amenable to revascularisation?

A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed was whether the use of sympathectomy was of benefit in non-revascularisable critical leg ischaemia. Altogether 387 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We conclude that lumbar sympathectomy is a minimally invasive procedure with a low complication rate. Randomized controlled trials have failed to identify any objective benefits for lumbar sympathectomy, but subjective improvements in symptoms for patients with highly symptomatic critical leg ischaemia have been consistently demonstrated in multiple cohort studies with sustained symptom improvements in approximately 60% of patients. Lumbar sympathectomy should be considered for symptomatic patients with critical leg ischaemia as an alternative to amputation in patients with otherwise viable limbs.