VIDEO COMMENTARY ON THORACIC SYMPATHECTOMY RADIOFREQUENCY ABLATION

INDICATIONS FOR THORACIC SYMPATHECTOMY RADIOFREQUENCY ABLATION

• Cardiac arrhythmias: including:-

  • Jervell/Lang/Nielson Syndrome and
  • Ramano/Ward idiopathic long Q-T syndrome.

• Ischemic cardiac pain

THE PROCEDURE

• The C-arm image intensifier should lie in the postero-anterior plane to identify the body of T2 vertebrae. (Figure 1A &B)

• C-arm is rotated 10-15 degrees cranio-caudal to square the upper thoracic vertebral bodies, following which the c-arm is rotated 20 degrees ipsilateral oblique to get a good delineation of the costo-vertebral angle. (Figure 2A &B)

• The entry point should be lateral border of the lower part of the body of T2, just above the head of the third rib.

• Use a 25G needle to infiltrate the superficial tissues and then inset the 22G, 10cm curved needle with 10 mm active tip needs advanced in tunnel vision keeping it as close as possible to the lateral border of T2 to reduce the risk of pneumothorax. (Figure 3A &B)

• The depth is confirmed in the lateral x-rays. Advance the needle till it reaches halfway along the side of the body.

• Inject 1.5-2 ml contrast Omnipaque 240, which should freely flow cranially and caudally. (Figure 4)

• Once the needle is in correct position, replace the RF needle stiletto with thermocouple electrode and apply sensory stimulation at Frequency: 50Hz and Voltage: 0.4-0.6 V.

• Also to rule out stimulation of the intercostals nerves must do a motor stimulation at Frequency: 2 Hz and Voltage: double the sensory but at least 1 V (Figure 5)

• This is followed by a conventional RF at lesion 80 degrees for 90 seconds two such lesions are done at each level.

Fig -1A.

Fig -1B.

Fig -2A.

Fig -2B.

Fig -3A.

SIDE EFFECTS

• Beware of pneumothorax, for whose management all facilities should be available at the centers. A chest x-ray post procedure to rule out pneumothorax is essential.

Fig -3B.

Fig -4.

Fig -5.