Thoracoscopic Sympathectomy

Number: 0310

Policy

1. Aetna considers thoracoscopic sympathectomy medically necessary for any of the following conditions:

1. Causalgia; or
2. Catecholaminergic polymorphic ventricular tachycardia (CPVT), in persons who remain symptomatic despite maximal medical therapy; or
3. Long QT syndrome, in persons who have failed medical therapy and have frequent shocks with an implantable cardioverter defibrillator (ICD) despite medications; or
4. Raynaud's disease; or
5. Shoulder-hand syndrome; or
6. Some types of visceral pain (e.g., chronic pancreatic pain and cancer-derived visceral abdominal pain); or
7. Ventricular tachycardia/ventricular fibrillation (VT/VF) storm, in whom a beta blocker, other antiarrhythmic medications, and catheter ablation are ineffective, not tolerated, or not possible; or
8. Vascular occlusive disease; or
9. Intractable, disabling axillary or palmar primary hyperhidrosis (excessive sweating) when all of the following are met (see also CPB 0504 - Hyperhydrosis)
    
   1. Iontophoresis or electrophoresis, (e.g., Drionic^® device) is ineffective (see CPB 0229 - Iontophoresis) (a trial of botulinum toxin can be substituted for iontophoresis in persons with predominantly axillary hyperhidrosis – see CPB 0113 - Botulinum Toxin); and
   2. Significant disruption of professional and/or social life has occurred because of excessive sweating; and
   3. Topical aluminum chloride or other extra-strength antiperspirants are ineffective or result in a severe rash; and
   4. Unresponsive or unable to tolerate pharmacotherapy prescribed for excessive sweating (e.g., anti-cholinergics, beta-blockers, benzodiazapines) if sweating is episodic. 

2. Aetna considers thoracoscopic sympathectomy cosmetic for excessive spontaneous facial blushing.  Facial blushing (flushing) is considered a cosmetic indication as it does not result in functional impairment.

3. Aetna considers thoracoscopic sympathectomy experimental and investigational for all other indications (e.g., acne vulgaris, craniofacial or plantar hyperhidrosis) becasue its effectiveness for indications other than the ones listed above has not been established.

4. Aetna considers left thoracoscopic sympathectomy experimental and investigational for cardiac denervation in persons with heart failure because the effectiveness of this approach for these indications has not been established.

See also CPB 0031 - Cosmetic Surgery.

Background

Sympathectomy is a surgical procedure that involves cauterizing (cutting and sealing) a portion of the sympathetic nerve chain that runs down the inside of the chest cavity. This operation permanently interrupts the nerve signal that is causing the body to sweat excessively and can be performed in either of the two sympathetic trunks. Each trunk is divided into three regions: cervical (neck), thoracic (chest) and lumbar (lower back). Sympathectomy is commonly targeted to the upper thoracic region.

Endoscopic thoracic sympathectomy (ETS) is performed by inserting a scope with a camera into the chest via a small incision under the axilla. The lung is temporarily collapsed so the surgeon can cut or otherwise destroy the nerve paths associated with the overactive sweat glands. The same procedure is repeated on the other side of the body. Side effects, especially compensatory hyperhidrosis in other parts of the body, may reduce long term satisfaction with this procedure. Sweating returns in approximately 50% of patients.

A report by the Finnish Office of Health Technology Assessment systematically evaluated the literature on the safety and effectiveness of thoracoscopic sympathectomy for treatment of sweating and for treatment of social phobia (Malmivaara et al, 2005).  Thoracoscopic sympathectomy aims to reduce excessive sweating of the face and hands and facial flushing by interrupting stimulation of sweat glands by the sympathetic nervous system.  The treatment is performed as an endoscopic procedure, where the upper thoracic chain of the sympathetic nerve trunk is transsected or clamped.

The authors stated that it is difficult to conduct even a qualitative synthesis of studies of thoracoscopic sympathectomy, due to poor reporting of patient characteristics and variation among studies in the reporting of outcomes (Malmivaara et al, 2005).  In addition, the authors found most of the studies to be of poor methodologic quality.  The authors stated, however, that available literature suggests that thoracoscopic sympathectomy reduces excessive sweating of the palms and facial flushing.  Patient satisfaction was reported as good or moderately good.  The authors identified only 1 study that followed subjects for more than 2 years.

The reported rates of acute post-operative complications following endoscopic thoracic sympathetomy varided widely among studies studies (Malmivaara et al, 2005).  Acute post-operative complications, some severe, occurred in as many as 10 % of subjects.  The most commonly reported chronic complication was compensatory sweating below the breast level, often with substantial resultant disability.  Other chronic complications included dryness of the face or palms and gustatory sweating.  The authors noted that, due to wide variation in the reporting of complications, it is probable that these complications have been under-reported in most series.

The authors concluded that "due to lack of controlled trials there is no reliable evidence for the effectiveness of endoscopic thoracic sympathectomy for excessive sweating in the face and hands or for flushing of the face" (Malmivaara et al, 2005).  The authors also found no reliable evidence of the effectiveness of endoscopic thoracoscopic sympathectomy for social phobia.  The authors concluded that endoscopic thoracic sympathectomy is associated with significant immediate and long-term adverse effects.

A follow-up article to the FinOHTA assessment (Malmivaara et al, 2007) re-affirmed these earlier findings, concluding that: "The evidence for the effectiveness of ETS [endoscopic thoracic sympathectcomy] is weak.  The intervention is associated with severe immediate complications in some patients and persistent adverse effects for many."  The methodological quality and the reporting of clinically relevant characteristics were poor.  The quality scores of the included studies ranged from 0 to 8; only 3 studies scored 6 or more.  The authors stated that blushing and excessive sweating decreased after ETS in all studies, but no further details were reported.  Complications following ETS included pneumothorax and/or haemothorax and Horner's syndrome in some patients in almost all studies.  Compensatory excessive sweating was observed in 50 % or more of patients in 13 of the 15 studies, and was considered to cause significant disability in 3 to 15 % of those who experienced it.

A review by the Royal Australasian College of Surgeons (Watt et al, 2009) concluded that "[a] lack of high quality randomised trial evidence on ETS means that it is difficult to make a judgment on the safety and effectiveness of this technique", and that "[t]here is potentially a number of safety issues associated with this procedure."

Patients with palmar hyperhidrosis who fail topical therapies and iontophoresis, and who do not tolerate or get relief from botulinum toxin, can be treated effectively with endoscopic thoracic sympathectomy (Smith, 2008).  Side effects, especially compensatory hyperhidrosis in other parts of the body, may reduce long-term patient satisfaction with this procedure.  Endoscopic thoracic sympathectmy can also be used for axillary hyperhidrosis, but the relapse rate is high.

Hofferberth et al (2014) reported the outcomes of a single-institution experience using video-assisted thoracoscopic left cardiac sympathetic denervation as an adjunctive therapeutic technique in pediatric and young adult patients with life-threatening ventricular arrhythmias.  These investigators conducted a retrospective clinical review of all patients who underwent left cardiac sympathetic denervation by means of video-assisted thoracoscopic surgery at the authors’ institution.  From August 2000 to December 2011, a total of 24 patients (13 with long QT syndrome, 9 with catecholaminergic polymorphic ventricular tachycardia, and 2 with idiopathic ventricular tachycardia) were identified from the cardiology database and surgical records.  There were no intra-operative complications.  The median post-operative length of stay was 2 days (range of 1 to 32 days).  There were no major peri-operative complications.  Longer-term follow-up was available in 22 of 24 patients at a median follow-up of 28 months (range of 4 to 131 months).  Sixteen (73 %) of the 22 patients experienced a marked reduction in their arrhythmia burden, with 12 (55 %) becoming completely arrhythmia-free after sympathectomy.  Six (27 %) of the patients were non-responsive to treatment; each had persistent symptoms at follow-up.  The authors concluded that video-assisted thoracoscopic left cardiac sympathetic denervation can be safely and effectively performed in most patients with life-threatening ventricular arrhythmias.  They stated that this minimally invasive procedure is a promising adjunctive therapeutic option that achieves a beneficial response in most symptomatic patients.  These preliminary findings need to be validated by well-designed studies.

De Ferrari and Schwartz (2014) stated that heart failure (HF) is characterized by an autonomic imbalance with withdrawal of vagal activity and increased sympathetic activity.  Novel non-pharmacological approaches to HF aimed at increasing vagal activity are being proposed.  Left cardiac sympathetic denervation (LCSD) has been shown to modify favorably the outcome of several disorders characterized by life-threatening arrhythmias triggered by increased sympathetic activity.  These investigators discussed the rationale and the limited experimental and clinical experience suggesting a potential role for LCSD in the treatment of patients with advanced HF.  Possible future clinical applications of LCSD may include HF patients who are intolerant to beta-adrenergic blockade, HF patients who have frequent implantable cardioverter-defibrillator shocks, and HF patients in countries where the likelihood of receiving a device is limited, but the capability to perform a one in a lifetime procedure is present.

An UpToDate review on "Management of refractory heart failure" (Colucci, 2015) does not mention thoracoscopic sympathectomy as a therapeutic option.

Costello et al (2015) stated that congenital ion channel disorders, including congenital long QT syndrome (LQTS), cause significant morbidity in pediatric patients.  When medication therapy does not control symptoms or arrhythmias, more invasive treatment strategies may be necessary.  These researchers examined their institution's clinical experience with surgical cardiac denervation therapy for management of these arrhythmogenic disorders in children.  An institutional review board-approved retrospective review identified 10 pediatric patients with congenital ion channelopathies who underwent surgical cardiac denervation therapy at a single institution between May 2011 and April 2014; 8 patients had a diagnosis of congenital LQTS, 2 patients were diagnosed with catecholaminergic polymorphic ventricular tachycardia (CPVT).  All patients underwent sympathectomy and partial stellate ganglionectomy via video-assisted thoracoscopic surgery (VATS).  Six of the 10 patients had documented ventricular arrhythmias pre-operatively, and 70 % of the patients had pre-operative syncope.  The corrected QT interval decreased in 75 % of patients with LQTS following sympathectomy.  Post-operative arrhythmogenic symptoms were absent in 88 % of congenital LQTS patients, but both patients with CPVT continued to have symptoms throughout the duration of follow-up.  All patients were alive after a median follow-up period of 10 months.  The authors concluded that surgical cardiac denervation therapy via VATS is a useful treatment strategy for congenital LQTS patients who failed medical management, and its potential benefit in the management of CPVT is unclear.  They stated that a prospective comparison of the effectiveness of surgical cardiac denervation therapy and implantable cardioverter-defibrillator use in congenital ion channelopathies is timely and crucial.

Thoracoscopic Sympathectomy for the Treatment of Acne Vulgaris

Kaplan et al (2014) examined the therapeutic effect of thoracoscopic sympathicotomy performed at their clinic for facial/scalp hyperhidrosis or blushing on coincidental facial acne vulgaris based on previous reports indicating an association between the sympathetic nerve stimulus, epithelial melanocyte system and sebogenesis.  The possible therapeutic effects of sympathicotomy on facial acne vulgaris were analyzed in a study design of retrospective review with prospective collection of the data from March 2005 to March 2013.  A total of 42 patients were operated on at the authors’ clinic due to facial/scalp hyperhidrosis or blushing and 30 of these also had facial acne vulgaris.  However, none harbored a systemic co-morbidity.  Patients' medical history indicated that they had used several medical therapies including topical or systemic anti-biotherapies to treat their acne for several years but this had met with limited success and the treatment was stopped in all patients an average of 8 ± 2.4 months prior to the operations.  Furthermore, the patients with acne vulgaris also underwent a thoracoscopic sympathicotomy procedure at the second costal head (R2) for hyperhidrosis or blushing.  All 30 patients showed marked improvement of their acne grade at the 1st post-operative month (p < 0.01).  The authors concluded that in this study, the patients' facial acne vulgaris grade significantly improved after undergoing a sympathicotomy.  This can be explained by the possible effect the nervous system had on the epithelial melanocyte system and sebogenesis.  However, these researchers stated that prospective studies with an increased number of patients are needed to verify these findings.

Furthermore, an UpToDate review on "Treatment of acne vulgaris" (Graber, 2016) does not mention thoracoscopic sympathectomy as a therapeutic option.

Trans-Umbilical Thoracic Sympathectomy for the Treatment of Palmar Hyperhidrosis

Zhu et al (2016) noted that thoracic sympathectomy is considered as the most effective method to treat palmar hyperhidrosis (PH).  These investigators reported their experience of trans-umbilical thoracic sympathectomy with an ultra-thin flexible endoscope for PH in a series of 148 patients with up to 4 years of follow-up.  A prospective database was used in this retrospective analysis of 148 patients (61 males, 87 females, with a mean age of 21.3 years) with PH who were operated on by the same surgeon in a single institution from April 2010 to March 2014.  All procedures were performed under general anesthesia involving intubation with a double-lumen endotracheal tube.  Demographic, post-operative and long-term data of patients were recorded and statistical analyses were performed.  All patients were followed-up at least 6 months post-procedure through clinic visits or telephone/e-mail interviews.  The procedure was performed successfully in 148 of the 150 patients; 2 patients had to be converted to conventional thoracoscopic procedure because of severe pleural adhesions.  The mean operating time was 43 minutes (ranging from 39 to 107) and the mean post-operative length of stay was 1 day (range of 1 to 4).  All patients were interviewed 6 to 48 months after surgery and no diaphragmatic hernia or syndrome was observed.  The rate of resolution of PH and axillary hyperhidrosis was 98 and 74.6 %, respectively.  Compensatory sweating was reported in 22.3 % of patients.  Almost all of the patients were satisfied with the surgical results and the cosmetic outcome of the incision.  The authors concluded that these preliminary findings suggested that trans-umbilical thoracic sympathectomy was a safe and effective alternative to the conventional approach.  This technique avoided the chronic pain and chest wall paresthesia that are associated with the chest incision.  In addition, this novel procedure afforded maximum cosmetic benefits.  The main drawbacks of this study were:

1. the lack of a comparison group and
2. it was a single-center study and the procedure was performed by a single surgeon.

Thoracoscopic Sympathectomy for Long QT Syndrome

Antonopoulos and associates (2017) stated that long QT syndrome (LQTS) is an uncommon and potentially fatal cardiac channelopathy.  Therapeutic options can be medical with beta-blockers or surgical with implantable cardioverter defibrillator (ICD) implantations and left cardiac sympathetic denervation (LCSD).  These investigators stated that the Heart Rhythm Society (HRS), the European Heart Rhythm Association (EHRA) and the Asia Pacific Heart Rhythm Society (APHRS) expert consensus has recommended for LCSD to be performed in high-risk patients with a diagnosis of LQTS in whom ICD therapy is contraindicated or refused; and/or beta-blockers are either not effective in preventing syncope/arrhythmias, not tolerated, not accepted or contraindicated (Class I) and it may be useful in patients with a diagnosis of LQTS who experience breakthrough events while on therapy with beta-blockers/ICD (Class IIa).

Surman and colleagues (2019) noted that multiple case studies have suggested that VATS reduces the occurrence and frequency of symptoms in LQTS.  To-date there has not been a literature review to report on the short-term and long-term outcomes of this procedure.  These investigators reviewed the literature on the clinical outcomes of VATS for long QT syndrome and presented a case-report on the outcomes of T2-T5 sympathectomy.  Relevant articles were identified by a systematic search of PubMed, Cochrane and Scopus databases, from November 1985 to October 2015.  A total of 520 patients from 21 publications were included for analysis and discussion in 3 main areas: presenting symptoms and indication for surgery, peri-operative complications, and patient quality of life (QOL) following surgery.  The case study reviewed a 49-year old woman with recently diagnosed long QT syndrome and intolerance to beta blocker therapy successfully managed with T2-T5 TS.  The most common presenting indication for operative management of long QT syndrome was syncope (208/520 patients) and tachyarrhythmia (207/520 patients); T1-T5 left sympathectomy was performed in 15/21 published reports (332/520 patients) with partial stellate removal or in its entirety.  Follow-up of patients ranged from 1 month to 11 years; 4 patients died in the post-operative period, from fatal arrhythmias.  The most common post-operative findings were no symptoms (64/520 patients); tachyarrhythmia (55/520 patients), syncope (45/520 patients), and Horner's syndrome (13/520 patients with 27 patients reporting associated symptoms); 13 cases reported on the QTc changes post-TS and 9/13 cases involving 220/520 patients showed marked QTc reduction following surgery.  Mean pre-operative QTc was 558 ms and median 559 ms.  Mean post-operative QTc was 476 ms and median 466 ms.  The patient showed a marked reduction in QTc following surgery, with no evidence of arrhythmias and reduced beta blocker dependence.  The authors concluded that surgical management of LQTS has historically involved a left cervicothoracic stellectomy removing stellate ganglia and typically part of the left thoracic sympathetic chain resulting in reduction in symptoms but increasing the risk of Horner's syndrome and intermittent temperature changes.  These researchers stated that surgical resection of the thoracic ganglia alone for management of LQTS is scarce in the literature.  Short-term follow-up in this case study following a T2-T5 TS revealed reduction in symptoms, no requirement for beta blocker therapy and reduced QTc interval.  Moreover, they stated that further follow-up using greater patient numbers will further support T2-T5 sympathectomy as an option for surgical management of LQTS.

Thoracoscopic Sympathectomy  for Refractory Electrical Storm After Coronary Artery Bypass Grafting / Internal Cardioverter Defibrillator (ICD) Implantation

Wehman and colleagues (2018) reported on the findings of a patient with refractory electrical storm after coronary artery bypass grafting (CABG) who was successfully treated with TS.  Cardiac arrest with VT occurred on post-operative day 2, and the patient required emergency support with veno-arterial extra-corporeal membrane oxygenation (ECMO).  Frequent episodes of VT prevented cardiac recovery and weaning from mechanical circulatory support.  A percutaneous left stellate ganglion block initially demonstrated successful prevention of VT, and definitive sympathetic denervation was achieved by a left TS.  The patient remained in normal sinus rhythm and gained recovery of baseline ventricular function, permitting successful de-cannulation and weaning of inotropic support.  These preliminary findings need to be validated by well-designed studies.

Tellez and associates (2019) noted that the combined treatment of beta-blockers with ablation and ICD therapy continues to be the mainstay treatment for ventricular arrhythmias (VAs).  Despite treatment, some patients remain refractory.  Recent studies have shown success rates using VATS cardiac denervation as an effective therapeutic option for these patients.  During a period of 3 years, from 2015 through 2017, a total of 20 patients failed traditional medical and interventional treatment for the management of VAs and electrical storms.  After remaining refractory, the patients were referred to the authors’ thoracic surgery department for a VATS-based treatment.  The participants all had ventricular VAs and electrical storms secondary to different cardiomyopathies; they were refractory to combined medical (beta-blockers), ICD and ablation therapy.  All 20 patients agreed to surgery and were taken to cardiac denervation using a bilateral VATS approach by 2 thoracic surgeons at a single cardiothoracic center.  During the month prior to bilateral VATS denervation a combined total of 29 ICD shocks were registered in addition to 6 cases of electrical storms averaging 3 shocks/day.  Mean shocks/patient was 2.3.  During the first 3 months following VATS, the subjects had a 90 % (n = 18/20) total resolution of ICD registered shocks, a 100 % (n = 6/6) resolution of electrical storms, and a 92 % (n = 11/12) resolution of shocks in patients having previous ablation therapy.  No complications were documented following surgery except for 1 case of pneumothorax as a result of the procedure, and there were no peri-operative mortalities.  The authors concluded that  bilateral thoracoscopic cardiac denervation could be a safe and seemingly effective therapeutic option for patients presenting with life-threatening refractory VAs and electrical storms in a variety of cardiomyopathies including Chagas disease.  These investigators stated that small sample size (n = 20) and short follow-up periods (1 to 9 months) were the main drawbacks of this study.  Furthermore, they stated that because of variable results in the literature, further controlled studies and long-term follow-up is needed to determine optimal technique effectiveness.

If an arrhythmia is not suppressed adequately with medical therapy and a PVC trigger is identifiable, the patient should be referred for catheter ablation. If catheter ablation is unsuccessful, cardiac sympathetic denervation (autonomic modulation) is a reasonable option (class IIb) to reduce arrhythmic burden (Al-Khatib et al, 2018).

Salewski and associates (2020) stated that recurrent ventricular tachycardia (VT) can occur after left ventricular assist device (LVAD) implantation.  In this scenario, medical treatment might be insufficient.  These investigators reported a case of a left-sided thoracoscopic sympathectomy as a feasible treatment escalation for intractable VT.  A 72-year old patient underwent an internal cardioverter defibrillator (ICD) implantation as primary prophylaxis for VTs in the setting of staged heart failure therapy.  Afterwards, due to a progressive dilative cardiomyopathy he underwent a minimal-invasive LVAD implantation.  After an uneventful minimal-invasive LVAD-implantation the patient was discharged to a rehabilitation program.  However, after 7 weeks he developed recurrent VTs, which were successfully terminated by ICD shocks deliveries leading to severe discomfort and frequent hospitalizations.  Eventually, the patient was admitted with an electrical VT storm.  Successful endocardial catheter ablation (CA) of all inducible VTs were performed combined with multiple re-arrangements of his oral anti-arrhythmic medication; however, all these treatments could not suppress further occurrence of VTs.  After an inter-disciplinary discussion, the patient agreed to a left-sided video-assisted thoracoscopic sympathectomy.  After a follow-up of 150 days the patient was free from VTs apart from 1 short event.  The authors believed video-assisted thoracoscopic sympathectomy might be a surgical therapeutic option in patients with intractable recurrent VTs after CA of VT reentrant substrate even after minimal-invasive LVAD implantation.

Krause and colleagues (2021) noted that electrical storm (ES) is a life-threatening condition that affects up to 20 % of patients with ICDs.  In a retrospective study, these investigators reported their findings with left video-assisted thoracoscopic sympathectomy/ganglionectomy (VATSG) to treat refractory ES in low ejection fraction (EF) patients who were not candidates for catheter ablations (CA).  They identified 12 patients who presented with ES and underwent a total of 14 VATSG, including 3 patients on veno-arterial extracorporeal membrane oxygenation (VA ECMO).  These researchers reviewed demographic data, survival to discharge, number of cardioversions (before and after VATSG), need for re-admissions, and need for right-sided procedures.  In the 30 days prior to a left VATSG, the mean number of shocks was 22.67 for all patients.  For the patients who survived to discharge the mean was 3.55 since surgery with a median of 0 shocks after a median follow-up of 358 days; 6 patients had not experienced any further cardioversions since their last VATSG and 5 had never been re-admitted for VT.  Two patients had staged bilateral procedures due to recurrences and of those, 1 never needed any further cardioversions.  The authors concluded that limited left VATSG was an appropriate and effective initial treatment for ES patients who are not candidates for CA, including patients on VA ECMO for hemodynamic support.

Furthermore, an UpToDate review on "Electrical storm and incessant ventricular tachycardia" (Passman, 2021) states that "Management of refractory cases -- Rarely, patients will continue to have refractory electrical storm or incessant VT in spite of medical therapy and catheter ablation attempts.  A variety of salvage therapies may be considered … including … Stellate ganglion blockade is a temporizing measure, and terminal sympathectomy via surgical cardiac sympathetic denervation (CSD) or orthotopic heart transplantation may be needed for eligible non-responders in whom other treatments have also failed".

Table: CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
CPT codes covered if selection criteria are met:
32664	Thoracoscopy, surgical; with thoracic sympathectomy
Other CPT codes related to the CPB:
64650	Chemodenervation of eccrine glands; both axillae
64804	Sympathectomy, cervicothoracic
93650 - 93657	Intracardiac catheter ablation procedures
97033	Application of a modality to one or more areas; iontophoresis, each 15 minutes
Other HCPCS codes related to the CPB:
J0585	Botulinum toxin type A, per unit
J0587	Botulinum toxin type B, per 100 units
ICD-10 codes covered if selection criteria are met:
G56.40 - G56.42	Causalgia of upper limb
G57.70 - G57.72	Causalgia of lower limb
I45.81	Long QT syndrome [in persons who have failed medical therapy and have frequency ICD shocks despite medications]
I47.2	Ventricular tachycardia
I49.01	Ventricular fibrillation
I73.00 - I73.01	Raynaud's syndrome
L74.510, L74.512, L74.519 - L74.52	Primary and secondary focal hyperhidrosis [intractable, disabling - see criteria]
ICD-10 codes not covered for indications listed in the CPB:
I50.1 - I50.9	Heart failure
L70.0	Acne vulgaris
L74.511	Primary focal hyperhidrosis, face
L74.513	Primary focal hyperhidrosis, soles
R23.2	Flushing

The above policy is based on the following references: