Mechanism-Directed Management of Refractory Vasospasm: Sympathetic Blockade vs Thermal Modulation.

IMAGE: Serial angiography of pain-associated and cold-associated vasospasm refractory to intra-arterial vasodilators during peripheral endovascular intervention. CASE SUMMARY: Two patients with systemic sclerosis underwent tibial intervention for chronic limb-threatening ischemia and developed diffuse vasospasm beyond the treated segment despite repeated intra-arterial vasodilators. In the first, severe procedural pain preceded vasospasm, which resolved immediately after sciatic nerve blockade. In the second, vasospasm occurred during cold exposure despite sciatic nerve blockade and improved after active limb warming. TAKE-HOME MESSAGE: Vasodilator-resistant vasospasm may arise from mechanisms beyond device manipulation; recognizing pain-associated or cold-associated triggers may guide mechanism-directed management.