Abstract <p>Lumbar sympathectomy (LS) remains a therapeutic option for patients with chronic limb-threatening ischaemia not amenable to revascularisation. A systematic review was performed with sixteen total studies included. Retroperitoneoscopic LS was safer than open LS, with a shorter hospital stay. Chemical LS showed comparable efficacy with fewer complications and a reduced admission time. Irrespective of modality, LS provided consistent pain relief, wound healing, and quality-of-life improvement, though haemodynamic improvements were inconsistent. Limb salvage rates were generally favourable with no procedure-associated mortality. LS remains a niche, palliative intervention that may offer meaningful symptomatic relief when revascularisation is not feasible. Further long-term prospective studies measuring key haemodynamic parameters are required to refine patient selection and ascertain the potential of LS in modern chronic limb-threatening ischaemia management.</p> Graphical Abstract <p></p>