Surgical Cardiac Sympathetic Denervation (CSD) is a procedure which involves surgical removal of terminal cervical and thoracic sympathetic ganglion for reducing sympathetic discharge to the heart. CSD is usually performed as a last desperate measure in treatment of ventricular tachycardia (VT). We report here the clinical profile and long-term follow-up of all our patients who underwent CSD (unilateral or bilateral) predominantly upfront prior to considering catheter ablation of VT for VT storm. We retrospectively collected data of all patients who underwent CSD for VT storm between year 2010 till 2019. Success of CSD was defined as successful discharge of patient from the hospital after the procedure more than 75% decrease in the frequency of VT after two weeks of surgical procedure. A total of 65 patients underwent CSD in the above-mentioned period and the average duration of follow-up was 28 months. The clinical parameters, demographic data and outcome analysis is provided in details in table 1. Only 14 (21.5%) patients underwent attempt of catheter ablation of VT prior to considering CSD. CSD was successful in 53 (81.5%) of patients. There was a significant decline in the incidence of number of ICD or external shocks before and after CSD (25.2±39.4 vs 1.09±2.9) respectively. There was no significant effect of CSD on ejection fraction. None of the available clinical parameters predicted the success of CSD. The current retrospective analysis reemphasize the role of surgical CSD in treatment of patients with VT storm. As in predominant patient's CSD was performed even before the attempting catheter-based ablation, it brings in a new dimension in the treatment of VT. Efficacy of CSD (81.5%) in experienced hand is equivalent or even better than catheter-based ablation in patients with VT storm. Type of funding source: None

<b>Background/Objectives</b>: The stellate ganglion (SG), formed by the fusion of the inferior cervical and first thoracic sympathetic ganglia in approximately 80% of individuals, plays crucial roles in cardiac innervation, pain management, and autonomic regulation. This review examines the anatomical variations, histological structure, clinical applications, and therapeutic implications of the SG and stellate ganglion block (SGB), presenting original high-resolution magnetic resonance imaging (MRI) evidence of SG visualization, an underutilized approach in autonomic nervous system research. <b>Methods</b>: We conducted a comprehensive literature review of anatomical, physiological, and clinical studies on the SG, incorporating original anatomical dissections and high-resolution MRI. Contemporary research on SGB applications, complications, and mechanisms of action was analysed and correlated with imaging characteristics. <b>Results</b>: The SG demonstrates significant anatomical variability, including the presence of intermediate ganglia, accessory nerve pathways, and variable relationships with surrounding vascular structures. Our original MRI imaging consistently identified the SG at the thoracic inlet, anterior to the neck of the first rib, lateral to the longus colli muscle, and posterior to the vertebral artery, demonstrating that advanced imaging can reliably visualize this critical autonomic structure and its anatomical variants. Histologically, it contains typical sympathetic architecture, comprising postganglionic neurons, satellite glial cells, and specialized SIF cells that modulate ganglionic transmission. SGB shows therapeutic efficacy across diverse conditions, including cardiac arrhythmias, chronic pain syndromes, post-traumatic stress disorder, sleep disorders, and immune dysfunction. The procedure's mechanisms involve both direct sympathetic blockade and complex neuroimmune pathways that affect central autonomic centers and lymphoid organs. Complications include vascular injury, pneumothorax, and nerve blocks affecting the recurrent laryngeal and phrenic nerves. <b>Conclusions</b>: The SG represents a critical autonomic structure with expanding clinical applications. This work advances the field by demonstrating that high-resolution MRI can consistently and non-invasively visualize the SG and its anatomical variations, knowledge previously mostly limited to cadaveric studies. Understanding these imaging-defined anatomical variations is essential for optimizing therapeutic interventions. Advanced imaging guidance integrated with comprehensive anatomical knowledge is crucial for maximizing efficacy while minimizing complications in stellate ganglion block procedures.