Evaluation of collateral circulation of the hand

In 1929, Edgar V. Allen described a noninvasive evaluation of the patency of the arterial supply to the hand of patients with thromboangitis obliterans (Am J Med Sci 1929;178:237). In the early 1950s, Allen's test was modified (Wright I. Vascular diseases in clinical practice. Chicago: Year Book Medical Publishers, 1952) for use as a test of collateral circulation prior to arterial cannulation. This test involves the examiner occluding the patient's ulnar and radial arteries while the patient makes a fist, causing the hand to blanch. The patient is then asked to extend the fingers. After the hand is open, the examiner releases the ulnar artery while continuing to maintain pressure on the radial artery. Adequate collateral circulation is felt to be indicated by return of normal color to the hand. The patient is instructed not to hyperextend the fingers when opening the hand. Hyperextension may cause a decrease in perfusion to the arch, possibly resulting in a false interpretation of the Allen test (Anesthesiology 1972;37:356). The modified Allen's test can be performed quickly and easily, but it is susceptible to error. (With Allen's original test, both hands were tested simultaneously. The patient clenched both fists tightly for 1 minute while the examiner compressed one artery of each hand. This method helps diagnose complete occlusion, just as Allen intended. The test was later modified, however, to evaluate the adequacy of collateral circulation. To perform the modified Allen's test, the examiner compresses both arteries while the patient's fists are clenched. The patient then opens the hand, and the adequacy of circulation is evaluated when the examiner releases one of the arteries.) This study was designed to combine the modified Allen's test with the sensitivity of oximetry and plethysmography to provide a quantifiable and reproducible evaluation of the palmar collateral circulation with or without the subject's cooperation. Superficial palmar arches of 90 normal volunteers (aged 22–45 years) were evaluated with the modified Allen's test. These results were compared with the flow patterns demonstrated by plethysmography and pulse oximetry. All of the modified Allen's tests were normal, with the palmar blush occurring in an average of 2.3 seconds (range, 2–5 s). Results were recorded independently by two observers, with agreement in all cases. Four of the 90 (4.4%) palmar arches were found to have abnormal circulatory patterns. Plethysmography clearly demonstrated the dominant arterial supply to the hand and, in appropriate cases, indicated the existence of an incomplete arch. The four abnormal circulatory patterns (two incomplete palmar arches and two other aberrant arterial communications) were clearly shown by plethysmography. Pulse oximetry was found to be too sensitive. Significant changes in flow did not result in a decrease in saturation. Only the incomplete superficial palmar arches resulted in a change in saturation. The two abnormal arterial communications were not detected by pulse oximetry. Pulse oximetry also could not show dominant flow patterns. Our findings indicate that plethysmography can be used to demonstrate palmar collateral circulation, but that pulse oximetry cannot.This work was funded by the Anesthesiology Research Foundation and the Samuel J. Roessler Research Scholarship.This paper was presented at the Society of Critical Care Medicine's 19th Annual Education and Scientific Symposium, San Francisco, California, May, 1990.     

Evaluation of collateral circulation of the hand

In 1929, Edgar V. Allen described a noninvasive evaluation of the patency of the arterial supply to the hand of patients with thromboangitis obliterans (Am J Med Sci 1929;178:237). In the early 1950s, Allen's test was modified (Wright I. Vascular diseases in clinical practice. Chicago: Year Book Medical Publishers, 1952) for use as a test of collateral circulation prior to arterial cannulation. This test involves the examiner occluding the patient's ulnar and radial arteries while the patient makes a fist, causing the hand to blanch. The patient is then asked to extend the fingers. After the hand is open, the examiner releases the ulnar artery while continuing to maintain pressure on the radial artery. Adequate collateral circulation is felt to be indicated by return of normal color to the hand. The patient is instructed not to hyperextend the fingers when opening the hand. Hyperextension may cause a decrease in perfusion to the arch, possibly resulting in a false interpretation of the Allen test (Anesthesiology 1972;37:356). The modified Allen's test can be performed quickly and easily, but it is susceptible to error. (With Allen's original test, both hands were tested simultaneously. The patient clenched both fists tightly for 1 minute while the examiner compressed one artery of each hand. This method helps diagnose complete occlusion, just as Allen intended. The test was later modified, however, to evaluate the adequacy of collateral circulation. To perform the modified Allen's test, the examiner compresses both arteries while the patient's fists are clenched. The patient then opens the hand, and the adequacy of circulation is evaluated when the examiner releases one of the arteries.) This study was designed to combine the modified Allen's test with the sensitivity of oximetry and plethysmography to provide a quantifiable and reproducible evaluation of the palmar collateral circulation with or without the subject's cooperation. Superficial palmar arches of 90 normal volunteers (aged 22–45 years) were evaluated with the modified Allen's test. These results were compared with the flow patterns demonstrated by plethysmography and pulse oximetry. All of the modified Allen's tests were normal, with the palmar blush occurring in an average of 2.3 seconds (range, 2–5 s). Results were recorded independently by two observers, with agreement in all cases. Four of the 90 (4.4%) palmar arches were found to have abnormal circulatory patterns. Plethysmography clearly demonstrated the dominant arterial supply to the hand and, in appropriate cases, indicated the existence of an incomplete arch. The four abnormal circulatory patterns (two incomplete palmar arches and two other aberrant arterial communications) were clearly shown by plethysmography. Pulse oximetry was found to be too sensitive. Significant changes in flow did not result in a decrease in saturation. Only the incomplete superficial palmar arches resulted in a change in saturation. The two abnormal arterial communications were not detected by pulse oximetry. Pulse oximetry also could not show dominant flow patterns. Our findings indicate that plethysmography can be used to demonstrate palmar collateral circulation, but that pulse oximetry cannot.This work was funded by the Anesthesiology Research Foundation and the Samuel J. Roessler Research Scholarship.This paper was presented at the Society of Critical Care Medicine's 19th Annual Education and Scientific Symposium, San Francisco, California, May, 1990.     

心肌缺血与侧支循环生成的关系

临床调查结果显示心肌梗死前的心绞痛能够有效保护左室功能,其机制与冠状动脉侧支循环生成有关。目前的实验研究已经初步证明心肌缺血、缺氧能够诱导促血管生长因子的表达,促发血管新生过程,增加心肌侧支循环血流量,保护心肌功能。为了方便心肌缺血负荷和侧支循环生成之间关系的进一步探索,综述了动物心肌缺血模型的建立、心肌缺血负荷与侧支循环生成的关系方面的研究进展及意义,以期为临床医学和康复干预提供理论依据。     

烟雾病侧枝循环的MRI表现

目的:探讨烟雾病(MMD)侧枝循环的类型及其MRI表现。方法:回顾分析了16例成年MMD患者的MRI和MRA表现。MRI至少包括横断面T1WI、T2WI;16例行MRA检查,采用3D-TOF法。结果:MMD侧枝循环的来源主要有3条途径:颅底烟雾血管、来自大脑后动脉(PCA)的柔脑膜侧枝血管以及来自颈外动脉(ECA)系统穿过硬脑膜的侧枝血管。5例PCA侧枝循环表现正常,7例增加,6例减少;13例ECA侧枝血管表现正常(单侧12例),15例增加(其中双侧3例)。4例少量颅底烟雾血管,7例大量烟雾血管,5例减少、闭塞。MRA和T2WI均可显示颅底烟雾血管,PCA和ECA侧枝血管仅在MRA满意显示。结论:MRI和MRA是诊断MMD患者侧枝循环十分有用的工具。     

冠状动脉侧支循环与年龄、性别因素的关系

目的 探讨冠状动脉侧支循环的形成与年龄、性别因素的关系。方法 将1997年1月至2002年3月经冠状动脉造影证实至少一只冠状动脉血管直径狭窄≥75％的265例冠心病患者为入选对象(排除辩膜痛、先天性心病、心肌病和肺心病)。将显示有侧支的患者以55和65岁为界，分成年轻组、中年组及老年组，初步分析年龄及性别因素与侧支循环开放率之间的关系。结果 冠心病患者冠状动脉侧支开放率与年龄有关，55～65岁年龄组侧支开放率最高，女性因生理原因冠状动脉病变发生较晚，故侧支开放明显滞后，在65岁以后冠状动脉侧支开放率仍低于男性，差别有统计学意义。结论 冠心病患者冠状动脉侧支开放率与年龄有关，且男性高于女性。     

The transient appearance of collateral circulation during coronary spasm

This article reports a case of transient augmentation of collateral circulation due to spontaneous coronary arterial spasm during angiography. The patient's electrocardiogram revealed ST-segment depression during vasospastic attack; this depression differs from the typical change of the ST-segment elevation in coronary spasm without collateral circulation.     

猪冠状动脉侧支循环生成的免疫组化研究

目的：探讨免疫组化法分析猪冠状动脉侧支循环生成的可行性，为冠心病康复的机制研究奠定方法学基础。方法：健康成年小型猪45只，建立可控性心肌缺血动物模型，分别设立假手术组、缺血组和运动组。缺血组予以单纯冠状动脉水囊充气诱发的短暂缺血．运动组除行缺血刺激外再给予平板有氧训练，共持续8周。实验终点时取冠状动脉钝缘支支配区心肌组织行心肌毛细血管密度测定：①常规HE染色后镜检计数：②免疫组化分析Ⅷ因子相关抗原标记并镜检计数。对两种方法检测毛细血管密度的重复性进行检验。结果：HE染色与免疫组化均显示运动组心肌缺血区毛细血管密度明显高于单纯缺血组（P〈0.01）及假手术组（P〈0.01），缺血组明显高于假手术组（P〈0.01）。免疫组化检测的毛细血管密度显著高于HE检测（P〈0.05）。两种方法的结果有较好的重复性（P〈0.05），均与冠状动脉侧支血流量（CCBF）正相关，但免疫组化检测结果与CCBF相关系数显著高于HE（P〈0．05）。结论：免疫组化可以准确有效地量化分析猪冠状动脉侧支血管状态。     

糖尿病对冠心病患者冠状动脉侧支循环开放的影响

目的　探讨糖尿病对冠状动脉侧支循环形成的作用及影响。方法　将经冠状动脉造影证实至少有一支冠状动脉血管直径狭窄≥ 75 %的 385例冠心病患者 ,按有无糖尿病分成两组 ,再以 5 5岁为界分为 4个亚组 ,进行侧支循环情况比较。结果　冠状动脉开放率糖尿病组 (4 4 .5 % )低于非糖尿病组 (6 9.5 % ) ,P <0 .0 5 ;其中 <5 5岁糖尿病组 (6 8.0 % )高于非糖尿病组 (37.7% ) ,P <0 .0 5 ;≥ 5 5岁糖尿病组 (4 2 .2 % )低于非糖尿病组 (6 7.4 % ) ,P <0 .0 5。结论　冠心病患者冠状动脉侧支循环发展程度与糖尿病有关。     

短暂缺血阈强度运动促进心肌侧支循环生成的机制

目的在小型猪可控性心肌缺血动物模型上,观察短暂缺血阈强度运动促进缺血区冠状动脉侧支循环生成的机制。 方法选择健康广西巴马小型猪32头,钝缘支装上水囊缩窄器制作可控性心肌缺血动物模型,4周后行冠状动脉造影证实模型建立成功。实验动物随机分为假手术组、单纯缺血组和运动组。单纯缺血组通过缩窄器注水加压制造心肌缺血,每日2次,每次2 min,每周5 d,共8周;运动组除制造静息状态心肌缺血外,每天还进行平板训练30 min,其中包括2次缺血阈强度运动,每次2 min,每周训练5 d,共8周。假手术组不作任何干预。采用微球测定训练前、后缺血区相对心肌血流量（RMBF）;采用Western-blot及Real-time RT-PCR法测定缺血心肌局部血管内皮细胞生长因子（VEGF）及其受体胎肝激酶-1（Flk-1）的蛋白及mRNA表达量;采用ELISA法测定血清肌钙蛋白含量以确定训练的安全性;应用电镜观察心肌细胞损伤情况。 结果运动组RMBF显著高于单纯缺血组及假手术组（均P<0.01）;单纯缺血组RMBF亦显著高于假手术组（P<0.01）。运动组VEGF及Flk-1的蛋白及mRNA表达量均显著高于单纯缺血组及假手术组（P<0.05,P<0.01）。单纯缺血组的VEGF及Flk-1的蛋白及mRNA表达量均显著高于假手术组（P<0.05）。单纯缺血组及运动组训练后,血清肌钙蛋白与训练前相比无显著增加（均P&rt;0.05）。光镜及电镜检查无明显异常。 结论小型猪可控性心肌缺血动物模型给予适宜短暂缺血阈强度运动,可通过缺血心肌局部VEGF及其受体Flk-1的上调安全有效地促进冠状动脉侧支循环生成。     

短暂缺血阈强度运动促进心肌侧支循环生成的机制

目的 在小型猪可控性心肌缺血动物模型上,观察短暂缺血阈强度运动促进缺血区冠状动脉侧支循环生成的机制.方法 选择健康广西巴马小型猪32头,钝缘支装上水囊缩窄器制作可控性心肌缺血动物模型,4周后行冠状动脉造影证实模型建立成功.实验动物随机分为假手术组、单纯缺血组和运动组.单纯缺血组通过缩窄器注水加压制造心肌缺血,每日2次,每次2 min,每周5 d,共8周;运动组除制造静息状态心肌缺血外,每天还进行平板训练30 min,其中包括2次缺血阈强度运动,每次2 min,每周训练5 d,共8周.假手术组不作任何干预.采用微球测定训练前、后缺血区相对心肌血流量(RMBF);采用Western-blot及Real-time RT-PCR法测定缺血心肌局部血管内皮细胞生长因子(VEGF)及其受体胎肝激酶-1(Flk-1)的蛋白及mRNA表达量;采用ELISA法测定血清肌钙蛋白含量以确定训练的安全性;应用电镜观察心肌细胞损伤情况.结果 运动组RMBF显著高于单纯缺血组及假手术组(均P＜0.01);单纯缺血组RMBF亦显著高于假手术组(P＜0.01).运动组VEGF及Flk-1的蛋白及mRNA表达量均显著高于单纯缺血组及假手术组(P＜0.05,P＜0.01).单纯缺血组的VEGF及Flk-1的蛋白及mRNA表达量均显著高于假手术组(P＜0.05).单纯缺血组及运动组训练后,血清肌钙蛋白与训练前相比无显著增加(均P＞0.05).光镜及电镜检查无明显异常.结论 小型猪可控性心肌缺血动物模型给予适宜短暂缺血阈强度运动,可通过缺血心肌局部VEGF及其受体Flk-1的上调安全有效地促进冠状动脉侧支循环生成.     

心肌梗塞患者的冠状动脉侧支循环与心室晚电位

观侧２２例心肌梗塞患者冠状动脉侧支循环与心室晚电位。对比研究结果：心肌梗塞后侧支循环良好者，左室射血分数提高（Ｐ＜０．００５），缺血性心律失常减少（Ｐ＜０．０５）；心室晚电位（ＱＲＳ－Ｄ、ＬＡＳ、ＲＭＳ４０）３项指标在侧支循环不良组与良好组之间存在着非常显著的差异。提示：冠状动脉侧支循环的建立对维护患者心功能、维持心肌电活动的稳定性、减少心脏猝死机率均有积极作用。     

"复合"技术治疗合并体肺侧支动脉重症法洛四联征疗效分析

目的:评价体肺侧支动脉封堵同期联合根治术治疗重症法洛四联征的临床效果.方法:经造影证实存在粗大体肺侧支动脉的33例重征法洛四联征患者,在杂交手术室先行侧支动脉封堵术.之后行传统根治手术.结果:33例患者中共发现体肺侧支动脉53支,成功封堵粗大侧支动脉35支,未发生造影及封堵相关并发症,死亡2例,余均痊愈出院.结论:"复合"技术治疗合并体肺侧支动脉重症法洛四联征安全、简便、有效.