Correlation of hemodynamic and functional variables with the angiographic extent of peripheral arterial occlusive disease

The aim of the study was to determine whether hemodynamic and functional variables are related to the angiographic extent of lower limb atherosclerosis. In 150 patients with stable intermittent claudication, the Bollinger angiogram score was compared with the resting Doppler pressure values, and the initial claudication distance (ICD) and absolute claudication distance (ACD) with treadmill exercise. The extent of lower limb atherosclerosis correlated significantly with the age of the patients and the duration of the claudication. The angiogram scores of the patients were negatively correlated with the ankle systolic blood pressure (SBP) and the ankle/brachial index (ABI). In a multiple regression analysis, ABI was the most predictive variable for the angiographic severity of disease. ICD, ACD and work on the treadmill failed to correlate with the angiogram summation score. If patients were classified into groups for those with iliac or femoropopliteal disease, a weak correlation between ACD and femoropopliteal angiogram score was found. The comparison between Doppler measurements and treadmill exercise testing showed no significant correlation between SBP/ABI of the more diseased limb and ICD. However, both SBP and ABI did correlate significantly with ACD (r = 0.16, p < 0.05 and r = 0.20, p < 0.01, respectively). In conclusion, SBP and ABI are reliable parameters for indirect assessment of the angiographic extent of lower limb atherosclerosis. In contrast, the walking capacity of claudicant patients is independent of the angiographic severity of the disease.     

Effects of ethaverine hydrochloride on the walking tolerance of patients with intermittent claudication

The effect of ethaverine hydrochloride on exercise tolerance of patients with intermittent claudication was evaluated in a double-blind, placebo-controlled study conducted at three sites. Forty-five patients with symptoms of occlusive arterial insufficiency of the lower extremities were randomly assigned to receive ethaverine 200 mg or placebo four times daily. The patients were evaluated biweekly for 12 weeks with treadmill claudication tests, patient and investigator assessments of symptom severity, and reports of adverse reactions. Doppler ankle/brachial pressure ratios were recorded for 26 patients. Walking tolerance improved for patients in both groups during the course of the study. Increases in distance-to-claudication were significantly greater for patients receiving ethaverine after 6, 8, 10, and 12 weeks of therapy. Ankle/brachial pressure index after exercise was unchanged in both groups. Incidence of adverse reactions was similar for the two groups. Although patients were generally unaware of any improvement in symptoms, the investigators judged significant relief of claudication among those receiving ethaverine compared to those receiving placebo. It was concluded that ethaverine safely increased distance-to-claudication in patients with intermittent claudication.     

Doppler techniques for lower extremity arterial diagnosis

Doppler ultrasonic methods are based on a frequency shift incurred in the reflected sound from moving objects, for example, red blood cells. According to the desired depth of penetration, ultrasonic frequencies between 2 and 10 MHz are used. Continuous-wave Doppler detects all blood flow through the path of the ultrasound beam and pulsed-wave Doppler ultrasound permits detection of flow at specific sites in the arterial lumen. Through measurement of the systolic blood pressure, the extent of hemodynamically-significant arterial occlusive disease can be assessed. With the use of the ankle-arm index, which is normally greater than 1.0, compensation is enabled for variations in systemic pressure. Localization of the occlusive lesion can be obtained by measuring the systolic pressure at various levels in the limb. Normally, the ratio of high-thigh to brachial artery systolic pressure is greater than 1.2 and the difference in systolic pressure between any two adjacent levels in the leg should be less than 20 mm Hg. Measurement of toe pressure may be helpful when the ankle pressure is falsely elevated due to arterial calcification; in normal limbs, the systolic toe pressure is about 80 to 90% of the brachial systolic pressure. The use of small cuffs on large limbs can result in spuriously high pressure and medial calcification in the arterial wall can also lead to falsely high pressures. Treadmill exercise testing with determination of the immediate drop in ankle systolic pressure and the time for recovery to resting pressure is valuable to confirm or rule out intermittent claudication as the cause of leg pain and to detect severe multiple level arterial disease.(ABSTRACT TRUNCATED AT 250 WORDS)     

Exercise capacity and Doppler pressure measurements in symptomatic peripheral arterial obstructive disease

BACKGROUND: Doppler pressure measurements are a useful diagnostic tool in peripheral arterial obstructive disease. The aim of our study was to determine whether these pressure values do predict the degree of impairment of the walking capacity in symptomatic patients. PATIENTS AND METHODS: We compared the claudication distances (CDI: initial claudication distance, CDA: absolute claudication distance) of 939 patients (63 +/- 11 years) with stable intermittent claudication (Fontaine IIb) with the ankle pressure values at rest (APR) and after exercise (APE), with the ankle/brachial pressure index at rest (ABIR) and after exercise (ABIE), and with the ratio (ABIRATIO = ABIE/ABIR). Ankle systolic pressures were obtained using an 8 MHz Doppler probe. CD was measured by a treadmill test at constant-load conditions (3 km/hr; inclination 12%). Brachial systolic pressures were obtained using an automated blood pressure monitor. The values of the objectively worse leg were correlated with CDI and CDA. RESULTS: Low Doppler pressure values were not accompanied by significantly shorter walking distances in symptomatic patients. The resting pressure values (APR, ABIR) did not correlate with the claudication distances (CDI: 54 +/- 31 m; CDA: 87 +/- 41 m). For the exercise values (APE, ABIE), even a very slight inverse correlation with the claudication distances was found. In addition, the correlation between the pressure index ratio and the walking distances (ABIRATIO vs. CDI: r = -0.25, p < 0.01; ABIRATIO vs. CDA: r = -0.20, p < 0.01) was inverse, too, but slightly more pronounced. CONCLUSIONS: In patients with intermittent claudication the ankle artery pressures and the indices derived from these pressure values do not predict the walking distance. Therefore, the decision for angioplasty or bypass surgery should be made with regards to the impairment of quality of life rather than Doppler pressure values.     

Symptoms of chronic arterial insufficiency correlate with absolute ankle pressure better than with ankle: brachial index

BACKGROUND: Doppler-based measurement of the ankle: brachial index (ABI) has long been regarded as the standard by which to objectively quantify the degree of lower extremity arterial occlusive disease, but this method fails to account for the contribution of systemic blood pressure to actual limb perfusion. We hypothesized that the absolute blood pressure would be a better predictor of the severity of symptoms of chronic occlusive disease than the ABI. Experimental design: retrospective comparative study. Setting: university inpatient/outpatient vascular laboratory. Patients: 1396 evaluable patients out of 2436 total consecutive patients referred with suspected lower extremity arterial occlusive disease. Measures: comparison of absolute ankle and digital pressures and ABI according to severity of symptoms of chronic lower extremity ischemia using three-way analysis of variance (ANOVA), likelihood ratios, and receiver operator characteristic (ROC) curves. RESULTS: The symptoms of tissue ulcer/gangrene, rest pain, and gangrene were characterized by differences in absolute pressures in the great toe (47 +/- 42 mmHg vs 55 +/- 40 mmHg vs 62 +/- 33 mmHg [mean +/- SD], F = 19.05, p < 0.001) and ankle (92 +/- 53 mmHg vs 98 +/- 44 mmHg vs 106 +/- 37 mmHg, F = 12.91, p < 0.001), but not by the ABI (0.71 +/- 0.33 vs 0.68 +/- 0.34 vs 0.71 +/- 0.28, F = 1.24, p > 0.05). ROC curves confirmed absolute digital pressure (area under curve [AUC] = 0.628) and absolute ankle pressure (AUC = 0.607) to be superior to ABI (AUC = 0.572). CONCLUSIONS: The severity of symptoms for peripheral vascular disease correlate better with absolute pressure measurement than with ABI.     

Comparison between ankle and toe index in patients with peripheral arterial disease

In contrast to the systolic blood pressure at the posterior tibial artery, the evaluation of pressure at the digital artery of the foot before and after exercise in patients with peripheral arterial disease is not well known. Twenty three patients with peripheral vascular disease were examined. The systolic pressure was measured by means of an ultrasound velocity detector at the brachial and posterior tibial artery. Digital artery pressure was determined with photoplethysmography. Pressures were measured before and within 5 and 10 minutes after a treadmill test. Ankle and toe index was calculated. At rest the toe index is lower than the ankle index and after a treadmill test the decrease in toe index occurs in parallel to the ankle index.     

Comparison of standard one-minute treadmill exercise and strandness test (absolute walking distance) in relation to site of lesion, walking distance, and diastolic blood flow velocity (Doppler curves)

In 215 outpatients suffering from occlusive arterial disease of the lower limbs the authors compared the decrease in the ratio of ankle systolic pressure to brachial systolic pressure according to whether the treadmill exercise was limited to one minute or extended until pain forced the patient to stop. After a one-minute walk the pressure index always decreased significantly, especially when walking was restricted. The decrease in the pressure index was generally greater when the exercise was continued until the absolute walking distance, and the recovery time was usually twice as long. The fall in the pressure index was significantly greater for patients with single and multiple iliac stenoses than for those with stenoses at lower levels. In patients having a diastolic blood flow velocity on Doppler curves at rest, not modified by walking, a maximum drop in peripheral pressure was recorded after walking for one minute. In this instance there was no intensification of the decrease in peripheral pressure, unlike in patients without a diastolic blood flow velocity at rest. This one-minute test is not a maximal hemodynamic response, but it is sufficient for the appreciation of ischemia during exercise, according to the different parameters measured.     

Effects of handrail support on claudication and hemodynamic responses to single-stage and progressive treadmill protocols in peripheral vascular occlusive disease

Because handrail support reduces the energy cost of treadmill walking, claudication and hemodynamic responses of patients with peripheral vascular occlusive disease should also be affected. Furthermore, the reliability of the test results may be reduced unless the same pressure is applied to the handrails over repeated tests. The effect of handrail support on claudication and hemodynamic responses, and on their reliability, were examined during single-stage (2 mph, 12% grade) and progressive (2 mph, 0% grade with 2% increase every 2 minutes) treadmill protocols. Ten patients with stable disease performed both protocols 3 times, separated by 1 week, with and without handrail support. Claudication pain distance and maximal walking distance were greater (p less than 0.05) when handrail support was permitted, and they increased (p less than 0.05) over repeated tests of each protocol. No increase was noted over the tests without support. The responses and reliability of foot transcutaneous oxygen tension, ankle systolic pressure and ankle/brachial systolic pressure index after exercise to maximal tolerable pain were not affected by handrail support. Because claudication distances were altered, it is concluded that handrail support should not be allowed when assessing claudicants, unless balance cannot otherwise be maintained.     

Evaluation of the metabolic compensation after treadmill test in patients with peripheral occlusive arterial disease.

Patterns of release of lactate, hypoxanthine, and arginine into the bloodstream after a standardized treadmill test (twelve minutes, 1.6-2.8 mph, inclination 0,5,10,15%) were recorded in 21 consecutive patients with stage II peripheral arterial occlusive disease. Heart rate, systolic blood pressure, ankle blood pressure, and ankle/brachial systolic blood pressure ratio (A/B ratio), as well as plasma lactate, plasma hypoxanthine and serum arginine were recorded before and at fifteen to thirty-minute intervals for up to two hours after the treadmill test. Immediately after the treadmill test, lactate levels (36.6 +/- 3.7 mg/L) and hypoxanthine levels (2.73 +/- 0.19 mmol/L) were significantly (p less than 0.001) increased but returned to preexercise levels after thirty and sixty minutes, respectively. Arginine levels did not change significantly. Ankle blood pressure (57 +/- 5 mm Hg) and A/B ratio (0.40 +/- 0.04) were significantly (p less than 0.001) decreased after exercise, while heart rate and systolic blood pressure were increased. These parameters returned to normal as well within a half hour after exercise. Absolute walking distance correlated significantly (p less than 0.01) with the postexercise systolic blood pressure (r = -0.62), ankle pressure (r = 0.63) and A/B ratio (r = 0.72). Induced hypoxanthine and lactate production intercorrelated significantly positively (r = 0.57, p = 0.007) but were independent of the absolute walking distance. In contrast with lactate, hypoxanthine production correlated significantly with postexercise ankle pressure (r = 0.49, p = 0.02) and exercise-induced fall in A/B ratio (r = 0.66, p = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

老年下肢动脉闭塞患者的动脉造影特征及血清高敏C反应蛋白变化

目的分析老年下肢动脉闭塞患者动脉造影（DSA）的临床及病变特征,并测定血清高敏C反应蛋白（hs-CRP）水平,探讨hs-CRP检测的诊断意义。方法回顾性地分析第三军医大学老年科2008年1月至2012年12月间收治的41例老年下肢动脉闭塞患者的临床资料。分析临床特点、血压水平、性别差异、DSA的病变特点、hs-CRP水平及其与DSA造影结果的相关性。结果下肢动脉造影提示老年患者多存在多支、弥漫性病变,侧支循环形成差,症状较重,多以保守治疗为主。老年男性患者血压水平无明显升高,老年女性患者的收缩压水平高于男性患者,老年下肢动脉粥样硬化患者CRP明显增高,但无明显性别差异,也与病变的严重程度无关（P〈0．05）。结论DSA检测显示老年下肢动脉闭塞的患者病变有其独特性,血压升高水平有性别差异,hs-CRP在多数患者中有升高,但是无性别差异,也不能完全评估严重程度。     

The influence of age, sex, smoking, and diabetes on lower limb transcutaneous oxygen tension in patients with arterial occlusive disease

A retrospective study involving 129 patients (256 limbs) with unilateral or bilateral arterial occlusive disease was performed to assess the effects of age, sex, smoking, and diabetes on lower limb transcutaneous oxygen tension (TcPo2) measurements of were made according to a standard protocol, and the severity of lower limb arterial occlusive disease was estimated using the clinical signs and symptoms of disease or the ankle/brachial blood pressure index. The results demonstrated that age, sex, and smoking had no major effects on limb TcPo2 or disease severity; however, both limb TcPo2 and clinical disease severity were adversely affected by diabetes. When limbs with similar occlusive disease severity were compared, TcPo2 remained consistently lower in diabetic than in nondiabetic patients. We conclude that diabetes causes a reduction in limb TcPo2 beyond that which can be accounted for by large-vessel arterial occlusive disease alone.     

Relationship between free-living daily physical activity and peripheral circulation in patients with intermittent claudication

The purpose of this study was to determine the relationship between free-living daily physical activity and peripheral circulation under resting, reactive hyperemia, and maximal exercise conditions in peripheral arterial occlusive disease (PAOD) patients with intermittent claudication. Sixty-one PAOD patients (age = 70 +/- 6 years, ankle/brachial index [ABI] = 0.57 +/- 0.24) were recruited from the Vascular Clinic at the Baltimore Veterans Affairs Medical Center and from radio and newspaper advertisements. Free-living daily physical activity was measured as the energy expenditure of physical activity (EEPA), determined from doubly labeled water and indirect calorimetry. Patients also were characterized on ankle/brachial index, calf blood flow, calf transcutaneous oxygen tension (TcPO2), and calf transcutaneous heating power (TcHP). ABI and calf blood flow served as markers of the macrocirculation of the lower extremity, while TcPO2 and TcHP served as markers of the microcirculation. The claudication patients were sedentary, reflected by a mean EEPA value of 486 +/- 274 kcal/day. EEPA was related to calf TcHP at rest (282 +/- 24 mW; r = -0.413, p = 0.002), after postocclusion reactive hyperemia (275 +/- 22 mW; r = -0.381, p = 0.004), and after maximal exercise (276 +/- 20 mW; r = -0.461, p<0.001). ABI, calf blood flow, and calf TcPO2 were not related to EEPA under any condition. In conclusion, higher levels of free-living daily physical activity were associated with better microcirculation of the calf musculature in older PAOD patients with intermittent claudication.     

The instrumental diagnosis of arterial diseases especially of arterial occlusive diseases

Ultrasound Doppler sonography is the most important tool in the assessment of peripheral arterial occlusive disease. The determination of systolic ankle pressure gives an useful overview of the degree of the disease. In a normotensive patient with a systolic blood pressure of 140 mm Hg systolic ankle pressures between 100 and 140 mm Hg are present when the occlusive disease is in the stage of good compensation. Severe claudication will appear with ankle pressures between 70 and 95 mm Hg, lower values are indicating a critical limb ischaemia. Treadmill exercise is helpful for documentation of painfree and maximal walking distances. When a patient is suggested to be treated by percutaneous transluminal angioplasty or bypass surgery a duplex sonography or angiography is mandatory. In evaluating the Raynaud's phenomenon under the noninvasive techniques capillaroscopy of the nailfold is a useful tool. The diagnosis of thromboangiitis obliterans is usually established by clinical criterias. The radiographic findings may give important hints. In many cases of acute arterial occlusions angiography is necessary for finding the optimal therapy. The aneurysm of the abdominal aorta will be evaluated by ultrasound and computer tomography.     

The prevalence of atherosclerosis in cirrhotic patients: assessment of two aspects of atherosis and sclerosis

Aim: In general, cirrhotic patients are known to have a low prevalence of cardiovascular disease. Cirrhosis is often accompanied by diabetes mellitus, while blood pressure and serum cholesterol levels are low in liver cirrhosis. We examined the atherosclerosis of patients with chronic liver disease by two phases of atherosis "lipid deposition" and sclerosis "arterial fibrosis." Methods: Atherosis was assessed by carotid intima-media thickness and the ratio of the systolic blood pressure at the ankle to the average systolic blood pressure at the right arm (ankle brachial pressure index), while sclerosis was evaluated by brachial ankle pulse wave velocity. Results: There were no significant differences in intima-media thickness and ankle brachial index among grades of cirrhosis. Brachial ankle pulse wave velocity decreased closely as the severity of cirrhosis progressed (F = 4.90, P < 0.05). In univariate analysis, brachial ankle pulse wave velocity was correlated with systolic blood pressure, age, total bilirubin, albumin, prothrombin time, retention rate of indocyanine green at 15 min, blood ammonia, branched chain amino acids/tyrosine molar rate and fasting blood sugar. Multiple regression analysis showed that systolic blood pressure and total bilirubin were independent factors for the inhibition of vascular sclerosis progression. Conclusion: Although no difference in atherosis between cirrhotic patients and healthy controls was found, vascular sclerosis was decreased with the severity of cirrhosis through hypotension and hyperbilirubinemia.     

Comparison of three progressive exercise protocols in peripheral vascular occlusive disease.

Although claudication pain and hemodynamic responses to exercise are usually clinically assessed via graded treadmill walking, measuring these responses to other commonly performed tasks may yield a more nearly complete evaluation of peripheral vascular occlusive disease. Thus, the purpose of this study was twofold: (1) to determine the reliability of claudication and hemodynamic responses to level walking and stairclimbing and (2) to compare these responses with those obtained with graded walking at similar oxygen consumption. Ten patients with stable claudication symptoms performed graded walking, level walking, and stairclimbing progressive protocols with respective increases in grade, walking speed, and stepping rate on a modified stairclimbing device every two minutes. Similar peak oxygen consumption (13.60 to 14.18 mL/kg/min) was attained with the three protocols (P = NS). Reliability coefficients for the times to onset and to maximal claudication pain during level walking (R = 0.95 and 0.95, respectively) and during stairclimbing (R = 0.92 and 0.82, respectively) were similar to those previously obtained during graded walking. Reliability coefficients for foot transcutaneous oxygen tension during and following level walking (R = 0.78 to 0.96) and stairclimbing (R = 0.65 to 0.98) and for ankle systolic blood pressure following level walking (R = 0.95 to 0.97) and stairclimbing (R = 0.90 to 0.98) were also similar to those previously found with graded walking. Additionally, claudication and hemodynamic measurements were similar among the three exercise protocols. Thus, because graded walking, level walking, and stairclimbing progressive exercise protocols yield reliable and similar information about the hemodynamic severity of peripheral vascular occlusive disease, only one is needed for evaluation.     

Reversal of exertional hypotension after coronary bypass grafting.

A decrease in systolic blood pressure that occurs with treadmill exercise testing may be a sign of reversible ischemic left ventricular dysfunction. To test this hypothesis, we examined retrospectively the postoperative treadmill responses of 37 patients who had exertional hypotension (end exercise systolic blood pressure less than or equal to initial preexercise levels) before coronary arterial bypass grafting. This group of 37 patients was characterized preoperatively by an abnormal exercise electrocardiogram (36 patients), multiple vessel occlusive disease (36 patients) and a normal ejection fraction at rest (32 patients). Postoperative exercise tests showed improvement in hemodynamic and electrocardiographic changes with reversal of exertional hypotension (33 patients), and conversion to a normal exercise electrocardiogram (29 patients). Coronary bypass surgery can be expected to reverse exertional hypotension in patients with symptomatic angina pectoris and evidence of ischemia in the exercise electrocardiogram.     

短时运动对冠状动脉介入治疗术后冠心病患者肱动脉踝动脉脉搏波速度的影响

目的探讨短时运动对PCI术后冠心病患者肱动脉-踝动脉脉搏波速度(brachial-ankle artery pulse wave velocity.baPWV)的影响。方法选择PCI术后常规复查的男性冠心病患者69例,平板运动试验采用改良Bruce方案,试验前及试验结束后10 min测量患者baPWV值。结果患者短时运动后平均动脉压和baPWV值较运动前明显下降[(97.26±11.51)mm Hg vs(91.33±9.64)mm Hg(1 mm Hg=0.1 33 kPa),(1421.84±224.1 4)cm/svs(1 3 4i0.25±218.16)cm/s],差异有统计学意义(P<0.01);收缩压和舒张压较运动前有所下降,但差异无统计学意义(P>0.05)。结论短时运动可以有效改善冠心病患者的动脉僵硬度。     

Vascular laboratory for the surgeon

The introduction of a noninvasive vascular laboratory emerged from the need for more accurate differential diagnosis, localization of disease, measurement of severity, and documentation of progression of occlusive arterial disease and efficacy of treatment. Plethysmographic and Doppler techniques have been the cornerstones in the development of noninvasive studies. Our vascular laboratory experience during 1977–1994 includes 36,573 examinations performed on 19,646 patients. Occlusive arterial disease of the lower limb was evaluated by 7408 complete lower limb examinations, of which 4939 included also a treadmill exercise test, 4539 toe pressure measurements, and 10,585 follow-up examinations. Altogether, 9102 miscellaneous examinations included ambulatory ECG and systemic blood pressure monitoring, assessment of limb viability by tcpO₂, Laser Doppler flowmetry and skin perfusion pressure measurement, as well as upper extremity studies, among others. Although new techniques were introduced and tested during the years, the routine examinations have remained rather simple. Workup for claudication contains a structured questionnaire, segmental pressures and plethysmographic evaluation, and exercise test on treadmill, whereas diabetes and suspicion of CLI also necessitate toe pressures. Diabetic patients and those evaluated for aortic surgery also undergo ambulatory or stress test ECG monitoring. Carotid patients are noninvasively assessed by Duplex in the Radiological Department. A vascular laboratory managed by the vascular surgeon serves surgical needs well, as the tests can be tailor made to specifically answer relevant clinical questions.Part of this paper was presented at the 37th Annual World Congress, International College of Angiology, Helsinki, Finland, July 1995     

Evaluation of leg perfusion during exercise using technetium 99m sestamibi. A new test for peripheral vascular disease

Thirty patients with occlusive peripheral vascular disease underwent clinical examination, segmental blood pressure determinations, intra-arterial digital subtraction angiography, and treadmill stress testing with injection of technetium 99m sestamibi at peak exercise. Radionuclide images of the thighs, calves, and feet showed clear delineation of major muscle groups. Diminished radiotracer distribution was closely correlated with the presence of occlusive vascular disease on angiography and with the presence of claudication and reduced segmental blood pressure. A quantitative scheme based on pixel intensity was developed to compare areas of regional perfusion.     

测量踝部动脉血压与肱动脉血压、主动脉内血压的对比研究

目的　探讨下肢血压测量方法。方法　对高血压病组及非高血压病组共 10 7例病人采取将袖带缠于小腿下端监听足背动脉血压 ,并与肱动脉血压、主动脉内血压进行对比研究。结果　两组踝部动脉血压与肱动脉血压呈显著正相关 (P <0 0 0 1) ,两组四肢血压与主动脉内血压相关性检验 ,除高血压组踝部动脉舒张压外均有显著相关性 (P <0 0 5 )。踝部动脉收缩压和舒张压平均比肱动脉分别高 10和 5mmHg;肱动脉收缩压低于主动脉内收缩压 5mmHg ,舒张压约高于主动脉内舒张压 5～ 6mmHg ;踝部动脉收缩压高于主动脉内收缩压 6mmHg ,舒张压约高于主动脉内舒张压 10mmHg。结论　测量踝部动脉血压的方法是可信的 ,但高血压组的踝部动脉舒张压与主动脉内舒张压相关性较差。