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Heart, Lung and Circulation (2015) xx, 1–4 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2014.12.164

BRIEF COMMUNICATION

Measure the Vascular Flow Volume rather than Vascular Stenosis and Pressure Gradient Tugce Ozlem Kalayci, MD a*, Volkan C ¸ akir a, Mert Kestelli b, Melda Apaydin a a

Department of Radiology, Izmir Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey Department of Cardiovascular Surgery, Izmir Katip Celebi University Ataturk Training and Research Hospital, I˙zmir, Turkey

b

Received 15 June 2014; received in revised form 22 December 2014; accepted 23 December 2014; online published-ahead-of-print xxx

We aimed to investigate the extent to which measurements of flow volume (FV) with colour flow duplex ultrasonography (CDU) could predict tissue perfusion. A 68 year-old male patient was admitted to our clinic complaining of intermittent claudication in the right leg. Digital subtraction angiography showed total occlusion of the right femoral artery. The right popliteal artery (PA) was filling by collaterals. CDU showed that the FV in the right PA was higher than in the left. Arterial-venous FV measurement with CDU should be performed rather than the detection of arterial stenosis to assess whether intervention is necessary. Keywords

Peripheral arterial disease  Colour flow duplex ultrasonography  Lower extremities  Angiography  Ischaemia

Introduction Peripheral arterial disease (PAD) is characterised by flowlimiting stenosis or occlusion in the vessels supplying the lower limbs [1]. A non-invasive technique capable of measuring tissue perfusion would be of great clinical value for assessing the severity of the disease and monitoring the response to therapeutic interventions [2]. We assessed the extent to which measurement of flow volume (FV) with colour flow duplex ultrasonography (CDU) can be used to predict tissue perfusion in a patient with PAD. We then compared these results with those found using lower extremity digital subtraction angiography (DSA).

Case Report A 68 year-old male patient was admitted to our clinic complaining of intermittent claudication in the right leg. The

ankle brachial pressure index of his right leg was 0.6. DSA was performed for the lower extremity arterial system. CDU was then performed with an Aplio XG (Toshiba Corporation, Japan) using a 7–12 MHz linear array transducer. Analysis of the flow was carried out after 10 min of rest to allow the muscles to reach a resting state. Arterial and venous CDU was obtained in the supine position with the foot elevated 15 cm to neutralise the central venous pressure. The vessel diameter, blood flow velocity and FV in the arteries and veins of the lower extremities were calculated without compression. The common femoral artery (CFA) and popliteal artery (PA) were examined 1 cm above the bifurcation, and the common femoral vein (CFV) and popliteal vein (PV) were examined 1 cm above the saphenofemoral and saphenopopliteal junction. The anterior tibial artery (ATA), posterior tibial artery (PTA), anterior tibial vein (ATV), and posterior tibial vein (PTV) were examined 2 cm proximal to the ankle. DSA illustrated total occlusion of the right femoral artery (FA). The right PA was filling by collateral vessels from the

*Corresponding author at: Gazeteci Hasan Tahsin Caddesi, Izmir Katip Celebi Universitesi, Ataturk Training and Research Hospital, Department of Radiology, Karabaglar, Izmir, Turkey. Postal code: 35160 Tel.: +90 232 245 4545; fax: +90 232 243 3208 Tel.:+90 530 227 0218., Email: [email protected] © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.

Please cite this article in press as: Kalayci TO, et al. Measure the Vascular Flow Volume rather than Vascular Stenosis and Pressure Gradient. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j.hlc.2014.12.164

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Figure 1 A, B. Full occlusion of the right femoral artery from the origin to the distal third (*). Flow in the right popliteal artery (arrow) supplied by collateral vessels from the deep femoral artery is demonstrated.

deep FA (Figure 1). There was a 70% luminal stenosis by an atheroma in the distal part of the left FA (Figure 2). The left PA, ATA and PTA were not demonstrated. The CDU confirmed DSA findings showing several collaterals around the distal FA. FV was 230 ml/min (mean FV for PA, 100 ml/min) [3] in the right PA and 40 ml/min in the popliteal vein. The FV of the right PA, which was filling by collateral vessels from the deep femoral artery, was higher than the FV of the left PA. FV was 30 ml/min (mean FV for ATA-PTA, 15 ml/min) [3] in the right ATA, 0 ml/min in the ATV and 10 ml/min in the PTA-PTV. The mean flow rates, diameters and flow volume values for the CFA, CFV, PA, PV, ATA, ATV, PTA, and PTV in our patient are summarised in Table 1.

Femoropopliteal bypass grafting was recommended for the patient based on the DSA report; an ilio-popliteal bypass graft was performed on his right leg in the department of cardiovascular surgery in another medical centre.

Discussion In spite of total occlusion in CFA, capillary perfusion of cruris can be reconstituted by collateral vessels. We found normal PA, ATA and PTA flow values in the distal areas after occluded arterial segment. We suggest using this type of Doppler flow study for the evaluation of tissue ischaemia. This technique can be useful for cardiovascular surgeons to

Please cite this article in press as: Kalayci TO, et al. Measure the Vascular Flow Volume rather than Vascular Stenosis and Pressure Gradient. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j.hlc.2014.12.164

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Vascular flow volume measurement

Table 1 Comparison of the mean values of right and left arterial-venous measurements of the lower extremities taken during preoperative colour flow duplex ultrasonography examination. Flow rate

Diameter

Flow volume

(cm/s)

(mm)

(ml/min)

Right CFA

0

3,5

0

Left CFA

23

4,4

70

Right CFV Left CFV

26 7

3,2 5,3

40 50

Right PA

39

5,9

230

Left PA

17

5

100

Right PV

17

3,5

40

Left PV

17

4,8

70

Right ATA

21

2,4

30

Left ATA

8

1,4

0

Right ATV Left ATV

0 4,5

1,3 2,9

0 10

Right PTA

10

2,5

10

Left PTA

20

1,2

10

Right PTV

7,4

3,2

10

Left PTV

0

1,3

0

*CFA: common femoral artery, CFV: common femoral vein, PA: popliteal artery, PV: popliteal vein, ATA: anterior tibial artery, ATV: anterior tibial vein, PTA: posterior tibial artery, PTV: posterior tibial vein.

Figure 2 Luminal 70% stenosis level with the distal third of the left femoral artery.

decide whether to perform the surgery for tissue ischaemia. For this reason, indirect assessment of tissue perfusion by arterial and venous FV is more accurate for noninvasively assessing PAD than techniques that rely on degree of stenosis within the large vessels. We have confirmed our hypothesis that volume flow of crural arteries and veins may be enough through collateral circulation in a patient without significant clinical signs and symptoms despite an occlusion or severe stenosis in a large vessel. Pulselessness and intermittent claudication are not an indication for intervention in patients with PAD. Even when, as in this case, the arterial FV is 0, if the concomitant venous FV is 15 ml/min or higher, this value is sufficient for tissue perfusion in cruris, and we do not suggest intervention or surgery. However, for this patient, although not strictly required due to the relatively high blood FV

provided through collaterals, additional blood flow was provided to the right PA by an ilio-popliteal bypass graft. The right ATA FV was also 30 ml/min (twice the average) in this case. This operation conformed to current indication criteria. We suggest that additional blood flow is not necessary by an ilio-popliteal bypass graft in this patient while flow volume of PA, ATA and PTA were sufficient in distal of the occlusion. Current methods that are routinely used to diagnose PAD and evaluate its severity rely on imaging the degree of arterial stenosis, measuring pressure gradients, or identifying abnormalities in arterial pulse-volume recordings [4,5]. These techniques use macrovascular abnormalities as a surrogate marker of tissue ischaemia, largely ignoring adaptations in the cellular metabolism and within the microvasculature that develop during the evolution of vascular insufficiency [2]. Although the obstruction of blood flow is critical in the artery, the degree of haemodynamic impairment does not consistently relate to functional limitation [5]. The method proposed here relies on measuring the FV of the feeding arterial blood and the returning venous blood from the microvascular area. Arterial flow rate value or arterial stenosis degree calculated by CDU or DSA were inadequate for showing severe impaired tissue perfusion in patients with PAD. Arterial and venous flow volume values can provide more accurate and quantitative

Please cite this article in press as: Kalayci TO, et al. Measure the Vascular Flow Volume rather than Vascular Stenosis and Pressure Gradient. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j.hlc.2014.12.164

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information about capillary perfusion. We propose that arterial and venous FV measurements taken with CDU can be used instead of detection of arterial stenosis degree or occlusion to assess whether intervention is necessary. In this case, we found increased flow volume values in right PA and crural arteries despite right CFA occlusion. The FV values of arteries below the occlusion had enough collaterals and there was no need for surgery. We did not have the chance to evaluate the amount of flow volume after the surgery. Our hypothesis can be further strengthened by measuring FV before and after surgery in a large patient group. Our suggestion is, the arterial and venous FV measurements technique is the simplest way to indicate capillary perfusion parameters and this method can be used before the peripheral arterial intervention.

Conflict of Interest Statement The authors of this paper have no conflicts of interest, including specific financial interests, relationships and affiliations relevant to the subject matter or materials included.

Acknowledgements This study was presented as a poster presentation at the 63th International Congress of The European Society for Cardiovascular and Endovascular Surgery (ESCVS) Nice, France, April 24–27, 2014.

References [1] Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999–2000. Circulation 2004;110:738–43. [2] Isbell DC, Epstein FH, Zhong X, DiMaria JM, Berr SS, Meyer CH, et al. Calf muscle perfusion at peak exercise in peripheral arterial disease: measurement by first-pass contrast-enhanced magnetic resonance imaging. J Magn Reson Imaging 2007;25:1013–20. [3] Kalayci TO, Sarp AF, Apaydin M, Sonmezgoz F, Birlik B, Uluc ME, et al. Color Doppler ultrasound measurement of flow volume, flow velocity and diameter in lower extremity venous system may be indicator of tissue perfusion [abstract]. Insights Imaging 2014;5(suppl. 1):S369. [4] Jo¨rneskog G. Why critical limb ischemia criteria are not applicable to diabetic foot and what the consequences are. Scand J Surg 2012;101:114–8. [5] Anderson JD, Epstein FH, Meyer CH, Hagspiel KD, Wang H, Berr SS, et al. Multifactorial determinants of functional capacity in peripheral arterial disease: uncoupling of calf muscle perfusion and metabolism. J Am Coll Cardiol 2009;54:628–35.

Please cite this article in press as: Kalayci TO, et al. Measure the Vascular Flow Volume rather than Vascular Stenosis and Pressure Gradient. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j.hlc.2014.12.164

Measure the Vascular Flow Volume rather than Vascular Stenosis and Pressure Gradient.

We aimed to investigate the extent to which measurements of flow volume (FV) with colour flow duplex ultrasonography (CDU) could predict tissue perfus...
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