Intermittent sequential compression of the lower limbs prevents venous stasis in laparoscopic and conventional colorectal surgery

PURPOSE

This study was designed to evaluate the influence of intraoperative intermittent sequential compression (ISC) on venous blood return from the lower limbs during laparoscopic and conventional colorectal colectomy.

METHODS

Fifty patients undergoing laparoscopic (n = 25) or conventional (n = 25) colorectal surgery were included in a prospective study. Peak venous flow (PFV) and the cross-sectional area (CSA) of the femoral vein were assessed by Doppler ultrasound examination intraoperatively.

RESULTS

Age, gender, and body mass index were comparable between both groups. Baseline PFV was 21 +/- 6.6 cm/s in the conventional and 18.4 +/- 6.4 cm/s in the laparoscopic group (P = 0.2). ISC increased PFV to 156 +/- 29 percent of the baseline value in the conventional group and to 161 +/- 29 percent in the laparoscopic group. PFV decreased after abdominal insufflation to 127 +/- 19 percent of the baseline value in the laparoscopic group and after laparotomy to 134 +/- 27 percent in the conventional group (P = 0.3). PFV decreased slightly in both groups during surgery but remained well above the baseline value. Baseline CSA was 1.02 +/- 0.17 cm2 in the conventional group and 1 +/- 0.23 cm2 in the laparoscopic group. ISC decreased CSA to 0.91 +/- 0.18 cm2 (conventional) and 0.85 +/- 0.18 cm2 (laparoscopic) after initiation of ISC. CSA was 0.92 +/- 0.18 cm2 after abdominal insufflation in the laparoscopic group, and it was 0.93 +/- 0.18 cm2 after laparotomy in the conventional group (P = 0.4). During surgery, there were no differences in absolute CSA or CSA changes compared with the baseline value in both groups. Postoperative circumference of the calf and thigh were not different between both groups. Postoperative thromboembolic complications did not occur.

CONCLUSION

ISC effectively increases venous blood flow from the lower limbs during conventional and laparoscopic colorectal resections and may decrease the risk of postoperative deep vein thrombosis. Therefore, ISC is strongly recommended in every prolonged laparoscopic procedure.

Real-time ultrasound-guided femoral vein catheterization during cardiopulmonary resuscitation

STUDY OBJECTIVE

To compare the use of real-time-ultrasound guidance with the standard landmark-oriented approach for obtaining femoral vein catheterization in patients requiring intravenous access during CPR.

METHODS

Prospective, randomized, paired subject-controlled clinical trial in the setting of an urban teaching county hospital emergency department. The study comprised a convenience sample of 20 patients presenting with apnea and pulselessness in the ED. Each patient received bilateral femoral lines, one by ultrasound guidance and one by the landmark approach (control). Randomization determined which technique and which side would be attempted first. The following parameters were recorded: time to initial flash of blood, time to completion of catheterization, number of needle passes, and rate of arterial catheterization. CPR and Advanced Cardiac Life Support protocols were continued during both procedures.

RESULTS

Real-time ultrasound-guided catheterization had a higher success rate (90% versus 65%, P = .058), a lower number of needle passes (2.3 +/- 3 versus 5.0 +/- 5, P = .0057), and a lower rate of arterial catheterization (0% versus 20%, P = .025) than the standard landmark-oriented approach. Ultrasound was also slightly faster in time to blood flash and in time to catheterization. An incidental finding of interest was that real-time ultrasound demonstrated the presence of femoral vein pulsations during CPR.

CONCLUSION

Real-time ultrasound-guided femoral vein catheterization was faster and produced a lower rate of inadvertent arterial catheterization and a higher rate of success during CPR than the standard landmark-oriented approach. Also, ultrasound demonstrated that palpable femoral pulsation during CPR is venous rather than arterial.

Functional and morphological evaluation of canine veins following preservation in different storage media

Injuries of endothelial and smooth muscle cells of autologous vein due to preservation in standard storage media may be responsible for graft failure. The effects of vein preservation with University of Wisconsin solution (UWs) on endothelial and smooth muscle cell function and morphology were compared to the effects of preservation with autologous whole blood (AWB) and normal saline (NS), which are frequently used in cardiovascular surgery. Canine external jugular and common femoral vein segments were preserved in the different solutions at 4 degrees C for 45 min and 24 hr. Rings (4-5 mm in length) from control and preserved veins were evaluated by isometric tension studies at 37 degrees C and by scanning and transmission electron microscopy. Differences between groups were evaluated by Student's t test or Mann-Whitney U test and by analysis of the variance, and considered to be significant at P < 0.05. Sensitivities to norepinephrine (NE) showed that a 45-min vein storage in AWB (5.7 +/- 0.2 mumol/L) but not in NS (5.8 +/- 0.2 mumol/L) or UWs (6.5 +/- 0.2 mumol/L) had a deleterious effect on function of smooth muscle (P < 0.05) when compared to control veins (6.6 +/- 0.2 mumol/L). Maximum contractile responses and sensitivities to NE were significantly altered (P < 0.05) after 24-hr vein storage in AWB (0.09 +/- 0.02 g/mm2 and 5.4 +/- 0.07 mumol/L) and NS (0.12 +/- 0.03 g/mm2 and 5.6 +/- 0.08 mumol/L) but not in UWs (0.36 +/- 0.06 g/mm2 and 6.4 +/- 0.07 mumol/L). With both storage times, acetylcholine-induced endothelium-dependent maximum relaxations and sensitivities were significantly reduced (P < 0.05) in veins stored in AWB and NS, but not in UWs, compared with controls. Similarly, transmission electron microscopy revealed marked neutrophil migration beneath the intimal surface of vessels and extensive separation and desquamation of endothelial cells with exposure of subendothelial structures in veins stored in AWB and NS. The results suggest that UWs is a suitable storage medium when compared to AWB and NS.

The deep venous system in the puerperium: an ultrasound study

OBJECTIVE

To study the vessel wall diameter and blood flow velocity within the proximal deep venous system of the leg in the puerperium and to compare these measures with respect to the left versus right leg, 4th versus 42nd postnatal day, and vaginal versus caesarean delivery.

DESIGN

A combined longitudinal and cross-sectional observational study.

SETTING

The ultrasound department of a teaching maternity hospital.

RESULTS

A reduction in vessel diameter and an increase in flow velocity was observed between the 4th and 42nd postnatal day. Vessel diameter was greater and flow velocity was reduced in the left compared to the right leg. In those delivered by caesarean section, a trend towards reduced flow velocity in the proximal deep leg veins was observed when compared with those delivered vaginally.

CONCLUSIONS

These data suggest possible physiological mechanisms behind previous clinical observations relating to the period of greatest risk of deep vein thrombosis in the puerperium, the relative preponderance of left sided deep vein thrombosis and the risk of deep vein thrombosis associated with caesarean section.

An ultrasound study of gestational and postural changes in the deep venous system of the leg in pregnancy

OBJECTIVE

To investigate gestational and postural changes in diameter and blood flow in the proximal deep leg veins during pregnancy.

DESIGN

A longitudinal, prospective observational study.

SETTING

The ultrasound department of a teaching maternity hospital.

POPULATION

Twenty-four healthy women with uncomplicated singleton pregnancies.

METHODS

Real-time and duplex Doppler ultrasound assessments of the vessel diameter, flow velocity and respiratory flow fluctuation in the proximal deep leg veins of women serially measured from the first trimester of pregnancy to six weeks postnatally.

MAIN OUTCOME MEASURES

The effects of increasing gestation and the adoption of the left lateral position on the above parameters.

RESULTS

An increase in vessel diameter and a fall in flow velocity with increasing gestation was observed. However, no change in venous flow variation was observed. Delivery had reverse effects. Flow velocity was slower in the left than right legs, but on adoption of the left lateral position an increase in flow velocity and venous flow variation was observed in both legs during pregnancy.

CONCLUSIONS

These data are consistent with the observed increase in incidence and pattern of deep venous thrombosis in pregnancy and may aid interpretation of duplex Doppler ultrasound examinations for deep venous thrombosis in pregnancy. Postural changes should be part of this evaluation. The gravid uterus may not be the sole cause for postural changes in deep venous flow velocity.

Retrograde flow in the deep veins of subjects with normal venous function

BACKGROUND

Duplex ultrasonography has become the optimal non-invasive method of assessing the deep venous system of the leg. The stimuli used to promote reverse flow, subject positioning, and the veins scanned have varied between studies. Reverse flow of less than 0.5 s is accepted as 'normal', however, all published studies have demonstrated 'normal' subjects with deep vein reverse flow exceeding this time. The aim of this study was to establish the duration of reverse flow in all deep vein segments, and to determine the optimal method of eliciting reverse flow in individuals with proven normal deep vein function.

METHODS

Duplex scanning was used to detect the presence and duration of reverse flow in the superficial femoral, popliteal and posterior tibial veins of 61 legs with normal venous function. The veins were scanned with each subject inclined at 10 degrees, 45 degrees and standing erect. The abrupt release of distal tourniquet compression and the Valsalva manoeuvre were used as stimuli for reverse flow.

RESULTS

There was significantly less reverse flow in distal veins than in proximal veins when the subject was scanned at 10 degrees and 45 degrees. Median (range) reverse flow in the femoral vein at 10 degrees was 0.21 (0-1.18) s, posterior tibial vein 0.08 (0-0.67) s, (P < 0.0001); in the femoral vein at 45 degrees was 0.14 (0.04-2.14) s, posterior tibial vein 0.07 (0-0.56) s, (P < 0.0001). The duration of reverse flow was significantly less in the superficial femoral and popliteal veins when the subjects were erect than when inclined at 10 degrees and 45 degrees. Median (range) reverse flow in the femoral vein at 10 degrees was 0.21 (0-1.18), and when standing 0.1 (0-1.36) (P < 0.0001); below-knee popliteal vein at 10 degrees was 0.15 (0.04-1.95) s, and when standing 0.10 (0-1.03) (P = 0.0004). Reverse flow of more than 0.5 s was never elicited in the posterior tibial veins if the subject stood, nor did it occur in the popliteal vein during a Valsalva manoeuvre.

CONCLUSION

The optimal sites to assess deep vein reverse flow are the posterior tibial vein following removal of distal compression with the patient standing, and the popliteal vein during a Valsalva manoeuvre, as retrograde flow more than 0.5 s does not occur in subjects with normal venous function.

Extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock

Extracorporeal membrane oxygenation (ECMO) has had promising results in life-threatening respiratory failure and postcardiotomy cardiogenic failure. From October 1994 to October 1995, 18 patients received 19 ECMOs at National Taiwan University Hospital for severe cardiogenic shock after cardiac surgery. They included patients receiving cardiac massage or repeated bolus injections of norepinephrine to maintain blood pressure (n = 10), patients who could not be weaned off cardiopulmonary bypass after several attempts despite intraaortic balloon pumping and maximal doses of catecholamine (n = 7), and patients with progressive intractable cardiogenic shock after cardiac surgery. Venoarterial ECMO was set up via femoral artery (17 or 19 Fr cannula) and vein (19 or 21 Fr) in all patients except 2 infants. No left heart drainage was performed in any of the patients. The heparin-coated circuit (with Carmeda Bio-active Surface) was used in the last 13 patients to reduce bleeding. Ten (52.6%) of the 19 cases could be smoothly weaned off ECMO, and 6 (33.3%) of the 18 patients were discharged from the hospital in good condition. Four (80%) of the 5 patients after valvular surgery and all 3 heart transplant patients could be weaned off ECMO successfully with the survival rate being 60% and 67%, respectively. Complications included leg ischemia (n = 3), bleeding (n = 4), renal failure (n = 3), and tube rupture (n = 1). The inability to wean off ECMO was caused by multiple organ failure (n = 5), sepsis (n = 2), tube rupture (n = 1), and dysfunction of the ECMO system (n = 1). The major cause of multiple organ failure was hesitation to set up ECMO. Our preliminary results confirmed the effect of ECMO in postoperative cardiogenic shock.

"Veno-Press"--a new sequential intermittent pneumatic device for the prevention of perioperative deep vein thrombosis

The prevention of peri-operative deep vein thrombosis (DVT) and the potentially hazardous pulmonary embolism that may follow is still a major medical issue. Intermittent pneumatic compression is one of the many methods currently in use for this purpose. No information is available, however, regarding the venous flow alterations that occur during employment of a pneumatic compression device under general anesthesia. The aim of this study is to delineate these venous flow variations and to determine the optimal pump setting for the prevention of operative venous stasis and its sequelae, postoperative DVT. A new sequential intermittent pneumatic device, the "Veno-Press", was applied on 20 volunteers of whom 10 were undergoing surgery unrelated to the lower limbs, during the pre-anesthesia and during general anesthesia. The venous velocity patterns over the femoral vein were depicted via duplex scanning under different pressure and rhythm settings of the device. The "Veno-Press" induced a marked augmentation in venous blood velocity flow. A further 10-30% augmentation was noted when the patients were under general anesthesia, as well as a 10-30% increase in the femoral vein diameter. None of the patients developed postoperative DVT. This device is a very efficient tool for augmentation of venous blood velocity, especially during general anesthesia. Its effectiveness is most probably the result of the compressive action over the relaxed--and hence enlarged--capacitant veins of the anesthetized patient. We suggest that the "Veno-Press", if properly timed, is very efficient in venostasis prevention, leading presumably to a decline in the occurrence of DVT and pulmonary embolisms in the surgical patient.

Effect of a femoral arteriovenous fistula on lower extremity venous hemodynamics after femorocaval reconstruction

PURPOSE

To study the hemodynamic effects of an arteriovenous fistula (AVF) used as an adjunct to venous reconstructions and to determine the optimal size for such a fistula.

METHODS

A model of limb circulation with an AVF (in vitro system) was constructed with silicon elastic tubes and 40% glycerin solution as the fluid medium. Pulsatile arterial flow and venous return was maintained with a roller pump and a centrifugal assist device. Flows and pressures were measured for three different fistula diameters (3, 4, and 5 mm). A canine model of venous hypertension with outflow obstruction was constructed in 15 adult mongrel dogs. After 7 to 13 days an externally supported 8-mm expanded polytetrafluoroethylene femorocaval graft was implanted with a distal AVF (3 mm, n = 5; 4 mm, n = 5; 5 mm, n = 5). Arterial and venous flows and venous pressures were measured proximal and distal to the fistula before and after exercise.

RESULTS

In the in vitro system, flows through the venous graft increased with increasing fistula size, but venous return decreased progressively, increasing the distal venous pressure. In the canine model, flow in the venous graft increased with each AVF (p < 0.01). Only the 3-mm AVF resulted in decreased distal femoral vein pressure (p < 0.01), orthograde flow, and improved venous return with exercise.

CONCLUSION

AVFs increased flow through the femorocaval grafts, yet they impeded venous return. The ideal AVF-to-graft ratio used in our study was 0.375, because it increased graft flow, permitted forward flow in the femoral vein while reducing pressure, and improved venous return with exercise.

Effect of muscle acidity on muscle metabolism and fatigue during intense exercise in man

1. The aim of this study was to examine the effect of muscle pH on muscle metabolism and development of fatigue during intense exercise. 2. Seven subjects performed intense exhaustive leg exercise on two occasions: with and without preceding intense intermittent arm exercise leading to high or moderate (control) blood lactate concentrations (HL and C, respectively). Prior to and immediately after each exercise bout, a muscle biopsy was taken from m. vastus lateralis of the active leg. Leg blood flow was measured and femoral arterial and venous blood samples were collected before and frequently during the exhaustive exercises. 3. The duration of the exercise was shorter in HL than in C (3.46 +/- 0.28 vs. 4.67 +/- 0.55 min; means +/- S.E.M.; P < 0.05). Before exercise muscle pH was the same in C and HL (7.17 vs. 7.10), but at the end of exercise muscle pH was lower in HL than in C (6.82 vs. 6.65; P < 0.05). The release of potassium during exercise was higher (P < 0.05) in HL compared with C, but the arterial and femoral venous plasma potassium concentrations were the same at exhaustion in HL and C. 4. Muscle lactate concentration was higher in HL compared with C (3.7 +/- 0.4 vs. 1.6 +/- 0.2 mmol (kg wet weight)-1; P < 0.05), but the same at exhaustion (26.5 +/- 2.7 vs. 25.4 +/- 2.4 mmol (kg wet weight)-1). Total release of lactate in HL was lower than in C (18.7 +/- 4.5 vs. 50.4 +/- 11.0 mmol; P < 0.05), but rate of lactate production was not different (9.0 +/- 1.0 vs. 10.2 +/- 1.3 mmol (kg wet weight)-1 min-1). The rate of muscle glycogen breakdown was the same in C and HL (8.1 +/- 1.2 vs. 8.2 +/- 1.0 mmol (kg wet weight)-1 min-1). 5. The present data suggest that elevated muscle acidity does not reduce muscle glycogenolysis/glycolysis and is not the only cause of fatigue during intense exercise in man. Instead, accumulation of potassium in muscle interstitium may be an important factor in the development of fatigue.

Venous circulation in the maternal lower limb: a Doppler study with the Valsalva maneuver

In order to evaluate the normal physiology of the maternal venous circulation, Doppler examinations of the venous system in the right inferior extremity and suprainguinal part of the common femoral vein were carried out in 38 healthy pregnant women, in 12 non-pregnant controls and in 16 women at early puerperium. Examinations were carried out when the mother was lying in a left semi-recumbent supine position. Blood flow velocities in the suprainguinal femoral and deep femoral veins decreased significantly in the first trimester and were almost normalized by the third postpartum day. Continuous forward venous flow with respiratory fluctuation was maintained in the femoral veins over the whole gestational period. The response to the Valsalva maneuver was similar in the pregnant and non-pregnant women. Our findings provide evidence that the venous valvular system and wall distensibility in the femoral area and the inferior extremity are in vivo not greatly changed in pregnancy. A more important reason for decreased velocities is probably the pregnancy-associated decrease of the arterial input to this area.

Blood recirculation in temporary central catheters for acute hemodialysis

The low-flow method has been shown as a reliable evaluation of access recirculation. Few data is available on temporary central catheter blood recirculation; results of 2% and 4% have been reported in subclavian, 10% in 24 cm long femoral, and 18% in 15 cm long femoral catheters, mostly in indwelling catheters for chronic hemodialysis. The purpose of this prospective study was to evaluate blood recirculation in a larger number of recently inserted temporary intravenous catheters for acute hemodialysis, comparing subclavian and femoral sites. Fifty blood recirculation measurements were performed in 38 different temporary central venous dialysis catheters inserted in thirty-one critically ill patients from medical and surgical intensive care units presenting acute renal failure supported by intermittent hemodialysis. All the catheters used were well-functioning 11.5 French dual lumen Quinton of 13.5 or 19.5 cm length. Catheters presenting mechanical dysfunction, which did not allow a blood flow rate of 300 ml/min or for which lines had to be reversed were excluded from the analysis. Access blood recirculation was measured shortly after catheter insertion according to the low flow method applied after the first 30 minutes of hemodialysis at a blood flow rate of 300 ml/min. Mean blood recirculation for the 50 measurements was 10.3 +/- 9.2%. It was significantly higher in the 26 femoral catheters than in the 24 subclavian catheters, reaching respective means of 16.1 +/- 9.1% and 4.1 +/- 3.6% (p = 0.0001). Blood recirculation rate was not different between 13.5 cm and 19.5 cm long subclavian catheters (3.0 +/- 2.6%, n = 13, versus 5.4 +/- 4.3%, n = 11, respectively), but was significantly higher in 13.5 cm long femoral catheters (22.8 +/- 9.1%, n = 9, versus 12.6 +/- 6.9%, n = 17) (p = 0.004). Blood recirculation was measured on two separate occasions in 12 catheters randomly selected (5 femoral and 7 subclavian catheters); the obtained results were reproducible with a mean difference of only 2.1 +/- 1.8% between the two measurements and a correlation of 0.96. The mean time elapsed between catheter insertion and recirculation assessment was 2.2 +/- 3.1 days and was similar for femoral and subclavian catheters. No correlation was found between the percentage of recirculation and the arterial and venous resistances recorded during dialysis session or with the time from catheter insertion. Mean urea reduction ratio (URR) for the 50 dialysis sessions was 57.8 +/- 13.0%. It was significantly higher for sessions performed with subclavian than with femoral catheters (62.5 +/- 10.9%, n = 24, versus 54.5 +/- 14.2%, n = 26) (p = 0.03). In conclusion, the expected blood recirculation in well-functioning and recently inserted temporary dialysis catheters is under 5% for subclavian, over 12% in 19.5 cm femoral, and over 22% in shorter 13.5 cm femoral catheters at a blood flow rate of 300 ml/min. The consequently reduced dialysis efficiency with femoral catheters is another factor to be considered in the choice of a site for temporary dialysis catheter insertion in acute renal failure patients, particularly when dialysis dose delivery is a priority, such as intoxication cases treated by extracorporeal therapy.

Blood-flow augmentation of intermittent pneumatic compression systems used for prevention of deep vein thrombosis prior to surgery

PURPOSE

To compare, using Duplex ultrasonography, different intermittent pneumatic compression (IPC) systems to augment venous blood flow for deep venous thrombosis (DVT) prevention during and after surgery and during periods of immobility.

METHODS

This cross-over study randomly assigned 26 young, healthy, adult subjects, without history of DVT, hypertension, diabetes, stroke. vascular or cardiac pathologies, to an order of knee-high, foam, single-pulse IPC device and thigh-high, vinyl, sequential-pulse pneumatic compression systems. Prior to making the flow measurement, the girth of the calf and thigh and length of the leg of each subject were determined. The right leg was used in this evaluation.

RESULTS

The average flow augmentation, which is a direct measure of the amount of femoral vein blood flow velocity increase over the base, was 107%+/-49% with the knee-high system, and 77%+/-35% with the thigh-high IPC system (P<0.002). Augmentation was higher for 62% of the subjects with knee-high IPC, and for 23% of the subjects with the thigh-high system. Overall, the blood was actively moving through the vein during the decompression phase. On occasion, the velocity during the decompression phase would fall to zero for short intervals with both systems, indicating complete emptying of the vessel. Variation in limb anatomy did not significantly affect blood-flow augmentation with the knee-high IPC, but augmentation decreased with increase in girth with the thigh-high IPC.

CONCLUSIONS

The study indicates that the knee-high, foam, single-pulse IPC device produces a significantly higher venous blood-flow augmentation than the thigh-high, vinyl, sequential-pulse system.

Induction of neovascularization in vivo by glycerol

Glycerol, injected into a site between the femoral vessels of the rat, induced neovascularization, both from the preexisting microcirculation and from the side of the femoral vein facing the artery-vein interstitium where the glycerol was administered. The use of glycerol together with a known angiogenic substance (PGE2) did not modify the neocapillary density (NCD) obtained with glycerol alone. In contrast, the lower level of NCD achieved with an acylglycerol (triacetylglycerol) was increased when the latter was associated with PGE2. Values reached were similar to, but never higher than, those for glycerol alone, or combined with PGE2. The results suggest that glycerol and some substances containing glycerol, amongst which 1-butyrylglycerol has been previously considered, may stimulate angiogenesis by a direct or indirect mechanism of action.

Frequency of complications with prolonged femoral vein catheterization for hemodialysis access

Analysis of 120 cases of femoral vein catheterization for > or = 2 days for hemodialysis in 89 hospitalized patients was performed to determine the frequency of catheter-related complications including infection and venous thrombosis. The rate of clinically significant complications was < 3.5% and compared favorably with published complication rates of central vein catheters. We conclude that prolonged femoral vein catheterization for hemodialysis is associated with an acceptably low rate of complications when appropriate techniques for placement and catheter care are followed and should be considered a reasonable option for vascular access in hospitalized patients.

Venous hemodynamics during impulse foot pumping

PURPOSE

This study was designed to measure the effect of intermittent pneumatic compression of the plantar venous plexus on popliteal vein (PV) and common femoral vein (CFV) velocities measured by duplex ultrasound scanning.

METHODS

Thirty lower limbs in 15 healthy volunteers had venous duplex scanning measurement of PV and CFV velocities before and during foot pumping with an arteriovenous impulse foot pump system. Venous velocities were measured at two pump pressure settings (100 mm Hg, 200 mm Hg) and during two pump impulse durations (short = 1 second, normal = 3 seconds). All limbs were examined with the subjects in the supine position, and then measurements were repeated with subjects in the 15-degree reverse Trendelenburg position. The mean maximum venous velocity (MVV) produced by foot pumping was compared with resting venous velocity at each anatomic location and for each technologic variable.

RESULTS

Impulse foot pumping produced a statistically significant increase in MVV in both the PV and the CFV compared with resting velocities. This significant increase was observed for both pressure settings and both impulse durations, and no differences produced by these two individual variables could be detected. The increase in MVV produced by foot pumping was similar for limbs in the supine position and those examined in the reverse Trendelenburg position. The percentage increase in MVV produced by foot pumping was significantly higher in the PV than in the CFV.

CONCLUSIONS

Intermittent pneumatic compression of the plantar venous plexus produces measurable increases in venous outflow from the lower limbs of normal subjects. This study seems to justify further evaluation of the effectiveness of this technique for mechanical deep venous thrombosis prophylaxis in selected high-risk patient groups.

Differential vasodilatory action of 2-octynyladenosine (YT-146), an adenosine A2 receptor agonist, in the isolated rat femoral artery and vein

The vasodilatory action of 2-octynyladenosine (YT-146), an adenosine A2 receptor agonist, was investigated in the isolated rat femoral artery and vein. Exposure to YT-146 resulted in preferential vasodilatation; the vein was completely dilated at YT-146 concentrations as low as 10(-7) M; in contrast, a concentration of YT-146 greater than 10(-4) M was necessary to induce complete relaxation in the femoral artery. 2-[p-(2-Carboxyethyl)-phenethylamine]-5'-N-ethylcarboxamidoadenosine (CGS 21680) also evoked stronger dilation in the vein than in the artery. The vasodilatory action of N6-cyclopentyladenosine (CPA) was much weaker in the vein than that of YT-146. YT-146-induced vasodilation in the artery was antagonized by neither 10(-7) M 1,3-dipropyl-8-cyclopentylxanthine (DPCPX) nor 3 x 10(-6) M (E)-8-(3,4-dimethoxystylyl)-1,3-dipropyl-7-methylxanthine (KF17837), while the vasodilation in the vein was only antagonized by KF17837, suggesting that the vasodilation may involve adenosine A2 receptor activation in the vein. However, the present study did not provide evidence of a link between adenosine agonist-induced vasodilation and adenosine A2 receptor activation in the artery. The addition of 10(-4) M N omega-nitro-L-arginine partially reversed YT-146-induced vasodilation in the artery, but not in the vein. The reversal of YT-146-induced vasodilation by N omega-nitro-L-arginine in the artery was attenuated by the addition of 10(-3) M L-arginine. Removal of the endothelium decreased YT-146-induced vasodilation in the artery, but not in the vein.(ABSTRACT TRUNCATED AT 250 WORDS)

Haemodynamic effects of enalaprilat on portal hypertension in patients with HBsAg-positive cirrhosis

It has been suggested that enalaprilat inhibits the renin-angiotensin-aldosterone system in plasma and tissue; it may therefore reduce portal vascular pressure owing to secondary hyperaldosteronism in patients with liver cirrhosis. In order to evaluate this concept, 20 patients with hepatitis B surface antigen (HBsAg)-positive liver cirrhosis and portal hypertension received an intravenous infusion of 2.5 mg of enalaprilat. Wedged hepatic venous pressure, free hepatic venous pressure and cardiac index were measured before, immediately after, and then 15 min, 30 min and 1 h after intravenous enalaprilat infusion. The mean pressure gradient between wedged hepatic venous pressure and free hepatic venous pressure was significantly decreased, by 13% immediately after, 18% at 15 min, 23% at 30 min and 13% at 1 h after infusion of enalaprilat. Thirteen patients experienced a decrease of hepatic venous pressure gradient (HVPG) greater than 5 mmHg, another three 3-5 mmHg and the remaining four patients exhibited no significant change in HVPG. Systemic haemodynamic indices, including pulmonary arterial pressure, pulmonary capillary wedge pressure and central venous pressure, decreased significantly at 15 and 30 min after enalaprilat infusion (P < 0.01). Liver function, renal function and blood routine before and after enalaprilat infusion showed no significant change. There were no adverse effects during or after enalaprilat infusion. We conclude that enalaprilat infusion can quickly and safely reduce the hepatic venous pressure gradient in patients with HBsAg-positive cirrhosis.

Physical training in patients with stable chronic heart failure: effects on cardiorespiratory fitness and ultrastructural abnormalities of leg muscles

OBJECTIVES

The present study was designed to evaluate the effect of an ambulatory training program on ultrastructural morphology and the oxidative capacity of skeletal muscle and its relation to central and peripheral hemodynamic variables in patients with chronic heart failure.

BACKGROUND

Clinical evidence supports the hypothesis that exercise intolerance in patients with chronic heart failure is not only a consequence of low cardiac output, but is also a result of alterations in oxidative metabolism of skeletal muscle.

METHODS

Twenty-two patients were prospectively randomized either to a training group (mean [+/-SD] ejection fraction 26 +/- 9%, n = 12) participating in an ambulatory training program or to a physically inactive control group (ejection fraction 27 +/- 10%, n = 10). At baseline and after 6 months, patients underwent symptom-limited bicycle exercise testing, and central and peripheral hemodynamic variables were measured. Percutaneous needle biopsy samples of the vastus lateralis muscle were obtained at baseline and after 6 months. The ultrastructure of skeletal muscle was analyzed by ultrastructural morphometry.

RESULTS

After 6 months, patients in the training group achieved an increase in oxygen uptake at the ventilatory threshold of 23% (from 0.86 +/- 0.2 to 1.07 +/- 0.2 liters/min, p < 0.01 vs. control group) and at peak exercise of 31% (from 1.49 +/- 0.4 to 1.95 +/- 0.4 liters/min, p < 0.01 vs. control group). There was no significant change in oxygen uptake at the ventilatory threshold and at peak exercise in the control group. The total volume density of mitochondria and volume density of cytochrome c oxidase-positive mitochondria increased significantly by 19% (from 4.7 +/- 1.5 to 5.6 +/- 1.5 vol%, p < 0.05 vs. control group) and by 41% (from 2.2 +/- 1.0 to 3.1 +/- 1.0 vol%, p < 0.05 vs. control group) after 6 months of regular physical exercise. Cardiac output at rest and at submaximal exercise remained unchanged but increased during maximal symptom-limited exercise from 11.9 +/- 4.0 to 14.1 +/- 3.3 liters/min in the training group (p < 0.05 vs. baseline; p = NS vs. control group). Peak leg oxygen consumption increased significantly by 45% (from 510 +/- 172 to 740 +/- 254 ml/min, p < 0.01 vs. control group). Changes in cytochrome c oxidase-positive mitochondria were significantly related to changes in oxygen uptake at the ventilatory threshold (r = 0.82, p < 0.0001) and at peak exercise (r = 0.87, p < 0.0001).

CONCLUSIONS

Regular physical training increases maximal exercise tolerance and delays anaerobic metabolism during submaximal exercise in patients with stable chronic heart failure. Improved functional capacity is closely linked to an exercise-induced increase in the oxidative capacity of skeletal muscle.

Technical note: compression stockings and posture: a comparative study of their effects on the proximal deep veins of the leg at rest

Graduated compression stockings have been shown to reduce the incidence of deep venous thrombosis. While they are thought to act primarily by increasing venous flow velocity, their mode of action remains uncertain. Doppler ultrasound was employed to study the relative effects of three types of support stocking on the deep venous diameter, flow velocity and pulsatility in 10 non-pregnant female subjects. In addition, the effect of altered posture on the same parameters was assessed. Significant effects of the graduated stockings were found at the level of the popliteal vein, where a reduction in both the diameter and the amplitude of respiratory phasicity was recorded (p < 0.05). No significant increase in flow velocities was recorded. Adopting the left lateral position significantly increased flow velocity in the right common femoral vein (p < 0.05). The application of stockings in this position produced no additional increase in flow velocities, but did alter the amplitude of respiratory phasicity. These data do not support the widely held view that graduated compression stockings increase flow velocities at rest. Adopting a lateral recumbent position significantly increases flow velocity in the non-dependent leg.

Posture, blood velocity in common femoral vein, and prophylaxis of venous thromboembolism

Might leg elevation and avoidance of poor postures provide better prophylaxis against venous thromboembolism than heparin or mechanical methods? 12 supine subjects tilted in 3 degrees increments from 6 degrees leg-down to 12 degrees leg-up showed linear increase in mean peak blood velocity and reduction in calibre in the common femoral vein (colour-duplex ultrasound). Between horizontal and 6 degrees leg-up, velocity was increased by 17% and diameter reduced by 14%. A ranking of mean peak velocities in six postures (sitting; standing; trunk raised 35 degrees to legs which were first horizontal and then tilted up 6 degrees; supine, first horizontal then 6 degrees leg-up) showed significant increases in velocity between consecutive positions.

Acute effects of glyburide on the regulation of peripheral blood flow in normal humans

Recent animal studies have demonstrated that selective blockade of ATP-sensitive K+ (KATP) channels of vascular smooth muscle results in a significant increase in peripheral vascular tone. The main aim of this study was to assess whether glyburide, a selective blocker of KATP channels and commonly used antidiabetic agent, influences resting blood flow and reactive hyperemic response of peripheral tissues of normal subjects. Baseline calf blood flow was measured non-invasively in six normal subjects with femoral venous occlusive plethysmography. Calf blood flow was also serially measured every 30-60 s after the release of calf arterial occlusion (10 min duration). Reactive hyperemia was expressed in terms of peak post-occlusive flow, duration of hyperemia and reactive hyperemic volume. In each subject, baseline flow and reactive hyperemia were measured before (control) and every hour for 5 h after the oral ingestion of either 7.5 mg glyburide or a placebo on two separate days. Baseline calf flow declined by 30 and 42% of control values after 1 and 2 h of glyburide intake (P < 0.05) with a return to control values by hours 3, 4 and 5. Peak post-occlusive flow after 1, 2 and 3 h of glyburide ingestion was lower than control values by 22, 30 and 28%, respectively (P < 0.05). The duration of reactive hyperemia after 2 and 3 h of glyburide ingestion was significantly longer than control values (P < 0.05), whereas reactive hyperemic volume remained unaffected by glyburide intake. Placebo elicited no significant changes in baseline flow or reactive hyperemia throughout the 5-h experimental period.(ABSTRACT TRUNCATED AT 250 WORDS)

Continuous intravenous infusion in the unrestrained rat--procedures and results

1. A method of continuous infusion in the unrestrained rat is described, which provides a scientifically acceptable and easily maintained rodent model for use in toxicological investigations. 2. Sprague Dawley SPF rats had cannulas implanted into the vena cava via the femoral vein, and were continuously infused with physiological saline for a total of 28 or 90 days. 3. The results indicate that there was no change in body weight, food consumption, clinical observations or clinical biochemistry of infused rats when compared to non-infused rats. There were small changes in haematological parameters, however none were toxicologically significant. Urinary volume was increased and urinary specific gravity and osmolality were decreased. At macroscopic and microscopic examination there were findings of scar formation associated with the area of surgery and minimal irritation in the area of the vena cava which accommodated the cannula. 4. These results indicate that implantation of a cannula into the vena cava of a rat and subsequent continuous intravenous infusion of physiological saline produces no toxicological adverse effects over a period of 90 days. Consequently, this model can be recommended for the continuous intravenous administration of test substances to rats.

Plasma insulin and glucagon responses to propionate infusion into femoral and mesenteric veins in sheep

Propionate (1, 2, 4, 8, 16, 32, and 64 mumol.kg BW-1.min-1 for 30 min) was infused into the femoral and mesenteric veins of adult sheep to investigate the physiological significance of propionate in regulating plasma insulin and glucagon concentrations. The increments in arterial blood propionate concentrations during propionate infusion increased (P < .001) with increasing infusion rates for both infusion sites, and they were smaller (P < .001) for the mesenteric vein infusion than for the femoral vein infusion. Plasma insulin concentrations during propionate infusion increased (P < .10) from preinfusion values with infusion rates of > or = 8 mumol.kg BW-1.min-1 for both infusion sites. The response areas of plasma insulin concentration above basal tended to be smaller (P < .112) for the mesenteric vein infusion than for the femoral vein infusion. Plasma glucagon concentrations during propionate infusion increased (P < .05) from preinfusion values with infusion rates of > or = 8 and 64 mumol.kg BW-1.min-1 for the femoral and mesenteric vein infusions, respectively. The response areas of plasma glucagon concentration above basal were smaller (P < .011) for the mesenteric vein infusion than for the femoral vein infusion. We conclude that in sheep propionate absorbed from the alimentary tract has a physiological role in regulating circulating concentrations of insulin and glucagon.