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Mr-Plethysmography and the Effect of Elastic Compression on Venous Hemodynamics of the Leg

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Mr-Plethysmography and the Effect of Elastic Compression on Venous Hemodynamics of the Leg Mr-plethysmography and the effect of elastic compression on venous hemodynamics of the leg D. G. Christopoulos, M.D., A. N. Nicolaides, M.S., G. Szendro, M.D., A. T. Irvine, F.R.C.R.C., Mui-lan BuR, B.Sc., and H. H. G. Eastcott, M.S., London, England Leg volume changes during exercise have been measured in absolute units (milliliters) by means of a new method of air-plethysmography. Venous volume (VV), venous filling time, and venous filling index on standing from the recumbent position, ejected volume (EV) and ejection fraction (EF = EV x 100/VV) with one tiptoe movement, and residual volume (RV) and residual volume fraction (RVF = RV x 100/VV) after 10 tiptoe move- ments were measured in normal limbs, limbs with superficial venous incompetence, and limbs with deep venous disease. The same measurements were repeated with a graduated medium compression stocking in limbs with SVI and graduated high compression stock- ings in limbs with DVD. Ambulatory venous pressure was measured at the same time, with a needle in a vein in the foot. The results indicate that this method of air-plethys- mography is not only of diagnostic value but offers a new and unique technique to assess and study the hemodynamic effects of different forms of elastic compression. The lower ambulatory venous pressure, produced by the elastic compression, was the result of a reduction in reflux and an improvement in the calf muscle ejecting ability during rhythmic exercise. (J Vase SURG 1987;5:148-59.) Recent interest in reconstructive surgery of the effect of elastic compression on the calf muscle, deep veins, ls combined with continuing controversy pump. about the mechanism of the effect of elastic compres- sion on venous hemodynamics in the lower limb, 6-12 MATERIAL AND METHODS has created a need for the noninvasive quantitative Air-plethysmography. The air-plethysmograph assessment of reflux and calf muscle pump ejection. (provided by Kendall Research Center, Barrington, Such a method of study would have the added value Ill.) (Fig. 1) consists of a 14-inch long tubular pgly- of being repeatable at different stages of the natural vinyl chloride (PVC) air-chamber (capacity, 5 lite,s) history and therapy. We have used air-plethysmog- that surrounds the whole leg (from knee to anlde). raphy to study calf muscle pump function by deter- This is inflated to 6 mm Hg and connected to a mining changes in volume of the whole leg as a result pressure transducer, amplifier, and recorder. The of postural changes and exercise. The study was con- pressure of 6 mm Hg is the lowest that ensures good ducted in two parts. In the first part, we investigated contact between the air-chamber and the leg. A PVC, the calf muscle pump function in limbs of normal bag (capacity, 1 liter) is placed between the air-cham- subjects and limbs of patients with superficial venous ber and the leg used for calibration. insufficiency (SVI) and deep venous disease (DVD). Measurements are made at room temperature In the second part of the study we determined the (22 ° to 24 ° C). The air-plethysmograph is fitted with the patient in the supine position and the leg elevated (at 45 degrees) to empty the veins, with the heet, From the Irvine Laboratoryfor CardiovascularInvestigation and resting on the support. The air-chamber is inflated Research, Academic Surgical Unit and Department of Radi- to 6 mm Hg and the leg is kept in this position for ology, St. Mary's Hospital Medical School. Presented at the Fortieth Annual Meeting of the Societyfor Vas- 5 minutes to allow the development of a stable leg/ cular Surgery, New Orleans, La., June 9-10, 1986. air-chamber/room temperature gradient and to en- Supported in part by the A. G. LeventisFoundation. sure a resting arterial inflow to the leg. A baseline re- Reprint requests: A. N. Nicolaides, Academic Surgical Uni% St. Mary's Hospital Medical School, Praed Street, London, W2 cording is obtained and calibration is performed by: 1PG, U.K. the injection of 200 m_l of water into the smaller bag 148 Volume 5 Number I January. 1987 Air-plethysmography and effect of dastic compression on leg vein hemodynamics !49 . P 8 (mmHg) 7 ,~0 I00 150 2O0 V (too P Fig. 2. Calibration curve shows pressure changes in the air chamber with water injected into calibration bag in incre- Fig. 1. Air-plethysmograph consists of pol~iwl chloride ments of 50 ml. (PVC) air chamber (5 liter capacity) connected to pres- sure transducer (P) and a smaller PVC bag (1 liter ca- pz Cry) used for calibration by injecting known volumes of water (V). volume (milliliters/100 ml) (see Leg volume mea- surements described later). Because of the variation in leg size, normalized units arc more appropriate in increments of 50 ml at 37 ° C and observation of for comparisons between different clinical groups. A the corresponding pressure changes in the air-cham- sunmaary of the direct and derived measurements in ber (Fig. 2). The water is then removed. After a stable absolute and normalized units is given in Table I. baseline recording is obtained again (Fig. 3, a), the The reproducibility of air-plethysmography has subject is asked to stand with the weight on the op- been determined by studying one normal limb, three posite leg, holding onto a frame. The foot of the leg limbs with SVI, and one limb with DVD on five being examined rests on the ground. An increase in different days. The range of the coefficients of vari- the leg volume is observed in the recording as a result ation for all the measurements is shown in Table II. of venous filling. The subject is asked to keep still Leg vohtme measurements. The volume of the until a plateau is reached, indicating that the veins leg included in the air-plethysmograph is determined are full (Fig. 3, b). This increase represents the func- by water displacement. The leg is immersed into wa- tional venous volume (W). The time taken to ter initially up to the ankle and subsequently up to achieve 90% of filling has been defined as venous just below the lmee according to skin marks made filling time 90 (VFT90). The venous filling index when the air-chamber is on the limb. This is done 0rFI) is defined as VFI = 90%W/VFT90 (Fig. 3). so that the results of VV, EV, RV and VFI can be This is a measure of the average filling rate and is expressed not only as absolute units (milliliters or expressed in milliliters per second. The subject is milliters per second) but also as blood volume per then asked to do one tiptoe movement with his unit volume of tissue (milliliters/100 ml) (Table I). weight on both legs and return to the initial posi- Ambulato~" venous pressure (AVP) and pres- tion (Fig. 3, c). The recorded decrease is the ejected sure recovelT time (RT90). A vein on the dorsum *volume (EV) as a result of the calf muscle contrac- of the foot was cannulated by a 21-gauge butterfly tion. After a new plateau is reached, the subject does needle, which was connected to a pressure trans- 10 tiptoe movements at a rate of one per second ducer, amplifier, and recorder. The patient was asked (Fig. 3, d ) and returns to rest holding onto the frame to stand still with the body weight on both legs, (Fig. 3, e). A volume decrease to a new steady state holding onto a frame. When the pressure recording is observed. The residual volume (RV) is calculated achieved a plateau, the patient was asked to perform £rom thc original baseline value and the volume at a standard exercise of i0 tiptoe movements at the the end of exercise. The ejection fraction (EF) of the rate of one per second. At the end of the exercise the first step is derived from: EF = (EV/W) × 100 patient remained still while the recove W in pressure and the residual volume fraction (RVF) from: was being recorded. The pressure at the end of ex- RVF = (RV/VV) x 100 (Fig. 3). ercise has been defined as the AVP (Fig. 4). The time The volume measurements (W, EV, RV, and taken for the pressure to return to the standing rest- VFI) are expressed in absolute units (milliliters) and ing pressure levels is the pressure recover T time. For normalized units (i.e., as fractions of the whole leg practical reasons we measured the 90% recove W time Journal of VASCULAR 150 Christopoulos et al. SURGERY b c d e 0 1 ml * VFT 90- see ~-vt:l EV xl00=EF R--.--~-V x 100= RVF VFT 90 .... VV VV Fig. 3. Diagrammatic representation of typical recording of volume changes during standard sequence of posmral changes and exercise. Patient in supine position with leg elevated 45 degrees (a); patient standing with weight on nonexamined leg (b); single tiptoe movement (c); ten tiptoe movements (d); same as in (b)/(e). VV = functional venous volume; VFT = venous filling time; VFI =venous filling index; EV = ejected volume; RV = residual volume; El: = ejection fraction; RVF = residual volume fraction. Table I. Direct and derived measurements in absolute and normalized units Normalized units Absolute units (% of whole leg volume) Direct measurement Leg volume (LV) ml Functional venous volume (VV) (the increase in leg volume on standing) ml ml/lO0 ml Venous filling time (VFT90) (time taken to reach 90% of VV) SCC Ejected volume (EV) (decrease in leg volume as result of one tiptoe ml ml/lO0 ml movement) Derived measurements Venous filling index (VFI) (average filling rate 90% VV/VFT90) ml/sec ml/100 ml/sec Ejection fraction (EF) ([EV/VV] × 100) % Residual volume (RV) (VV - EV) ml ml/100 ml Residual volume fraction (RVF) ([RV/VV] × 100) % (RT90) instead of the full recovery time because this patients with DVD.
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