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IPC对动脉旁路移植术后血液动力学的影响HaemodynamiceffectofintermittentpneumaticcompressionofthelegafterinfrainguinalarterialbypassgraftingK.T.Dells1,M.J.Husmannl,G.Szendro1,N.S.Peters2,J.H.N.Wolfe1andA.O.Mansfield1RegionalVascularSurgeryUnitand2DepartmentofAcademicCardiology,StMary'sHospital,ImperialCollegeSchoolofMedicine,London,UKCorrespondenceto:Mr.K.T.Dells,4AbingerCourt,34GordonRoad,LondonW52AF,UK(e-mail:k.delis@ic.ac.uk)Background:Intermittentpneumaticcompression(IPC)mayincreasebloodflowthroughinfrainguinalarterialgrafts,andhaspotentialclinicalapplicationasbloodflowvelocityattenuationoftenprecedesgraftfailure.ThepresentstudyexaminedtheimmediateeffectsofIPCappliedtothefoot(IPCfoot),thecalf(IPCfoot)andtobothsimultaneously(IPCfoot+calf)onthehaemodynamicsofinfrainguinalbypassgrafts.Methods:Eighteenfemoropoplitealand18femorodistaiautologousveingraftswerestudied;allhadarestinganklebrachialpressureindexof0.9ormore.Clinicalexamination,graftsurveillanceandmeasurementofgrafthaemodynamicswereconductedatrestandwithin5sofIPCineachmodeusingdupleximaging.Outcomemeasuresincludedpeaksystolic(PSV),mean(MV)andenddiastolic(EDV)velocities,pulsatilityindex(PI)andvolumeflowinthegraft.Results:AllIPCmodessignificantlyenhancedMV,PSV,EDVandvolumeflowinbothgrafttypes;IPCfoot+calfwasthemosteffective.IPCfoot+calfenhancedmedianvolumeflow,MVandPSVinfemoropoplitealgraftsby182,236and49percent,respectively,andattenuatedPIby61percent.Enhancementinfemorodistalgraftswas273,179and53percentrespectively,andPIattenuationwas63percent.Conclusion:IPCwaseffectiveinimprovinginfrainguinalgraftflowvelocity,probablybyreducingperipheralresistance.IPChasthepotentialtoreducetheriskofbypassgraftthrombosis.PresentedtotheInauguralMeetingoftheSocietyofAcademicandResearchSurgery',London,UK,January2002Paperaccepted9December2003Publishedonline27February.2004inWileyInterScience().DOE10.1002/bis.4482IntroductionIntermittentpneumaticcompression(IPC)oftheleggeneratesasignificantincreaseinarterialbloodflowinpatientswithperipheralvasculardisease1-3.IPCofthefoot(IPCfoot)increasesarterialcalfinflowby50-90percentinarteriopaths,andbymoreinnormalsubjects1.3.Athreefoldtofourfoldincreaseinthecalfbloodflowhasbeenreportedwithfootandcalfcompression(IPCfoot+calf)inpatientswithsuperficialfemoralarteryocclusion2.4.TheapplicationofIPC.forover4monthsamelioratesintermittentclaudicationandimprovestheanklebrachialpressureindex(ABPI)5.6.Thisisprobablyduetoaflowdependentpromotionofcollateralcirculation5.6.Arterialgraftsarecomplicatedbyearlyocclusioninupto20percentofdistalbypasses7.Failurethatoccurswithinthefirst2or3daysisusuallyduetopoorselectionortechnicalerror;latefailurewithinthefirstmonthresultsfromanumberoffactors,includingtechnicalimperfectionpersistentunderlyingdiseaseandsurfacethrombogenicityofthegraft8.9Ithasbeensuggestedthatthereisacriticalthresholdvelocityrequiredforensuringgraftpatencyintheseearlystages10.11Thelikelihoodofearlythrombosisishighinasmall-calibregraftplacedintoahighresistancecirculation,suchasinthecaseofafemorodistalbypassgraftinthepresenceoflowflowvelocities.Itwashypothesizedthat,analogoustoitsbeneficialeffectonnativearterialbloodflow,theapplicationofIPCmightalsoenhancearterialbloodflowthroughaninftainguinalbypassgraft.Thismighthaveclinicaladvantages,aslowflowvelocityprecedesgraftfailure12.TheaimofthisstudywastocomparetheimmediateeffectsofIPCfoot,IPCfoot+calfandIPCofthecalf(IPCcalf)onarterialbypassgrafthaemodynamicsinpatientswhohadinfrainguinalrevascularizationforischaemia.PatientsandmethodsStudygroupsGraftflowvelocitiesduringIPCweremeasuredin16patientswith18femoropoplitealgrafts(fiveaboveand13belowknee)andin18patientswith18femorodistalgrafts(twoperoneal,nineposteriortibial,fiveanteriortibialandtwodorsalispedis).Therewere13menandthreewomenofmean(s.d.)age65.9(9.6)yearsintheformergroup,and15menandthreewomenaged68.8(7.5)yearsinthelattergroup.Allgraftswereautologousvein.Thefemoropoplitealgraftshadbeeninsertedforamedianof17(interquartilerange7.5-33)monthsandthefemorodistalgraftsforamedianof18(interquartilerange12-26)months.PatientswhohadaninfrainguinalbypasswereassessedbymeasurementofrestingABPIfollowedbygraftsurveillanceusingdupleximaging.Uncompromisedgrafts,definedbyarestingABPIof0-9ormore,andnosignificant(50percentdiameterormore)stenosisondupleximaging,wererecruitedintothestudy.StudydesignThesequenceofIPCapplicationwassubjecttoacrossoverdesign.Toeliminatebiasfromcarry-overeffects,thetwostudygroups,comprising18legseach,hadallsixpossiblecombinationsofIPCsequences(IPCfoot-IPCcalf-IPCfoot+calf,IPCfoot-IPCfoot+calf-IPCcalf,etc.)appliedtotheirlegsandinvestigatedevenly(threelegspersequence).Thesesequenceswereallottednumbers1-18atrandomfromsealedenvelopes,oneforeachnewentry.ExaminationandimagingprotocolGraftbloodflowwasstudiedusingcolourduplexultrasonographywithalinear-array7.5-MHzprobe.Subjectswerescannedinthesittingposition,withtheirlegsdependent,slightlyextendedattheknees,andtheirfeetrestingonalowstool.FootandcalfpadsenablingIPCdeliverywereapplied,andarestingperiodof15min