Hyperaemia of the calf after arterial reconstruction for atherosclerotic occlusion. A plethysmographic study

Compression therapy in peripheral artery disease: a literature review

OBJECTIVE

Our objective is to examine the pathophysiology of oedema in the ischaemic and post-revascularised limb, compare compression stockings to pneumatic compression devices, and summarise compression regimens in patients with severe peripheral artery disease (PAD) without revascularisation, after revascularisation, and in mixed arterial and venous disease.

METHOD

A scoping literature review of the aforementioned topics was carried out using PubMed.

RESULTS

Compression therapy has been shown to increase blood flow and aid in wound healing through a variety of mechanisms. Several studies suggest that intermittent pneumatic compression (IPC) devices can be used to treat critical limb ischaemia in patients without surgical options. Additionally, compression stockings may have a role in preventing oedema after peripheral artery bypass surgery, thereby diminishing pain and reducing the risk of surgical wound dehiscence.

CONCLUSION

Oedema may occur in the ischaemic limb after revascularisation surgery, as well as in combination with venous disease. Clinicians should not fear using compression therapy in PAD.

Pathophysiology and treatment of edema following femoropopliteal bypass surgery

Substantial lower-limb edema affects the majority of patients who undergo peripheral bypass surgery. Edema has impairing effects on the microvascular and the macrovascular circulation, causes discomfort and might delay the rehabilitation process of the patient. However, the pathophysiology of this edema is not well understood. The Cochrane Library and Medline were used to retrieve literature on edema following peripheral bypass surgery. Factors other than local wound healing alone are suggested in the literature to play a role, given the severity and duration of this edema. Hyperemia, microvascular permeability, reperfusion-associated inflammation and lymphatic disruptions are likely to facilitate the development of edema. Preventive methods could be lymphatic-sparing surgery, intraoperative antioxidative therapy and postoperative elevation. Successful treatment strategies to reduce postoperative edema are based on lymph massage and external compression. In conclusion, the pathophysiology of edema following peripheral surgery is not fully understood, although reperfusion-associated inflammation and lymphatic disruptions are likely to play a crucial role. When future less-invasive techniques prove to be successful, postoperative edema might be minimized. Until then, a careful lymphatic-sparing dissection should be executed when performing a peripheral bypass reconstruction. Postoperatively, the use of compression stockings and leg elevation are currently the golden standards.

Twenty-four hour blood flow in the forefoot after reconstructive vascular surgery

Local blood flow in the forefoot (SBF) was measured continuously during 24 hours by 133xenon clearance technique in 10 patients prior to and at least 1 year after successful reconstructive vascular surgery for severe arterial insufficiency (mean: 18 months, range: 12-36). A group of 10 patients with normal peripheral circulation served as a control group. In spite of a considerable increase of the ankle/arm systolic blood pressure index--preoperative: 0.30 +/- 0.12, postoperative: 0.78 +/- 0.28 (mean +/- 1 SD)--the SBF decreased by 50% (p less than 0.001) following reconstructive vascular surgery during day activities. During sleep, however, SBF increased by 80% (p less than 0.001). The relative changes in SBF from day to night at the postoperative examination did not differ from that of the control group, i.e., the normal 24-hour blood flow pattern had been obtained. These changes in SBF are explained by the reappearance of peripheral vasoregulatory mechanisms. Postreconstructive hyperemia was evaluated by the same technique. The changes in SBF following surgery in the positions supine, awake and supine, asleep were found to be insignificant (0.80 less than p less than 0.90). It is concluded that the long-term postreconstructive hyperemia merely is a reflection of the normal 24-hour blood flow pattern.

Local regulation of blood flow and the occurrence of edema after arterial reconstruction of the lower limbs

The relation between edema after arterial reconstruction of the lower limbs and various potential etiologic factors, including disturbances in local blood flow regulating mechanisms, was investigated in 22 patients with occlusive arterial disease. The occurrence of edema was unrelated to the severity of symptoms as well as to the perioperative changes in distal arterial blood pressure. Postreconstructive edema developed independently of postreconstructive hyperemia and of disturbances in the local vasoconstrictor response to increased venous pressure. The decisive factor for development of edema was the extensive dissection in the thigh and in the popliteal region required for femoropopliteal bypass surgery. Edema developed after nine of nine femoropopliteal bypass operations, and only after one of 12 reconstructions in the aorto-iliac or in the profound femoral segments (p = 0.001). It is concluded that the postreconstructive edema is a lymphedema due to surgical trauma, rather than the result of microvascular derangement.

Persistent hyperemia following prolonged arterial occlusion

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