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Avila ML, Bentley RF, Bastas D, Brandão LR, Schneiderman JE, Ward L, Wong G, Stephens S, Liu K, Thomas S. Unraveling the pathophysiology of lower-limb postthrombotic syndrome in adolescents: a proof-of-concept study. Blood Adv 2023; 7:2784-2793. [PMID: 36763520 PMCID: PMC10275697 DOI: 10.1182/bloodadvances.2022009599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/07/2023] [Accepted: 02/07/2023] [Indexed: 02/11/2023] Open
Abstract
A better understanding of the pathophysiology of pediatric postthrombotic syndrome (PTS) is needed to develop strategies to treat this condition. We investigated calf pump function, exercise capacity, balance in power output, and changes in limb muscle oxygen saturation (SmO2) and fluid content during exercise in 10 pediatric patients with unilateral lower-limb PTS, and in age- and sex-matched controls (1:1-1:2 ratio). Outcomes were investigated using bioimpedance spectroscopy, torque-sensing pedals, and near-infrared spectroscopy during incremental- and constant-load cycling tests. The median age at participation was 17 years (25th-75th percentile, 15-18 years); 68% of participants were females. The median CAPTSure score in the affected leg of affected participants was 35 points (25th-75th percentile, 24-46 points), indicating moderate/severe PTS; 20% of patients had a history of central venous catheter-related thrombosis. Increasing PTS severity was associated with higher calf pump venous volume and higher ejection volume, leading to compensated calf pump performance. We found no evidence of PTS impact on exercise capacity. Leg contribution to power output was similar in affected and unaffected legs. However, the PTS-affected legs showed lower SmO2 during active cycling and recovery with increasing PTS severity, indicating impaired microvascular function in the muscle. These findings suggest that PTS severity is associated with impaired blood flow, presumably from elevated venous pressure during and after exercise. The fact that microvascular function is impaired in young patients with PTS underscores the relevance of developing strategies to mitigate the effects of this chronic vascular disease to minimize its deleterious effects as children grow older.
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Affiliation(s)
- M. Laura Avila
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Robert F. Bentley
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Denise Bastas
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leonardo R. Brandão
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Jane E. Schneiderman
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Clinical Research Services, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leigh Ward
- School of Chemistry and Molecular Biosciences, The University of Queensland, St. Lucia, Brisbane, Australia
| | - Gina Wong
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Samantha Stephens
- Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Kuan Liu
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Scott Thomas
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
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Holmes M, Koutakis P, Ismaeel A. Aging alters gastrocnemius muscle hemoglobin oxygen saturation (StO 2) characteristics in healthy individuals. Eur J Appl Physiol 2022; 122:1509-1520. [PMID: 35419666 DOI: 10.1007/s00421-022-04944-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 03/28/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE Functional limitations during exercise from alterations in the balance of oxygen supply and demand-as reported by lower tissue oxygen saturation and longer recovery time-are well documented in clinical populations. We aimed to assess changes in skeletal muscle hemoglobin oxygen saturation (StO2) characteristics during exercise as a result of aging in otherwise healthy individuals. METHODS We recruited healthy male and female participants (n = 101) from three age ranges-young (18-39 years), middle age (40-65 years), and older (> 65 years)-to complete exercise tests commonly used in clinical populations. Using near-infrared spectroscopy (NIRS) we assessed StO2 in the medial gastrocnemius during the Gardner Treadmill Protocol and 6 min walk test (6MWT). RESULTS Minimum StO2 (%) during the treadmill test was significantly lower for both middle-age (36.1 ± 20.6) and older (27.3 ± 19.4) participants compared to young (46.8 ± 14.8) (p < 0.05 and p < 0.01 respectively), and recovery time (minutes) was significantly prolonged (young = 0.22 ± 0.34; middle age = 0.66 ± 0.52; older = 1.04 ± 1.00) (p < 0.001 for both middle age and older compared to young). Similar results were shown during the 6MWT, as minimum StO2 (%) was lower in middle-age (41.7 ± 17.2) and older (40.0 ± 25.9) participants compared to young (53.6 ± 14.5) (p < 0.05), and recovery times (minutes) were prolonged (young: 0.11 ± 0.17; middle age: 0.46 ± 0.42; older: 0.93 ± 0.43) (p < 0.001 for both middle age and older compared to young). Simple linear regression analyses demonstrated that age predicted treadmill recovery and 6MWT recovery. CONCLUSION Our study provides evidence that aging, even in otherwise healthy individuals, negatively impacts muscle StO2 characteristics. In older individuals, working muscle tissue may reach lower oxygen saturation during exercise and take longer to return to baseline oxygen saturation post-exercise.
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Affiliation(s)
- Michael Holmes
- Max E, Wastl Human Performance Laboratory, Department of Health and Kinesiology, Purdue University, West Lafayette, IN, USA
| | | | - Ahmed Ismaeel
- Department of Biology, Baylor University, Waco, TX, USA.
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Crispin P. Effect of anemia on muscle oxygen saturation during submaximal exercise. Transfusion 2019; 60:36-44. [PMID: 31714628 DOI: 10.1111/trf.15588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/17/2019] [Accepted: 10/17/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Objective measures to assess the need for transfusion in chronic anemia are lacking. Near-infrared spectroscopy may be used, but there is wide variability. Assessment of muscle oxygen saturation (SmO2 ) during exercise could be used to measure the impact of anemia on performance of everyday activities. STUDY DESIGN AND METHODS Hematology patients and controls were recruited to undertake a 6-minute walk test (6MWT) and a 20-second isometric handgrip exercise. Muscle oxygen saturation in the exercising muscles was measured before and during exercise. Changes in saturation during exercise were described. Correlations between identified variables, hemoglobin concentration, and 6MWT distance were undertaken. The effect of transfusion was assessed on a transfused subset. RESULTS There were 95 sets of exercises conducted in 74 participants. Baseline SmO2 correlated with hemoglobin concentration and negatively with 6MWT distance. Paradoxically, a higher hemoglobin was associated with a greater SmO2 fall during the 6MWT, likely due to greater consumption from improved walk distances. The fall in SmO2 was independent of hemoglobin during isometric contraction, although levels were lower during contraction due to the lower starting SmO2 . There was a longer time to peak SmO2 during recovery following isometric exercise in anemia. There were 17 paired tests following a change in hemoglobin, with SmO2 not predicting improvement in those who had improved exercise capacity. CONCLUSION While baseline SmO2 correlated with hemoglobin concentration, the correlation was not strong enough to predict transfusion requirements. Recovery after isometric forearm contraction correlated with hemoglobin and warrants further investigation.
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Affiliation(s)
- Philip Crispin
- Canberra Hospital, Australian National University Medical School, John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia
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Yamaki T, Mizobuchi T, Sasaki Y, Kamei W, Hasegawa Y, Osada A, Nozaki M, Sakurai H. Noninvasive near-infrared spectroscopic evaluation of calf muscle oxygenation in patients with advanced chronic venous insufficiency associated with tricuspid regurgitation. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2019. [DOI: 10.23736/s1824-4777.18.01377-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Background The tip toe manoeuvre has been promoted as the gold standard plethysmography test for measuring calf muscle pump function. The aim was to compare the tip toe manoeuvre, dorsiflexion manoeuvre and a body weight transfer manoeuvre using the ejection fraction of air-plethysmography and evaluate which has the best pumping effect. Methods Sixty-six archived tracings on 22 legs were retrieved from an air-plethysmography workshop and analysed. Pumping performance was measured using the calf volume reduction after each manoeuvre. Results Expressed as median [inter-quartile range], body weight transfer manoeuvres resulted in a significantly greater ejection fraction (%) than tip toe manoeuvres at 59.7 [53.5-63.9] versus 42.6 [30.5-52.6], P < 0.0005 (Wilcoxon). There was no significant difference in the ejection fraction between the tip toe manoeuvre versus dorsiflexion manoeuvre, P = 0.615. The repeatability (confidence interval: 95%) of 66 ejection fraction tests was excellent: tip toe manoeuvre (±1.2), dorsiflexion manoeuvre (±1.3) and body weight transfer manoeuvre (±1.6). Conclusion The body weight transfer manoeuvre appears to be a better method of measuring the full potential of the calf muscle pump with a 40.1% relative increase in the ejection fraction compared to a tip toe manoeuvre. Exercises which involve body weight transfers from one leg to the other may be more important in optimizing calf muscle pump function than ankle movement exercises.
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Affiliation(s)
- Christopher R Lattimer
- 1 Josef Pflug Vascular Laboratory, Ealing Hospital, Middlesex, UK.,2 Department of Surgery Cancer, Imperial College, London, UK.,3 West London Vascular and Interventional Centre, Middlesex, UK
| | | | - Evi Kalodiki
- 1 Josef Pflug Vascular Laboratory, Ealing Hospital, Middlesex, UK.,2 Department of Surgery Cancer, Imperial College, London, UK.,3 West London Vascular and Interventional Centre, Middlesex, UK
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Yamaki T, Hasegawa Y, Osada A, Konoeda H, Hamahata A, Ochi M, Nozaki M, Sakurai H. Time taken to the maximum increase in the oxygenated hemoglobin level in calf muscle as a predictor of mild and moderate post-thrombotic syndrome. J Vasc Surg Venous Lymphat Disord 2016; 4:446-54. [PMID: 27638999 DOI: 10.1016/j.jvsv.2016.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 05/12/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Near-infrared spectroscopy (NIRS) allows continuous noninvasive monitoring of changes in the tissue levels of oxygenated hemoglobin (O2Hb) and deoxygenated hemoglobin (HHb) and can identify the severity of chronic venous diseases. Here we investigated the predictors of post-thrombotic syndrome (PTS) using NIRS in patients with a first episode of deep venous thrombosis (DVT). METHODS The study enrolled 129 patients with DVT. Risk factors in each patient were assessed at presentation. Venous abnormalities confirmed by ultrasound and parameters derived from NIRS were evaluated at 6 months after DVT. On standing, increases in O2Hb and HHb (ΔO2Hbst and ΔHHbst) and the times taken for each concentration to become maximal (TO2Hbst, and THHbst) were measured. During 10 tiptoe movements, O2Hb showed a continuous decrease (ΔO2Hbex), whereas venous expulsion (ΔHHbEex) and subsequent retention (ΔHHbRex) were observed. The oxygenation index (HbD; HbD = O2Hb - HHb) was also calculated at the end of standing and at the end of 10 tiptoe movements (ΔHbDst and ΔHbDex). Final clinical manifestations were evaluated at 6 years, and PTS was considered to be present if the Villalta score was ≥5. RESULTS Thirteen patients were excluded and 116 patients were finally included. Of these, 19 (16%) developed PTS. Among various NIRS-derived parameters, TO2Hbst had the highest area under the curve (0.88; 95% confidence interval [CI], 0.80-0.93; P < .01) with the best cutoff value (TO2Hbst ≤48 seconds). On univariate analysis, variables associated with greater risk for development of PTS were stroke (odds ratio [OR], 5.59; 95% CI, 0.74-42.41; P = .06), idiopathic DVT (OR, 4.13; 95% CI, 1.36-12.55; P < .01) and iliofemoral DVT (OR, 4.31; 95% CI, 1.48-12.60; P < .01) at initial presentation, venous occlusion combined with reflux (OR, 4.24; 95% CI, 1.50-12.00; P < .01), and NIRS-derived TO2Hbst ≤48 seconds (OR, 43.03; 95% CI, 9.04-204.81; P < .01) at 6 months. Multivariate logistic regression analysis finally revealed venous occlusion combined with reflux (OR, 4.80; 95% CI, 1.03-22.36; P < .05) and NIRS-derived TO2Hbst ≤48 seconds (OR, 53.73; 95% CI, 8.43-342.41; P < .01) to be independently associated with PTS progression. CONCLUSIONS NIRS-derived TO2Hbst ≤48 seconds is a promising time-course predictor of PTS progression.
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Affiliation(s)
- Takashi Yamaki
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan.
| | - Yuki Hasegawa
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Atsuyoshi Osada
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Hisato Konoeda
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Atsumori Hamahata
- Department of Plastic and Reconstructive Surgery, Saitama Cancer Center, Kitaadachigun, Saitama, Japan
| | - Masakazu Ochi
- Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Motohiro Nozaki
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Hiroyuki Sakurai
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan
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Measurement of calf muscle oxygenation during light-intensity exercise in patients with post-thrombotic syndrome. J Vasc Surg Venous Lymphat Disord 2014; 2:424-32. [PMID: 26993549 DOI: 10.1016/j.jvsv.2014.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 05/25/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Near-infrared spectroscopy (NIRS) provides continuous noninvasive monitoring of changes in the levels of oxygenated hemoglobin (O2Hb) and deoxygenated hemoglobin (HHb) in tissues. The purpose of this study was to investigate changes in calf muscle O2Hb and HHb levels during standing and exercise in the follow-up of deep venous thrombosis (DVT). METHODS Forty-three patients with a first episode of unilateral proximal DVT were included. Final clinical manifestations were evaluated at a mean follow-up point of 53 months after diagnosis of DVT, and post-thrombotic syndrome (PTS) was considered to be present if the Villalta score was >5. Moreover, to assess the severity of PTS, the revised Venous Clinical Severity Score (VCSS) was employed. NIRS was used to measure changes in the levels of O2Hb and HHb in calf muscle. On standing, increases in O2Hb and HHb were calculated by subtracting the baseline value from the maximum value (ΔO2Hbst and ΔHHbst). The times taken for the O2Hb and HHb concentrations to become maximal (TO2Hbst, and THHbst) were also measured. During 10 tiptoe movements, the relative change in O2Hb was calculated by subtracting the value measured at the end of exercise from the value measured at the beginning of exercise (ΔO2Hbex). On the other hand, 10 tiptoe movements produced venous expulsion (ΔHHbEex) and a subsequent retention (ΔHHbRex). The oxygenation index (HbD; HbD = O2Hb - HHb) was also calculated at the end of standing and at the end of 10 tiptoe movements (ΔHbDst and ΔHbDex). RESULTS Among the 43 limbs evaluated, 21 had PTS. On standing, the ΔHbDst was significantly decreased in patients with PTS relative to the patients without PTS (12 ± 8, 22 ± 11 μmol/L; P = .001). The TO2Hbst was also significantly reduced in patients with PTS relative to those without (43 ± 41, 107 ± 58 seconds; P = .001). During 10 tiptoe movements, the ΔHHbEex was significantly reduced in patients with PTS relative to those without (-2 ± 1, -3 ± 3 μmol/L; P = .016). Similarly, the ΔHHbRex was significantly increased in patients with PTS relative to those without (8 ± 7, 3 ± 2 μmol/L; P = .001). Furthermore, falls in ΔHbDex were more pronounced in patients with PTS (-10 ± 16, 10 ± 10 μmol/L; P < .001). NIRS-derived TO2Hbst (r = -0.568; P < .001) and ΔHbDex (r = -0.645; P < .001) showed strong inverse correlations with VCSS. Similarly, NIRS-derived ΔHHbEex (r = 0.409; P < .01) and ΔHHbRex (r = 0.476; P < .01) showed moderate positive correlations and ΔHbDst (r = -0.422; P < .01) had a moderate inverse correlation with VCSS. CONCLUSIONS Changes in O2Hb and HHb concentrations differ between patients with and without PTS. The reduced TO2Hbst may indicate impairment of the venoarteriolar reflex in patients who have PTS. Furthermore, severe falls in HbD in patients with PTS might reflect the pain of venous claudication. These findings may have implications for investigations of the microcirculation in the context of post-thrombotic sequelae.
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