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Menêses A, Krastins D, Nam M, Bailey T, Quah J, Sankhla V, Lam J, Jha P, Schulze K, O'Donnell J, Magee R, Golledge J, Greaves K, Askew CD. Toward a Better Understanding of Muscle Microvascular Perfusion During Exercise in Patients With Peripheral Artery Disease: The Effect of Lower-Limb Revascularization. J Endovasc Ther 2024; 31:115-125. [PMID: 35898156 DOI: 10.1177/15266028221114722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Leg muscle microvascular blood flow (perfusion) is impaired in response to maximal exercise in patients with peripheral artery disease (PAD); however, during submaximal exercise, microvascular perfusion is maintained due to a greater increase in microvascular blood volume compared with that seen in healthy adults. It is unclear whether this submaximal exercise response reflects a microvascular impairment, or whether it is a compensatory response for the limited conduit artery flow in PAD. Therefore, to clarify the role of conduit artery blood flow, we compared whole-limb blood flow and skeletal muscle microvascular perfusion responses with exercise in patients with PAD (n=9; 60±7 years) prior to, and following, lower-limb endovascular revascularization. MATERIALS AND METHODS Microvascular perfusion (microvascular volume × flow velocity) of the medial gastrocnemius muscle was measured before and immediately after a 5 minute bout of submaximal intermittent isometric plantar-flexion exercise using contrast-enhanced ultrasound imaging. Exercise contraction-by-contraction whole-leg blood flow and vascular conductance were measured using strain-gauge plethysmography. RESULTS With revascularization there was a significant increase in whole-leg blood flow and conductance during exercise (p<0.05). Exercise-induced muscle microvascular perfusion response did not change with revascularization (pre-revascularization: 3.19±2.32; post-revascularization: 3.89±1.67 aU.s-1; p=0.38). However, the parameters that determine microvascular perfusion changed, with a reduction in the microvascular volume response to exercise (pre-revascularization: 6.76±3.56; post-revascularization: 2.42±0.69 aU; p<0.01) and an increase in microvascular flow velocity (pre-revascularization: 0.25±0.13; post-revascularization: 0.59±0.25 s-1; p=0.02). CONCLUSION These findings suggest that patients with PAD compensate for the conduit artery blood flow impairment with an increase in microvascular blood volume to maintain muscle perfusion during submaximal exercise. CLINICAL IMPACT The findings from this study support the notion that the impairment in conduit artery blood flow in patients with PAD leads to compensatory changes in microvascular blood volume and flow velocity to maintain muscle microvascular perfusion during submaximal leg exercise. Moreover, this study demonstrates that these microvascular changes are reversed and become normalized with successful lower-limb endovascular revascularization.
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Affiliation(s)
- Annelise Menêses
- VasoActive Research Group, School of Health, University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - Digby Krastins
- VasoActive Research Group, School of Health, University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - Michael Nam
- Department of Cardiology, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Tom Bailey
- VasoActive Research Group, School of Health, University of the Sunshine Coast, Sippy Downs, QLD, Australia
- Physiology and Ultrasound Laboratory in Science and Exercise, Centre for Research on Exercise, Physical Activity & Health, School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Jing Quah
- Department of Cardiology, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Vaibhav Sankhla
- Department of Cardiology, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Jeng Lam
- Department of Cardiology, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Pankaj Jha
- Department of Vascular Surgery, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Karl Schulze
- Sunshine Vascular Clinic, Buderim, QLD, Australia
| | - Jill O'Donnell
- Department of Vascular Surgery, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Rebecca Magee
- Department of Vascular Surgery, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University and Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, QLD, Australia
| | - Kim Greaves
- Department of Cardiology, Sunshine Coast University Hospital, Birtinya, QLD, Australia
- Sunshine Coast Health Institute, Sunshine Coast Hospital and Health Service, Birtinya, QLD, Australia
| | - Christopher D Askew
- VasoActive Research Group, School of Health, University of the Sunshine Coast, Sippy Downs, QLD, Australia
- Sunshine Coast Health Institute, Sunshine Coast Hospital and Health Service, Birtinya, QLD, Australia
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Gardner AW, Montgomery PS, Wang M, Liang M, Proctor DN. Maximal calf conductance is associated with 6-minute walk distance in participants with and without peripheral artery disease. Vasc Med 2023; 28:113-121. [PMID: 36847177 DOI: 10.1177/1358863x231155299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
INTRODUCTION The aims were (a) to compare the maximal calf conductance and 6-minute walk distance of participants with and without peripheral artery disease (PAD) and claudication, (b) to determine whether maximal calf conductance was more strongly associated with 6-minute walk distance in participants with PAD than in the controls, and (c) to determine whether this association was significant in participants with PAD after adjusting for ABI, as well as for demographic, anthropometric, and comorbid variables. METHODS Participants with PAD (n = 633) and without PAD (n = 327) were assessed on maximal calf conductance using venous occlusion plethysmography, and on 6-minute walk distance. Participants were further characterized on ABI, and on demographic, anthropometric, and comorbid variables. RESULTS The PAD group had lower maximal calf conductance than the control group (0.136 ± 0.071 vs 0.201 ± 0.113 mL/100 mL/min/mmHg, p < 0.001). Additionally, the PAD group had a lower 6-minute walk distance (375 ± 98 m vs 480 ± 107 m, p < 0.001). Maximal calf conductance was positively associated with 6-minute walk distance in both groups (p < 0.001) and was more strongly associated in the PAD group (p < 0.001). In adjusted analyses, maximal calf conductance remained positively associated with 6-minute walk distance in the PAD group (p < 0.001) and in the control group (p < 0.001). CONCLUSIONS Participants with PAD and claudication had impaired maximal calf conductance and a lower 6-minute walk distance than those without PAD, and maximal calf conductance was positively and independently associated with 6-minute walk distance within each group before and after adjusting for ABI, and for demographic, anthropometric, and comorbid variables.
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Affiliation(s)
- Andrew W Gardner
- Department of Physical Medicine & Rehabilitation, Penn State College of Medicine, Hershey, PA, USA.,University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Polly S Montgomery
- Department of Physical Medicine & Rehabilitation, Penn State College of Medicine, Hershey, PA, USA.,University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ming Wang
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Menglu Liang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - David N Proctor
- Department of Kinesiology, Penn State University, University Park, PA, USA
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Becker AB, Chen L, Ning B, Hu S, Hossack JA, Klibanov AL, Annex BH, French BA. Contrast-Enhanced Ultrasound Reveals Partial Perfusion Recovery After Hindlimb Ischemia as Opposed to Full Recovery by Laser Doppler Perfusion Imaging. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:1058-1069. [PMID: 35287996 PMCID: PMC9872654 DOI: 10.1016/j.ultrasmedbio.2022.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 06/03/2023]
Abstract
Mouse models are critical in developing new therapeutic approaches to treat peripheral arterial disease (PAD). Despite decades of research and numerous clinical trials, the efficacy of available therapies is limited. This may suggest shortcomings in our current animal models and/or methods of assessment. We evaluated perfusion measurement methods in a mouse model of PAD by comparing laser Doppler perfusion imaging (LDPI, the most common technique), contrast-enhanced ultrasound (CEUS, an emerging technique) and fluorescent microspheres (conventional standard). Mice undergoing a femoral artery ligation were assessed by LDPI and CEUS at baseline and 1, 4, 7, 14, 28, 60, 90 and 150 d post-surgery to evaluate perfusion recovery in the ischemic hindlimb. Fourteen days after surgery, additional mice were measured with fluorescent microspheres, LDPI, and CEUS. LDPI and CEUS resulted in broadly similar trends of perfusion recovery until 7 d post-surgery. However, by day 14, LDPI indicated full recovery of perfusion, whereas CEUS indicated ∼50% recovery, which failed to improve even after 5 mo. In agreement with the CEUS results, fluorescent microspheres at day 14 post-surgery confirmed that perfusion recovery was incomplete. Histopathology and photoacoustic microscopy provided further evidence of sustained vascular abnormalities.
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Affiliation(s)
- Alyssa B Becker
- Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia, USA
| | - Lanlin Chen
- Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia, USA
| | - Bo Ning
- Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia, USA
| | - Song Hu
- Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia, USA
| | - John A Hossack
- Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia, USA
| | - Alexander L Klibanov
- Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia, USA; Department of Medicine, Cardiovascular Division, University of Virginia, Charlottesville, Virginia, USA
| | - Brian H Annex
- Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia, USA; Department of Medicine, Cardiovascular Division, University of Virginia, Charlottesville, Virginia, USA
| | - Brent A French
- Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia, USA; Department of Medicine, Cardiovascular Division, University of Virginia, Charlottesville, Virginia, USA.
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Soman D, Hodovan J, Macon CJ, Davidson BP, Belcik JT, Mudd JO, Park BS, Lindner JR. Contrast Ultrasound Assessment of Skeletal Muscle Recruitable Perfusion after Permanent Left Ventricular Assist Device Implantation: Implications for Functional Recovery. J Am Soc Echocardiogr 2021; 35:495-502. [PMID: 34973393 PMCID: PMC9081119 DOI: 10.1016/j.echo.2021.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/17/2021] [Accepted: 12/21/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND In heart failure with reduced ejection fraction (HFrEF), abnormal regulation of skeletal muscle perfusion contributes to reduced exercise tolerance. The aim of this study was to test the hypothesis that improvement in functional status after permanent left ventricular assist device (LVAD) implantation in patients with HFrEF is related to improvement in muscle perfusion during work, which was measured using contrast-enhanced ultrasound (CEUS). METHODS CEUS perfusion imaging of calf muscle at rest and during low-intensity plantar flexion exercise (20 W, 0.2 Hz) was performed in patients with HFrEF (n = 22) at baseline and 3 months after placement of permanent LVADs. Parametric analysis of CEUS data was used to quantify muscle microvascular blood flow (MBF), blood volume index, and red blood cell flux rate. For subjects alive at 3 months, comparisons were made between those with New York Heart Association functional class I or II (n = 13) versus III or IV (n = 7) status after LVAD. Subjects were followed for a median of 5.7 years for mortality. RESULTS Echocardiographic data before and after LVAD placement and LVAD parameters were similar in subjects classified with New York Heart Association functional class I-II versus functional class III-IV after LVAD. Skeletal muscle MBF at rest and during exercise before LVAD implantation was also similar between groups. After LVAD placement, resting MBF remained similar between groups, but during exercise those with New York Heart Association functional class I or II had greater exercise MBF (111 ± 60 vs 52 ± 38 intensity units/sec, P = .03), MBF reserve (median, 4.45 [3.95 to 6.80] vs 2.22 [0.98 to 3.80]; P = .02), and percentage change in exercise MBF (median, 73% [-28% to 83%] vs -45% [-80% to 26%]; P = .03). During exercise, increases in MBF were attributable to faster microvascular flux rate, with little change in blood volume index, indicating impaired exercise-mediated microvascular recruitment. The only clinical or echocardiographic feature that correlated with post-LVAD exercise MBF was a history of diabetes mellitus. There was a trend toward better survival in patients who demonstrated improvement in muscle exercise MBF after LVAD placement (P = .05). CONCLUSIONS CEUS perfusion imaging can quantify peripheral vascular responses to advanced therapies for HFrEF. After LVAD implantation, improvement in functional class is seen in patients with improvements in skeletal muscle exercise perfusion and flux rate, implicating a change in vasoactive substances that control resistance arteriolar tone.
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Affiliation(s)
- Divya Soman
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - James Hodovan
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Conrad J Macon
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Brian P Davidson
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - J Todd Belcik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - James O Mudd
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Byung S Park
- School of Public Health, Oregon Health & Science University, Portland, Oregon
| | - Jonathan R Lindner
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Oregon National Primate Research Center, Oregon Health & Science University, Portland, Oregon.
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Meneses AL, Nam MCY, Bailey TG, Anstey C, Golledge J, Keske MA, Greaves K, Askew CD. Skeletal muscle microvascular perfusion responses to cuff occlusion and submaximal exercise assessed by contrast-enhanced ultrasound: The effect of age. Physiol Rep 2021; 8:e14580. [PMID: 33038050 PMCID: PMC7547535 DOI: 10.14814/phy2.14580] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/22/2020] [Accepted: 08/28/2020] [Indexed: 11/24/2022] Open
Abstract
Impairments in skeletal muscle microvascular function are frequently reported in patients with various cardiometabolic conditions for which older age is a risk factor. Whether aging per se predisposes the skeletal muscle to microvascular dysfunction is unclear. We used contrast‐enhanced ultrasound (CEU) to compare skeletal muscle microvascular perfusion responses to cuff occlusion and leg exercise between healthy young (n = 12, 26 ± 3 years) and older (n = 12, 68 ± 7 years) adults. Test–retest reliability of CEU perfusion parameters was also assessed. Microvascular perfusion (microvascular volume × flow velocity) of the medial gastrocnemius muscle was measured before and immediately after: (a) 5‐min of thigh‐cuff occlusion, and (b) 5‐min of submaximal intermittent isometric plantar‐flexion exercise (400 N) using CEU. Whole‐leg blood flow was measured using strain‐gauge plethysmography. Repeated measures were obtained with a 15‐min interval, and averaged responses were used for comparisons between age groups. There were no differences in post‐occlusion whole‐leg blood flow and muscle microvascular perfusion between young and older participants (p > .05). Similarly, total whole‐leg blood flow during exercise and post‐exercise peak muscle microvascular perfusion did not differ between groups (p > .05). The overall level of agreement between the test–retest measures of calf muscle perfusion was excellent for measurements taken at rest (intraclass correlation coefficient [ICC] 0.85), and in response to cuff occlusion (ICC 0.89) and exercise (ICC 0.95). Our findings suggest that healthy aging does not affect muscle perfusion responses to cuff‐occlusion and submaximal leg exercise. CEU muscle perfusion parameters measured in response to these provocation tests are highly reproducible in both young and older adults.
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Affiliation(s)
- Annelise L Meneses
- VasoActive Research Group, School of Health and Sport Sciences, University of the Sunshine Coast, Maroochydore, QLD, Australia
| | - Michael C Y Nam
- Department of Cardiology, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Tom G Bailey
- VasoActive Research Group, School of Health and Sport Sciences, University of the Sunshine Coast, Maroochydore, QLD, Australia.,Centre for Research on Exercise, Physical Activity and Health, School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Chris Anstey
- Department of Intensive Care, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia.,Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, QLD, Australia
| | - Michelle A Keske
- School of Exercise and Nutrition Sciences, Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Kim Greaves
- VasoActive Research Group, School of Health and Sport Sciences, University of the Sunshine Coast, Maroochydore, QLD, Australia.,Department of Cardiology, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Christopher D Askew
- VasoActive Research Group, School of Health and Sport Sciences, University of the Sunshine Coast, Maroochydore, QLD, Australia.,Sunshine Coast Health Institute, Sunshine Coast Hospital and Health Service, Birtinya, QLD, Australia
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Duscha BD, Kraus WE, Jones WS, Robbins JL, Piner LW, Huffman KM, Allen JD, Annex BH. Skeletal muscle capillary density is related to anaerobic threshold and claudication in peripheral artery disease. Vasc Med 2020; 25:411-418. [PMID: 32841100 DOI: 10.1177/1358863x20945794] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Peripheral artery disease (PAD) is characterized by impaired blood flow to the lower extremities, causing claudication and exercise intolerance. Exercise intolerance may result from reduced skeletal muscle capillary density and impaired muscle oxygen delivery. This cross-sectional study tested the hypothesis that capillary density is related to claudication times and anaerobic threshold (AT) in patients with PAD. A total of 37 patients with PAD and 29 control subjects performed cardiopulmonary exercise testing on a treadmill for AT and gastrocnemius muscle biopsies. Skeletal muscle capillary density was measured using immunofluorescence staining. PAD had decreased capillary density (278 ± 87 vs 331 ± 86 endothelial cells/mm2, p = 0.05), peak VO2 (15.7 ± 3.9 vs 24.3 ± 5.2 mL/kg/min, p ⩽ 0.001), and VO2 at AT (11.5 ± 2.6 vs 16.1 ± 2.8 mL/kg/min, p ⩽ 0.001) compared to control subjects. In patients with PAD, but not control subjects, capillary density was related to VO2 at AT (r = 0.343; p = 0.038), time to AT (r = 0.381; p = 0.020), and time after AT to test termination (r = 0.610; p ⩽ 0.001). Capillary density was also related to time to claudication (r = 0.332; p = 0.038) and time after claudication to test termination (r = 0.584; p ⩽ 0.001). In conclusion, relationships between capillary density, AT, and claudication symptoms indicate that, in PAD, exercise limitations are likely partially dependent on limited skeletal muscle capillary density and oxidative metabolism.
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Affiliation(s)
- Brian D Duscha
- Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, NC, USA
| | - William E Kraus
- Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - William S Jones
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer L Robbins
- Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, NC, USA
| | - Lucy W Piner
- Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, NC, USA
| | - Kim M Huffman
- Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, NC, USA
| | - Jason D Allen
- Department of Kinesiology, Curry School of Education and Human Development, University of Virginia, Charlottesville, VA, USA
- Division of Cardiovascular Medicine, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Brian H Annex
- Department of Medicine, Medical College of Georgia, Augusta, GA, USA
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Abnormal Microvascular Architecture, Fibrosis, and Pericyte Characteristics in the Calf Muscle of Peripheral Artery Disease Patients with Claudication and Critical Limb Ischemia. J Clin Med 2020; 9:jcm9082575. [PMID: 32784470 PMCID: PMC7464726 DOI: 10.3390/jcm9082575] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/17/2020] [Accepted: 07/22/2020] [Indexed: 01/05/2023] Open
Abstract
Work from our laboratory documents pathological events, including myofiber oxidative damage and degeneration, myofibrosis, micro-vessel (diameter = 50–150 μm) remodeling, and collagenous investment of terminal micro-vessels (diameter ≤ 15 µm) in the calf muscle of patients with Peripheral Artery Disease (PAD). In this study, we evaluate the hypothesis that the vascular pathology associated with the legs of PAD patients encompasses pathologic changes to the smallest micro-vessels in calf muscle. Biopsies were collected from the calf muscle of control subjects and patients with Fontaine Stage II and Stage IV PAD. Slide specimens were evaluated by Quantitative Multi-Spectral and Fluorescence Microscopy. Inter-myofiber collagen, stained with Masson Trichrome (MT), was increased in Stage II patients, and more substantially in Stage IV patients in association with collagenous thickening of terminal micro-vessel walls. Evaluation of the Basement Membrane (BM) of these vessels reveals increased thickness in Stage II patients, and increased thickness, diameter, and Collagen I deposition in Stage IV patients. Coverage of these micro-vessels with pericytes, key contributors to fibrosis and BM remodeling, was increased in Stage II patients, and was greatest in Stage IV patients. Vascular pathology of the legs of PAD patients extends beyond atherosclerotic main inflow arteries and affects the entire vascular tree—including the smallest micro-vessels.
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Fischer C, Krix M, Weber MA, Loizides A, Gruber H, Jung EM, Klauser A, Radzina M, Dietrich CF. Contrast-Enhanced Ultrasound for Musculoskeletal Applications: A World Federation for Ultrasound in Medicine and Biology Position Paper. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:1279-1295. [PMID: 32139152 DOI: 10.1016/j.ultrasmedbio.2020.01.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/23/2020] [Accepted: 01/24/2020] [Indexed: 06/10/2023]
Abstract
This World Federation for Ultrasound in Medicine and Biology position paper reviews the diagnostic potential of ultrasound contrast agents for clinical decision-making and provides general advice for optimal contrast-enhanced ultrasound performance in musculoskeletal issues. In this domain, contrast-enhanced ultrasound performance has increasingly been investigated with promising results, but still lacks everyday clinical application and standardized techniques; therefore, experts summarized current knowledge according to published evidence and best personal experience. The goal was to intensify and standardize the use and administration of ultrasound contrast agents to facilitate correct diagnoses and ultimately to improve the management and outcomes of patients.
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Affiliation(s)
- Christian Fischer
- Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Ultrasound Center, HTRG-Heidelberg Trauma Research Group, Heidelberg University Hospital, Heidelberg, Germany.
| | | | - Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany
| | - Alexander Loizides
- Department of Radiology, Ultrasound Center, Innsbruck Medical University, Innsbruck, Austria
| | - Hannes Gruber
- Department of Radiology, Ultrasound Center, Innsbruck Medical University, Innsbruck, Austria
| | | | - Andrea Klauser
- Department of Radiology, Ultrasound Center, Innsbruck Medical University, Innsbruck, Austria
| | - Maija Radzina
- Diagnostic Radiology Institute, Riga Stradins University, Riga, Latvia
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Davidson BP, Hodovan J, Mason OR, Moccetti F, Gupta A, Muller M, Belcik JT, Annex BH, Lindner JR. Limb Perfusion During Exercise Assessed by Contrast Ultrasound Varies According to Symptom Severity in Patients with Peripheral Artery Disease. J Am Soc Echocardiogr 2019; 32:1086-1094.e3. [PMID: 31235422 DOI: 10.1016/j.echo.2019.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 05/01/2019] [Accepted: 05/01/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND In patients with peripheral artery disease (PAD), the severity of symptoms correlates poorly with ankle-brachial index (ABI). The aim of this study was to test the hypothesis that limb perfusion assessed using contrast-enhanced ultrasound (CEU) during contractile exercise varies according to functional class in patients with PAD, particularly those with ABIs in the 0.4 to 0.6 range whose symptoms vary widely. METHODS Bilateral quantitative CEU perfusion imaging of the calf was performed in normal control subjects (n = 10) and patients with PAD who had at least one limb with a moderately reduced ABI (0.4-0.6; n = 17). Imaging was performed at rest and immediately after 30 sec of modest periodic (0.3-Hz) plantar flexion (10 W). RESULTS In patients with PAD, Rutherford symptom classification for each limb varied widely, including in limbs with ABIs of 0.4 to 0.6 (n = 6 with mild or no symptoms, n = 14 with moderate to severe symptoms). CEU perfusion imaging parameters at rest were similar between control subjects and patients with PAD irrespective of ABI. In normal control subjects, limb flow increased on average by > 20-fold after only 30 sec of moderate exercise. In patients with PAD, muscle exercise perfusion for all limbs was reduced compared with control subjects and decreased according to the severity of ABI reduction, primarily from reduced microvascular flux rate. Even limbs with ABIs > 0.9 in patients with PAD had lower exercise perfusion than in control subjects (P = .03). In subjects with PAD, exercise perfusion was lower in those with moderate to severe versus mild symptoms when analyzed for all limbs (median, 30 IU/sec [interquartile range (IQR), 21-52 IU/sec] vs 84 IU/sec [IQR, 36-177 IU/sec]; P = .01) and limbs with ABIs of 0.4 to 0.6 (median, 26 IU/sec [IQR, 14-41 IU/sec] vs 54 IU/sec [IQR, 31-105 IU/sec]; P = .05). CONCLUSIONS In patients with PAD, CEU exercise perfusion imaging detects differences in limb muscle perfusion that are likely to be responsible for differences in symptom severity and can detect the flow abnormalities from microvascular dysfunction even in limbs with normal ABIs.
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Affiliation(s)
- Brian P Davidson
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; VA Portland Health Care System, Portland, Oregon
| | - James Hodovan
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - O'Neil R Mason
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Federico Moccetti
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Avi Gupta
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Matthew Muller
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - J Todd Belcik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Brian H Annex
- Robert M. Berne Cardiovascular Research Center, University of Virginia, Charlottesville, Virginia
| | - Jonathan R Lindner
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Oregon National Primate Research Center, Oregon Health & Science University, Portland, Oregon.
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10
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Nguyen T, Davidson BP. Contrast Enhanced Ultrasound Perfusion Imaging in Skeletal Muscle. J Cardiovasc Imaging 2019; 27:163-177. [PMID: 31161755 PMCID: PMC6669180 DOI: 10.4250/jcvi.2019.27.e31] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 04/21/2019] [Indexed: 12/14/2022] Open
Abstract
The ability to accurately evaluate skeletal muscle microvascular blood flow has broad clinical applications for understanding the regulation of skeletal muscle perfusion in health and disease states. Contrast-enhanced ultrasound (CEU) perfusion imaging, a technique originally developed to evaluate myocardial perfusion, is one of many techniques that have been applied to evaluate skeletal muscle perfusion. Among the advantages of CEU perfusion imaging of skeletal muscle is that it is rapid, safe and performed with equipment already present in most vascular medicine laboratories. The aim of this review is to discuss the use of CEU perfusion imaging in skeletal muscle. This article provides details of the protocols for CEU imaging in skeletal muscle, including two predominant methods for bolus and continuous infusion destruction-replenishment techniques. The importance of stress perfusion imaging will be highlighted, including a discussion of the methods used to produce hyperemic skeletal muscle blood flow. A broad overview of the disease states that have been studied in humans using CEU perfusion imaging of skeletal muscle will be presented including: (1) peripheral arterial disease; (2) sickle cell disease; (3) diabetes; and (4) heart failure. Finally, future applications of CEU imaging in skeletal muscle including therapeutic CEU imaging will be discussed along with technological developments needed to advance the field.
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Affiliation(s)
- TheAnh Nguyen
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Brian P Davidson
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA.,Veterans Affairs Portland Health Care System, Portland, OR, USA.
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Meneses AL, Nam MCY, Bailey TG, Magee R, Golledge J, Hellsten Y, Keske MA, Greaves K, Askew CD. Leg blood flow and skeletal muscle microvascular perfusion responses to submaximal exercise in peripheral arterial disease. Am J Physiol Heart Circ Physiol 2018; 315:H1425-H1433. [DOI: 10.1152/ajpheart.00232.2018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Peripheral arterial disease (PAD) is characterized by stenosis and occlusion of the lower limb arteries. Although leg blood flow is limited in PAD, it remains unclear whether skeletal muscle microvascular perfusion is affected. We compared whole leg blood flow and calf muscle microvascular perfusion after cuff occlusion and submaximal leg exercise between patients with PAD ( n = 12, 69 ± 9 yr) and healthy age-matched control participants ( n = 12, 68 ± 7 yr). Microvascular blood flow (microvascular volume × flow velocity) of the medial gastrocnemius muscle was measured before and immediately after the following: 1) 5 min of thigh-cuff occlusion, and 2) a 5-min bout of intermittent isometric plantar-flexion exercise (400 N) using real-time contrast-enhanced ultrasound. Whole leg blood flow was measured after thigh-cuff occlusion and during submaximal plantar-flexion exercise using strain-gauge plethysmography. Postocclusion whole leg blood flow and calf muscle microvascular perfusion were lower in patients with PAD than control participants, and these parameters were strongly correlated ( r = 0.84, P < 0.01). During submaximal exercise, total whole leg blood flow and vascular conductance were not different between groups. There were also no group differences in postexercise calf muscle microvascular perfusion, although microvascular blood volume was higher in patients with PAD than control participants (12.41 ± 6.98 vs. 6.34 ± 4.98 arbitrary units, P = 0.03). This study demonstrates that the impaired muscle perfusion of patients with PAD during postocclusion hyperemia is strongly correlated with disease severity and is likely mainly determined by the limited conduit artery flow. In response to submaximal leg exercise, microvascular flow volume was elevated in patients with PAD, which may reflect a compensatory mechanism to maintain muscle perfusion and oxygen delivery during recovery from exercise. NEW & NOTEWORTHY This study suggests that peripheral arterial disease (PAD) has different effects on the microvascular perfusion responses to cuff occlusion and submaximal leg exercise. Patients with PAD have impaired microvascular perfusion after cuff occlusion, similar to that previously reported after maximal exercise. In response to submaximal exercise, however, the microvascular flow volume response was elevated in patients with PAD compared with control. This finding may reflect a compensatory mechanism to maintain perfusion and oxygen delivery during recovery from exercise.
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Affiliation(s)
- Annelise L. Meneses
- VasoActive Research Group, School of Health and Sport Sciences, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - Michael C. Y. Nam
- Department of Cardiology, Sunshine Coast Hospital and Health Service, Birtinya, Queensland, Australia
| | - Tom G. Bailey
- VasoActive Research Group, School of Health and Sport Sciences, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
- Centre for Research on Exercise, Physical Activity and Health, School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Rebecca Magee
- Department of Surgery, Sunshine Coast Hospital and Health Service, Birtinya, Queensland, Australia
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University and Department of Vascular and Endovascular Surgery, Townsville Hospital, Townsville, Queensland, Australia
| | - Ylva Hellsten
- Department of Nutrition, Exercise and Sport, University of Copenhagen, Copenhagen, Denmark
| | - Michelle A. Keske
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Burwood, Victoria, Australia
| | - Kim Greaves
- VasoActive Research Group, School of Health and Sport Sciences, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
- Department of Cardiology, Sunshine Coast Hospital and Health Service, Birtinya, Queensland, Australia
| | - Christopher D. Askew
- VasoActive Research Group, School of Health and Sport Sciences, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
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