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Original Article |

Limb Salvage Using High-Pressure Intermittent Compression Arterial Assist Device in Cases Unsuitable for Surgical Revascularization FREE

Paul S. van Bemmelen, MD; David B. Gitlitz, MD; Rishad M. Faruqi, MD; Joan Weiss-Olmanni, RVT; Valerie A. Brunetti, DPM, FACFAS; Fabio Giron, MD; John J. Ricotta, MD
[+] Author Affiliations

From the Departments of Vascular Surgery (Drs van Bemmelen, Gitlitz, and Faruqi, and Ms Weiss-Olmanni) and Podiatry (Dr Brunetti), VA Medical Center, Northport, NY; and the Division of Vascular Surgery, State University of New York at Stony Brook (Drs van Bemmelen, Gitlitz, Faruqi, Giron, and Ricotta). Dr van Bemmelen has a patent agreement with ACI Medical Inc, San Marcos, Calif.


Arch Surg. 2001;136(11):1280-1285. doi:10.1001/archsurg.136.11.1280.
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Published online

Hypothesis  Intermittent compression therapy for patients with inoperable chronic critical ischemia with rest pain or tissue loss may have beneficial clinical and hemodynamic effects.

Study Design  Case series of 14 consecutive ischemic legs that underwent application of a 3-month treatment protocol during a 2½-year study.

Setting  Veterans Administration Hospital.

Patients  Thirteen patients with 14 critically ischemic legs (rest pain, n = 14; tissue loss, n = 13) who were not candidates for surgical reconstruction were treated with rapid high-pressure intermittent compression. The patients had a mean age of 76.2 years, 8 were diabetic, and they represented 10% of referrals for chronic critical ischemia. They were not amenable to revascularization owing to lack of outflow arteries (n = 7), lack of autogenous vein (n = 5), or poor general medical condition (n = 3).

Intervention  All patients were instructed to use the arterial assist device for 4 hours a day at home for a 3-month period.

Main Outcome Measures  Limb salvage and calibrated pulse volume amplitude.

Results  After 3 months, 9 legs had a significant increase in pulse-volume amplitude (P<.05). These legs were salvaged, whereas the 4 amputated legs demonstrated no hemodynamic improvement. We noted a direct correlation between patient compliance and clinical outcome. Patients in whom limb salvage was achieved used their compression device for longer periods of time (mean time, 2.38 hours a day) compared with those who underwent amputation (mean time, 1.14 hours a day) (P<.05). These mean hours of use were derived from an hour counter built into the compression units.

Conclusions  Intermittent high-pressure compression may allow limb salvage in patients with limb-threatening ischemia who are not candidates for revascularization. Further studies are warranted to assess intermittent compression as an alternative to amputation in an increasingly older patient population.

Figures in this Article

SURGICAL CORRECTION of distal arterial obstruction in the leg has made enormous progress in the last 3 decades. Distal to the crural level, the dorsalis pedis bypass has been shown to be often feasible in diabetic patients1 with moderate2 to good3 long-term results. Patient selection remains crucial for achieving a good outcome. In a large series of these bypass procedures, the dorsalis pedis artery was visible on preoperative angiogram in 95% of cases.1 For other pedal arteries, including common plantar, lateral plantar, medial plantar, tarsal, metatarsal, and unnamed branch arteries, successful bypasses have been described as well.46 Since no large series involving these bypasses have been reported to our knowledge, they are often lumped together with dorsalis pedis bypasses under the group name "inframalleolar bypass." Unfavorable results, though they might occur, may not be frequently submitted for publication.

Less favorable results are experienced when foot arteries are not visualized on preoperative arteriography or when limited autogenous vein is available. The long-term patency of prosthetic conduits for distal (below-knee) bypasses is limited.7 Adjunct techniques, such as vein cuffs and distal arteriovenous fistulas, have been advocated. The limb salvage rate after previous bypass is reduced when compared with legs without prior bypass.8 Even with the most aggressive approach to distal revascularization, intimal hyperplasia and progression of the disease will ultimately cause many grafts to fail within 24 months.

Despite the continued improvements in our treatment armamentarium, a nationwide study9 found no evidence that major amputation (below-knee amputation [BKA] and above-knee amputation [AKA]) rates have decreased over the past decade, with an estimated number of 73 717 major amputations being performed in 1996. These considerations have stimulated interest in alternative treatment modalities, such as angiogenic gene therapy, intermittent pneumatic limb compression,1013 and vacuum suction devices.14,15 Despite increasing numbers of publications on these physical treatments, there have been limited reports on intermittent compression for the purpose of limb salvage. This may be an important void as vascular surgeons have a unique position to select patients for compression therapy, based on clinical, hemodynamic, and angiographic findings, and can institute treatment before irreversible damage to the foot has occurred. We report our findings on the use of this treatment modality for limb salvage in patients unable to undergo surgical revascularization.

The purposes of this study were to (1) evaluate whether a 3-month course of intermittent compression had lasting beneficial clinical or hemodynamic effects for nonsurgical patients with rest pain and/or progressive tissue loss, and (2) assess the applicability of this treatment in terms of patient acceptance and prevalence of suitable cases.

INCLUSION CRITERIA

Patients with either progressive tissue loss or persistent rest pain (documented at ≥2 visits) and who met the hemodynamic criteria of chronic critical ischemia were selected by a team of 2 vascular surgeons and a foot surgeon to undergo 3 months of intermittent compression on the basis of 1 or more of the following criteria (Table 1):

  • No visible run-off arteries visualized in the foot on selective digital subtraction angiography (n = 7)

  • Inability to find suitable autogenous vein by duplex ultrasound mapping of greater and lesser saphenous and cephalic veins (n = 5)

  • A history of multiple failed ipsilateral bypasses (n = 9) (mean number of prior bypasses, 2.0)

  • General condition too poor for surgery (n = 3) (severely disabling stroke in 2 cases, aged 90 years, and multiple medical contraindications in the third patient.)

For the purpose of eligibility for compression therapy, tissue loss was defined as one or more spontaneously occurring ischemic skin lesions on the forefoot.

HEMODYNAMIC CRITERIA

In all patients, noninvasive studies confirmed the presence of hemodynamically critical ipsilateral disease on the basis of an absolute toe pressure equal to or less than 35 mm Hg. The PVR (pulse volume recording) waveforms were blunted at the metatarsal level. Absolute ankle pressure was reduced in all patients with compressible arteries. Based on previous studies,16 the ankle-brachial index was not considered useful in patients with diabetes, who composed 62% of the study population.

EXCLUSION CRITERIA

The following conditions are not contraindications for compression treatment, but to achieve a homogeneous study group, these conditions were excluded: ulcers at the ankle; isolated ulcers of the heel (these usually have a decubitus and/or pressure component); pretibial ulcers (often having a traumatic origin and/or component); neuropathic-diabetic ulcers on the plantar aspect of the foot or toes, which occur at localized pressure sites and are related to skeletal deformities such as metatarsal prominence and hammer toes; and patients with indication for primary amputations, as described in the "Patient Acceptance" section.

After patients gave informed consent, they were instructed to apply a compression protocol, which consisted of 4 applications of 1 hour at a time, spread out over the day. This was performed prospectively on 14 consecutive legs, which presented with rest pain and/or progressive tissue loss at the forefoot. The severity of rest pain and progression of tissue loss required intervention, but these patients were deemed to be unsuitable for bypass and were hence facing the immediate prospect of major amputation.

All but 1 patient underwent arteriography, which confirmed extensive disease, distal to the knee, in each case. Photographic documentation of foot lesions was performed with a macrocamera (Yashica dental eye III; Kyocera Co, Tokyo, Japan) at monthly intervals.

In legs with tissue loss, the extent of the necrosis at the start of treatment ranged from 1 to 3 necrotic toes (mean, 1.4 toes), with 0 to 1 involved metatarsal heads (mean, 0.25). Fourteen legs of 13 patients treated with intermittent compression form the basis of this study; all patients were male. The mean age was 76.2 years. Only 1 patient had rest pain without tissue loss. Eight (62%) of 13 patients had diabetes.

Treatments were performed at the patient's home with patients sitting upright in a comfortable chair. Patient compliance was monitored monthly with an hour counter hidden inside the device. The compression device (ArtAssist; ACI Medical Inc, San Marcos, Calif) is a commercially available unit that applies pressure to the foot and leg of 100 to 120 mm Hg for a short period (3 seconds). This period alternates with a longer period (17 seconds) of zero-compression pressure, while the pressure rise and fall times are extremely short (<0.3 second). This time-pressure cycle was based on our earlier work.12 There is a 1-second delay between the start of foot compression and the start of calf compression.

Calibrated PVR machine (Healthwatch, Life Sciences Cambridge, Vista, Calif) recordings were performed at the ankle and metatarsal levels, prior to and on completion of the compression treatment. If the 3-month treatment was not completed, a repeated PVR was performed prior to amputation.

A source of problems in all diabetic limbs with critical ischemia, regardless of treatment, is the unpredictable onset of invasive infection. Gram-negative organisms, in particular Pseudomonas, have been linked to a high incidence of amputation.17 Antibiotic treatments were given based on wound culture results whenever clinically indicated. Deep vein thrombosis was ruled out in swollen legs by duplex ultrasound prior to the start of compression treatment to avoid the possible risk of pulmonary embolization. No patients had symptoms or signs of pulmonary embolization during the study period.

STATISTICAL METHODS AND ANALYSIS

Differences in patient compliance and body weight were assessed using unpaired t tests. Categoric variables between groups (limb salvage vs amputees) were compared using χ2 analysis.

CLINICAL RESULTS

No patients were lost to follow-up during the 30 months of the study. Owing to the limited life expectancy and serious limb loss, the mean follow-up was 8.7 ± 6.9 months (range, 0.5-23 months).

Limb Salvage

As illustrated in Figure 1, 4 amputations were performed on compression patients during the study period (3 BKA, 1 AKA). Despite rehabilitation efforts, no patients undergoing amputation were ambulatory with a prosthesis at the time of this study.

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Figure 1.

Kaplan-Meier curve for cumulative limb salvage in 14 legs treated with intermittent compression.

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Patient Survival

Two patients died during the study period; neither had undergone amputation prior to death. The first patient died of a myocardial infarction 2 weeks after the initiation of treatment. Compression treatment was stopped while patient was intubated and bedridden; he subsequently died from cardiac arrhythmia. The second patient died (with a healed foot and no rest pain) 1½ years after the start of compression treatment; he did not require additional treatment after completion of the 3-month protocol.

Patient Acceptance

In all but 1 patient, the rest pain improved at least temporarily during the compression sessions. This allowed us to continue to treat these feet conservatively. If the foot was tender, the compression was temporarily limited to the calf.

The applicability of compression treatment was studied by comparison to the total number of patients treated during the study period for critical ischemic legs. From April 1998 to October 2000, 137 legs underwent operations for chronic critical ischemia at the VA Medical Center in Northport, NY. Of these, 107 underwent lower extremity revascularization. During this time, 30 legs underwent major amputation (BKA or AKA). Fifteen amputations were performed after a mean of 2.7 bypass procedures (range, 1-6 procedures). The remaining 15 had primary amputations (ie, without any reconstructive attempts prior to amputation). The indications for primary amputations included (1) extensive gangrene and (2) bedridden patients living in a nursing home with severe contractures of the hip and knee joints, with either poorly controlled rest pain or tissue loss. These patients did not undergo compression therapy.

HEMODYNAMIC RESULTS

The PVR waveform amplitudes prior to treatment were decreased; the mean amplitude at metatarsal level was 2.9 mm. Figure 2 shows the PVR at ankle and metatarsal levels, before and after completion of the compression protocol in one of the patients. Improvement did not always occur in those legs that were extremely ischemic at the start of treatment, as seen by a completely flat waveform at the ankle. Figure 3A and Figure 3B show the ankle and metatarsal PVR amplitudes in 14 legs before and after completion of the 3-month protocol. The increases in amplitudes at ankle and metatarsal levels were significant (P<.05) (paired t test) on the 9 salvaged limbs; the early death was excluded from this subanalysis. Figure 4 shows mean PVR amplitudes for amputated vs salvaged legs. While lack of hemodynamic improvement was noted with ultimate amputation, this did not reach statistical significance (P<.20) (χ2 analysis). Analysis of the amputated cases revealed several factors and trends that may have contributed to limb loss.

Place holder to copy figure label and caption
Figure 2.

Pulse volume recording (PVR; Healthwatch, Life Sciences Cambridge, Vista, Calif) of one of the legs at the ankle (A) and metatarsal (B) levels, before and after 3 months of treatment. Increase in amplitudes is evident.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Pulse volume recording (PVR; Healthwatch, Life Sciences Cambridge, Vista, Calif) amplitudes at ankle level (A) and metatarsal level (B) in 14 legs, before and after treatment.

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Figure 4.

Mean ± SE ankle (A) and metatarsal (B) pulse volume recording (PVR; Healthwatch, Life Sciences Cambridge, Vista, Calif) amplitude before and after treatment in amputated vs salvaged legs.

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Lack of Patient Compliance

A low mean number of hours used per day, based on the counter readings, resulted in a greater risk of failure. When averaged over the active treatment period, patients undergoing amputation used the compression on average only for 1.14 hours a day (instead of the prescribed 4 hours a day), while patients not undergoing amputation used their device for 2.38 hours a day (P<.05) (Figure 5). It is possible that the patients who were less compliant were more infirm.

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Figure 5.

Mean (±SE) number of actual hours of compression applied per day in amputated vs salvaged legs, based on hour-counter readings.

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Extremely Low Body Weight

Prior to amputation, the body weight of 2 of the patients undergoing amputation (who were of average height) was 54.3 kg and 58.9 kg vs a mean weight of 79.3 kg in patients not undergoing amputation (P<.05). This finding probably reflects a very poor (emaciated) patient condition.

Flat-Line PVR at the Ankle Level

Prior to treatment, 3 of 4 amputated limbs had a flat-line PVR at the ankle in contrast to 1 of 9 patients for whom limb salvage was achieved (P<.05). (The one early death was excluded from this subanalysis.) Pseudomonas infection was seen in 1 of 4 amputated limbs but also seen in 1 of 9 limbs that did not require amputation (findings from χ2 analysis were not significant). One of 4 amputated limbs had a recently occluded distal bypass, while none of the successfully treated limbs had a recent bypass failure. This did not reach statistical significance.

Although substantial world literature exists regarding the immediate effects of intermittent compression on arterial blood flow,1013,1821 there are few2224 reports demonstrating a clinical benefit with long-term use. Until recently, these were single-author articles originating from "the angiologic wilderness."25 Dillon22 used a thigh-high boot with end-diastolic compression. In that report, 22 of 25 patients with severely diseased legs were reported to have improved from the treatment. Steinberg23 used cardiosynchronous limb compression triggered by the electrocardiogram. Only 2 of his patients had rest pain, which improved after 4 to 7 weeks of treatment. Twelve patients had nonhealing pedal ulcers in combination with abnormal findings on noninvasive studies (ankle-arm index and photoplethysmograph waveform amplitude). Inclusion of patients with pedal ulceration is problematic because of the multifactorial origin, namely neuropathy, skeletal deformity with pressure, and angiopathy.

In 1993, Mehlsen et al15 demonstrated a beneficial effect of 2 months of intermittent suction compression treatment in a double-blinded, randomized study of 22 patients with stable intermittent claudication. Delis et al24 published a study on the effects of intermittent compression of the foot on patients with intermittent claudication. In the latter 2 studies, an increase was found in pain-free and maximal walking distances, as well as a significant increase in the ankle-brachial blood pressure index.

The compression used in each of these studies2224 was different from the compression used in the current study. Compression of the calf results in a much larger increase in popliteal blood flow than compression of the foot alone.12 An upright patient position during the compression maximizes the effect on arteriovenous pressure differences26 and is important to obtain arterial flow augmentation. Devices that include the thigh require an extended knee position with the patient in a horizontal position, which minimizes the increase in arteriovenous pressure differences. One problem with many early devices was the long amount of time it took for the slow air pumps to inflate the large garment bladders. Typically, up to a minute was required to inflate the bladder and to reach the desired pressure level, during which time there is an actual reduction in skin perfusion as soon as the bladder pressure reaches 10 to 20 mm Hg.27 As soon as the cuff pressure reached the preset point (typically 60-70 mm Hg), the air pump would stop and the air would slowly vent through relatively small tubing. The skin perfusion would remain decreased until the compression pressure fell below 10 mm Hg. A short time to reach a high pressure (>100-120 mm Hg) can be obtained with the use of a small bladder compressing only the foot, but this does not result in the larger flow augmentation that can be obtained by compression of the calf. Pressures greater than 120 mm Hg are generally uncomfortable on the calf. The use of relatively small bladders on the calf and foot, in conjunction with a storage tank for compressed air, results in optimum conditions for arterial flow increase with the device used in the current study.

In addition to the simple mechanical effect, it was previously12 calculated that a reduction of vascular resistance was an additional short-term effect of compression. This is contrary to the widely held belief that vascular resistance distal to an area of obstruction cannot be further reduced28,29 and that distal vasodilation is already maximal in areas of ischemia. The immediate effect of intravascular prostacyclin analogues on distal resistance supports the idea that distal resistance is not minimal in ischemic legs.3032

Conditions that temporarily increase flow velocity and shear stress such as exercise,33 mechanical deformation of the vessel wall,34 arteriovenous fistula,35 and postcompression flow enhancement result in increased nitric oxide activity and vasodilation. Recent in vitro studies36 of endothelial cells have confirmed that an up-regulation of endothelial nitric oxide synthase occurs after 6 hours of compression and increased shear.

Application of compression treatment to the more advanced stages of rest pain and tissue loss has important implications for daily practice but presents unique problems. Rest pain is not readily quantifiable; although a subjective pain scale can be applied, the pain that a patient experiences is the end result of ischemic and inflammatory pain surrounding the foot lesions and the loss of pain perception owing to diabetic neuropathy. Likewise, healing of foot lesions is a multifactorial process, which, in addition to the severity of ischemia, is affected by the absence of recurrent trauma, the presence and virulence of bacterial infection, diabetes, nutritional status, etc. It is apparent that our patients had profound ischemia; the mean pretreatment PVR at the metatarsal level (2.9 mm) in our compression treatment group is comparable to the mean preoperative PVR amplitude (4 mm) in a large series of dorsalis pedis bypasses.1

The spontaneous appearance of multiple skin lesions on non–weight bearing areas of the forefoot is probably the most specific sign of hypoperfusion of the forefoot; therefore, the current study was limited to necrosis of the forefoot. Major amputation and death are the main clinical endpoints in this study.

The transformation of the documented immediate effect on blood flow into a sustained benefit after several months of compression therapy is likely to involve the development of collaterals. The stimulus for collateral vessels to increase in size has been shown37 to be the shear stress at the endothelial surface, which results in nitric oxide release and relaxation of the underlying muscle. With compression treatment, this would occur periodically, both owing to the mechanical effects of intermittent compression and because of the reduction in peripheral resistance.

If compression therapy were to effectively reduce the number of major amputations, this would potentially affect short-term survival by eliminating the surgical mortality of major amputation, which was as high as 82% (9 of 11) in the subgroup aged 80 years in one series.38 Another relevant point is that rehabilitation outcome after amputation for nonreconstructable arterial disease is much worse than generally assumed. In one report,39 only 26% of patients with a mean age of 72 years were able to ambulate with a prosthesis outdoors, 2 years after amputation.

A 3-month period of intermittent compression treatment was associated with limb salvage in 9 legs (70%) at maximum follow-up of 2.5 years in 14 treated legs. The study group consisted of 10% of the patients referred for chronic critical ischemia. These patients were deemed to face amputation if left untreated but were not considered candidates for surgical revascularization. Treatment was well tolerated by nearly all patients and did not result in serious adverse effects, allowing for prolonged conservative treatment of these legs. The hemodynamic effect consisted of significant increases in ankle and foot PVR amplitudes in most limbs.

We have demonstrated that rapid intermittent high-pressure compression treatment may be a useful addition to our treatment options in patients with limb-threatening ischemia who are unable to undergo reconstruction. While the numbers in our study are small owing to selection of a homogeneous patient group, the potential to offer considerable improvements in quality of life warrants further controlled multicenter studies to evaluate the role of compression therapy for limb salvage.

Corresponding author and reprints: Paul S. van Bemmelen, MD, Department of Surgery, Health Sciences Center, Stony Brook, NY 11794-8191.

Pomposelli  FBJepsen  SJGibbons  GW  et al.  A flexible approach to infrapopliteal vein grafts in patients with diabetes mellitus. Arch Surg. 1991;126724- 729
Link to Article
Harrington  EBHarrington  MESchanzer  HJacobson  JHHaimov  M The dorsalis pedis bypass: moderate success in difficult situations. J Vasc Surg. 1992;15409- 416
Link to Article
Gloviczki  PBower  TCToomey  BJ  et al.  Microscope-aided pedal bypass is an effective and low-risk operation to salvage the ischemic foot. Am J Surg. 1994;16876- 84
Link to Article
Ascer  EVeith  FJGupta  SK Bypasses to plantar arteries and other tibial branches: an extended approach to limb salvage. J Vasc Surg. 1988;8434- 441
Link to Article
Andros  GHarris  RWSalles-Cunha  SXDulawa  LBOblath  RW Lateral planter artery bypass grafting: defining the limits of foot revascularization. J Vasc Surg. 1989;10511- 521
Link to Article
Andros  G Bypass grafts to the ankle and foot: a personal perspective. Surg Clin North Am. 1995;75715- 729
Quinones-Baldrich  WJPrego  AAUcelay-Gomez  R  et al.  Long-term results of infrainguinal revascularization with polytetrafluoroethylene: a 10-year experience. J Vasc Surg. 1992;16209- 217
Link to Article
Timaran  CHStevens  SLGrandas  OHPiercy  KTFreeman  MBGoldman  MH Influence of hormone replacement therapy on graft patency after femoropopliteal bypass grafting. J Vasc Surg. 2000;32506- 518
Link to Article
Feinglass  JBrown  JLLoSasso  A  et al.  Rates of lower extremity amputation and arterial reconstruction in the United States, 1979-1996. Am J Public Health. 1999;891222- 1227
Link to Article
Morgan  RHCarolan  GPsaila  JVGardner  AMNFox  RHWoodcock  JP Arterial flow enhancement by impulse compression. Vasc Surg. 1991;258- 16
Link to Article
Abu-Own  ACheatle  TScurr  JHColeridge-Smith  PD Effects of intermitent pneumatic compression of the foot on the microcirculatory function in arterial disease. Eur J Vasc Surg. 1993;7488- 492
Link to Article
van Bemmelen  PSMattos  MAFaught  WE  et al.  Augmentation of blood flow in limbs with occlusive arterial disease by intermittent calf compression. J Vasc Surg. 1994;191052- 1058
Link to Article
Labropoulos  NWatson  WCMansour  MAKang  SLittooy  FNBaker  WH Acute effects of intermittent pneumatic compression on popliteal artery blood flow. Arch Surg. 1998;1331072- 1075
Link to Article
Agerskov  KTofft  HPFlemming  BJensen  BEngell  HC External negative thigh pressure: effect upon blood flow and pressure in the foot in patients with occlusive arterial disease. Dan Med Bull. 1990;37451- 454
Mehlsen  JHimmelstrup  HHimmelstrup  BWinther  KTrap-Jensen  J Beneficial effects of intermittent suction and pressure treatment in intermittent claudication. Angiology. 1993;4416- 20
Link to Article
Larsson  JApelqvist  JCastenfors  JAgardh  CDStenstrom  A Distal blood pressure as a predictor for the level of amputation in diabetic patients with a foot ulcer. Foot Ankle. 1993;14247- 253
Link to Article
Schmidt  KDebus  ESJessberger  SZiegler  UThiede  A Bacterial population of chronic crural ulcers: is there a difference between the diabetic, the venous, and the arterial ulcer? Vasa. 2000;2962- 70
Link to Article
Loane  RA Effect of rhythmically inflating a pneumatic cuff at the ankle on the blood flow in the foot. J Appl Physiol. 1959;14411- 413
Henry  JPWinsor  T Compensation of arterial insufficiency by augmenting the circulation with intermittent compression of the limbs. Am Heart J. 1965;7079- 88
Link to Article
Gaskell  PParrot  JCW The effect of a mechanical venous pump on the circulation of the feet in the presence of arterial obstruction. Surg Gynecol Obstet. 1978;146583- 592
Delis  KTLabropoulos  NNicolaides  ANGlenville  BStansby  G Effect of intermittent pneumatic foot compression on popliteal artery hemodynamics. Eur J Vasc Endovasc Surg. 2000;19270- 277
Link to Article
Dillon  RS Effect of therapy with the pneumatic end-diastolic leg compression boot on peripheral vascular tests and on the clinical course of peripheral vascular disease. Angiology. 1980;31614- 638
Link to Article
Steinberg  J Cardiosynchronous limb compression: effects on non-invasive vascular tests and clinical course of the ischemic limb. Angiology. 1992;43453- 461
Link to Article
Delis  KTNicolaides  ANWolfe  JHNStansby  G Improving walking ability and ankle brachial pressure indices in symptomatic peripheral vascular disease with intermittent pneumatic foot compression: a prospective controlled study with one-year follow-up. J Vasc Surg. 2000;31650- 661
Link to Article
Porter  JM Commentary. Yearbook of Vascular Surgery. St Louis, Mo Mosby–Year Book Inc1996;43
van Bemmelen  PSWeiss-Olmanni  JRicotta  JJ Rapid intermittent compression increases the skin circulation in chronically ischemic legs, with infra-popliteal arterial obstruction. Vasa. 2000;2947- 52
Link to Article
Halperin  MHFriedland  CKWilkins  RW The effect of local compression upon blood flow in the extremities of man. Am Heart J. 1948;35221- 237
Link to Article
Ludbrook  J Collateral artery resistance in the human lower limb. J Surg Res. 1966;6423- 434
Link to Article
Strandness  DESumner  DS Hemodynamics for Surgeons.  New York, NY Grune & Stratton1975;
Carlson  LErikson  I Femoral artery infusion of prostaglandin E1 in severe peripheral vascular disease. Lancet. 1973;1155- 156
Link to Article
Carlson  LAEricsson  MEricson  U Prostaglandin E1 (PGE1) in peripheral arteriographies. Acta Radiol Diag (Stockh). 1973;14583- 587
Pessi  TKaukinen  SYlitalo  PReinikainen  PVapaatalo  H Iloprost, a prostacyclin analog in the treatment of advanced peripheral arterial disease. Vasc Surg. 1986;20301- 306
Link to Article
Koller  AHuang  ASun  DKaley  G Exercise training augments flow-dependent dilatation in rat skeletal muscle arterioles. Circ Res. 1995;76544- 550
Link to Article
Lamontagne  DPohl  UBusse  R Mechanical deformation of the vessel wall and shear stress determine the basal release of endothelium-derived relaxing factor in the intact rabbit coronary vascular bed. Circ Res. 1992;70123- 130
Link to Article
Miller  VMAarhus  LLVanHoutte  PM Modulation of endothelium-dependent responses by chronic alterations of blood flow. Am J Physiol. 1986;251H520- H527
Dai  GTsukurov  OOrkin  RWAbbott  WMKamm  RDGertler  JP An in vitro cell culture system to study the influence of external pneumatic compression on endothelial function. J Vasc Surg. 2000;32977- 987
Link to Article
Unthank  JLNixon  JGDalsing  MC Inhibition of NO synthase prevents acute collateral artery dilatation in the rat hindlimb. J Surg Res. 1996;61463- 468
Link to Article
Warren  RKihn  RB A survey of lower extremity amputations for ischemia. Surgery. 1968;63107- 120
McWhinnie  DLGordon  ACCollin  JGray  DWRMorrison  JD Rehabilitation outcome 5 years after 100 lower limb amputations. Br J Surg. 1994;811596- 1599
Link to Article

Figures

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Figure 1.

Kaplan-Meier curve for cumulative limb salvage in 14 legs treated with intermittent compression.

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Figure 2.

Pulse volume recording (PVR; Healthwatch, Life Sciences Cambridge, Vista, Calif) of one of the legs at the ankle (A) and metatarsal (B) levels, before and after 3 months of treatment. Increase in amplitudes is evident.

Graphic Jump Location
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Figure 3.

Pulse volume recording (PVR; Healthwatch, Life Sciences Cambridge, Vista, Calif) amplitudes at ankle level (A) and metatarsal level (B) in 14 legs, before and after treatment.

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Figure 4.

Mean ± SE ankle (A) and metatarsal (B) pulse volume recording (PVR; Healthwatch, Life Sciences Cambridge, Vista, Calif) amplitude before and after treatment in amputated vs salvaged legs.

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Figure 5.

Mean (±SE) number of actual hours of compression applied per day in amputated vs salvaged legs, based on hour-counter readings.

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References

Pomposelli  FBJepsen  SJGibbons  GW  et al.  A flexible approach to infrapopliteal vein grafts in patients with diabetes mellitus. Arch Surg. 1991;126724- 729
Link to Article
Harrington  EBHarrington  MESchanzer  HJacobson  JHHaimov  M The dorsalis pedis bypass: moderate success in difficult situations. J Vasc Surg. 1992;15409- 416
Link to Article
Gloviczki  PBower  TCToomey  BJ  et al.  Microscope-aided pedal bypass is an effective and low-risk operation to salvage the ischemic foot. Am J Surg. 1994;16876- 84
Link to Article
Ascer  EVeith  FJGupta  SK Bypasses to plantar arteries and other tibial branches: an extended approach to limb salvage. J Vasc Surg. 1988;8434- 441
Link to Article
Andros  GHarris  RWSalles-Cunha  SXDulawa  LBOblath  RW Lateral planter artery bypass grafting: defining the limits of foot revascularization. J Vasc Surg. 1989;10511- 521
Link to Article
Andros  G Bypass grafts to the ankle and foot: a personal perspective. Surg Clin North Am. 1995;75715- 729
Quinones-Baldrich  WJPrego  AAUcelay-Gomez  R  et al.  Long-term results of infrainguinal revascularization with polytetrafluoroethylene: a 10-year experience. J Vasc Surg. 1992;16209- 217
Link to Article
Timaran  CHStevens  SLGrandas  OHPiercy  KTFreeman  MBGoldman  MH Influence of hormone replacement therapy on graft patency after femoropopliteal bypass grafting. J Vasc Surg. 2000;32506- 518
Link to Article
Feinglass  JBrown  JLLoSasso  A  et al.  Rates of lower extremity amputation and arterial reconstruction in the United States, 1979-1996. Am J Public Health. 1999;891222- 1227
Link to Article
Morgan  RHCarolan  GPsaila  JVGardner  AMNFox  RHWoodcock  JP Arterial flow enhancement by impulse compression. Vasc Surg. 1991;258- 16
Link to Article
Abu-Own  ACheatle  TScurr  JHColeridge-Smith  PD Effects of intermitent pneumatic compression of the foot on the microcirculatory function in arterial disease. Eur J Vasc Surg. 1993;7488- 492
Link to Article
van Bemmelen  PSMattos  MAFaught  WE  et al.  Augmentation of blood flow in limbs with occlusive arterial disease by intermittent calf compression. J Vasc Surg. 1994;191052- 1058
Link to Article
Labropoulos  NWatson  WCMansour  MAKang  SLittooy  FNBaker  WH Acute effects of intermittent pneumatic compression on popliteal artery blood flow. Arch Surg. 1998;1331072- 1075
Link to Article
Agerskov  KTofft  HPFlemming  BJensen  BEngell  HC External negative thigh pressure: effect upon blood flow and pressure in the foot in patients with occlusive arterial disease. Dan Med Bull. 1990;37451- 454
Mehlsen  JHimmelstrup  HHimmelstrup  BWinther  KTrap-Jensen  J Beneficial effects of intermittent suction and pressure treatment in intermittent claudication. Angiology. 1993;4416- 20
Link to Article
Larsson  JApelqvist  JCastenfors  JAgardh  CDStenstrom  A Distal blood pressure as a predictor for the level of amputation in diabetic patients with a foot ulcer. Foot Ankle. 1993;14247- 253
Link to Article
Schmidt  KDebus  ESJessberger  SZiegler  UThiede  A Bacterial population of chronic crural ulcers: is there a difference between the diabetic, the venous, and the arterial ulcer? Vasa. 2000;2962- 70
Link to Article
Loane  RA Effect of rhythmically inflating a pneumatic cuff at the ankle on the blood flow in the foot. J Appl Physiol. 1959;14411- 413
Henry  JPWinsor  T Compensation of arterial insufficiency by augmenting the circulation with intermittent compression of the limbs. Am Heart J. 1965;7079- 88
Link to Article
Gaskell  PParrot  JCW The effect of a mechanical venous pump on the circulation of the feet in the presence of arterial obstruction. Surg Gynecol Obstet. 1978;146583- 592
Delis  KTLabropoulos  NNicolaides  ANGlenville  BStansby  G Effect of intermittent pneumatic foot compression on popliteal artery hemodynamics. Eur J Vasc Endovasc Surg. 2000;19270- 277
Link to Article
Dillon  RS Effect of therapy with the pneumatic end-diastolic leg compression boot on peripheral vascular tests and on the clinical course of peripheral vascular disease. Angiology. 1980;31614- 638
Link to Article
Steinberg  J Cardiosynchronous limb compression: effects on non-invasive vascular tests and clinical course of the ischemic limb. Angiology. 1992;43453- 461
Link to Article
Delis  KTNicolaides  ANWolfe  JHNStansby  G Improving walking ability and ankle brachial pressure indices in symptomatic peripheral vascular disease with intermittent pneumatic foot compression: a prospective controlled study with one-year follow-up. J Vasc Surg. 2000;31650- 661
Link to Article
Porter  JM Commentary. Yearbook of Vascular Surgery. St Louis, Mo Mosby–Year Book Inc1996;43
van Bemmelen  PSWeiss-Olmanni  JRicotta  JJ Rapid intermittent compression increases the skin circulation in chronically ischemic legs, with infra-popliteal arterial obstruction. Vasa. 2000;2947- 52
Link to Article
Halperin  MHFriedland  CKWilkins  RW The effect of local compression upon blood flow in the extremities of man. Am Heart J. 1948;35221- 237
Link to Article
Ludbrook  J Collateral artery resistance in the human lower limb. J Surg Res. 1966;6423- 434
Link to Article
Strandness  DESumner  DS Hemodynamics for Surgeons.  New York, NY Grune & Stratton1975;
Carlson  LErikson  I Femoral artery infusion of prostaglandin E1 in severe peripheral vascular disease. Lancet. 1973;1155- 156
Link to Article
Carlson  LAEricsson  MEricson  U Prostaglandin E1 (PGE1) in peripheral arteriographies. Acta Radiol Diag (Stockh). 1973;14583- 587
Pessi  TKaukinen  SYlitalo  PReinikainen  PVapaatalo  H Iloprost, a prostacyclin analog in the treatment of advanced peripheral arterial disease. Vasc Surg. 1986;20301- 306
Link to Article
Koller  AHuang  ASun  DKaley  G Exercise training augments flow-dependent dilatation in rat skeletal muscle arterioles. Circ Res. 1995;76544- 550
Link to Article
Lamontagne  DPohl  UBusse  R Mechanical deformation of the vessel wall and shear stress determine the basal release of endothelium-derived relaxing factor in the intact rabbit coronary vascular bed. Circ Res. 1992;70123- 130
Link to Article
Miller  VMAarhus  LLVanHoutte  PM Modulation of endothelium-dependent responses by chronic alterations of blood flow. Am J Physiol. 1986;251H520- H527
Dai  GTsukurov  OOrkin  RWAbbott  WMKamm  RDGertler  JP An in vitro cell culture system to study the influence of external pneumatic compression on endothelial function. J Vasc Surg. 2000;32977- 987
Link to Article
Unthank  JLNixon  JGDalsing  MC Inhibition of NO synthase prevents acute collateral artery dilatation in the rat hindlimb. J Surg Res. 1996;61463- 468
Link to Article
Warren  RKihn  RB A survey of lower extremity amputations for ischemia. Surgery. 1968;63107- 120
McWhinnie  DLGordon  ACCollin  JGray  DWRMorrison  JD Rehabilitation outcome 5 years after 100 lower limb amputations. Br J Surg. 1994;811596- 1599
Link to Article

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