Chronic
Impairment
of Leg Muscle
Blood
Catheterization Downloaded from www.ajronline.org by 183.167.250.140 on 10/07/15 from IP address 183.167.250.140. Copyright ARRS. For personal use only; all rights reserved
JAN
KOVRANEK’
venous in that
in the extremity
used
for catheterization
AND
MILAN
-
by the
route only. Maximal blood flow was significantly lower extremity where the femoral artery had been catheter-
of whether
dinger
the
percutaneous
arterial
catheterization
technique,
arteriotomy,
involved
the Sel-
or mere cannu-
January Roentgen
1979 Ray Society
sample
blood.
Muscle 99 patients
blood flow in the lower extremities (52 male and 47 female) in whom
and
Methods was measured in cardiac catheteri-
was 2.7 years. In all cases diagnostic
cardiac
catheterization
purposes,
in 80
children
had for
been
indicated
ital cardiac
defect
right-to-left
shunt.
cardiac
disease
In the
without
congenital
mitral
quent
disease
lung
with a left-to-right remaining
a shunt,
group
included
a
congenital
artery stenosis
and
The
fre-
as an indication
catheterization and angiography was idiopathic monary fibrosis and lung hypoplasia, followed situations in which pulmonary resection had
bronchiectasis. The investigated
pulmonary a congen-
with
predominated.
served
of a
in seven children,
16 patients
pulmonary
insufficiency
which
shunt;
for
suspicion
clinical
congenital cardiac defect and in 19 for severe disease. In 57 of these children we had demonstrated
those patients
most
for cardiac
interstitial pulin incidence by been done for
in whom
only
vessels of one lower extremity were used for catheterization. In all patients we carried out complete catheterization of the right heart after introduction of the catheter percutaneously through the femoral vein by the Seldinger technique, and in children up to age 2 years, after surgical preparation of the saphenous vein. In 15 children only the venous route was used for cardiac catheterization without touching the femoral artery. However, in the majority of cases the femoral artery was involved. In 31 children , the femoral artery was only cannulated for the purpose of sampling arterial blood and measuring pressure. Puncture of the femoral artery in children younger than 1 year was carried
out after previous
surgical
dissection
of the superficial
artery, but percutaneously in the older children. the catheter was introduced in the femoral
neously
using
the
Seldinger
catheters (AB Kifa, Solna, using a closed-tip catheter
Received May 2, 1977; accepted after revision September 13, 1978. , Cardiopulmonary Laboratory, Center of Pediatric Cardiology and Cardiac Address reprint requests to M. Sam#{225}nek. American
and
of muscle blood flow was 10.8 years (range, 3-21 years). The shortest time interval from cardiac catheterization was 5 months; the longest, 1 1 years. The mean time interval between cardiac catheterization and investigation of muscle blood flow
,
132:71-75,
pressure
zation had been performed between 2 months and 16 years of age (mean, 8.1 years). The mean age at the time of investigation
The reported incidence of disturbances in blood flow in the peripheral arterial bed after catheterization and angiography of the arterial system range from 0% to 100’Yo [1-9]. The principal cause of this scatter is differences in the manner of determining such complications and their evaluation. Clinical investigation reveals only very crude disturbances of arterial patency. More sensitive methods include oscillometry [1 5, 9-12] or the Doppler technique [12]. A more objective evaluation of disturbances in function which result from puncture catheterization or angiography is measurement of blood flow in the involved extremity [10-12]. Plethysmographic methods after catheterization have shown a significant decrease in blood flow to the calf, increased resistance, and decreased venous blood volume. Repair to these changes took about 1 week [10]. Unfortunately, measurement limited to resting blood flow does not reveal slight disturbances in blood supply [13-15] or inadequate blood supply during periods other than resting conditions. We studied late disturbances in peripheral blood flow resulting from catheterization. The method allowed us to measure this parameter in any selected muscle, not only at rest but also with increased muscle demands on the blood supply. The investigated group included only those patients with congenital heart defects or with severe respiratory disease, in whom catheterization and angiocardiography had been carried out in childhood and in whom clinical investigation and, in suspect cases, oscillometry had not revealed any disturbance of blood
© 1979
measure
Subjects
lation of the femoral artery. The values in the involved extremity did not differ significantly from the values in a healthy population.
AJR
AMANEK1
flow to the lower extremity following the investigation. Because of discordant views on the incidence of complications related to arterial catheterization technique, we attempted to evaluate differences between the two basic technical approaches percutaneous Seldinger technique and surgical insertion of the catheter. Two further subgroups were formed by patients in whom left heart catheterization was carried out transseptally and the femoral artery was not involved or only cannulated to
ized or cannulated for pressure measurement and blood sampling. The disturbance in maximal flow was shown regardless
Cardiac
in Childhood
In 99 patients with congenital heart defects or chronic respiratory disease without clinical symptoms of disturbances in peripheral circulation, resting and maximal blood flow in the anterior tibial muscle of both extremities were investigated 2.7 years (average) after cardiac catheterization. The method used involved ‘“Xe clearance. Resting blood flow was normal and no difference could be demonstrated between the extremity originally used for catheterization and the contralateral control extremity. No disturbance in maximal blood flow could
be proved
Flow Following
71
Surgery,
University
Hospital
technique.
Sweden) were was indicated,
Motol,
Red
femoral
In 36 patients artery percuta-
and
gray
Kifa
used. If angiography we began with arteri-
150 06 Prague,
Czechoslovakia.
o361-8o3x/79/1321-0071
$0.00
72
SKOVRANEK
AND TABLE
Catheterization Reference
Downloaded from www.ajronline.org by 183.167.250.140 on 10/07/15 from IP address 183.167.250.140. Copyright ARRS. For personal use only; all rights reserved
(n Blood
Route
Low er Limb Diffe rence Affected
Mean
Resting
Maximal
Note-Data
on 15 patients
report
SD
Intact
Mean
SD
3.2
1.7
3.3
78.6
27.0
92.3
ad in milliliters
per 100 g p er minute.
N5
All patients
received
several
5-20 mg of Heparin
Works, Prague, from the femoral
minutes
of manual
compression.
percutaneous puncture, this manual than with needle puncture alone. compression was not carried out. In returned to the ward after cessation applied a compressive bandage or
siteof puncture. Muscle blood flow was lower extremities in reclining clearance. The solution tibial muscle in a dose
(Spofa/United
Czechoslovakia). artery, bleeding
4.0
2.4
33.9
88.0
25.0
Pharof by
the Seldinger
compression lasted longer After arteriotomy, manual all cases the patients were of bleeding and we never sandbags as weight at the
measured
simultaneously
de
constructions #{233}letriques de Charleroi, The head of the collimator was located
Charleroi, 10 cm over
the region to be measured. By means of an analyzer-amplifier (ISN 1OA, Ateliers de constructions #{233}letriquesde Charleroi, Charleroi, recorded
Texas
Belgium) only on a stripchart
Instruments)
constant
was
the 81 keV emission was selected and two-channel pen recorder (Recti/riter,
at a paper
speed
of 3.75 cm/mm.
The time
was
maintained
the muscle
during
resting
Then cuffs placed around values of 200 torr, and the to an ergometer. The rate
at 60 strokes/mm.
After
the occur-
rence of intensive ischemic pain in both lower extremities, usually after 3 mm, the cuffs were rapidly deflated and the curves of decline of radioactivity in the phase of postischemic hyperemia were recorded. By using this method, maximal muscle blood flow is reached in all cases [16, 17]. Muscle
blood
flow is calculated
OM
where
QM
5
P
t
+4.9
1.7630
NS
0.5491
NS
resting off
flow,
from
to one half of the initial value. For calculation ot values of T’12 were put into the equation as read
the
clearance
curves
recorded
at rest.
For
calculation
of maximal muscle blood flow we used values of T’12 from curves obtained during postischemic hyperemia. The details of this measurement are presented elsewhere [13, 14, 17]. Difterences measured between the catheterized and the intact extremity were evaluated for each patient separately by a paired test. As reference values we used the values of 60 measurements in 54 young patients (30 male and 24 female), obtained
by the same technique
[14]. The mean age of this control
group
was 11 years (range, 5-17 years). The significance of difterences of mean values in the separate groups from reference values was evaluated by Student’s t test. Results Catheterization, Femoral
Venous
Route,
Without
Touching
Artery
The
venous
15 children
route (nine
of inserting
boys
and
six
a catheter girls)
was
without
used
in
cannulation
or puncture of the femoral artery. The mean age at time of the investigation was 5.3 years (range, 4 months to 14 years). The mean age at investigation of muscle blood flow was 8.3 years (range, 4.5-17 years). The mean time interval from catheterization was 3.0 years (range, 8 monthsto 11 years). Resting muscle blood flow was normal in both extremities (table 1). Maximal muscle blood flow in the catheterized
extremity
contralateral
limits
did
not
extremity.
of the normal
differ
from
Both
values
that
in the
were
control
within
the
range.
1 sec.
The wash-out curve of ‘33Xe from conditions was recorded for 15 mm. both thighs were inflated to pressure patients lifted a 1 kg weight attached of exercise
decreased
in both
patients by means of ‘“Xe muscle of ‘33Xe was injected into the anterior of 50-100 Ci in a volume of 0.1 ml. The
clearance of the radionuclide was measured by two scintillation detectors containing 5 cm sodium-iodide thalium-activated crystals with cylindrical collimators 7 cm long (Duovigraph, Ateliers Belgium).
%
-17.5
not significant.
=
After removal was prevented
After
SD
Mean
1.6
otomy. Later on, such a procedure was reserved for children only in the first year of life. This group included 17 patients after femoral arteriotomy. Angiography formed a part of the investigation in all cases. The contrast material used was salts of substituted tri-iodinated benzoic acids (Conray 60%, Braccollndustria Chimica SpA.. Milan, Italy; Verografin 76%, SpofalUnited Pharmaceutical Works, Prague, Czechoslovakia) in total dose of 1-4 mg/kg body weight. maceutical the cannula
to Intact
Flow Affected
.
AJR:132, January 1979
1
by the Venous
Values 60)
=
SAMANEK
muscle
100 blood
[16]:
A.2/ml/100
flow,
g/min/,
A is muscle-to-blood
coefficient corrected for hematocrit interval during which the clearance
[18],
curve
and
T
/2
partition is the time
in a semilog
plot
Catheterization
Blood first
or Cannulation
flow
in the
to the anterior
entire
group
of Femoral
tibial
Artery
muscle
of 84 patients
was
without
evaluated regard
to
the methods of catheterization (table 2). Resting muscle blood flow in the catheterized extremity did not differ from that in the control extremity. Values measured in both lower extremities in these patients also did not differ from the normal control group. Maximal muscle blood flow in the catheterized extremity was significantly lower than in the control extremity (P < 0.001), whereas values of maximal muscle blood flow on the catheterized side did not differ significantly from the norm. Values measured in the control extremity were raised over the norm (P < 0.02). Femoral arteriotomy (table 3). From a group of 84 patients, 17 (eight boys and nine girls) had retrograde
AJR:132, January 1979
MUSCLE
BLOOD
FLOW
AFTER
CARDIAC
TABLE Catheterization Reference
Downloaded from www.ajronline.org by 183.167.250.140 on 10/07/15 from IP address 183.167.250.140. Copyright ARRS. For personal use only; all rights reserved
(‘p
of the Femoral
Lower
Limb
Difference
60)
=
Affected Mean
Resting
3.2
Maximal
%
1.7
78.6
Difference
SD
on 84 patients
reported
from
values
reference
P
3.2
27.0
NS
Reference
(n Blood
-5.9 -16.7
0.9122
NS
6.0286
Impairment
of Leg Muscle
Blood
Catheterization Downloaded from www.ajronline.org by 183.167.250.140 on 10/07/15 from IP address 183.167.250.140. Copyright ARRS. For personal use only; all rights reserved
JAN
KOVRANEK’
venous in that
in the extremity
used
for catheterization
AND
MILAN
-
by the
route only. Maximal blood flow was significantly lower extremity where the femoral artery had been catheter-
of whether
dinger
the
percutaneous
arterial
catheterization
technique,
arteriotomy,
involved
the Sel-
or mere cannu-
January Roentgen
1979 Ray Society
sample
blood.
Muscle 99 patients
blood flow in the lower extremities (52 male and 47 female) in whom
and
Methods was measured in cardiac catheteri-
was 2.7 years. In all cases diagnostic
cardiac
catheterization
purposes,
in 80
children
had for
been
indicated
ital cardiac
defect
right-to-left
shunt.
cardiac
disease
In the
without
congenital
mitral
quent
disease
lung
with a left-to-right remaining
a shunt,
group
included
a
congenital
artery stenosis
and
The
fre-
as an indication
catheterization and angiography was idiopathic monary fibrosis and lung hypoplasia, followed situations in which pulmonary resection had
bronchiectasis. The investigated
pulmonary a congen-
with
predominated.
served
of a
in seven children,
16 patients
pulmonary
insufficiency
which
shunt;
for
suspicion
clinical
congenital cardiac defect and in 19 for severe disease. In 57 of these children we had demonstrated
those patients
most
for cardiac
interstitial pulin incidence by been done for
in whom
only
vessels of one lower extremity were used for catheterization. In all patients we carried out complete catheterization of the right heart after introduction of the catheter percutaneously through the femoral vein by the Seldinger technique, and in children up to age 2 years, after surgical preparation of the saphenous vein. In 15 children only the venous route was used for cardiac catheterization without touching the femoral artery. However, in the majority of cases the femoral artery was involved. In 31 children , the femoral artery was only cannulated for the purpose of sampling arterial blood and measuring pressure. Puncture of the femoral artery in children younger than 1 year was carried
out after previous
surgical
dissection
of the superficial
artery, but percutaneously in the older children. the catheter was introduced in the femoral
neously
using
the
Seldinger
catheters (AB Kifa, Solna, using a closed-tip catheter
Received May 2, 1977; accepted after revision September 13, 1978. , Cardiopulmonary Laboratory, Center of Pediatric Cardiology and Cardiac Address reprint requests to M. Sam#{225}nek. American
and
of muscle blood flow was 10.8 years (range, 3-21 years). The shortest time interval from cardiac catheterization was 5 months; the longest, 1 1 years. The mean time interval between cardiac catheterization and investigation of muscle blood flow
,
132:71-75,
pressure
zation had been performed between 2 months and 16 years of age (mean, 8.1 years). The mean age at the time of investigation
The reported incidence of disturbances in blood flow in the peripheral arterial bed after catheterization and angiography of the arterial system range from 0% to 100’Yo [1-9]. The principal cause of this scatter is differences in the manner of determining such complications and their evaluation. Clinical investigation reveals only very crude disturbances of arterial patency. More sensitive methods include oscillometry [1 5, 9-12] or the Doppler technique [12]. A more objective evaluation of disturbances in function which result from puncture catheterization or angiography is measurement of blood flow in the involved extremity [10-12]. Plethysmographic methods after catheterization have shown a significant decrease in blood flow to the calf, increased resistance, and decreased venous blood volume. Repair to these changes took about 1 week [10]. Unfortunately, measurement limited to resting blood flow does not reveal slight disturbances in blood supply [13-15] or inadequate blood supply during periods other than resting conditions. We studied late disturbances in peripheral blood flow resulting from catheterization. The method allowed us to measure this parameter in any selected muscle, not only at rest but also with increased muscle demands on the blood supply. The investigated group included only those patients with congenital heart defects or with severe respiratory disease, in whom catheterization and angiocardiography had been carried out in childhood and in whom clinical investigation and, in suspect cases, oscillometry had not revealed any disturbance of blood
© 1979
measure
Subjects
lation of the femoral artery. The values in the involved extremity did not differ significantly from the values in a healthy population.
AJR
AMANEK1
flow to the lower extremity following the investigation. Because of discordant views on the incidence of complications related to arterial catheterization technique, we attempted to evaluate differences between the two basic technical approaches percutaneous Seldinger technique and surgical insertion of the catheter. Two further subgroups were formed by patients in whom left heart catheterization was carried out transseptally and the femoral artery was not involved or only cannulated to
ized or cannulated for pressure measurement and blood sampling. The disturbance in maximal flow was shown regardless
Cardiac
in Childhood
In 99 patients with congenital heart defects or chronic respiratory disease without clinical symptoms of disturbances in peripheral circulation, resting and maximal blood flow in the anterior tibial muscle of both extremities were investigated 2.7 years (average) after cardiac catheterization. The method used involved ‘“Xe clearance. Resting blood flow was normal and no difference could be demonstrated between the extremity originally used for catheterization and the contralateral control extremity. No disturbance in maximal blood flow could
be proved
Flow Following
71
Surgery,
University
Hospital
technique.
Sweden) were was indicated,
Motol,
Red
femoral
In 36 patients artery percuta-
and
gray
Kifa
used. If angiography we began with arteri-
150 06 Prague,
Czechoslovakia.
o361-8o3x/79/1321-0071
$0.00
72
SKOVRANEK
AND TABLE
Catheterization Reference
Downloaded from www.ajronline.org by 183.167.250.140 on 10/07/15 from IP address 183.167.250.140. Copyright ARRS. For personal use only; all rights reserved
(n Blood
Route
Low er Limb Diffe rence Affected
Mean
Resting
Maximal
Note-Data
on 15 patients
report
SD
Intact
Mean
SD
3.2
1.7
3.3
78.6
27.0
92.3
ad in milliliters
per 100 g p er minute.
N5
All patients
received
several
5-20 mg of Heparin
Works, Prague, from the femoral
minutes
of manual
compression.
percutaneous puncture, this manual than with needle puncture alone. compression was not carried out. In returned to the ward after cessation applied a compressive bandage or
siteof puncture. Muscle blood flow was lower extremities in reclining clearance. The solution tibial muscle in a dose
(Spofa/United
Czechoslovakia). artery, bleeding
4.0
2.4
33.9
88.0
25.0
Pharof by
the Seldinger
compression lasted longer After arteriotomy, manual all cases the patients were of bleeding and we never sandbags as weight at the
measured
simultaneously
de
constructions #{233}letriques de Charleroi, The head of the collimator was located
Charleroi, 10 cm over
the region to be measured. By means of an analyzer-amplifier (ISN 1OA, Ateliers de constructions #{233}letriquesde Charleroi, Charleroi, recorded
Texas
Belgium) only on a stripchart
Instruments)
constant
was
the 81 keV emission was selected and two-channel pen recorder (Recti/riter,
at a paper
speed
of 3.75 cm/mm.
The time
was
maintained
the muscle
during
resting
Then cuffs placed around values of 200 torr, and the to an ergometer. The rate
at 60 strokes/mm.
After
the occur-
rence of intensive ischemic pain in both lower extremities, usually after 3 mm, the cuffs were rapidly deflated and the curves of decline of radioactivity in the phase of postischemic hyperemia were recorded. By using this method, maximal muscle blood flow is reached in all cases [16, 17]. Muscle
blood
flow is calculated
OM
where
QM
5
P
t
+4.9
1.7630
NS
0.5491
NS
resting off
flow,
from
to one half of the initial value. For calculation ot values of T’12 were put into the equation as read
the
clearance
curves
recorded
at rest.
For
calculation
of maximal muscle blood flow we used values of T’12 from curves obtained during postischemic hyperemia. The details of this measurement are presented elsewhere [13, 14, 17]. Difterences measured between the catheterized and the intact extremity were evaluated for each patient separately by a paired test. As reference values we used the values of 60 measurements in 54 young patients (30 male and 24 female), obtained
by the same technique
[14]. The mean age of this control
group
was 11 years (range, 5-17 years). The significance of difterences of mean values in the separate groups from reference values was evaluated by Student’s t test. Results Catheterization, Femoral
Venous
Route,
Without
Touching
Artery
The
venous
15 children
route (nine
of inserting
boys
and
six
a catheter girls)
was
without
used
in
cannulation
or puncture of the femoral artery. The mean age at time of the investigation was 5.3 years (range, 4 months to 14 years). The mean age at investigation of muscle blood flow was 8.3 years (range, 4.5-17 years). The mean time interval from catheterization was 3.0 years (range, 8 monthsto 11 years). Resting muscle blood flow was normal in both extremities (table 1). Maximal muscle blood flow in the catheterized
extremity
contralateral
limits
did
not
extremity.
of the normal
differ
from
Both
values
that
in the
were
control
within
the
range.
1 sec.
The wash-out curve of ‘33Xe from conditions was recorded for 15 mm. both thighs were inflated to pressure patients lifted a 1 kg weight attached of exercise
decreased
in both
patients by means of ‘“Xe muscle of ‘33Xe was injected into the anterior of 50-100 Ci in a volume of 0.1 ml. The
clearance of the radionuclide was measured by two scintillation detectors containing 5 cm sodium-iodide thalium-activated crystals with cylindrical collimators 7 cm long (Duovigraph, Ateliers Belgium).
%
-17.5
not significant.
=
After removal was prevented
After
SD
Mean
1.6
otomy. Later on, such a procedure was reserved for children only in the first year of life. This group included 17 patients after femoral arteriotomy. Angiography formed a part of the investigation in all cases. The contrast material used was salts of substituted tri-iodinated benzoic acids (Conray 60%, Braccollndustria Chimica SpA.. Milan, Italy; Verografin 76%, SpofalUnited Pharmaceutical Works, Prague, Czechoslovakia) in total dose of 1-4 mg/kg body weight. maceutical the cannula
to Intact
Flow Affected
.
AJR:132, January 1979
1
by the Venous
Values 60)
=
SAMANEK
muscle
100 blood
[16]:
A.2/ml/100
flow,
g/min/,
A is muscle-to-blood
coefficient corrected for hematocrit interval during which the clearance
[18],
curve
and
T
/2
partition is the time
in a semilog
plot
Catheterization
Blood first
or Cannulation
flow
in the
to the anterior
entire
group
of Femoral
tibial
Artery
muscle
of 84 patients
was
without
evaluated regard
to
the methods of catheterization (table 2). Resting muscle blood flow in the catheterized extremity did not differ from that in the control extremity. Values measured in both lower extremities in these patients also did not differ from the normal control group. Maximal muscle blood flow in the catheterized extremity was significantly lower than in the control extremity (P < 0.001), whereas values of maximal muscle blood flow on the catheterized side did not differ significantly from the norm. Values measured in the control extremity were raised over the norm (P < 0.02). Femoral arteriotomy (table 3). From a group of 84 patients, 17 (eight boys and nine girls) had retrograde
AJR:132, January 1979
MUSCLE
BLOOD
FLOW
AFTER
CARDIAC
TABLE Catheterization Reference
Downloaded from www.ajronline.org by 183.167.250.140 on 10/07/15 from IP address 183.167.250.140. Copyright ARRS. For personal use only; all rights reserved
(‘p
of the Femoral
Lower
Limb
Difference
60)
=
Affected Mean
Resting
3.2
Maximal
%
1.7
78.6
Difference
SD
on 84 patients
reported
from
values
reference
P
3.2
27.0
NS
Reference
(n Blood
-5.9 -16.7
0.9122
NS
6.0286
