Noninvasive evaluation of peripheral vascular disease using transcutaneous oxygen tension

doi:10.1016/0002-9610(82)90604-3

The American Journal of Surgery

Volume 144, Issue 1, July 1982, Pages 68-75

https://doi.org/10.1016/0002-9610(82)90604-3 Get rights and content

Abstract

Transcutaneous oxygen tension (P_tcO₂) was used for noninvasive determination of blood supply in 25 patients evaluated for peripheral arterial disease. p_tcO₂ values were compared with segmental Doppler pressure, pulse volume recording, pulse reappearance time, and angiography in patients being evaluated for wound healing problems, amputations, and peripheral bypass procedures. P_tcO₂ was measured using a heated (45 °C) Clark polarographic electrode to quantitate the oxygen which diffuses from the dermal capillaries to the skin surface. Control P_tcO₂ values recorded over the chest or shoulder taken while patients were breathing room air were 78 ± 8 mm Hg. P_tcO₂ values greater than 50 mm Hg predicted success for levels of amputation and for wound healing without reconstructive procedures; values of 40 mm Hg or less were associated with continued wound problems and complication after amputation. Increased P_tcO₂ values after vascular reconstruction of the legs predicted improved clinical status on follow-up examinations up to 6 months. P_tcO₂ predicted the extent of vascular disease as well as the other noninvasive tests and angiography. We conclude that (1) P_tcO₂ tension is a simple, accurate, noninvasive method to determine the appropriate level of amputation, wound healing potential, and effectiveness of bypass procedures, and (2) P_tcO₂ values correlate well with angiography and noninvasive evaluations.

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Cited by (103)

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2023, Journal of Vascular Surgery
Transmetatarsal amputation (TMA) is a durable and important functional limb salvage option. We have presented our results in identifying the angiographic predictors of TMA healing using single-institution retrospective data.
Consecutive patients within our institution who had undergone TMA and lower extremity arteriography from 2012 to 2020 were included. Patients whose TMA had healed were compared with those whose TMA had not healed. Using pre- and perioperative patient factors, in addition to the Global Limb Anatomic Staging System (GLASS) and evaluation of the tibial runoff vessels, multivariate analysis was used to define the predictors of TMA healing at 30 days and 1 year. For those patients who had undergone an intervention after TMA, including repeat interventions, the postintervention GLASS stage was calculated. All patients were followed up by the vascular surgeon using standard ultrasound surveillance and clinical examinations. Once the predictors had been identified, an analysis was performed to correlate the 30-day and 1-year limb salvage rates.
A total of 89 patients had met the inclusion criteria for the study period. No difference was found in the GLASS femoropopliteal or infrapopliteal stages for those with a healed TMA and those without. After multivariate regression analysis, the presence of a patent pedal arch vs a nonintact arch had a 5.5 greater odds of TMA healing at 30 days but not at 1 year. Additionally, the presence of a patent arch was strongly associated with limb salvage at both 30 days (86% vs 49%; P < .01) and 1 year (79% vs 49%; P < .01).
In the present series of patients who had undergone TMA and arteriography, with appropriate GLASS staging, we found patency of the pedal arch was a significant predictor of healing and limb salvage. The GLASS femoropopliteal and infrapopliteal stages did not predict for TMA healing.
Hemodynamic Threshold for Wound Healing in Critical Limb Ischemia
2017, JACC: Cardiovascular Interventions
Heterogeneity of Ankle-Brachial Indices in Patients Undergoing Revascularization for Critical Limb Ischemia
2017, JACC: Cardiovascular Interventions
This study sought to describe the distribution of pre-intervention treated-limb ankle-brachial indices (ABIs) among patients with critical limb ischemia (CLI) undergoing percutaneous vascular intervention (PVI) or surgical revascularization (SR).
CLI is diagnosed by the presence of rest pain, tissue ulceration, or gangrene due to chronic arterial insufficiency. It is unclear what fraction of patients with suspected CLI have severe peripheral artery disease (PAD) on noninvasive functional testing.
The study included patients who underwent lower extremity revascularization for CLI in a multicenter registry in Michigan from January 2012 through June 2015. ABIs were classified as normal (ABI: 0.91 to 1.40), mild-moderate (ABI: 0.41 to 0.90), and severe (ABI: ≤0.40). Pre- and post-intervention Peripheral Artery Questionnaire summary scores were assessed in a subset of patients.
Among 10,756 patients with signs or symptoms of CLI, 9,113 (84.7%) underwent PVI and 1,643 (15.3%) underwent SR. ABIs were recorded in 4,972 (54.6%) PVI and 1,012 (61.6%) SR patients. Patients undergoing PVI had higher ABIs than those undergoing SR, with substantial variation in both groups (PVI: 0.72 ± 0.29 vs. SR: 0.61 ± 0.29; p < 0.001). Nearly a quarter of patients with compressible arteries had normal ABIs (24.0%), whereas severe PAD was uncommon (16.5%). A significant improvement in Peripheral Artery Questionnaire scores was noted after intervention across all ABI categories.
Among patients undergoing revascularization for CLI in contemporary practice, the authors found substantial heterogeneity in pre-intervention ABIs. The disconnect between ABI results and clinical diagnosis calls into question the utility of ABIs in this population and suggests the need for standardization of functional PAD testing.
TcPO<inf>2</inf> prognostic value of healing in diabetic foot after revascularization
2015, Angiologia
La medición de la presión transcutánea de oxígeno (TcPO₂) es una herramienta útil en el diagnóstico vascular no invasivo, además de ser una prueba con valor pronóstico de cicatrización de úlceras vasculares antes y después de la revascularización.
Nuestro estudio tiene como objetivo hallar el valor umbral de TcPO₂ más fiable para predecir la cicatrización, así como valorar si el ascenso de la TcPO₂ tras una revascularización es un buen predictor de buena evolución tras la misma en pacientes diabéticos isquémicos con úlceras isquémicas.
Realizamos un estudio retrospectivo de la base de datos de la Unidad de Pie Diabético del Hospital Universitario Fundación de Alcorcón, mantenida prospectivamente. Se reclutaron pacientes diabéticos con ulceración y criterios de isquemia crítica, sobre los que se realizó TcPO₂ pre y posrevascularización. Se registró el tipo de lesión (clasificación de TEXAS), tipo de revascularización, éxito de cicatrización y tiempo hasta la misma.
Se encontraron 18 pacientes, el 72% eran varones y el 28% mujeres. La edad media fue de 68 años, el 94,7% eran hipertensos, el 73,7% tenían dislipidemia y el 63,2% presentaban retinopatía. Se realizaron en total 19 revascularizaciones, de las cuales 13 fueron endovasculares, 4 bypass y 2 procedimientos híbridos. El ITB no fue valorable en el 68%. Se obtuvo una tasa de cicatrización del 53% y una mediana de tiempo hasta la misma de 103 días. La media de los valores preoperatorios de TcPO₂ en cicatrizados y no cicatrizados fue de 14,6 ± 9,40 y 18,6 ± 12,93 mm Hg respectivamente (p = 0,4404). Los niveles postoperatorios fueron de 40,8 ± 10,85 mm Hg en cicatrizados y de 23,5 ± 13,27 mm Hg en no cicatrizados (p = 0,0063). Mediante el análisis de las curva ROC determinamos que cifras de TcPO₂ superiores o iguales a 35 mm Hg eran cifras superiores o indicadores de buen pronóstico para la cicatrización. El incremento de la TcPO₂ por encima de 15 mm Hg es un factor de buen pronóstico tras la revascularización en el pie diabético.
La TcPO₂ es una herramienta útil para determinar el valor pronóstico en la cicatrización del paciente diabético con isquemia crítica, especialmente en pacientes con presiones parciales no valorables. El valor umbral de buen pronóstico de cicatrización se sitúa, según nuestro estudio, en una cifra ≥ 35 mm Hg. También es factor de buen pronóstico el incremento de la TcPO₂ por encima de 15 mm Hg respecto del valor basal tras la revascularización.
The measurement of transcutaneous oxygen pressure (TcPO₂) is a useful tool in non-invasive vascular diagnosis, as well as being a valuable prognostic test of vascular ulcer healing before and after revascularization.
The aim of this study was to determine the most reliable TtPO₂ cut—off value for predicting healing, as well as to find out if the increase in the TcPO₂ after revascularization can be predictor of a good outcome after this intervention in diabetic patients with ischemic ulcers.
A retrospective study was performed using the prospectively maintained data base of the Diabetic Foot Unit of the Hospital Universitario Fundación de Alcorcón. Diabetic patients with ulceration and critical ischemia criteria were included, particularly those that had TcPO₂ performed before and after revascularization, successful wound healing and time to healing.
A total of 18 patients were found, of whom 72% were males and 28% females. The mean age was 68 years, with 94.7% hypertension, 73.7% dyslipidemia, and 63.2% retinopathy. A total of 19 revascularizations were performed, of which 13 were endovascular, 4 bypass, and 2 hybrid procedures. The ankle-brachial index was not assessable in 68%. A healing rate of 53% and a median time to healing of 103 days were obtained. The mean preoperative TcPO₂ values in healed and non-healed was 14.6 ± 9.40 and 18.6 ± 12.93 mm Hg, respectively (P = .4404). The mean postoperative levels of TcPO2 were 40.8 ± 10.85 mm Hg in healed and 23.5 ± 13.27 mmHg in non-healed (P = .0063). Using ROC curve analysis, it was determined that TcPO2 levels equal to or greater than 35 mmHg were indicators of a good prognosis for wound healing. An increase in the TcPO₂ above 15 mm Hg is a factor of a good prognosis after revascularization of diabetic foot.
TcPO2 is a useful tool for determining the prognostic value in wound healing in the diabetic patient with critical ischemia, particularly in patients with non-assessable partial pressures. The cut-off for a good prognosis of wound healing, according to this study, is equal to or greater than 35 mm Hg. An increase in the TcPO₂ above 15 mm Hg from the baseline value is also a factor of a good prognosis after revascularization.
Contemporary assessment of foot perfusion in patients with critical limb ischemia
2014, Seminars in Vascular Surgery
Citation Excerpt :
Transcutaneous oxygen monitoring, more specifically, transcutaneous partial pressure of oxygen (TcPO2) measurement, provides information regarding local tissue perfusion and skin oxygenation. This technology has been studied to noninvasively assess the healing potential of lower-extremity ulcers or amputation sites as early as 1982, in a seminal article by White et al [11] that demonstrated the utility of TcPO2 in patients with severe peripheral arterial disease (PAD) and CLI before and after undergoing revascularizations, as well as assessing amputation healing potential. The test is performed with platinum oxygen electrodes placed on the chest wall and legs or feet.
Significant progress in limb salvage for patients with peripheral arterial disease and critical limb ischemia has occurred in the past 2 decades. Improved patient outcomes have resulted from increased knowledge and understanding of the disease processes, as well as efforts to improve revascularization techniques and enhance patient care after open and endovascular procedures. An imaging modality that is noninvasive, fast, and safe would be a useful tool for clinicians in assessing lower-extremity perfusion when planning interventions. Among the current and emerging regional perfusion imaging modalities are transcutaneous oxygen monitoring, hyperspectral imaging, indocyanine green dye−based fluorescent angiography, nuclear diagnostic imaging, and laser Doppler. These tests endeavor to delineate regional foot perfusion to guide directed revascularization therapy in patients with critical limb ischemia and foot ulceration.
The use of transcutaneous oximetry to predict healing complications of lower limb amputations: A systematic review and meta-analysis
2012, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
Nineteen of the studies in this review, representing 1212 patients with 1280 amputations, reported the results of a univariable association through Student’s t-test or the Mann–Whitney U test. Eighteen studies26–30,32,33,38,40,41,43–45,47,48,52,53,55 demonstrated a significant difference between the mean TcPO2 levels of the healed and non-healed groups, as defined by a p-value of less than 0.05. Only one study36 showed no significant difference.
To determine the validity of transcutaneous oximetry (TcPO₂) as a predictor of lower limb amputation healing complications.
A systematic review and meta-analysis.
We searched five major medical databases, relevant review articles and reference lists and included all studies that evaluated TcPO₂ for its ability to predict lower limb amputation healing failure. We selected eligible articles and conducted data abstraction independently and in duplicate.
Thirty-one studies, enrolling 1824 patients with 1960 amputations, met our inclusion criteria. Only one study reported undertaking a multivariable analysis, which demonstrated that a TcPO₂ level below 20 mmHg was an independent predictor of re-amputation occurrence (adjusted odds ratio (OR) 3.08, 95% confidence interval (CI) 1.19–7.98). Fourteen prospective cohort studies reported data that allowed for the calculation of an unadjusted relative risk of lower limb amputation healing complications leading to amputation revision associated with a TcPO₂ level below cut-offs of 10 mmHg (1.80; 95% CI 1.19–2.72), 20 mmHg (1.75; 95% CI 1.27–2.40) 30 mmHg (1.41; 95% CI 1.22–1.62) and 40 mmHg (1.24; 95% CI 1.13–1.39).
This review suggests that TcPO₂ predicts healing complications of lower limb amputations. A value of less than 40 mmHg results in a 24% increased risk of healing complication compared to over 40 mmHg and the risk further increases as the TcPO₂ decreases. There is, however, insufficient evidence to judge whether this tool adds important information beyond clinical data or to suggest an optimal threshold value. There is a need for a large, sufficiently powered study that adjusts for appropriate clinical variables.

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^☆: Presented at the 53rd Annual Meeting of the Pacific Coast Surgical Association, Napa, California, February 14–17, 1982.

¹: From the Department of Surgery, Harbor/UCLA Medical Center, Torrance, California.

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Scientific paperNoninvasive evaluation of peripheral vascular disease using transcutaneous oxygen tension☆

Abstract

J Surg Res

Management of acute lower extremity arterial ischemia due to embolism and thrombosis

Surgery

An index of healing in below knee amputations: leg blood pressure by Doppler ultrasound

Surgery

Vascular laboratory criteria for the management of peripheral vascular disease of the lower extremities

Surgery

The value of thermography in peripheral vascular disease

Angiography

Wound healing in below knee amputations in relation to skin perfusion pressure

Acta Orthop Scand

Determination of amputation level measurement of skin blood flow with xenon133

Arch Surg

Scientific paper
Noninvasive evaluation of peripheral vascular disease using transcutaneous oxygen tension☆

Determination of amputation level measurement of skin blood flow with xenon¹³³