Pierre Abraham

Measurement and Interpretation of the Ankle-Brachial Index A Scientific Statement From the American Heart Association

Measurement and interpretation of the ankle-brachial index : a scientific statement from the Ammerican Heart Association

Measurement of Walking Distance and Speed in Patients With Peripheral Arterial Disease A Novel Method Using a Global Positioning System

Background— The maximal walking distance (MWD) performed on a treadmill test remains the “gold standard” in estimating the walking capacity of patients who have peripheral arterial disease with intermittent claudication, although treadmills are not accessible to most physicians. We hypothesized that global positioning system (GPS) recordings could monitor community-based outdoor walking and provide valid information on walking capacity in patients with peripheral arterial disease. Methods and Results— We studied 24 patients (6 women) with arterial claudication (median [25th to 75th percentile] values: 57 years old [48 to 67 years], 169 cm tall [164 to 172 cm], weight 81 kg [71 to 86 kg], and ankle-brachial index 0.64 [0.56 to 0.74]). MWD on the treadmill was 184 m (144 to 246 m), which was compared with the results of self-reported MWD, the distance score from the Walking Impairment Questionnaire, MWD observed during a 6-minute walking test, and MWD measured over a GPS-recorded unconstrained outdoor walk in a public park. Self-reported MWD, Walking Impairment Questionnaire distance score, 6-minute walking test score, and GPS-measured MWD were 300 m (163 to 500 m), 28% (15% to 47%), 405 m (338 to 441 m), and 609 m (283 to 1287 m), respectively. The best correlation with MWD on the treadmill test was obtained with the MWD measured by the GPS (Spearman r=0.81, P<0.001). Conclusions— Outdoor walking capacity measured by a low-cost GPS is a potentially innovative way to study the walking capacity of patients with peripheral arterial disease. It opens new perspectives in the study of walking capacity for vascular patients with claudication under free-living conditions or for physicians who do not have a treadmill.

Transcutaneous Oxygen Pressure Measurements on the Buttocks During Exercise to Detect Proximal Arterial Ischemia Comparison With Arteriography

Background—We sought to identify whether transcutaneous oxygen tension (tcPo2) measurements could be used to noninvasively detect lesions in the arterial network supplying blood flow to the hypogastric circulation. Methods and Results—A study was undertaken in vascular patients with suspected (PC, n=43) and not with suspected (NPC, n=34) proximal ischemia. TcPo2 was measured on both buttocks and with a chest reference electrode. Arteriography on the right or left side was positive for stenoses (≥75%) or occlusion of one or more of the following arteries: the aorta, the common iliac arteries, or the internal iliac arteries. The arteriography was compared with the resting tcPo2 values (REST) and with the minimal value (MIN) and maximal change from rest normalized to eventual chest changes (DROP) recorded during or after a treadmill test. REST, MIN, and DROP were, respectively, as follows in positive versus negative arteriograms (mean±SD; in mm Hg): 80.2±10.9 versus 78.6±11.5 (P >0.05), 55.2±20.0 versus 69.9±15.8 (P <0.001), and −31.8±17.6 versus −9.5±6.4 (P <0.0001) in PC and 78.9±14.0 versus 80.5±14.3 (P >0.05), 64.4±21.0 versus 75.1±14.6 (P <0.02), and −24.1±13.5 versus −8.7±4.8 (P <0.0001) in NPC. In PC and NPC respectively, with a cutoff point of −16 and −15 mm Hg, DROP showed, respectively, 83%/82% and 79%/86% sensitivity/specificity in the diagnosis of positive arteriograms. Conclusions—Proximal ischemia is a frequent finding in vascular patients. TcPo2 measurement on the buttocks during exercise is a sensitive and specific indicator for lesions in the arterial tree toward the hypogastric circulation. Potentially it could objectively assess the response to endovascular or surgical approaches to iliac lesions.

Assessment of skin microvascular function and dysfunction with laser speckle contrast imaging.

In recent years, skin microcirculation has been considered an easily accessible and potentially representative vascular bed to evaluate and understand the mechanisms of microvascular function and dysfunction.1–3 Vascular dysfunction (including impaired endothelium-dependent vasodilation) induced by different pathologies is evident in the cutaneous circulation.4–7 It has been suggested that the skin microcirculation may mirror generalized systemic vascular dysfunction in magnitude and underlying mechanisms.1 Furthermore, minimally invasive skin-specific methodologies using laser systems make the cutaneous circulation a useful translational model for investigating mechanisms of skin physiology and skin pathophysiology induced either by skin disease itself or by other diseases such as vascular, rheumatologic, and pneumologic. To date, the skin has been used as a circulation model to investigate vascular mechanisms in a variety of diseased states, including hypercholesterolemia,8 Alzheimer disease,9 carpal tunnel syndrome,10 schizophrenia,11 hypertension,6 renal disease,12 type 2 diabetes,13 peripheral vascular disease,14 atherosclerotic coronary artery disease,2 heart failure,15 systemic sclerosis,16 obesity,17 primary aging,18,19 and sleep apnea.20 Assessment of skin microvascular function can be done by both invasive and noninvasive techniques. Among noninvasive techniques, laser systems are mainly used.21 The recent development of the laser speckle contrast imaging (LSCI) technique for monitoring skin microvascular function enables its use as a surrogate end point in clinical trials. LSCI allows for noncontact, real-time, and noninvasive monitoring of cutaneous blood flow changes.22,23 Recent evidence has shown that the LSCI technique dramatically reduces the variability of clinical measurements compared with laser Doppler flowmetry (LDF), making the technique a fascinating tool to facilitate microvascular studies in clinical routine.23,24 In this review, we describe …

Microvascular endothelial function in obstructive sleep apnea: Impact of continuous positive airway pressure and mandibular advancement.

OBJECTIVES Endothelial dysfunction has been proposed as a potential mechanism implicated in the pathogenesis of cardiovascular complications of obstructive sleep apnea syndrome (OSAS). This study aimed to evaluate the microvascular endothelial function (MVEV) in OSAS and the impact on MVEF of 2 months of treatment with continuous positive airway pressure (CPAP) and mandibular advancement device (MAD). METHODS Microvascular reactivity was assessed using laser Doppler flowmetry combined with acetylcholine (Ach) and sodium nitroprusside (SNP) iontophoresis in 24 OSAS patients and 9 control patients. In 12 of the 24 OSAS patients, microvascular reactivity was reassessed after 2 months of CPAP and MAD using a randomized cross-over design. RESULTS Ach-induced vasodilation was significantly lower in OSAS patients than in matched controls and correlated negatively with apnea hypopnea index (r=-0.49, p<0.025) and nocturnal oxygen desaturations (r=-0.63, p<0.002). Ach-induced vasodilation increased significantly with both CPAP and MAD. The increase in Ach-induced vasodilation under OSAS treatment correlated with the decrease in nocturnal oxygen desaturations (r=0.48, p=0.016). CONCLUSION Our study shows an impairment of MVEF in OSAS related to OSAS severity. Both CPAP and MAD treatments were associated with an improvement in MVEF that could contribute to improve cardiovascular outcome in OSAS patients.

Non-nociceptive capsaicin-sensitive nerve terminal stimulation allows for an original vasodilatory reflex in the human skin

A significant increase of cutaneous laser Doppler flowmetry was found before blood flow decreases with increasing pressure during a 5 mmHg min-1 increase of pressure strain on the finger. Pre-treatment with a local anaesthetic or chronically applied capsaicin, resulted in the disappearance of the vasodilatory response. These results suggest an original vasodilatory axon reflex response to non-noxious pressure strain which is initiated by capsaicin-sensitive nerve terminals in the human skin.

Increasing the "region of interest" and "time of interest", both reduce the variability of blood flow measurements using laser speckle contrast imaging.

OBJECTIVE Both spatial variability and temporal variability of skin blood flow are high. Laser speckle contrast imagers (LSCI) allow non-contact, real-time recording of cutaneous blood flow on large skin surfaces. Thereafter, the observer can define different sizes for the region of interest (ROI) in the images to decrease spatial variability and different durations over which the blood flow values are averaged (time of interest, TOI) to decrease temporal variability. We aimed to evaluate the impact of the choices of ROI and TOI on the analysis of rest blood flow and post occlusive reactive hyperemia (PORH). METHODS Cutaneous blood flow (CBF) was assessed at rest and during PORH. Three different sizes of ROI (1mm(2), 10mm(2) and 100mm(2)), and three different TOI (CBF averaged over 1s, 15s, and 30s for rest, and over 1s, 5s and 10s for PORH peak) were evaluated. Inter-subjects and intra-subjects coefficient of variations (inter-CV and intra-CV) were studied. RESULTS The inter-subject variability of CBF is about 25% at rest and is moderately improved when the size of the ROI increases (inter-CV=31%, for 1s and 1mm(2) versus inter-CV=23%, for 15s and 100mm(2)). However, increasing the TOI does not improve the results. The variability of the PORH peak is lower with an inter-CV varying between 11.4% (10s and 100mm(2)) and 21.6% (5s and 1mm(2)). The lowest intra-CV for the CBF at rest was 7.3% (TOI of 15s on a ROI of 100mm(2)) and was 3.1% for the PORH peak (TOI of 10s on a ROI of 100mm(2)). CONCLUSION We suggest that a size of ROI larger than 10mm(2) and a TOI longer than 1s are required to reduce the variability of CBF measurements both at rest and during PORH peak evaluations at the forearm level. Many technical aspects such as comparison of laser speckle contrast imaging and laser Doppler imaging or the effect of skin to head distance on recorded values with LCSI are required to improve future studies using this fascinating clinical tool.

Mechanisms of the cutaneous vasodilator response to local external pressure application in rats: involvement of CGRP, neurokinins, prostaglandins and NO

Local pressure‐induced vasodilation (PIV) is a neural vasodilator response to non‐nociceptive externally applied pressure in the skin, previously described in humans. We first determined whether PIV exists in rats and depends on capsaicin‐sensitive fibres as it does in humans. We then examined the mediators involved in the efferent pathway of PIV. Cutaneous blood flow was measured by laser Doppler flowmetry during 11.1 Pa s−1 increases in local applied pressure in anaesthetized rats. The involvement of capsaicin‐sensitive fibres in PIV was tested in rats treated neonatally with capsaicin. To antagonize CGRP, neurokinin‐1, −2, or −3 receptors, different groups of rats were treated with CGRP8–37, SR140333, SR48968 or SR142801, respectively. Prostaglandins involvement was tested with indomethacin treatment. To inhibit nitric oxide synthase (NOS) activity or specific neuronal NOS, rats were treated with NG‐nitro‐L‐arginine or 7‐nitroindazole, respectively. PIV was found in rats, as in humans. PIV was abolished by neonatal treatment with capsaicin and by administration of CGRP8–37 but remained unchanged with SR140333, SR48968 and SR142801 treatments. Prostaglandin inhibition resulted in a significant decrease in PIV. Inhibition of NOS abolished PIV, whereas inhibition of neuronal NOS caused a diminution of PIV. These data suggest that PIV depends on capsaicin‐sensitive fibres in rats, as in humans. It appears that CGRP plays a major role in the PIV, whereas neurokinins have no role. Furthermore, PIV involves a contribution from prostaglandins and depends on endothelial NO, whereas neuronal NO has a smaller role.

Current-Induced Vasodilation during Water Iontophoresis (5 min, 0.10 mA) Is Delayed from Current Onset and Involves Aspirin Sensitive Mechanisms

Study of the microcirculation by iontophoresis is potentially confounded by any non-specific effects of current application. Laser Doppler flow (LDF, mean ± SD; arbitrary units; AU) was recorded on the forearms of healthy volunteers during and 20 min following application of 0.10-mA current for 1, 3 and 5 min, using deionised water as a vehicle. Local heating to 44°C was then applied for 24 min to assess maximal vasodilation. Cathodal current applications resulted in delayed and prolonged vasodilation (peak values: 78 ± 29, 75 ± 19, 80 ± 37 AU) whereas anodal peak LDF was 13 ± 6, 27 ± 34 and 72 ± 40 AU for 1-, 3- and 5-min periods of current applications, respectively. From current onset, inflexion points in the responses to 3- and 5-min anodal current applications occurred at 4.5 and 6.5 min, respectively, and at ∼1.5 min for all cathodal current applications. For 5-min current applications: a preliminary tourniquet ischaemia neither changed the time course nor the amplitude of the response to current application. In this situation, local anaesthesia abolished the current-induced vasodilation. Chronic capsaicin pretreatment decreased the amplitude of the vasodilation. Pretreatment with 500 mg oral aspirin decreased the cathodal vasodilation and abolished the anodal vasodilation, even in the absence of preliminary ischaemia. We conclude that vasodilation to prolonged application of 0.10-mA continuous monopolar current after transient tourniquet ischaemia cannot be exclusively the result of an axon reflex initiated by current onset. This current-induced vasodilation is at least partly dependent on capsaicin-sensitive afferent fibres and relies on aspirin-sensitive mechanisms at both polarities.

Relevance of Laser Doppler and Laser Speckle Techniques for Assessing Vascular Function: State of the Art and Future Trends

In clinical and research applications, the assessment of vascular function has become of major importance to evaluate and follow the evolution of cardiovascular pathologies, diabetes, hypertension, or foot ulcers. Therefore, the development of engineering methodologies able to monitor noninvasively blood vessel activities-such as endothelial function-is a significant and emerging challenge. Laser-based techniques have been used to respond-as much as possible-to these requirements. Among them, laser Doppler flowmetry (LDF) and laser Doppler imaging (LDI) were proposed a few decades ago. They provide interesting vascular information but possess drawbacks that prevent an easy use in some clinical situations. Recently, the laser speckle contrast imaging (LSCI) technique, a noninvasive camera-based tool, was commercialized and overcomes some of the LDF and LDI weaknesses. Our paper describes how-using engineering methodologies-LDF, LDI, and LSCI can meet the challenging clinician needs in assessing vascular function, with a special focus on the state of the art and future trends.