Clinical Research
Effects of Lower Extremity Revascularization on the Endothelial Functions Measured With Noninvasive Brachial Artery Flow-Mediated Dilatation

https://doi.org/10.1016/j.avsg.2011.02.013Get rights and content

Background

Endothelial function is best measured with the noninvasive brachial artery flow-mediated dilatation (FMD) method. Peripheral arterial diseases and systemic cardiovascular diseases have FMD-lowering effect. The effects of lower extremity ischemia are associated with muscle inflammation and claudication, which may further lead to arterial stress. Our aim in this study was to investigate the effects of peripheral arterial revascularization on the endothelial functions through noninvasive brachial artery FMD.

Methods

Between January 2007 and February 2008, 54 patients diagnosed with lower extremity arterial disease undergoing revascularization were included in the study. Endothelial function is measured preoperatively and at the fourth week postoperatively using the brachial artery FMD method. Blood samples were collected at the same intervals for the measurement of interleukin-6, leukocyte count, tumor necrosis factor-alpha, and nitric oxide values.

Results

Femoropopliteal bypass grafting was performed in all patients with a synthetic graft. The mean ankle–brachial index in the preoperative period was 0.29 ± 0.083, and after the operation, dorsalis pedis and/or posterior tibial artery became palpable in all patients. The nitric oxide, interleukin-6, high-sensitivity C-reactive protein, and tumor necrosis factor-alpha levels decreased significantly after 4 weeks postoperatively as compared with the preoperative levels (p < 0.05). Postoperative Doppler ultrasonography FMD of brachial artery increased from preoperative value of 9.2 ± 2.1 to 16.2 ± 4.5 (p < 0.01) at postoperative week 4.

Conclusions

Systemic inflammation and muscle ischemia lead to reduced endothelial functions. After successful lower extremity revascularization, endothelial functions improve dramatically, which may be easily detected with the noninvasive brachial artery FMD method.

Introduction

Atherosclerosis results from endothelial dysfunction and depends on the availability of nitric oxide (NO) synthesized by the endothelial cells. Availability of NO synthesis is accounted as an early marker of future atheromatous changes, even long before visible changes and symptoms in the arterial tree.1, 2 Flow-mediated dilatation (FMD) is defined as the change in the arterial diameter in response to reactive hyperemia. FMD is also an endothelium-dependent process. Increased flow is created by the healthy endothelial lining with a mechanism called endothelium-dependent dilation in arteries.1, 2, 3

Flow-mediated endothelium-dependent dilation can be evaluated noninvasively by ultrasonography. The method has been used to determine endothelial functions in large vessels,4, 5 and the lower limb is one of the areas of interest in the case of arterial occlusive disease. Previously published data include various reports and attempts to enhance endothelial functions in the diseased segments of the arterial tree. In a recent study by Husmann et al., it has been shown that endovascular treatment of the atherosclerotic disease at the lower extremity improved the endothelial functions.6

The aim of the present study is to determine the effect of surgical revascularization of ischemic lower extremity on endothelial functions. To the best of our knowledge, this is the first noninvasive prospective study to detect the effects of surgical revascularization on endothelial functions in patients with lower extremity occlusive disease.

Section snippets

Patients

Between February 2007 and January 2008, 54 consecutive patients with the symptoms of Fountain Class 2B claudication and diagnosis of lower limb arterial occlusive disease who were scheduled for surgical revascularization at our clinic were enrolled into this prospective study. Procedures were explained in detail to the patients and they were included in the research after obtaining their consent. All patients underwent the 6-minute walk test. Ankle–brachial index (ABI) was measured at admission

Baseline Characteristics (Preoperative Period)

Patient characteristics are summarized in Table I. The mean age of the patients was 46.9 ± 7.2 years (range: 27-54 years). The female to male ratio was 22:32. In all, 18 of the patients were diabetic. Ischemic cardiac pathology was present in 35 patients. Smoking history was present in all patients and eight of the patients were still actively smoking at the time of hospital admission and before surgery. There was chronic renal failure in 11 patients. As a vasculitis cause, two patients had

Discussion

The endothelium is of essential importance for the maintenance of vascular tone. It participates in the regulation of blood flow in response to changes in tissue and organ perfusion requirements. When blood flow increases through a vessel, the vessel dilates. This phenomenon is called FMD. Schretzenmayer7 was the first to describe this physiological response, and FMD has been demonstrated subsequently in several conduit arteries in vitro and in vivo, in animals and in human beings. An intact

Conclusion

In conclusion, atherosclerosis is a kind of inflammation in the vessel wall and the effects of inflammation and such effects are not only local but also systemic. Attempts have been made to prevent early progression and development of this inflammation; however, up to date no agent has been successful in treating the underlying mechanisms completely. As a result, mainstay of the treatment of atherosclerosis in symptomatic patients is mediated by revascularization means to relieve clinical

References (16)

There are more references available in the full text version of this article.

Cited by (16)

  • Flow Mediated Dilatation and Progression of Abdominal Aortic Aneurysms

    2017, European Journal of Vascular and Endovascular Surgery
    Citation Excerpt :

    Since the first report by Knipp et al., which showed impaired FMD in patients with AAA compared with healthy volunteers or those with peripheral occlusive arterial disease,6 two other small case series (n ≤ 66) further reported the inverse association between FMD and the diameter of AAAs.4,5 Further, it has been shown that vascular intervention for occlusive arterial disease, either in the form of endovascular intervention or surgical bypass,10,11 can lead to significant improvements in brachial artery FMD. In the broader literature for cardiovascular disease, endothelial dysfunction has also been shown to correlate with the severity of atherosclerotic arterial disease, and is a potentially reversible risk factor.12

  • A Systematic Review of Interleukins as Diagnostic and Prognostic Biomarkers for Peripheral Artery Disease

    2023, Biomolecules

  • Endothelial function in patients with critical and non-critical limb ischemia undergoing endovascular treatment

    2021, Kardiologia Polska

  • The Effect of Lower Limb Revascularization on Flow, Perfusion, and Systemic Endothelial Function: A Systematic Review

    2021, Angiology

  • Effect of drug-coated balloons versus bare-metal stents on endothelial function in patients with severe lower limb peripheral artery disease

    2020, Vascular

  • Peripheral revascularization attenuates the exercise pressor reflex and increases coronary exercise hyperemia in peripheral arterial disease

    2018, Journal of Applied Physiology
View all citing articles on Scopus
View full text
Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier B.V. All rights reserved.