Hypertensive extracorporeal limb perfusion for critical limb ischemia

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Hypertensive extracorporeal limb perfusion for critical limb ischemia Nyan Y. Khin, BE, Martijn L. Dijkstra, MD, Matt Huckson, MEng, Mark Phillips, PhD, Darryl McMillan, CCP, Seiji Itoh, MD, Greg Roger, MD, Rodney J. Lane, MD Journal of Vascular Surgery Volume 58, Issue 5, Pages 1244-1253 (November 2013) DOI: 10.1016/j.jvs.2013.05.004 Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 1 Schematic shows two peripheral access systems (PASs) with isolation from the systemic circulation via an inflatable extravascular balloon. Device 1 is the inflow from the heart to the pump. Device 2 takes blood from the pump to the isolated limb at high pressures and flows. Journal of Vascular Surgery 2013 58, 1244-1253DOI: (10.1016/j.jvs.2013.05.004) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 2 The inflatable balloon is placed circumferentially around the arterial inflow to isolate the ischemic limb. The diameter is fixed via sutures through the strap. The tube is passed externally for manual inflation and deflation as required. Journal of Vascular Surgery 2013 58, 1244-1253DOI: (10.1016/j.jvs.2013.05.004) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 3 A polytetrafluoroethylene adventitia “skirt” is placed around the primary anastomosis to minimize bleeding. This is fixed to the adventitia by a continuous PROLENE suture (Ethicon, Somerville, NJ) after appropriate fashioning. Journal of Vascular Surgery 2013 58, 1244-1253DOI: (10.1016/j.jvs.2013.05.004) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 4 Two flexible access systems in situ in the right common femoral artery with exit cutaneous foramina. The extravascular balloon cuff is not visible. The metal caps lock the internal plunger in position to avoid patient tampering. Device 1 is the inflow from the heart to the pump. Device 2 takes blood from the pump to the isolated limb at high pressures and flows. Journal of Vascular Surgery 2013 58, 1244-1253DOI: (10.1016/j.jvs.2013.05.004) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 5 A 24-hour sequence with pressure and flow variation plotted against time. As time progresses, there is a gradual increase in flow with an associated decrease in the required pump pressure. This relationship reflects a decrease in peripheral resistance. Journal of Vascular Surgery 2013 58, 1244-1253DOI: (10.1016/j.jvs.2013.05.004) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 6 Graph shows pressure vs flow at different times. Initial flow rates are compared with those 12 hours later, after a rest period and after pump reconnection, and then again after 24 hours. Peripheral resistance improved after different pumping sessions. Journal of Vascular Surgery 2013 58, 1244-1253DOI: (10.1016/j.jvs.2013.05.004) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 7 Monitoring thermogram is used to indicate the need for pump reconnection. This system is helpful for long-term follow-up. These images correspond to the clinical presentation. After receiving hyperperfusion, thermographic improvement is maintained. Journal of Vascular Surgery 2013 58, 1244-1253DOI: (10.1016/j.jvs.2013.05.004) Copyright © 2013 Society for Vascular Surgery Terms and Conditions