Photoplethysmographic characteristics of the efficiency of the calf muscle-venous pump in norm and in patients with cvd of various clinical classes according to CEAP

Introduction. A literature review on the use of plethysmographic methods for studying the features of venous blood flow in lower extremities under physiological conditions and for global assessment of venous hemodynamics in chronic venous diseases urges to conduct further studies.
The aim of the study was to carrying off a detailed statistical analysis of the value of the refilling time (RT) obtained during a photoplethysmographic study (PPG) to evaluate the degree of effectiveness of the calf muscle-venous pump in normal and in patients of different clinical classes according to CEAR.
Materials and methods. For the period from 2002 to 2012, 116 healthy individuals with no symptoms of chronic venous diseases and 530 patients with CVD were examined with the use of PPG, with their distribution in accordance with the CEAR international classification as follows: C0-C1 – 140 people (26.42%), C2-C3 – 218 people (41.13%) and 172 persons (32.45%) had trophic disorders, that is, they belonged to the C4-C6 clinical classes. The analysis of the statistical significance of the obtained mathematical characteristics in groups by conducting a t-test for two independent samples calculated by the program and the student’s criterion Z-statistics, to conduct a correlation analysis.
Results and discussion. Statistical comparative analysis of the RT value as a result of the t-test at the significance level p < 0,05 showed statistically significant differences between С0-С1, С2-С3 and С4-С6 groups with test with (or no) compression cuff. A stable correlation of average strength was observed between the groups in all cases. The differences were not statistically significant between the Norm and C0-C1 groups. The testing hypotheses for adequacy using linear regression methods allowed us to conclude that conducting a photoplethysmographic examination of patients with CVD of different clinical classes as part of the venous reflux test can provide objective information about the effectiveness of the calf muscle - venous pump. A comparative analysis in groups using the criteria RT > 20 sec and 10 < RT < 20 sec showed that there was no correlation between many groups.
Conclusion. PPG is not a universal tool for diagnosing disorders of venous hemodynamics in the lower extremities. The value of RT > 20 seconds can be used as a criterion for evaluating the effectiveness of the calf muscle-venous pump, since more than 70% of cases occur in norm and in patients with C0-C1 clinical classes.

1. Lazarenko V.A., Sannikov A.B. Diagnostics of hemodynamic disorders in patients with varicose veins. kursk: kGMu; 2003. 105 p. (In Russ.) Available at: https://library.kursksmu.net.

2. Barnes R.W., Garret W.V., Hummel E.E., Siamaker E.E., Maixner W., Reinertson J.E. Photoplethysmographic assessement of altered cutaneous circulation in the postphlebitic syndrome. Proc Assoc Adv Med Instrum. 1978;13:25–29.

3. Breslau P.J., Van Soest M.G., Prevoo R., Jagtman B. hemodynamic parameters for venous valve incompetence in the lower extremity. Neth J Surg. 1986;3818(1):1–5. Available at: https://pubmed.ncbi.nlm.nih.gov/3515233.

4. McEnroe C. S., O’Donnell T.F., Mackey W.C. Correlation of clinical findings with venous hemodynamics in 386 patients with chronic venous insufficiency. Am J Surg. 1988;156(2):148–152. doi: 10.1016/S0002-9610(88)80377-5.

5. Nicolaides A.N., Miles C. Photoplethysmographyin the assessment of venous insufficiency. J Vasc Surg. 1987;5(3):405–412. Available at: https://pubmed.ncbi.nlm.nih.gov/3334678.

6. Abramowitz H.B., Queral L.A., Flinn W.R., Nora P.F.Jr., Peterson L.K., Bergan J.J., Yao J.S. The use of photoplethysmography in the assessment of venous insufficiency: a comparison to venous pressure measurements. Surgery. 1979;86(3):434–441. Available at: https://pubmed.ncbi.nlm.nih.gov/473029.

7. Bays R.A., Healy D.A., Atnip R.G., Neumyer M., Thiele B.I. Validation of air plethysmography, photoplethysmography and duplex ultrasonography in the evaluation of severe venous stasis. J Vasc Surg. 1994;20(5):721–727. doi: 10.1016/S0741-5214(94)70159-8.

8. Sharif-kashani B., Behzadnia N., Shahabi P., Sadr M. Screening for deep vein thrombosis in asymptomatic high-risk patients: a comparison between digital photoplethysmography and venous ultrasonography. Angiology. 2009;60(3):301–307. doi: 10.1177/0003319708323494.

9. Welch H.J., Faliakou E.C., McLaughlin R. I., Umphrey S.E., Belkin M., O’Donnell T.F. Jr. Comparison of descending phlebography with quantitative photoplethysmography, air plethysmography and duplex quatitative valve closure time in assessing deep venous reflux. J Vasc Surg. 1992;16(6):913–920. doi: 10.1016/0741-5214(92)90054-C.

10. Pokrovski JA. V., Sapelkin S.V., Galaktionova L.A., Fedorov E.E. The assessment of medical therapy effectiveness of patients with lower limb chronic venous insufficiency: the results of prospective study with Ginkor fort. Angiologiya i sosudistaya khirurgiya = Angiology and Vascular Surgery. 2005;11(3):47–55. (In Russ.) Available at: http://www.angiolsurgery.org/magazine/2005/3.

11. Darvall K.A. L., Sam R.C., Bate G.R., Adam D.J. Silverman S.H., Bradbury A.w. Photoplethysmographyc venous refilling times following ultrasound guided foam sclerotherapy for symptomatic superficial venous reflux: relationship with clinical outcomes. Eur J Vasc Endovasc Surg. 2010;40(2):267–272. doi: 10.1016/j.ejvs.2010.02.025.

12. Saliba Júnior O.A., Giannini M., Mórbio A.P., Saliba O., Rollo H.A. Pre- and postoperative evaluation by photoplethysmography in patients receiving surgery for lower-limb varicose veins. Int J Vasc Med. 2014;2014:562782. doi: 10.1155/2014/562782.

13. Dezotti N.R.A., Dalio M.B., Ribeiro M.S., Piccinato C.E., Joviliano E.E. The clinical importance of air plethysmography in the assessment of chronic venous disease. J Vasc Bras. 2016;15(4):287–292. doi: 10.1590/1677-5449.002116.

14. Bogachev V.Yu., Boldin B.V., Arkadan N.R., Lobanov V.N. Some features of compression therapy for early forms of chronic venous diseases of the lower limbs. Ambulatornaya khirurgiya = Ambulatory Surgery (Russia). 2019;(3-4):89–94. (In Russ.) doi: 10.21518/1995-1477-2019-3-4-89-94.

15. Sannikov A.B., Emelyanenko V.M., Drozdova I.V. Review of the plethysmographic methods for studying hemodynamic disorders in patients with chronic lower extremites venous diseases. Ambulatornaya khirurgiya = Ambulatory Surgery (Russia). 2020;(1–2):58–70. (In Russ.) doi: 10.21518/1995-1477-2020-1-2-58-70.

16. Beraldo S., Satpathy A., Dodds S.R. A study of the routine use of venous photoplethysmography in a one-stop Vascular Surgery clinic. Ann R Coll Surg Engl. 2007;89(4):379–383. doi: 10.1308/003588407x183355.

17. Savelev V.S. (ed.). Phlebology. Moscow: Medicina; 2001. 660 p. (In Russ.).

18. Leon M., Volteas N., Labropoulos N., kalodiki E., Chan P., Belcaro G., Nicolaides A.N. The effect of elastic stockings on the elasticity of varicose veins. Int Angiol. 1993;12(2):173–177. Available at: https://pubmed.ncbi.nlm.nih.gov/8371000.

19. Dunn R.M., Fudem G.M., Walton R.L., Anderson F.A., Malhotra R. Free flap valvular transplantation for refractory venous ulceration. J Vasc Surg. 1994;19(3):525–531. doi: 10.1016/S0741-5214(94)70081-8.

20. Gonzales-Fajardo J.A., Rodríguez-Camarero S.J., de Marino P., Castro V.M.A., March G.J.R., Carpinteiro M.L. Photopletysmographic evaluation of the effect of a vascular tonic drug. Angiologia. 1990;42(5):167–171. Available at: https://pubmed.ncbi.nlm.nih.gov/2285166.

21. Gaitini D., Torem S., Pery M., Kaftori J.K. Image-directed Doppler ultrasound in the diagnosis of lower-limb venous insufficiency. J Clin Ultrasound. 1994;22(5):291–297. doi: 10.1002/jcu.1870220502.

22. Fonseca F.P., Sarquis A.L., Evangelista S.S.M. Surgery for Primary Troncular Varicose Veins without Stripping the Saphenous Vein — Pre- and Post-Operative Evaluation by Duplex Scan and Photoplethysmography. In: Negus D., Jantet G., Coleridge-Smith P.D. (eds.). Phlebology ’95. Springer, London; 1995. doi: 10.1007/978-1-4471-3095-6_183.

23. Tucker E.A., Lamb L.E., Callicott C., Cooke S.D., Cooke E.D. Measurements of calf muscle pump efficiency during simulated ambulation. Int Angiol. 1998;17(4):255–259. Available at: https://pubmed.ncbi.nlm.nih.gov/10204658.

24. Sarin S., Shields D.A., Farrah J., Scurr J.H., Coleridge Smith P.D. Photoplethysmography: A valuable noninvasive tool in the assessment of venous dysfunction? J Vasc Surg. 1992;16(2):154–162. doi: 10.1016/0741-5214(92)90103-F.

25. Orsted H.L., Radke L., Gorst R. The impact of musculoskeletal changes on the dynamics of the calf muscle pump. Ostomy Wound Manage. 2001;47(10):18–24. Available at: https://pubmed.ncbi.nlm.nih.gov/11890075.

26. Khorev N.G., Kuznetsova D.V., Kon’kova V.O., Shoikhet Ya.N. Plethysmography as a method for the functional evaluation of venous reflux and obstruction associated with chronic venous disease. Flebologiya. 2017;18(1):32–36. (In Russ.) doi: 10.17116/flebo201711132-36.

27. Lazarenko V.A., Sannikov A.B., Shevelev E.L. Segmental venous hypervolemia as one of the main pathohemodynamic factors of development and progression of chronic venous insufficiency of the lower extremities in patients with varicose disease. Vestnik hirurgii im. I.I. Grekova = Grekov’s Bulletin of Surgery. 2003;5:18–25. (In Russ.) Available at: https://elibrary.ru/item.asp?id=30560345.

28. Sannikov A.B., Emelianenko V.M., Rachkov M.A. The specific anatomical features of structure of the calf intramuscular veins in the healthy subjects and the patients presenting with chronic venous disease: Data Obtained by multi-spiral computed phlebography. Flebologiya. 2018;(4):292–299. (In Russ.) doi: 10.17116/flebo201812041292.

29. Shaĭdakov E.V., Sannikov A.B., Emelianenko V.M., Rachkov M.A., Drozdova I.V., Solokhin S.A. Variants of ectatic development of the leg intramuscular veins in patients with chronic venous diseases according to multispiral computed tomography phlebography. Operativnaya hirurgiya i klinicheskaya anatomiya = Russian Journal of Operative Surgery and Clinical Anatomy. 2019;3(3):22–30. (In Russ.) doi: 10.17116/operhirurg2019303122.

30. Shaidakov E.V., Sannikov A.B., Emel’yanenko V. M., Rachkov M.A., Drozdova I.V. ultrasound criteria of diameter of the intramuscular veins of the leg in the normal and the degree of their ectasia in varicose disease of the lower extremities: results of a multicenter controlled comparative study. Operativnaya hirurgiya i klinicheskaya anatomiya = Russian Journal of Operative Surgery and Clinical Anatomy. 2020;4(3):16–24. (In Russ.) doi: 10.17116/operhirurg2020403116.