The correlation between three methods of skin perfusion pressure measurement: Radionuclide washout, laser Doppler flow, and photoplethysmography

doi:10.1016/0741-5214(92)90717-M

Journal of Vascular Surgery

Volume 15, Issue 5, May 1992, Pages 823-830

Presented at the Fifteenth Annual Meeting of the Midwestern Vascular Surgical Society, Chicago, Ill., Sept. 20–21, 1992.

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Abstract

The most accurate measurement of skin perfusion pressure is made with use of radioisotopic clearance techniques. We compared the skin perfusion pressure using radioisotope to the skin perfusion pressure measured simultaneously by placing laser Doppler and photoplethysmography probes within a transparent polyvinylchloride plastic blood pressure cuff in 13 subjects. A new device, which was created for this experiment, consisted of a plastic bladder into which light-emitting probes can be placed, so that the pressure applied to the skin was transmitted by the surface of the bladder, rather than by the surface of a rigid probe. The cuff was inflated to a suprasystolic pressure over the intradermal injection site of technitium Tc 99m, then deflated in 10 mm Hg decrements at 3-minute intervals. The pressures at which radioisotope clearance began, at which microcirculatory flow was detected by laser Doppler, and at which deflection of the photoplethysmography (DC mode) output occurred, were recorded as the skin perfusion pressure. The range of radioisotopic determined skin perfusion pressure was 0 to 100; skin perfusion pressure-laser Doppler was 0 to 100; and skin perfusion pressure-photoplethysmography was 60 to 100, with 7 of 13 limbs demonstrating no clear deflection point and thus an unobtainable skin perfusion pressure-photoplethysmography reading. Linear regression revealed a coefficient of correlation of 0.991 for skin perfusion pressure when the radioisotopic and laser Doppler methods were compared. Our study is not in agreement with previous reports of the successful determination of skin perfusion pressure with use of photoplethysmography. This may be due to differences in our technique when compared with previous reports of skin perfusion pressure-photoplethysmography determination. We conclude that the determination of skin perfusion pressure with the laser Doppler is a simple bedside technique, easily measured in a noninvasive vascular laboratory, yielding results that correlate well with the determination of skin perfusion pressure by means of radioisotope clearance. (J Vasc Surg 1992;15:823–30.)

Section snippets

Methods

We compared the SPP using the radionuclide washout method to the SPP measured simultaneously by placing laser Doppler and PPG probes within a transparent blood pressure cuff in 13 limbs. The mean age of normal subjects was 34.5 years and of patients with ischemic limbs 67.3 years (range, 26 to 77 years).

The experimental protocol was approved by the Internal Review Board of Morristown Memorial Hospital for use with human subjects, all of whom gave informed consent.

Only the return of

Results

The range of SPP determined by radionuclide washout was 0 to 100;SPP-laser Doppler was 0 to 100; and SPP-PPG was 60 to 100, with 7 of 13 limbs demonstrating no clear deflection point on PPG, and thus giving no obtainable SPP. A marked deflection of the PPG in the DC mode is the result of a sudden influx of blood. When the pressure is deflated over a long period of time, no sudden influx results, and there is no clear deflection in our experience.

Linear regression revealed a coefficient of

Discussion

The diabetic patient with occlusive vascular disease is difficult to evaluate accurately with noninvasive methods. 10, 11, 12 Segmental systolic pressures are unreliable because of medial calcification; the more accurate indexes obtained with toe pressures are often impossible to measure in this population either because of direct involvement of the digit in the gangrenous process or because of previous minor amputations. Toe pressure measurements are difficult to make at low values, and in the

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Cited by (40)

Photoplethysmography for the assessment of peripheral vascular disease
2021, Photoplethysmography: Technology, Signal Analysis and Applications
This chapter focuses on Photoplethysmography (PPG) and its application to peripheral vascular disease assessment of the arteries, veins, and microcirculation. A significant emphasis is placed on PPG pulse measurement and analysis for the detection of occlusive peripheral arterial disease (PAD), particularly for assessments utilizing innovative multisite pulse technology. The chapter also shows the potential of PPG for microvascular assessment including the vasospastic condition known as Raynaud's which can be secondary to an underlying medical condition. The application of PPG for peripheral venous insufficiency and reflux assessment is also overviewed. There remains great scope to advance the role of PPG in the assessment of macro- and microcirculation across a range of clinical measurement and research settings.
Vasodilator Response Correlates with Outcome in Chronic Critical Limb Ischemia
2010, Journal of Surgical Research
Citation Excerpt :
SPP was determined using a laser Doppler scanner (LASERDOPP PV2000; Vasamedics, Eden Prairie, MN). The measurements were performed as described by Malvezzi et al. [10]. The patient was placed in the supine position in a room at temperature of 24 to 25°C.
There are few predictors of limb salvage in patients with critical limb ischemia (CLI). We evaluated the accuracy of correlation of skin perfusion pressure (SPP) measurements in response to vasodilation to clinical outcome.
Patients with CLI were evaluated by SPP at baseline. After injection of the vasodilator alprostadil, SPP was re-evaluated at 120 min and at day 7.
Patients showing clinical improvement demonstrated increased SPP in response to vasodilation (120 min: 34.12±2.44 to 48.33±3.41 mm Hg, P < 0.01; day 7: 33.13±3.14 to 45.83±3.79 mm Hg, P < 0.01), whereas patients who clinically deteriorated demonstrated no increase in SPP (120 min: 30.00±2.67 to 35.00±2.31 mm Hg, P = 0.086; day 7: 35.00±3.54 to 27.5±4.33 mm Hg, P = 0.22).
Prognosis for limb salvage correlated with SPP improvement post-vasodilator treatment after both early and late time points. Measurement of SPP after vasodilator treatment may be clinically useful in the treatment of patients with CLI. A multi-center trial of SPP in response to vasodilators is warranted.
Clinical reliability and utility of skin perfusion pressure measurement in ischemic limbs-Comparison with other noninvasive diagnostic methods
2008, Journal of Vascular Surgery
We studied whether the measurement of skin perfusion pressure (SPP) is useful for evaluating ischemic limbs and predicting wound healing.
Two hundred eleven patients (age range, 45 to 90 years; mean age, 69.6 ± 9.2 years; 170 men and 41 women), 403 limbs with arteriosclerosis obliterans, were included in this study. Half of the patients had diabetes or were receiving dialysis or both.
Significant correlations were found between SPP and ankle blood pressure (ABP), SPP and toe blood pressure (TBP), and SPP and the transcutaneous oxygen pressure (tcPO₂) (P < .0001, r = 0.75; P < .0001, r = 0.85; P < .0001, r = 0.62; respectively). In 94 limbs with ulcer or gangrene, wound healing was predicted by the SPP. The mean SPP (mean ± SD) in the healed-wound group (25 limbs, 48 ± 20 mm Hg) was greater than that in the unhealed-wound group (69 limbs, 23 ± 11 mm Hg) (P <.001). According to the receiver operating characteristic (ROC) curve, the cut-off value of SPP was 40 mm Hg (sensitivity, 72%; specificity, 88%). Furthermore, we studied whether the combination of SPP and another measurement could predict wound healing more accurately than could any single variable. There was a strong correlation between SPP, TBP, and the healing rate (P < .001, r = 0.69) and healing could be accurately predicted if the SPP was greater than 40 mm Hg and if the TBP was greater than 30 mm Hg.
Our results suggest that measurement of SPP is an objective method for assessing the severity of peripheral arterial disease or for predicting wound healing.
When is a more proximal amputation needed?
2005, Clinics in Podiatric Medicine and Surgery
The Role of Skin Perfusion Pressure and Transcutaneous Partial Pressure Oxygen Measurements in Chronic Critical Limb Ischemia
2005, Vascular Diagnosis
Laser Doppler skin perfusion pressure in the assessment of Raynaud's phenomenon
2004, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
Castronuovo et al. reported a new non-invasive technique for skin perfusion pressure measurement using laser Doppler.12 Measurement with a laser Doppler probe can be performed in a few minutes and its result correlates well with the results of skin perfusion pressure by means of the radionuclide washout method.6,12 Non-invasive examinations with the laser Doppler method have now been widely used in vascular laboratories.
Objectives. In the assessment of Raynaud's phenomenon, objective evaluation of digital microcirculatory flow is important, and so we investigated whether the measurement of laser Doppler skin perfusion pressure could be of use.
Materials and methods. Ten fingers of five patients with secondary Raynaud's phenomenon due to systemic sclerosis, 22 fingers of 11 patients with primary Raynaud's phenomenon and 10 fingers of five control patients were examined. Skin perfusion pressure was measured on the third finger of both hands at rest, and then again 3 min after local cold exposure.
Results. Laser Doppler skin perfusion pressure at rest in patients with secondary Raynaud's phenomenon was significantly lower than that in patients with primary Raynaud's phenomenon and the control patients (p<0.05). Skin perfusion pressure decreased significantly in both patient groups upon local cold exposure (p=0.005). There were significant differences in perfusion pressure after cold exposure among both groups (p<0.05).
Conclusions. The low skin perfusion pressure at rest in patients with secondary Raynaud's phenomenon suggested the presence of obstructive arterial lesions. The marked pressure decrease in all Raynaud's patients after local cold exposure might be due to vasospasm of the microvasculature in the digits. These results indicate that the measurement of laser Doppler skin perfusion pressure is valuable in the diagnosis of Raynaud's phenomenon.

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^*: Supported by the Reeves Surgical Research Fund.

^**: Reprint requests: John J. Castronuovo, Jr., MD, Department of Surgery, Morristown Memorial Hospital, 100 Madison Ave., Morristown, NJ 07962-1956.

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Original Articles from the Midwestern Vascular Surgical SocietyThe correlation between three methods of skin perfusion pressure measurement: Radionuclide washout, laser Doppler flow, and photoplethysmography*,**

Abstract

Section snippets

Methods

Results

Discussion

J VASC SURG

J VASC SURG

Am J Surg

Eur J Vasc Surg

Skin perfusion pressure measured as the external pressure required to stop isotope washout

Scand J Clin Lab Invest

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

Acta Orthop Scand

Original Articles from the Midwestern Vascular Surgical Society
The correlation between three methods of skin perfusion pressure measurement: Radionuclide washout, laser Doppler flow, and photoplethysmography*,**