Lower limb venous haemodynamic impairment on dependency: quantification and implications for the “economy class” position

Konstantinos T. Delis; Alison L. Knaggs; Tans N. Sonecha; Vasileios Zervas; Michael P. Jenkins; John H. N. Wolfe

doi:10.1160/TH03-12-0754

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2004; 91(05): 941-950
DOI: 10.1160/TH03-12-0754

Blood Coagulation, Fibrinolysis and Celular Haemostasis

Schattauer GmbH

Lower limb venous haemodynamic impairment on dependency: quantification and implications for the “economy class” position

Konstantinos T. Delis

¹Department of Vascular Surgery, Imperial College, Faculty of Medicine, London, UK

,

Alison L. Knaggs

²Department of Anaesthesia, St. Mary’s Hospital, Imperial College, Faculty of Medicine, London, UK

,

Tans N. Sonecha

¹Department of Vascular Surgery, Imperial College, Faculty of Medicine, London, UK

,

Vasileios Zervas

¹Department of Vascular Surgery, Imperial College, Faculty of Medicine, London, UK

,

Michael P. Jenkins

¹Department of Vascular Surgery, Imperial College, Faculty of Medicine, London, UK

,

John H. N. Wolfe

¹Department of Vascular Surgery, Imperial College, Faculty of Medicine, London, UK

› Author Affiliations

Abstract

Summary

The role of stasis in venous disease is undisputed, yet surprisingly, its haemodynamic quantitation remains largely undefined. We investigated the phenomenon of venous stasis in the lower limb upon sitting and standing and project its implications to economy class aircraft passengers. 26 normal limbs, 13 subjects, age 29-54, selected after duplex, plethysmography and ABPI, had peak[V_peak], mean[V_mean] and minimum[V_min] velocities, volumeflow[Q_venous], pulsatility index [PI_venous] and diameter obtained on horizontal, sitting (as in economy aircraft seats) and standing with duplex, at popliteal, femoral[FV] and common femoral[CFV]veins [differences in median %]. V_peak, V_mean and Q_venous decreased from horizontal to sitting in the CFV [57%, 71%, 31%, respectively], FV [51%, 70%, 34%] and popliteal [31%, 58%, 42%] (all, p<.001). V_peak, V_mean and Q_venous decreased further from sitting to standing in the CFV [26%, 44%, 25%, respectively], FV [21%, 42%, 27%] and popliteal [14%, 42%, 20%] (all, p <.001). Diameter, V_min and PI_venous increased from horizontal to sitting in the CFV [50%, 63%, 38%, respectively], FV [39%, 23%, 66%] and popliteal [21%, 14%, 84%] (all, p <.001)]. Diameter, V_min and PI_venous increased further from sitting to standing in CFV [10%, 22%, 19%, respectively; p ≤.004], FV [12%, 68%, 2%_[ns]; p <.001)] and popliteal [14%, 50%, 24%; p ≤.017]. In all postures: V_peak, V_mean, Q_venous and diameter at CFV exceeded FV (p <.025) and popliteal (p <.001) ones; also those at FV exceeded the popliteal ones (p ≤.003), except for the diameter on horizontal. V_min in popliteal was higher than in CFV (p ≤.003) or FV (p <.025), on horizontal and standing. PI_venous in CFV was lower than in FV or popliteal (p <.025) on sitting. Right to left differences nonsignificant. [Wilcoxon_+Bonferroni test: significance at p <.025] A shift from horizontal to sitting generates a most significant attenuation in Q_venous, V_peak and V_mean linked to a reciprocal increase in V_min, PI_venous and vein diameter, with further exacerbation on standing. V_peak, V_mean and Q_venous decline with distance from groin enhancing venous stasis in the periphery. By restricting activation of the natural venous pumps, sitting cramped during long flights may protract the status of haemodynamic stagnation sustained on dependency which paired with marked venous dilatation generates a milieu that may promote thrombogenesis.

Keywords

Venous stasis - haemodynamics - dependency - flow quantification - coagulation - economy class

Full Text

References

References
1 Nordstrom M, Lindblad B, Bergqvist D. et al. A prospective study of the incidence of deepvein thrombosis within a defined urban population. J Intern Med 1992; Aug; 232 (02) 155-60.
2 Kahn RR, Solymoss S, Lamping DL. et al. Long-term outcomes after deep vein thrombosis: postphlebitic syndrome and quality of life. J Gen Inter Med 2000; 15: 425-9.
3 Ruckley CV. Socioeconomic impact of chronic venous insufficiency and leg ulcers. Angiology 1997; 48 (01) 67-9.
4 Smith JJ, Garratt AM, Guest M. et al. Evaluating and improving health related quality of life in patients with varicose veins. J Vasc Surg 2000; 30: 710-9.
5 Nicolaides AN. and consensus authors. Investigation of chronic venous insufficiency. Circulation 2000; 102: e126-63.
6 Mitchell RN. Hemodynamic disorders, thrombosis and shock. In Robbins SL, Cotran RS, Kumar V, Collins T. (editors): Pathologic basis of disease. W.B. Saunders; Philadelphia: 1999: 71-88.
7 Chevru A, Clagett P. Bleeding and clotting disorders. In Dean RH, Yao JST, Brewster DC. (eds): Current diagnosis and treatment in vascular surgery. Appleton and Lange; Connecticut: 1995: 55-79.
8 Meissner MH, Strandness Jr DE. Pathophysiology and natural history of acute DVT. In Rutherford RB. (editor): Vascular Surgery. WB Saunders; Philadelphia, Pennsylvania: 2000: 1920-37.
9 Ashby EC, Ashford NS, Campbell MJ. Posture, blood velocity in common femoral vein, and prophylaxis of venous thromboembolism. Lancet 1995; Feb 18, 345 8947 419-21.
10 Ansell JE. Air travel and venous thromboembolism. N Engl J Med 2001; 345 (11) 828-9.
11 Scurr JH, Machin SJ, Bailey-King S. et al. Frequency and prevention of symptomless deep-vein thrombosis in long-haul flights: a randomised trial. Lancet 2001; May 12; 357 (9267): 1485-9.
12 Lapostolle F, Surget V, Borron SW. et al. Severe pulmonary embolism associated with air travel. N Engl J Med 2001; 345 (11) 779-83.
13 Agu O, Hamilton G, Baker D. Graduated compression stockings in the prevention of venous thromboembolism. Br J Surg 1999; Aug 86 (08) 992-1004.
14 Delis KT, Slimani G, Hafez HM. et al. Enhancing venous outflow in the lower limb with intermittent pneumatic compression. A comparative haemodynamic analysis on the effect of foot vs. calf vs. foot and calf compression. Eur J Vasc Endovasc Surg 2000; Mar; 19 (03) 250-60.
15 Alishahi S, Francis N, Crofts S. et al. Central and peripheral adverse hemodynamic changes during laparoscopic surgery and their reversal with a novel intermittent sequential pneumatic compression device. Ann Surg 2001; Feb 233 (02) 176-82.
16 Delis KT, Nicolaides AN, Wolfe JHN. et al. Improving walking ability and ankle brachial pressure indices in symptomatic peripheral vascular disease using intermittent pneumatic foot compression: a prospective controlled study with one year follow-up. J Vasc Surg 2000; 31: 650-61.
17 Delis KT, Ibegbuna V, Nicolaides AN. et al. Prevalence and distribution of incompetent perforating veins in chronic venous insufficiency. J Vasc Surg 1998; Nov 28 (05) 815-25.
18 Delis KT, Husmann M, Kalodiki E. et al. In situ hemodynamics of perforating veins in chronic venous insufficiency. J Vasc Surg 2001; Apr 33 (04) 773-82.
19 Nicolaides AN, Kalodiki E. The contribution of colour flow imaging in postoperative surveillance for DVT. In Bergqvist D, Comerota AJ, Nicolaides AN, Scurr JH. (editors): Prevention of venous thromboembolism. Med-Orion; London: 1994: 93-102.
20 Delis KT, Nicolaides AN, Stansby G. Effect of posture on popliteal artery hemodynamics. Arch Surg 2000; Mar 135 (03) 265-9.
21 Altman DG. Practical Statistics for medical research. Chapman and Hall/CRC; Boca Raton: 1999
22 Thies R. Circulatory Hemodynamics. In Thies R. (editor): Physiology. Springer-Verlag; NY: 1995
23 Delis KT, Nicolaides AN, Wolfe JH. Peripheral sympathetic autoregulation in arterial calf inflow enhancement with intermittent pneumatic compression. Eur J Vasc Endovasc Surg 2001; 22: 317-25.
24 Labropoulos N. Thesis. University of London: 1995
25 Wu A, Mansfield AO. The morphological changes of the endothelium to venous stasis as observed under the scanning electron microscope. J Cariovasc Surg (Torino) 1980; 21 (02) 193-202.
26 Neri GGSerneri. Pathophysiological aspects of platelet aggregation in relation to blood flow rheology in microcirculation. Ric Clin Lab 1981; 11 Suppl: (Suppl. 01) 39-46.
27 Shreeniwas R, Koga S, Karakurum M. et al. Hypoxia mediated induction of endothelial cell interleukin-1 alpha: An autocrine mechanism promoting expression of leukocyte adhesion molecules on the vessel surface. J Clin Invest 1992; 90 (06) 2333-9.
28 Delis KT, Azizi Z, Stevens RGJ. et al. Determining the optimum intermittent pneumatic compression stimulus for lower limb venous emptying using direct pressure measurements. Eur J Vasc Endovasc Surg 2000; 19 (03) 261-70.
29 Gardner AMN, Fox RH. Peripheral venous physiology. In Gardner AMN, Fox RH. (editors): The return of blood to the heart. John Libbey; London: 1993: 61-88.
30 Hamer JD, Malone PC. Experimental deep venous thrombogenesis by a non-invasive method. Ann R Coll Surg Engl 1984; 66: 416-9.
31 Malone PC. Air travel and risk of venous thromboembolism (letter). BMJ 2001; 322: 1183-4.
32 Slimani G. Effect of intermittent pneumatic compression on lower limb venous haemodynamics. Thesis; University of London: 1997
33 Symington IS, Stack BHR. Pulmonary thromboembolism after travel. Br J Chest 1977; 17: 138-40.
34 Landgraf H, Vanselow B, Schulte-Huermann D. et al. Economy class syndrome: rheology, fluid balance, and lower leg edema during a simulated 12-hour long distance flight. Aviat Space Environ Med 1994; Oct; 65 (10 Pt 1): 930-5.
35 Gertler JP, Perry L, L’Italien G. et al. Ambient oxygen tension modulates endothelial fibrinolysis. J Vasc Surg 1993; 18: 939-46.
36 Carruthers M, Arguelles AE, Mosovich A. Man in transit: biochemical and physiological changes during intercontinental flights. Lancet 1976; 01: 977-81.
37 Bendz B, Rostrup M, Sevre K. et al. Association between acute hypobaric hypoxia and activation of coagulation in human beings (Research Letter). Lancet 2000; 356: 1657-8.