NEW NON-INVASIVE METHOD FOR MEASURING COEFFICIENT ОF MICROCIRCULATION

122M. M. Mantskava

 

I.Beritashvili Center of Experimental Biomedicine, 0160, Tbilisi, Georgia, L.Gotua St.14,

 e-mail: mantskavamaka@rambler.ru

                             

 

               Annotation. The resistive arteries of blood circulatory system appear to be the subject for indirect diagnostic studies of microcirculatory channel. At not altered levels of general arterial and venous pressure, the blood flow velocity measured in the resistive arteries depends precisely on the state of the relevant resistive arteries, as a result of its branching. We used an ultrasonic device "Dop 8/4" (Germany) with four inputs for probes with built-in self-recorder. According to the dynamics of changes in blood flow velocity in the radial and posterior tibial arteries in all leads after standard ischemia during the development of post-ischemic hyperemia, the state of branching of the resistive arteries, as well as the blood filling of microcirculatory channel can be judged.For description of the reactions of resistive arteries in all leads, which control a peripheral resistance and microcirculation, the coefficient of microcirculation k has been introduced, which appears to be the ratio of the total post-ischemic blood flow to the average volumetric background blood flow.

 

Physical meaning of microcirculation coefficient – the ratio of post-ischemic blood flow in four leads simultaneously to an average background blood flow in time unit equals the coefficient of microcirculation. The necessity of the evaluation of peripheral system is dictated by the active participation of microcirculation in the development of cardio-vascular system diseases, neuro-humoral disorders, endocrine changes, angiologic pathologies, diseases of the musculoskeletal system, at reconstructive surgeries, at postoperative period and many other pathological situations. The direct not-invasive methods of microcirculation promotes to the improvement of the tactics for the treatment of diseases and their complications, especially at hypertension, diabetic foot, reconstructive surgeries, fractures, a varicose phlebectasia, atherosclerotic phenomena, allergies, Raynaud's disease, etc. 

Key words: Resistive artery, microcirculation, coefficient of microcirculation

 

            Blood Circulation consists of macro- and microcirculation. At the anatomical border of these parts the resistive arteries are located. Being certain taps of blood circulation the resistive arteries provide the transfer of blood to the periphery. The functional state of resistive arteries depends on endothelial factor, while the elasticity of blood vessels forms the tonus of resistive arteries. The resistive arteries are in charge of intravascular state of blood, also they play an indirect role in angiogenesis, in the provision of relative parallelism of coagulation/anticoagulation and in constriction/dilation. Normal blood supply of all organs and tissues, the constancy of the level of total blood pressure, to a large extent, are due to the peripheral resistance of blood circulatory system of, for which the resistive arteries are responsible. The adequacy of microcirculation in organs and tissues is due to the functional state of resistive arteries which regulate the vascular lumen. The resistive arteries take part in the development of compensatory and pathological processes in the system of regional blood circulation and microcirculation. Besides, the resistive arteries of blood circulatory system appear to be the subject for indirect diagnostic studies of microcirculatory channel [7].

            The present work concerns the description of the original non-invasive method for the calculation of microcirculation coefficient by means of the estimation of resistive arteries functional state.

            The principle of the evaluation of microcirculation coefficient appeared to be the calculation of increased blood flow and the reaction of resistive arteries to regulate blood flow velocity at post-ischemic (reactive) hyperemia, arisen as a result of standard stopping of local blood flow lasting 60 s. The blood flow in the places of pulsation on the left and right hand radial arteries and at the left and right sides of leg posterior tibial arteries in the state of rest was studied (name of leads – SIN H, DEX H, SIN F, DEX F ), as well as at post-ischemic hyperemia in the same leads. The study was performed by means of Doppler device probe (see Fig. 1).

 
   

120

Figure 1. Schematic of the study of microcirculation

 

The Doppler effect occurs when the change in the specific frequency ultrasonic oscillations takes place depending on the velocity of sound source vibrations, where the erythrocytes appear to be the source. The diameter of the erythrocytes does not exceed 7 microns without hematological abnormalities. Depending on the caliber of the vessels, the blood flow differs by various profiles of velocity. The erythrocytes determine the velocity profile, and depending on the contour of vectors shift of multi-speed flows (Magnus effect), the profile of the erythrocyte movement changes, undulating the movement of erythrocyte membrane to a continuous flow. By sending an ultrasonic signal to the radial (SIN H, DEX H) and tibial arteries (SIN F, DEX F) at 45 gradus angle, the reflection of this signal from the erythrocytes of flowing blood is recorded, according to the frequency of incident and reflected signals, the linear blood flow velocity is determined in the corresponding resistive arteries, as a result of the branching of this artery.

At not altered levels of general arterial and venous pressure, the blood flow velocity measured in the resistive arteries depends precisely on the state of the relevant resistive arteries, as a result of its branching. According to the dynamics of changes in blood flow velocity in the radial and posterior tibial arteries in all leads after standard ischemia during the development of post-ischemic hyperemia, the state of branching of the resistive arteries, as well as the blood filling of microcirculatory channel can be judged.

The standardized ischemia was caused by means of compression of shoulder (left, right) and patellar arteries (left, right). The scheme of blood flow in one of the leads in the state of rest is given in the Figure – normal (background) blood flow, at ischemia – absence of blood flow, at post-ischemic hyperemia – an increased blood flow. The curve of blood flow velocity was processed using texture analysis apparatus (Tas-Plus, Leitz) or perhaps by means of an alternative way using a personal computer with a built-in analog-to-digital plateau.

Figure 2. Scheme of the curve of linear flow in one of the leads.

121

 

                        We used an ultrasonic device "Dop 8/4" (Germany) with four inputs for probes with built-in self-recorder. To register a normal (background) flow, the probe was placed in the area of good pulsation audibility on the wrist and medial ankle, and increasing the pressure in the cuffs of sphygmomanometer imposed on the shoulder and patellar arteries, the blood flow was stopped for 60 seconds. After 60 seconds the compression was released, the pressure was quickly reduced to the zero in the cuff and post-ischemic reactive hyperemia was developed. The registration has been continued until the linear velocity of increased blood flow returned to normal background values of blood flow.

The microcirculation appears to be a part of the blood circulatory channel, through which the adequate blood supply of organs and tissues of the organism is provided. It is natural that the evaluation of the microcirculation is particularly informative in terms of the pathogenesis of diseases, their prevention, treatment and prognosis. The vascular changes: violation of thickness, structure and shape of the vessel impact on vessel permeability and transcapillary exchange. While reducing the blood flow velocity an occlusion of the arterioles takes place, which leads to the appearance of the plasmatic capillaries, deprived of the erythrocytes and not providing a transcapillary exchange of full value. Such violations occur at many diseases: DIC-syndrome, a shock of various origins, acute infectious processes, and coagulopathy. In our case, the compression of the arteries is so short, that most likely, the capillaries are not occluded or only a small number of them is "blinded" [3].

The level of microcirculation appears to be the key in cardio-vascular system, while other levels are designed to provide its basic function – transcapillary exchange. The blood with dissolved oxygen and nutrients, necessary for tissue metabolism, is transported from the vascular space into the capillary system [6]. This process takes place according to the laws of diffusion and is determined by means of the gradient of intra- and extravascular hydraulic pressure, as well as the gradient of intra- and extravascular oncotic pressure, by means of which the retention of the fluid in the blood vessels and the return of interstitial fluid are provided.

The ratio of these gradients appears to be the basis of fluid diffusion in arterial part of capillary and of its reabsorbtion – in venous one. The oncotic pressure of the blood is relatively permanent in normal conditions. Therefore a capillary hydrostatic pressure appears to be the determinant of the intensity of transcapillary exchange and the provision of nutrient needs of the tissues [4, 5].  The other sections of the cardiovascular system provide the establishment and maintenance of hydrostatic pressure  [1, 2, 4]. 

Therefore for the assessment of microcirculation it is so essential to investigate the reaction of resistive arteries in four leads. At working hyperemia against the background of the expansion of resistive vessels and the increase of blood flow velocity, the blood pressure increases in the capillaries with the strengthening blood filtration; this is followed by the increase of hematocrit index, ensuring the adequate supply of oxygen to tissues [5]. In the conditions of rest, the increase of resistive vessels tone is accompanied by the reduction of blood flow, the decrease in capillary pressure, the strengthening reabsorbtion of tissue fluid, the reduction of hematocrit and the converting the capillaries part into plasmatic ones –  “blind”.  Hydraulic pressure in the capillaries not always reflects  a systemic pressure. In pathological conditions it can be changed not depending on the changes in arterial pressure level [1]. The expansion of arterioles leads to the increase of capillary pressure even at the background of reduced arterial pressure. After this the extravasation enhances, as well as blood coagulation with the progressive disorder of peripheral blood circulation. If in normal conditions the value of capillary pressure is connected with the tone of pre-capillary resistive vessels, regulating blood flow, then in pathological conditions  the difficulty of blood outflow from the capillaries regarding the contraction or mechanical compression of post-capillary efferent vessels – venules and veins has a decisive significance. Basing on these fundamental laws the microcirculation was determined using the new method, by means of which the evaluation of microcirculation coefficient became possible.

 

The description of experiment

 

The person under examination was placed on a medical couch in horizontal position with hands and legs spread apart in normally lightened room at temperature of 20-230. In all four leads (SIN H, DEX H, SIN F, DEX F, which correspond to left, right point of pulsation on wrist and to left, right points of pulsation on foot) a normal background linear blood flow was registered as a curve on the self-recorder. Background volumetric blood flow rate equals the sum of discrete values of the velocity, which receives all points on the curve during the time interval t. Consequently, volumetric blood flow in the lead SIN H equals ΣV1t, in DEX H – ΣV2 t, in the lead SIN F – ΣV3t and in DEX F – ΣV4t. An average background blood flow equals a total background blood flow divided by 4, i.e. ΣΣV1t/4 = (ΣV1+ ΣV2+ ΣV3+ ΣV4)t/4, where t is a time interval, when the background blood flow is registered. Total post ischemic hyperemia appears to be the sum of enhanced volumetric blood flow in the same four leads – SIN H, DEX H, SIN F, DEX F:  ΣΣV1postt/1post, where V1post – an enhanced linear velocity at post-ischemic hyperemia, t/1post – time interval, when an enhanced linear velocity reaches normal background values at post ischemic hyperemia.

 For description of the reactions of resistive arteries in all leads, which control a peripheral resistance and microcirculation, the coefficient of microcirculation k has been introduced, which appears to be the ratio of the total post-ischemic blood flow to the average volumetric background blood flow.

k – post-ischemic blood flow/average background blood flow  

k=Spost/Sbackground= ΣΣV1postt/1post/ ΣΣV1t

while using mathematical calculations:

k=4(ΣV1t/1+ ΣV2t/2+ ΣV3t/3+ ΣV4t/4)/( ΣV1+ ΣV2+ ΣV3+ ΣV4)t,

where t1, t2, t3, t4 are time intervals, at which the enhanced post-ischemic blood flow in various leads returned to normal background values.

[k]=4 ΣV1postt1post/ ΣV1t.

 

Physical meaning of microcirculation coefficient

 

The ratio of post-ischemic blood flow in four leads simultaneously to an average background blood flow in time unit equals the coefficient of microcirculation.

The necessity of the evaluation of peripheral system is dictated by the active participation of microcirculation in the development of cardio-vascular system diseases, neuro-humoral disorders, endocrine changes, angiologic pathologies, diseases of the musculoskeletal system, at reconstructive surgeries, at postoperative period and many other pathological situations.

The impact on microcirculatory channel for conducting medical and preventive therapies appears to be a topical approach. It became possible thanks to the delivery of a large number of medications to pharmaceutical market, affecting the vascular wall. The direct not-invasive methods of microcirculation promotes to the improvement of the tactics for the treatment of diseases and their complications, especially at hypertension, diabetic foot, reconstructive surgeries, fractures, a varicose phlebectasia, atherosclerotic phenomena, allergies, Raynaud's disease, etc. 

 

Conclusion

The investigation of microcirculation on the basis of its coefficient appears to be very informative. The significance of the given methodology of total peripheral blood flow research and the reaction of arterioles, except a positive fundamental and clinic character also has a financial aspect. If one notes that the method described in this paper appears to be easily investigated and implementable for medical staff in inpatient and outpatient sectors, does not need large spaces of medical institutions, the apparatus is nor very expensive and the method itself is not uncomfortable for patients, then this method maybe recommended for including into the list of tests for functional diagnostics as a direct and quantitative method for the microcirculation determination without extra expenses at the medical institutions, for the insurance companies and patients budget.

Basing on the investigation of microcirculation coefficient, it is possible to diagnose the blood supply of organs and tissues, make adjustments to the treatment strategy and to implement preventive measures. It is necessary to carry out population studies, which will allow the better understanding the pathogenesis of various pathologies in the blood circulation system, as well as to use the methods for the study of diseases, connected with the impairment of functions. 

REFERENCE

1. Abramovich S. G., Mashanskaya A.V lazernaya dopplerovskaya floumetriya v otsenke mikrotsirkulyatsiiu zdorovyih lyudey i bolnyih arterialnoy gipertoniey. Sibirskiy meditsinskiy zhurnal. –2010. – T. 92,  – # 1. – S. 57–59.

2. Babarskov E. V., Shulagin Yu. A., Chernyak A. V. Neinvazivnyiy metod issledovaniya legochnoy mikrotsirkulyatsii. – 2010. – T.2, – # 18. – S. 271–273.

3. Kozlov, V. I. Mikrotsirkulyatsiya krovi : otsenka sostoyaniya i diagnostika rasstroistv kapillyarnogo krovotoka [Tekst] / V. I. Kozlov //Tez. dokladov V Vseross. s mezhdunar. uchastiem shkolyi-konferentsii, M. – 2012. – 110 s.

4. ParfYonov A.S. Ekspress-diagnostika serdechnososudistyih zabolevavniy //Mir izmereniy. – 2008. – # 6. – S. 74–82.

5. Terehin S. S., Tihomirova I. A. Otsenka mikrotsirkulyatsii u lits s raznyim urovnem rezerva krovotoka metodom lazernoy dopplerovskoy floumetrii i vitalnoy biomikroskopii. //Yaroslavskiiy pedagogicheskiiy vestnik. – 2012. – T.3, – # 3. – S. 141–144. (Estestvennyie nauki) UDK 612.1.

6. Kelly R. I., Pearse R, Bull R. H., Leveque J. L., de Rigal J, Mortimer P. S. The effects of aging on the cutaneous microvasculature //Journal of the American Academy of Dermatology. – 1995. – No 33. – P. 749–756.

7. Mchedlishvili G., Mantskava M., Urdulashvili T. Appraisal of functional state of the human resistance arteries. //Russian Journal of Biomechanics. – 2004. –V. 8, – No 1. – P. 55-59.

 

         

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