Skip to main content

Brachial artery reactivity and vascular reactive hyperemia for preoperative anaesthesia risk assessment – an observational study

Abstract

Background

Non-invasive measures of vascular reactivity have emerged to refine cardiovascular risk. However, limited data exists investigating vascular reactivity as a preoperative diagnostic tool for anesthesiologists. In this study, we compare the utility of two non-invasive techniques, Brachial Artery Reactivity Testing (BART) and Digital Thermal Monitoring (DTM), as surrogates for measuring vascular reactivity.

Methods

Following IRB approval, 26 patients scheduled for major thoracic surgery (e.g. esophagectomy and pneumonectomy) were studied prospectively. BART [Flow mediated dilation (FMD) and Peak flow velocity (PFV)] and DTM [Temperature rebound (TR%)] were performed preoperatively at baseline using 5 minute blood pressure cuff occlusion of the upper arm. Statistical summaries were provided for the comparison of BART and DTM with select patient characteristics, and correlations were used to investigate the strength of the relationship between BART and DTM measurements.

Results

Patients preoperatively diagnosed with hyperlipidemia were associated with lower FMD% values {Median (Range): 14.8 (2.3, 38.1) vs. 6.2 (0.0, 14.3); p = 0.006}. There were no significant associations between BART and DTM techniques in relation to cardiovascular risk factors or postoperative complications.

Conclusion

Our study suggests that impaired vascular reactivity as measured by BART is associated with the incidence of hyperlipidemia. Also, using a novel technique such as DTM may provide a simpler and more accessible point of care testing for vascular reactivity in a perioperative setting. Both non-invasive techniques assessing vascular function warrant further refinement to better assist preoperative optimization strategies aimed at improving perioperative vascular function.

Peer Review reports

Background

Postoperative cardiovascular events are responsible for a substantial proportion of the morbidity and mortality of patients undergoing non-cardiac surgery [1]. With the availability of many practical lifestyle and pharmacological interventions that can be directed at patients with an increased risk of vascular complications (i.e. smoking cessation, exercise or statin therapy [2]), early identification of these patients has long been of interest to clinicians in order to prevent postoperative complications [3, 4]. Recently, non-invasive measures of vascular function have gained increasing importance, as they are used in addition to standard cardiovascular disease (CVD) risk factors in an attempt to refine risk stratification in patients undergoing non-cardiac surgery [5]. However, these measures are technically challenging and not ideal for clinical purposes, especially if serial measurements are required [6].

Brachial Artery Reactivity Testing (BART) is a non-invasive technique that has been established over the past few years for the evaluation of preclinical disease states geared at improving vascular function with targeted specific interventions and risk factor modifications [7]. Unfortunately, assessing flow-mediated dilation (FMD) and peak flow velocity (PFV) requires technical expertise and ultrasound equipment. Hence, it is restricted to the setting of a vascular laboratory. A novel technique that is currently under investigation in clinical trials is Digital Thermal Monitoring (DTM). This non-invasive method is currently under evaluation for the assessment of peripheral vascular function and improvement of cardiovascular risk assessment [8, 9]. Similar to FMD measured by ultrasound, this method measures changes in skin blood flow induced by reactive hyperemia by utilizing a temperature rebound (TR) [10]. Controversy remains whether there is a correlation present between macrovascular- measured via ultrasound in the brachial artery (FMD), and predominantly microvascular hyperemic responses- measured at the fingertip via (DTM) or pulse waveform analysis.

A recent study investigating pulse waveform analysis refuted the claims that large (macrovascular) and small (microvascular) arterial stiffness are surrogate measures for sonographic assessments of brachial FMD [11].

The aim of this study was to evaluate two non-invasive techniques (BART and DTM) for the preoperative assessment of vascular function. Outcome parameters consisted of the two tested techniques with cardiovascular risk factors such as: hypertension, diabetes, hyperlipidemia, obesity, smoking and the incidence of postoperative complications.

Methods

The study was approved by the local Ethics Committee (The University of Texas M.D. Anderson Cancer Center, approval number 2003–0434) and all patients signed an informed consent. Thirty patients undergoing major thoracic surgery (lobectomy, pneumonectomy, esophagectomy) were eligible consented for this prospective observational study. We chose major thoracic surgery patients due to their high incidence of cardiovascular risk factors and postoperative cardiovascular complications (e.g. postoperative morbidity of 15-36% and mortality of 4.8-10.9% following pneumonectomy) [4, 12].

Four patients had to be excluded due to low baseline fingertip temperature at the start of the DTM assessment. Therefore, a total of twenty-six consecutive patients with thoracic cancer (i.e. pulmonary, esophageal cancer) participated in this study. Other exclusion criteria included: being under 18 years of age, pregnant, the presence of a recent or unstable myocardial infarction, cerebrovascular accident, pulmonary embolus, deep vein thrombosis, or any condition that deemed the patient unsatisfactory for surgery.

Brachial Artery Reactivity Testing (BART)

Patients were tested preoperatively within one week of undergoing surgery. With patients in a fasting state and in a supine position, ultrasound measurements of the brachial artery were performed in a quiet, dark room under stable temperature conditions (25°C). Resting blood pressure was measured by placing a blood pressure cuff on the right forearm. One operator blinded to the study patients’ medical history obtained right arm brachial artery ultrasound images (Philips Excelera, Andover, MA 01810, USA) at baseline and at 30, 60, 90 and 120 seconds after a 5 minute occlusion with 50 mmHg above systolic blood pressure. Post-occlusion FMD (in mm) and PFV (in cm/sec) were expressed in percent diameter and flow increase- absolute values were also recorded. Patients were grouped into low, medium, and high tertiles according to the increase of FMD and PFV values following arm occlusion.

Digital Thermal Monitoring (DTM)

DTM measurements were performed subsequent to FMD measurements, with at least 10 minutes between each procedure. After an overnight fast and abstinence from tobacco, alcohol, and caffeine, patients, in a supine position, were tested in a quiet, dark room under stable temperature conditions (25°C). DTM was measured using the VENDYS® 5000BC device (Endothelix Inc., Houston, TX, USA), which utilizes a computer-based thermometry system (0.01°C thermal resolution) and two fingertip thermocouple probes attached to the index finger of each hand (left: occlusion; right: control). Standard sphygmomanometer cuffs were placed on each upper arm (left: occlusion; right: control). After a period of stabilization of basal skin temperature, the right cuff was rapidly inflated to ≥ 50 mmHg above systolic blood pressure (measured on control arm). After a 5 minute arm occlusion the cuff was then rapidly deflated and a temperature rebound (TR%) was measured in the right index finger in response to the invoked reactive hyperemia for 5 minutes. A representative example of a temperature/time trace and a list of the measured DTM parameters are shown in the Figure 1 and Table 1.

Figure 1
figure 1

Representative example of a temperature – time trace within the DTM assessment.

Table 1 List of DTM parameters

Perioperative risk assessment

Patient data was obtained using the clinical database (ClinicStation™). In addition, patients’ perioperative risk profile was assessed using established pre-operative risk scores from the American Society of Anesthesiologists (ASA) Physical Status Classification System, the Modified Lee Cardiac Risk Index, and the American Heart Association/American College of Cardiology (ACC/AHA) Risk Score). Two blinded investigators collected data about perioperative events according to standardized criteria. Patients were monitored during their hospital stay, approximately 30 days, and 6 months after surgery. Postoperative events were evaluated according to predefined adverse event categories and definitions (Additional file 1).

Statistical analysis

Descriptive statistics consisting of means and standard deviations, medians and ranges, or frequencies and percents were used to summarize our patients’ data. Based on a previous study [13], we assumed a change in brachial artery diameter before and after forearm ischemia of 17.8 ± 10.9% (4.0 ± 0.6 mm at rest vs. 4.7 ± 0.6 mm at 60 sec.) after cuff deflation would be a detectable difference observable with 26 patients (α = 0.05 and power >0.8, two-sided paired t-test). For purposes of conducting exploratory analyses, select patient variables were converted to categorical variables by splitting the data at the median value thus creating a variable with two levels. Continuous measures of FMD%, PFV%, TR%, and TR(°C) were then compared between the levels of these patient characteristics using t-test or the Wilcoxon rank-sum test, if more appropriate. A correlation analysis was used to evaluate the bivariate relationship between BART and DTM parameters. For the DTM measurements, we excluded tests with a baseline fingertip temperature below 27°C in reference to a previous study indicating that it would provide an unreliable temperature rebound (TR) value due to predisposed vasoconstriction in a relatively cold finger [10].

Multivariate analyses were not undertaken due to the study’s small sample size. A p-value less than 0.05 was considered statistically significant.

Results

Clinical characteristics of the subjects (n = 26; age, 59 ± 10 years; range, 28–78) are shown in Table 2. Patients with hyperlipidemia were associated with lower FMD% values {Median (Range): 14.8 (2.3, 38.1) vs. 6.2 (0.0, 14.3); p = 0.006, Table 3). Patients with other preoperative cardiac risk factors (smoking, obesity, hypertension, diabetes, preoperative chemo-/radiation therapy) or classified with an ASA, Lee Cardiac Risk Index or ACC/AHA score greater than 2 did not differ in FMD%, PFV% and TR%-values when compared to the rest of the study group (Tables 3 and 4). Preoperative cardiovascular medication (statin, ACE-inhibitor, AT2-inhibitor or beta-blocker therapy) did not have an impact on BART or DTM values (Tables 3 and 4). Neither BART nor DTM were significantly related to the incidence of postoperative complication (Table 5). Neither FMD% nor PFV% were significantly correlated with TR% (Table 6). However, postoperative complications were associated with a longer length of hospital stay (29.7 ± 31.7 vs. 6.0 ± 4.3 days; p = 0.002).

Table 2 Summary of patient characteristics
Table 3 Summary of patient characteristics by BART parameters
Table 4 Summary of Patient Characteristics by DMT Parameters
Table 5 BART and DTM measures by complication
Table 6 Correlation of BART vs. DTM Parameters

Discussion

The aim of our study is to evaluate the utility of BART and DTM, two different techniques with similar endpoints, for the preoperative assessment of vascular function in patients presenting at the anesthesia clinic. Both techniques utilize the principle of indirectly measuring reactive hyperemia in response to arm occlusion. Our study indicated that both techniques were comparable with respect to preoperative cardiovascular risk factors (i.e. hypertension, diabetes, obesity, smoking) and the incidence of postoperative complications. However, patients with hyperlipidemia were found to be associated with significantly lower FMD% values as measured by BART.

In a clinical setting, non-invasive techniques assessing vascular function need to meet certain criteria in order to be established as practicable tools. They need to be reproducible and relatively easy to administer before they are recommended for widespread use. The predictive value of non-invasive vascular function measurements concerning perioperative morbidity and mortality has been controversial over the last years. Especially in non-cardiac surgery where there is a growing need for risk prediction, non-invasive techniques have yet to be established as useful tools in improving clinical outcomes. An increasing population of patients with cardiovascular risk factors (i.e. metabolic syndrome) serves as a counteracting force towards this dilemma. The success of either technique (BART and DTM) will depend on their ability to reliably measure an individual’s vascular function and to be added to the standard preoperative cardiovascular examinations thus refining therapeutic strategies which, in turn, will have a positive effect on postoperative outcomes.

BART studies have shown impaired vasodilatory responses in patients with cardiovascular risk factors such as hypertension [14, 15], diabetes mellitus [16], hypercholesterolemia [17], and smoking [18]. In asymptomatic patients, a prospective study investigating DTM suggested that this method correlated with certain risk factors identified in the Framingham Risk Score [19]. In our study, DTM variables trended toward an association between lower BART and DTM values in patients with risk factors and higher risk scores described by: hypertension requiring therapy, diabetes, hyperlipidemia requiring statin therapy, Lee Cardiac Risk Index ≤2, and ACC/AHA Risk Score ≤2, but this failure to reach statistical significance should not preclude further investigation of these non-invasive techniques.

BART – Strengths and weaknesses

One of the strengths of BART is that it is non-invasive and its repeatable use is applicable for monitoring the progress of atherosclerosis, especially in cardiac patients. In a prospective trial (N = 135), FMD was the strongest predictor of re-stenosis in patients undergoing stent implantation [20]. Although a large study (N = 444) suggests that measures of vascular reactivity do not have additional prognostic use in patients at high risk [6], the ability of FMD to monitor vascular function in response to therapy has been described in the literature [2123]. A limitation of BART is its technical challenge with a significant learning curve to achieve high quality and consistent performance. Preparation and proper positioning of the patient and the sonographer ensure ergonomic comfort while minimizing both stress-related fatigue during the scan period and error [7]. Furthermore, inconsistencies in the published studies [2427] highlight some of the difficulties of applying FMD technique in the setting of diabetes. Other confounders of FMD include arm length, sex, and postprandial state. Thus, comparison between groups of patients should use standard experimental conditions and, if possible, ensure that baseline vessel diameter and baseline blood flow are similar [28]. In our study we had similar conditions in both laboratory rooms when testing BART and DTM, patients were in the fasting state, and baseline vessel diameter and baseline blood flow were similar among the study population (3.9 ± 0.8 mm and 176.7 ± 51.7 cm/sec).

DTM - Strengths and weaknesses

The advantage of DTM is that ultrasound is replaced by measurements of fingertip thermal changes; thereby, providing a technique that is simpler and more accessible as a point of care test (POCT). It facilitates research into the perioperative kinetics of vascular reactivity following surgery, especially in the postoperative period where patients are often restricted to the postoperative recovery area (e.g. intensive care unit or surgical floor). In a recent study, a low DTM signal was found in patients with certain cardiovascular risk factors (abdominal obesity, smoking) [29]. Another study demonstrated that fingertip thermal response as measured by DTM was inversely related to increasing cardiovascular risk independent of age, sex and other cardiac risk factors [9]. Reactive hyperemia after a period of upper arm ischemia is a physiologic response of the vasculature, depending on an endothelium-derived nitric oxide release, resulting in a rapid increase in blood flow and temperature [30, 31]. DTM, utilizing this predominantly microvascular response, may be a useful point-of-care tool for the assessment of vascular function perioperatively. Furthermore, it may serve as a contributory marker of postoperative vascular function that has been reported to be impaired by systemic inflammation [32].

Limitations

There are differences in physics between the two techniques with BART measuring vascular diameter and blood flow and DTM measuring temperature as a surrogate marker of blood flow. However, both techniques utilize the principle of reactive hyperemia after a period of ischemia, which is a known physiologic response of the vasculature and endothelial system resulting in rapid increases in both local blood flow and temperature [30, 31, 33, 34].

DTM is highly dependent on ambient room temperature and the adjustment of the temperature probe to the surrounding condition. A stable equilibration time is required in order to avoid a temperature drift throughout the test that would have an impact on TF and TR. Also, vasoconstriction results from a cuff placed too tightly around the arm leading to false TF and TR values. This is not the only effector and other contributing factors may come from a cold fingertip (<27°C), a stressor like the white coat effect [35, 36], a myogenically mediated vasoconstriction, a rise in intravascular pressure, or even a direct damming of venous outflow and capillary outflow obstruction [37]. Furthermore, the extent a neurovascular response is involved in the measurement of reactive hyperemia remains unclear. Infrared imaging of the control hand during DTM testing revealed this phenomenon, which possibly leads to blunting of the temperature response to reactive hyperemia. Evaluation of the temperature data of the left finger, functioning as a control, might give additional value to observation although its interpretation has not been fully understood.

A further limitation of our study is that the sample size of our prospective, observational study is quite low. One of our pilot studies [38] investigating BART in a surgical population identified an optimal sample size of N = 165 patients is required to have adequate power for identifying the predictive value of BART for postoperative complications in future studies. Unfortunately, we were not able to achieve this sample size in our study.

Conclusion

To our knowledge this is the first study comparing the utility of two non-invasive techniques (BART and DTM) for the preoperative assessment of vascular function. Impaired vascular reactivity as measured by BART was associated with the incidence of hyperlipidemia but not with other preoperative cardiac risk factors or the incidence of postoperative complications. Although, non-invasive techniques assessing vascular function warrant further refinement, we conclude that BART and DTM are useful diagnostic tools for assisting preoperative optimization strategies aimed at improving vascular function in patients undergoing major surgery.

References

  1. Towards risk reduction in non-cardiac surgery. Lancet. 2011, 378 (9800): 1355-10.1016/S0140-6736(11)61548-1.

  2. Schouten O, Bax JJ, Dunkelgrun M, Feringa HH, van Urk H, Poldermans D: Statins for the prevention of perioperative cardiovascular complications in vascular surgery. J Vasc Surg. 2006, 44 (2): 419-424. 10.1016/j.jvs.2006.04.039.

    Article  PubMed  Google Scholar 

  3. Schachinger V, Britten MB, Zeiher AM: Prognostic impact of coronary vasodilator dysfunction on adverse long-term outcome of coronary heart disease. Circulation. 2000, 101 (16): 1899-1906. 10.1161/01.CIR.101.16.1899.

    Article  CAS  PubMed  Google Scholar 

  4. Junemann-Ramirez M, Awan MY, Khan ZM, Rahamim JS: Anastomotic leakage post-esophagogastrectomy for esophageal carcinoma: retrospective analysis of predictive factors, management and influence on longterm survival in a high volume centre. Eur J Cardiothorac Surg. 2005, 27 (1): 3-7. 10.1016/j.ejcts.2004.09.018.

    Article  CAS  PubMed  Google Scholar 

  5. Deanfield JE, Halcox JP, Rabelink TJ: Endothelial function and dysfunction: testing and clinical relevance. Circulation. 2007, 115 (10): 1285-1295.

    PubMed  Google Scholar 

  6. Fathi R, Haluska B, Isbel N, Short L, Marwick TH: The relative importance of vascular structure and function in predicting cardiovascular events. J Am Coll Cardiol. 2004, 43 (4): 616-623. 10.1016/j.jacc.2003.09.042.

    Article  PubMed  Google Scholar 

  7. Corretti M: Brachial artery reactivity: clinical tool or research toy?. J Am Soc Echocardiogr. 2004, 17 (6): 693-696. 10.1016/j.echo.2004.03.016.

    Article  PubMed  Google Scholar 

  8. Ahmadi N, Tirunagaram S, Hajsadeghi F, Flores F, Saeed A, Hecht H, Naghavi M, Budoff M: Concomitant insulin resistance and impaired vascular function is associated with increased coronary artery calcification. Int J Cardiol. 2010, 144 (1): 163-165. 10.1016/j.ijcard.2008.12.200.

    Article  PubMed  Google Scholar 

  9. Gul KM, Ahmadi N, Wang Z, Jamieson C, Nasir K, Metcalfe R, Hecht HS, Hartley CJ, Naghavi M: Digital thermal monitoring of vascular function: a novel tool to improve cardiovascular risk assessment. Vasc Med. 2009, 14 (2): 143-148. 10.1177/1358863X08098850.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Naghavi M, Falk E, Hecht HS, Jamieson MJ, Kaul S, Berman D, Fayad Z, Budoff MJ, Rumberger J, Naqvi TZ, Shaw LJ, Faergeman O, Cohn J, Bahr R, Koenig W, Demirovic J, Arking D, Herrera VL, Badimon J, Goldstein JA, Rudy Y, Airaksinen J, Schwartz RS, Riley WA, Mendes RA, Douglas P, Shah PK, Task Force SHAPE: From vulnerable plaque to vulnerable patient--Part III: Executive summary of the Screening for Heart Attack Prevention and Education (SHAPE) Task Force report. Am J Cardiol. 2006, 98 (2A): 2H-15H.

    Article  PubMed  Google Scholar 

  11. Wright CI, Scholten HJ, Schilder JC, Elsen BM, Hanselaar W, Kroner CI, Draijer R, Kastelein JJ, Stok W, Karemaker J, de Groot E: Arterial stiffness, endothelial function and microcirculatory reactivity in healthy young males. Clin Physiol Funct Imaging. 2008, 28 (5): 299-306. 10.1111/j.1475-097X.2008.00807.x.

    Article  CAS  PubMed  Google Scholar 

  12. Vaporciyan AA, Merriman KW, Ece F, Roth JA, Smythe WR, Swisher SG, Walsh GL, Nesbitt JC, Putnam JB: Incidence of major pulmonary morbidity after pneumonectomy: association with timing of smoking cessation. Ann Thorac Surg. 2002, 73 (2): 420-425. 10.1016/S0003-4975(01)03443-9. discussion 425–426

    Article  PubMed  Google Scholar 

  13. Parvathaneni L, Harp J, Zelinger A, Silver MA: Relation between brachial artery reactivity and noninvasive large and small arterial compliance in healthy volunteers. Am J Cardiol. 2002, 89 (7): 894-895. 10.1016/S0002-9149(02)02212-9.

    Article  PubMed  Google Scholar 

  14. Li J, Zhao SP, Li XP, Zhuo QC, Gao M, Lu SK: Non-invasive detection of endothelial dysfunction in patients with essential hypertension. Int J Cardiol. 1997, 61 (2): 165-169. 10.1016/S0167-5273(97)00153-8.

    Article  CAS  PubMed  Google Scholar 

  15. Taddei S, Virdis A, Mattei P, Ghiadoni L, Gennari A, Fasolo CB, Sudano I, Salvetti A: Aging and endothelial function in normotensive subjects and patients with essential hypertension. Circulation. 1995, 91 (7): 1981-1987. 10.1161/01.CIR.91.7.1981.

    Article  CAS  PubMed  Google Scholar 

  16. McNally PG, Watt PA, Rimmer T, Burden AC, Hearnshaw JR, Thurston H: Impaired contraction and endothelium-dependent relaxation in isolated resistance vessels from patients with insulin-dependent diabetes mellitus. Clin Sci (Lond). 1994, 87 (1): 31-36.

    Article  CAS  Google Scholar 

  17. Vogel RA, Corretti MC, Plotnick GD: Changes in flow-mediated brachial artery vasoactivity with lowering of desirable cholesterol levels in healthy middle-aged men. Am J Cardiol. 1996, 77 (1): 37-40. 10.1016/S0002-9149(97)89131-X.

    Article  CAS  PubMed  Google Scholar 

  18. Celermajer DS, Sorensen KE, Georgakopoulos D, Bull C, Thomas O, Robinson J, Deanfield JE: Cigarette smoking is associated with dose-related and potentially reversible impairment of endothelium-dependent dilation in healthy young adults. Circulation. 1993, 88 (5 Pt 1): 2149-2155.

    Article  CAS  PubMed  Google Scholar 

  19. Carlier SGGK, Wang Z, Jamieson C, Naghavi M: Digital Thermal Monitoring: the clinical utility of a new non-invasive, non-imaging device for cardiovascular risk assessment. Eur Heart J. 2006, 27: 499-

    Google Scholar 

  20. Akcakoyun M, Kargin R, Tanalp AC, Pala S, Ozveren O, Akcay M, Barutcu I, Kirma C: Predictive value of noninvasively determined endothelial dysfunction for long-term cardiovascular events and restenosis in patients undergoing coronary stent implantation: a prospective study. Coron Artery Dis. 2008, 19 (5): 337-343. 10.1097/MCA.0b013e328301ba8e.

    Article  PubMed  Google Scholar 

  21. Modena MG, Bonetti L, Coppi F, Bursi F, Rossi R: Prognostic role of reversible endothelial dysfunction in hypertensive postmenopausal women. J Am Coll Cardiol. 2002, 40 (3): 505-510. 10.1016/S0735-1097(02)01976-9.

    Article  PubMed  Google Scholar 

  22. Dogra GK, Watts GF, Herrmann S, Thomas MA, Irish AB: Statin therapy improves brachial artery endothelial function in nephrotic syndrome. Kidney Int. 2002, 62 (2): 550-557. 10.1046/j.1523-1755.2002.00483.x.

    Article  CAS  PubMed  Google Scholar 

  23. Dogra GK, Watts GF, Chan DC, Stanton K: Statin therapy improves brachial artery vasodilator function in patients with Type 1 diabetes and microalbuminuria. Diabet Med. 2005, 22 (3): 239-242. 10.1111/j.1464-5491.2004.01382.x.

    Article  CAS  PubMed  Google Scholar 

  24. Clarkson P, Celermajer DS, Donald AE, Sampson M, Sorensen KE, Adams M, Yue DK, Betteridge DJ, Deanfield JE: Impaired vascular reactivity in insulin-dependent diabetes mellitus is related to disease duration and low density lipoprotein cholesterol levels. J Am Coll Cardiol. 1996, 28 (3): 573-579. 10.1016/0735-1097(96)82380-1.

    Article  CAS  PubMed  Google Scholar 

  25. Goodfellow J, Ramsey MW, Luddington LA, Jones CJ, Coates PA, Dunstan F, Lewis MJ, Owens DR, Henderson AH: Endothelium and inelastic arteries: an early marker of vascular dysfunction in non-insulin dependent diabetes. BMJ. 1996, 312 (7033): 744-745. 10.1136/bmj.312.7033.744.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Zenere BM, Arcaro G, Saggiani F, Rossi L, Muggeo M, Lechi A: Noninvasive detection of functional alterations of the arterial wall in IDDM patients with and without microalbuminuria. Diabetes Care. 1995, 18 (7): 975-982. 10.2337/diacare.18.7.975.

    Article  CAS  PubMed  Google Scholar 

  27. Lambert J, Aarsen M, Donker AJ, Stehouwer CD: Endothelium-dependent and -independent vasodilation of large arteries in normoalbuminuric insulin-dependent diabetes mellitus. Arterioscler Thromb Vasc Biol. 1996, 16 (5): 705-711. 10.1161/01.ATV.16.5.705.

    Article  CAS  PubMed  Google Scholar 

  28. Lehmann ED, Riley WA, Clarkson P, Gosling RG: Non-invasive assessment of cardiovascular disease in diabetes mellitus. Lancet. 1997, 350 (Suppl 1): SI14-SI19.

    Article  PubMed  Google Scholar 

  29. Schier R, Marcus HE, Mansur E, Lei X, El-Zein R, Mehran R, Purugganan R, Heir JS, Riedel B, Gottumukkala V: Evaluation of Digital Thermal Monitoring as a Tool to Assess Perioperative Vascular Reactivity. J Atheroscler Thromb. 2013, 20 (3): 277-286. 10.5551/jat.15255.

    Article  PubMed  Google Scholar 

  30. Celermajer DS, Sorensen KE, Gooch VM, Spiegelhalter DJ, Miller OI, Sullivan ID, Lloyd JK, Deanfield JE: Non-invasive detection of endothelial dysfunction in children and adults at risk of atherosclerosis. Lancet. 1992, 340 (8828): 1111-1115. 10.1016/0140-6736(92)93147-F.

    Article  CAS  PubMed  Google Scholar 

  31. Freeman NE, Shaw JL, Snyder JC: The Peripheral blood flow in surgical shock: The Reduction in Circulation through the Hand Resulting from Pain, Fear, Cold, and Asphyxia, with Quantitative Measurements of the Volume Flow of Blood in Clinical Cases of Surgical Shock. J Clin Invest. 1936, 15 (6): 651-664. 10.1172/JCI100817.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Tonetti MS, D’Aiuto F, Nibali L, Donald A, Storry C, Parkar M, Suvan J, Hingorani AD, Vallance P, Deanfield J: Treatment of periodontitis and endothelial function. N Engl J Med. 2007, 356 (9): 911-920. 10.1056/NEJMoa063186.

    Article  CAS  PubMed  Google Scholar 

  33. Celermajer DS, Sorensen KE, Bull C, Robinson J, Deanfield JE: Endothelium-dependent dilation in the systemic arteries of asymptomatic subjects relates to coronary risk factors and their interaction. J Am Coll Cardiol. 1994, 24 (6): 1468-1474. 10.1016/0735-1097(94)90141-4.

    Article  CAS  PubMed  Google Scholar 

  34. Sessler DI: Skin-temperature gradients are a validated measure of fingertip perfusion. Eur J Appl Physiol. 2003, 89 (3–4): 401-402. author reply 403–404

    Article  PubMed  Google Scholar 

  35. Ogedegbe G: White-coat effect: unraveling its mechanisms. Am J Hypertens. 2008, 21 (2): 135-10.1038/ajh.2007.64.

    Article  PubMed  Google Scholar 

  36. Tsai PS: White-coat effect and blood pressure reactivity. Int J Cardiol. 2008, 126 (2): 273-10.1016/j.ijcard.2007.01.093. author reply 274–275

    Article  PubMed  Google Scholar 

  37. Edwards CM, Marshall JM, Pugh M: The cutaneous vasoconstrictor response to venous stasis is normal in subjects with primary Raynaud’s disease. Clin Auton Res. 1999, 9 (5): 255-262. 10.1007/BF02319455.

    Article  CAS  PubMed  Google Scholar 

  38. Schier R, Riedel B: Brachial artery reactivity testing for preoperative microvascular risk assessment in major thoracic surgery. Ann Thorac Surg. 2013, 95 (3): 1140-

    Article  PubMed  Google Scholar 

Pre-publication history

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Robert Schier.

Additional information

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

RS: Study design/subject recruitment/data collection/data analysis/scientific input/manuscript writing/reviewing. VS: Data analysis/scientific input/manuscript writing/reviewing. AS: Subject recruitment/data collection/data analysis. JA: Subject recruitment/data collection/data analysis. MH: Statistical analysis/scientific input/manuscript writing/reviewing. RJM: Scientific input/manuscript writing/reviewing. BR: Study design/data analysis/scientific input/manuscript writing/reviewing. JH: Scientific input/manuscript writing/reviewing. All authors read and approved the final manuscript.

Electronic supplementary material

Authors’ original submitted files for images

Below are the links to the authors’ original submitted files for images.

Authors’ original file for figure 1

Rights and permissions

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Schier, R., Schick, V., Amsbaugh, A. et al. Brachial artery reactivity and vascular reactive hyperemia for preoperative anaesthesia risk assessment – an observational study. BMC Anesthesiol 14, 47 (2014). https://doi.org/10.1186/1471-2253-14-47

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/1471-2253-14-47

Keywords