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Skin Research and Technology 2004: 10: 174–177 Copyright & Blackwell Munksgaard 2004 Capillary blood cell velocity in periulcerous regions of the lower leg measured by laser Doppler anemometry Markus Stu¨cker, Christina Huntermann, Falk Georges Bechara, Klaus Hoffmann Department of Dermatology and Allergology, Ruhr-University Bochum, Germany Background: The capillary blood flow of the nailfold can be Results: Laser Doppler flow was increased in all patients measured by means of modern non-invasive techniques like during resting period, whereas the tcpO2 was significantly the videocapillary microscope in vivo. To quantify the capil- decreased. LDF did not show an extension of tpCBV during lary blood cell velocity, apart from the nailfold capillaries, we reactive hyperemia after suprasystolic occlusion compared used a new technique, the so-called laser Doppler anemo- to the control group (73.6 Æ 31.1 vs. 164.1 Æ 52.5 s, P 5 0.003).
TcpO2 revealed significantly dereased tpCBV in patients with Objective: The present study investigated how far laser venous and mixed venous/arterial ulcers (90.1 Æ 61.7 vs.
Doppler fluxmetry (LDF), transcutaneous partial pressure 162.7 Æ 65.5 s, P 0.0001). LDA showed no significant differ- of oxygen (tcpO2), and LDA are capable of quantifying ences between patients and control group (P40.8). After appli- differences of cutaneous microcirculation between patients cation of prostaglandin E1, LDA revealed a significant increase with leg ulcera and a healthy control group. The effects of intravenous prostaglandin E1 and pentoxifylline were also [P 5 0,01]), whereas pentoxifylline had no significant effect.
Capillary density increased significantly after application of Patients and methods: Ten patients with venous leg ulcers prostaglandin E1 (5,1 Æ 2.7/mm2 to 8.9 Æ 3/mm2 [P 5 0.001]) and 10 patients with mixed venous/arterial ulcers were and pentoxifylline (5.3 Æ 1.8/mm2 to 8 Æ 2.1/mm2 [P 5 0.006]).
investigated with LDF, tcpO2, and LDA before and after Conclusion: The LDA is an important additional investiga- injection of prostaglandin E1 and pentoxifylline. We mea- tion tool for cutaneous microcirculation.
sured the resting capillary blood cell velocity (rCBV), themaximum hyperemia, and the time to peak capillary blood Key words: microcirculation – leg ulcer – blood flow – laser cell velocity (tpCBV) during hyperemia after 4 min of supra- systolic occlusion and compared them with the results of acontol group of 20 patients.
& Blackwell Munksgaard, 2004Accepted for publication 6 February 2004 the nipple or the nailfold, the capillary loops run ulcerous lesions show disturbances in cu- parallel to the skin surface. However, there has taneous microcirculation (1, 2). Pharmacologial been almost no technique available to measure skin treatment with prostaglandin E1 and pentoxifyl- blood flow in capillary loops located at a 901 angle line aims at an improvement of microcirculation to the skin surface, like the lower leg. Therefore, it was not possible to quantify the erythrocyte velo- city in capillaries of periulcerous regions.
means of non-invasive capillary microscopy, mostly performed on the nailfolds (7). Thus (LDA) a device is available to measure the capil- pathological changes and therapy effects can be lary blood flow in human capillaries oriented quantified. In general, capillary loops of the skin perpendicular to the skin surface. The reprodu- are perpendicularly oriented to the skin surface.
cibility of this method has already been docu- Only in a few areas of the human body, the lips, In the present study, the following problems (1.5 mW Laser Diode, wavelength 780 nm), fo- cused by a microscope objective lens to a spotsize of approximately 10 mm diameter. This re- (1) Is the LDA capable of demonstrating differ- sults in a very small sample volume, so that the ences in cutaneous microcirculation of the velocity in capillaries of 9.8–32.1 mm diameter can periulcerous regions of venous/arterial ul- be singled out. Using the capillarometry, capil- laries per field of view were counted.
(2) Are the effects of prostaglandin E1 and pen- toxifylline in periulcerous regions detectableby LDA? Test procedureAll subjects were investigated in a lying positionafter acclimatization for at least 20 min (room temperature: 22–24 1C). Before suprasystolic oc-clusion, all parameters in rest were investigated for 2 min (2–4 cm from the ulcers). After occlu- We investigated 20 patients, 10 with venous sion, parameters were again registered for 2 min.
ulcers (age: 62.1 Æ 11.6 years, five females, five Following parameters were determined: resting males), 10 with mixed venous/arterial ulcers capillary blood cell velocity (rCBV), time to peak (age: 78.2 Æ 4.6 years, six females, four males).
capillary blood cell velocity (tpCBV) during hy- Seven of 10 patients with venous ulcers had a peremia, and the maximum hyperemia. All mea- deep venous insufficiency, all patients showed an insufficiency of the longer saphenous vein (grade Patients with venous ulcers were again inves- tigated 15 min after application of 100 mg pentox- Patients with mixed venous/arterial ulcers ifylline (Trentals, Aventis Pharma, Bad Soden, showed an ankle-arm index of 0.59 Æ 0.07 (ankle Germany). Patients with peripheral arterial oc- artery pressure: 88.5 Æ 10.7 mmHg). All patients clusive disease received 40 mg of prostaglandin E1 had no signs of skin disease at place of measure- (Prostavasins, Schwartz Pharma, Mannheim, ment, apart from typical changes due to venous Germany) and were also examined 15 min after infusuion. Infusion time in all patients was 2 h.
Both groups were compared to a control group.
The control group for venous ulcers consisted ofthree healthy males and seven females (age 64.1 Æ 11.7 years). The control group for patients The values of the patient groups were compared with peripheral arterial occlusive disease also to those of the control groups using Student’s consisted of three healthy males and seven fe- t-test for unpaired samples. Differences between males (age: 56.4 Æ 9.7 years). Clinical examina- the values before and after infusion therapy were tested using Student’s t-test for paired samples chronic venous insufficiency or peripheral arter- (SPSS for Windows 11.0, SPSS, Chicago, IL, USA).
ial occlusive disease in the control groups. Sub-jects suffering from skin diseases (psoriasis, eczema) were excluded. Taking of medicaments,which have an influence on hemorheology, LDF was significantly increased in both patient thrombocyte aggregation, or vessel tonus was groups (venous ulcers: 31.7 Æ 12.4 AU vs. mixed venous/arterial ulcers: 61.7 Æ 46.3 AU) comparedto the respective control group (15.8 Æ 6.94/16.8 Æ 6.4 AU [P 0.01]). TcpO2 was significantly decreased in both groups (9.5 Æ 11.7 vs. 23.6 Æ Cutaneous microcirculation was investigated by 13.46 mmHg, P 5 0.004/6.8 Æ 4.0 vs. 18.7 Æ 6.3 laser Doppler fluxmetry (LDF) (DRT4, Moor-In- struments, Exminster, Great Britain), measuring 0.5 Æ 0.2 mm/s in all groups. Time to maximum hyperemia after suprasystolic occlusion was not (TCM3, Radiometer, Koppenhagen, Denmark), extended compared to the control group by LDF (P40.05). TcpO2 was significantly decreased in ford, UK). The CAM 1 includes a laser source patients with venous ulcers (73.6 Æ 31.1 vs. 164.1 Fig. 3. Capillary density before and after application of pentoxifylline in venous leg ulcers. Significant increase of capillary density (5.3 Æ 1.8/mm2 to 8 Æ 2.1/mm2 [P 5 0.006]).
Fig. 1. Resting capillary blood cell velocity (rCBV) before and afterapplication of prostaglandin E1 measured by LDA. Significant measurement techniques: the LDF, the tcpO2, and increase of rCBV (0.5 Æ 0.18 mm/s to 0.74 Æ 0.28 mm/s [P 5 0.01]).
The LDA offers a combination of video capil- laroscopy and laser Doppler measurement. The system includes a laser source (1.5 mW Laser Diode, wavelength 780 nm), focused by a micro- scope objective lens to a spot size of approxi- mately 10 mm diameter. This results in a very small sample volume, so that the velocity in capillaries of 9.8–32.1 mm diameter can be singledout. By this, almost every blood cell velocity is Fig. 2. Capillary density (capillaries/mm2) before and after applica- measurable, and for the first time a device is tion of prostaglandin E1 in mixed venous/arterial ulcers. Significantincrease of capillary density (5.1 Æ 2.7/mm2 to 8.9 Æ 3/mm2 available to measure the resting capillary blood cell velocity in human capillaries oriented per-pendicular to the skin surface. The instrument Æ 52.5 s of control group, P 5 0.003) and also with can be placed on almost all parts of the body mixed venous/arterial ulcers (90.1 Æ 61.7 vs.
162.7 Æ 65.5 s of control group, P 0.0001).
The conventional LDF only registers the pro- Before drug application, the LDA showed no duct of erythrocyte velocity and number of velo- significant differences between patients and con- city in a tissue volume of about 1 mm3. However, trol group (P40.8). Fifteen minutes after applica- the LDA is capable of analyzing a single capillary.
tion, there was no difference detected by LDF or Measurement depths depend on the constitution tcpO2. In contrast, the LDA revealed a significant and blood circulation of the investigated tissue increase of erythrocyte velocity after application (10). Therefore, the LDF only allows relative of prostaglandin E1 (from 0.5 Æ 0.18 to 0.74 Æ measurements, given in arbitrary units (11, 12).
0.28 mm/s [P 5 0.01]). No significant changes The tcpO2 reflects the local nutritive situation were demonstrated after application of pentox- of the skin surface. It depends mainly on the local ifylline (increase from 0.53 Æ 0.52 to 0.66 Æ 0.8 blood circulation, and diffusion properties (12), mm/s [P 5 0.29]). Capillary density raised from and is frequently used to reveal how vessel 5.1 Æ 2.7/mm2 to 8.9 Æ 3/mm2 (P 5 0.001) after diseases have influence on local skin situation application of prostaglandin E1, and from 5.3 Æ 1.8/mm2 to 8 Æ 2.1/mm2 (P 5 0.006) after To compare the relevance of these methods in medication with pentoxifylline (Figs 1–3).
therapy, we quantified the effects of prostaglan-din E1 and pentoxifylline on cutaneous micro-circulation in periulcerous lesions.
The missing increase of tcpO2 after infusion of The present study investigated the cutaneous prostaglandin E1 may be caused by the fact that microcirculation of venous leg ulcers and mixed patients with mixed venous/arterial ulcera were venous/arterial ulcers. We used three different examined. This is reflected by relatively high rates of tcpO2 in rest. In isolated peripheral measured by a new laser Doppler anemometer. Micro- bined with a prolongation of time to maximum ¨ cker M, Herde M, Baier V, Hoffmann K, Altmeyer P.
Klinische Provokationsmano¨ver mit dem Laser Doppler Anemometer. Phlebologie 1998; 27: 152–158.
However, the LDA could demonstrate an in- 10. Johansson K, Jakobsson A, Lindahl K, Lindhagen J, crease of erythrocyte velocity and capillary den- Lundgren O, Nilsson GE. Influence of fibre diameterand probe geometry on the measuring depth of laser Doppler flowmetry in the gastrointestinal application.
prostaglandin E1. The capillary density was also Int J Microcirc: Clin Exp 1991; 10: 219–229.
increased after application of pentoxifylline.
11. Fagrell B. Advances in microcirculation network evalua- tion: an update. Int J Microcirc Clin Exp 1995; 15 (Suppl.
The effect of both hemorheologica could only be shown by LDA, whereas the LDF and tcpO2 12. Bollinger A, Hoffmann U, Franzeck UK. Evaluation of did not reveal any significant changes in cuta- flux motion in man by the laser Doppler technique.
Blood Vessels 1991; 28: 21–26.
neous microcirculation of leg ulcers. In contrast, 13. Rooke TW. The use of transcutaneous oximetry in the the effects of prostaglandin E1 and pentoxifylline noninvasive vascular laboratory. Int Angiol 1992; 11: 36– on venous and arterial ulcers have been pre- 14. Stu¨cker M, Falkenberg M, Reuther T, Altmeyer P, Lu¨b- bers DW. Local oxygen content in the skin is increased in In summary, the LDA is an important addi- chronic venous incompetence. Microvasc Res 2000; 59: tional technique for the evaluation of cutaneous microcirculation. In contrast to investigations of 15. Acciavatti A, Laghi Pasini F, Capecchi PL, Messa GL, Lazzerini PE, De Giorgi L, Acampa M, Di Perri T. Effects capillary blood cell velocity on the nailfold, the of alprostadil on blood rheology and nucleoside meta- LDA allows to analyze all capillaries oriented bolism in patients affected with lower limb chronic ischemia. Clin Hemorheol Microcirc 2001; 24: 49–57.
16. Bandiera G, Forletta M, Di paola FM, Cirielli C. PGE 1 short term therapy in critical lower limb ischemia. IntAngiology 2003; 22: 58–63.
treatment of severe skin ischemia in patients with 1. Ju¨nger M, Hahn M, Klyscz T, Steins A. Role of micro- peripheral arterial insufficiency-the effect on skin micro- angiopathy in the developement of venous leg ulcers. In: circulation. VASA 1986; 15: 56–60.
Messmer K, ed. Microcirculation in chronic venous 18. Marchesi S, Pasqualini L, Lombardini R, Vaudo G, insufficiency. Progress in applied microcirculation, Vol.
Lipattelli G, Pirro M, Schillaci G, Mannarino E. Prosta- glandin E1 improves endothelial function in critical 2. Bollinger A, Hoffmann U, Franzeck UK. Microvascular limb ischemia. J Cardiovasc Pharmacol 2003; 41: changes in arterial occlusive disease: target for pharma- cotherapy. Vasc Med 1996; 1: 50–54.
19. Huch R, Huch A, Lu¨bbers DW. Transcutaneous PO2.
3. Jull A, Waters J, Arroll B. Pentoxifylline for treatment of venous leg ulcers: a systematic review. Lancet 2002; 359: 20. De Sanctis MT, Belcaro G, Cesarone MR, Ippolito E, Nicolaides AN, Incandela L, Geroulakos G. Treatment of 4. Colgan MP, Dormandy JA, Jones PW, Schraibman IG, venous ulcers with pentoxifylline: a 12-month, double- Shanik DG, Young RAL. Oxpentifylline treatement of blind, placebo controlled trial. Microcirculation and venous ulcers of the leg. BML 1990; 300: 972–975.
healing. Angiology 2002; 53 (Suppl. 1): 49–51.
5. Thum J, Caspary L, Creutzig A, Alexander K. Intra- arterial and intravenous administration of prostaglandinE1 cause different changes to skin microcirculation in patients with peripheral arterial occlusive disease.
Department of Dermatology and Allergology 6. Alt E. Development of radioligand assay for quantifying specific prostaglandin E1 binding in ischemic ulcers.
Acta Med Austriaca 2000; 27: 152–155.
7. Bollinger A, Fagrell B. Clinical capillaroscopy. Toronto: 8. Stu¨cker M, Baier V, Reuther T, Hoffmann K, Kellam K, Altmeyer P. Capillary blood cell velocity in human skin capillaries located perpendicularly to the skin surface:

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