Use of the Tourniquet in Reconstructive Surgery in Patients with Previous Ipsilateral Lower Extremity Revascularization: Is it Safe? A Survey

ABSTRACT

Tourniquet use in the previously revascularized ipsilateral lower extremity varies among micro-reconstructive surgeons due to the possible complication of graft failure. Examination of evidence-based literature and a current standard of care is needed to establish guidelines for such tourniquet use. Surveys were sent to vascular surgery program directors of ACGME-accredited residency programs to assess prevailing tourniquet use instruction. The survey addressed issues, including tourniquet use in previous bypass surgery, previous angioplasty, and location relative to graft anatomy. Twenty-eight responses were received out of 87 surveys sent (32 percent response rate). Ninety-three percent considered tourniquet use inappropriate in the ipsilateral lower extremity with previous revascularization. Seventy-one percent indicated tourniquet use inappropriate in previous ipsilateral angioplasty. Sixty-one percent regarded graft conduit type to be important in tourniquet use. There remains a lack of prospective, randomized, controlled studies determining risks of occlusion and other complications to the preexisting bypass graft during tourniquet use. Until such studies are done, this survey recommends avoiding tourniquet use in this patient population.

Tourniquet - primary revascularization - micro-reconstruction

REFERENCES

• 1 Scheinin T M, Lindfors O. Simplified repair of popliteal aneurysms.  J Cardiovasc Surg. 1979;  20 189-192
• 2 Bernhard V M, Boren C H, Towne J B. Pneumatic tourniquet as a substitute for vascular clamps in distal bypass surgery.  Surgery. 1980;  87 709-713
• 3 Shindo S, Tada Y, Sato O et al.. Esmarch's bandage technique in distal bypass surgery.  J Cardiovasc Surg. 1992;  33 609-612
• 4 Collier P E. Atraumatic vascular anastomoses using a tourniquet.  Ann Vasc Surg. 1992;  6 34-37
• 5 Myers K A. Semi-closed, in situ, non-reversed or reversed autogenous vein grafting. A technique for femoro-distal arterial bypass.  J Cardiovasc Surg. 1991;  32 110-116
• 6 Wagner W H, Treiman R L, Cossman D V et al.. Tourniquet occlusion technique for tibial artery reconstruction.  J Vasc Surg. 1993;  18 637-647
• 7 Reid H S, Camp R A, Jacob W H. Tourniquet hemostasis: a clinical study.  Clin Orthop. 1983;  177 230-234
• 8 Eyers P, Ashley S, Scott D JA. Tourniquets in arterial bypass surgery.  Eur J Vasc Endovasc Surg. 2000;  20 113-117
• 9 Saunders K C, Louis D L, Weingarden S I, Waylonis G W. Effect of tourniquet time on postoperative quadriceps function.  Clin Orthop. 1979;  143 194-199
• 10 Wilgis E F. Observations on the effects of tourniquet ischemia.  J Bone Joint Surg Am. 1971;  53 1343-1346
• 11 Rorabeck C H, Kennedy J C. Tourniquet-induced nerve ischemia complicating knee ligament surgery.  Am J Sports Med. 1980;  8 98-102
• 12 Tountas C P, Bergman R A. Tourniquet ischemia: ultrastructural and histochemical observations of ischemic human muscle and of monkey muscle and nerve.  J Hand Surg Am. 1977;  2 31-37
• 13 Miller S H, Price G, Buck D et al.. Effects of tourniquet ischemia and postischemic edema on muscle metabolism.  J Hand Surg Am. 1979;  4 547-555
• 14 Ward C M. Oedema of the hand after fasciectomy with or without a tourniquet.  Hand. 1976;  8 179-185
• 15 Pedowitz R A, Gershuni D H, Friden J, Garfin S R, Rydevik B L, Hargens A R. Effects of reperfusion intervals on skeletal muscle injury beneath and distal to a pneumatic tourniquet.  J Hand Surg. 1992;  17 245-255
• 16 Farlane M E, Spooner S JL. Chemical changes in muscle during and after ischaemia.  Br J Exper Pathol. 1946;  27 339-348
• 17 Appell H J, Gloser S, Duarte J A, Zellner A, Soares J M. Skeletal muscle damage during tourniquet-induced ischaemia.  Eur J Appl Physiol. 1993;  67 342-347
• 18 Guanche C A. Tourniquet-induced tibial nerve palsy complicating anterior cruciate ligament reconstruction.  Arthroscopy. 1995;  11 620-622
• 19 Hobbs A C, Weinik M. Spinal cord injury patient with compressive neuropathy from normal tourniquet pressure: a case report.  Arch Phys Med Rehabil. 2003;  84 A11-A12
• 20 Middleton R WD, Varian J P. Tourniquet paralysis.  Aust NZ J Surg. 1974;  44 124-128
• 21 Silva M S, Sobel M. Popliteal vascular injury during total knee arthroplasty.  J Surg Research. 2003;  109 170-174
• 22 Hagan P F, Kaufman E E. Vascular complication of knee arthroplasty under tourniquet: a case report.  Clin Orthop. 1990;  257 159-161
• 23 Paez-Hospital M, Herrero-Gento E, Buisan-Garrido F. Pulmonary embolism after placement of an Esmarch bandage for ankle surgery.  Rev Esp Anestesiol Reanim. 2003;  50 192-196
• 24 McGrath B J, Hsia J, Boyd A et al.. Venous embolization after deflation of lower extremity tourniquets.  Anesth Analg. 1994;  78 349-353
• 25 Parmet J L, Berman A T, Horrow J C, Harding S, Rosenberg H. Thromboembolism coincident with tourniquet deflation during total knee arthroplasty.  Lancet. 1993;  341 1057-1058
• 26 Ogino Y, Tatsuoka Y, Matsuoko R et al.. Cerebral infarction after deflation of a pneumatic tourniquet during total knee replacement.  Anesthesiology. 1999;  90 297-298
• 27 Ciervo A, Dardik H, Qin F et al.. The tourniquet revisited as an adjunct to lower limb revascularization.  J Vasc Surg. 2000;  31 436-442
• 28 Jeyaseelan S, Stevenson T M, Pfitzner J. Tourniquet failure and arterial calcification. Case report and theoretical dangers.  Anaesthesia. 1981;  36 48-50
• 29 Sloop G D, Fallon K B, Zieske A W. Atherosclerotic plaque-like lesions in synthetic arteriovenous grafts: implications for atherogenesis.  Atherosclerosis. 2002;  160 133-139
• 30 DeBakey M E, Jordan Jr J L, Abbott J P, Halpert B, O'Neal R M. The fate of Dacron vascular grafts.  Arch Surg. 1964;  89 757-782
• 31 Szilagyi D E, Smith R F, Elliott J P, Allen H M. Long-term behavior of a Dacron arterial substitute: clinical, roentgenologic, and histologic correlation.  Ann Surg. 1965;  162 453-477
• 32 Selman S H, Rhodes R S, Anderson J M, DePalma R G, Clowes A W. Atheromatous changes in expanded polytetrafluoroethylene grafts.  Surgery. 1980;  87 630-637
• 33 Carson S N, Hunter G, French S, Lord P, Wong H N. Occurrence of occlusive intimal changes in an expanded polytetrafluoroethylene graft.  J Cardiovasc Surg. 1980;  21 503-508
• 34 Castagna M T, Mintz G S, Weissman N J et al.. Calcification in saphenous vein graft: clinical correlates and intravascular ultrasound findings.  Angiog Interven Cardiology. 2002;  39(Suppl 1) 36A
• 35 Kirkley A, Rampersaud R, Griffin S, Amendola A, Litchfield R, Fowler P. Tourniquet versus no tourniquet use in routine knee arthroscopy: a prospective, double-blind, randomized clinical trial.  Arthoscopy. 2000;  16 121-126
• 36 Laurentis D A, Levitsky K A, Booth R E et al.. Arterial and ischemic aspects of total knee arthroplasty.  Am J Surg. 1992;  164 237-240
• 37 Zagoria R J, D'Souza V J, Sharling E S. Prosthetic arterial graft occlusion: a complication of tourniquet use during arteriography.  Radiology. 1988;  167 121-122
• 38 Eyers P, Wijesinghe L, Ashley S et al.. Using a tourniquet in femorodistal bypass.  Br J Surg. 1997;  84(Suppl 1) 564 , Abstract
• 39 Turner N S, Pagnano M W, Sim F H. Total knee arthroplasty after ipsilateral peripheral arterial bypass graft: acute arterial occlusion is a risk with or without tourniquet use.  J Arthroplasty. 2001;  16 317-321
• 40 Holmberg A, Sandhagen B, Bergqvist D. Hemorheologic variables in critical limb ischemia before and after infrainguinal reconstruction.  J Vasc Surg. 2000;  31 691-695
• 41 Ikeda Y, Rummel M C, Bhatnager P K et al.. Thrombolysis therapy in patients with femoropopliteal synthetic graft occlusions.  Am J Surg. 1996;  171 251-254
• 42 Itoh T, Kambayashi J, Tsujinaka T, Sakon M, Ohshiro T, Mori T. Pathogenesis of early thrombus formation in experimental vein graft.  Thrombosis Res. 1989;  53 357-365
• 43 Itoh T, Shiba E, Kambayashi J et al.. The pathogenesis of thrombosis in venous prostheses.  Eur J Vasc Surg. 1990;  4 625-631
• 44 Plate G, Hollier L H, Glovickzi P, Dewanjee M K, Kaye M P. Overcoming failure of venous vascular prostheses.  Surgery. 1984;  96 503-510
• 45 Cassar K, Bachoo P, Brittenden J. The role of platelets in peripheral vascular disease.  Eur J Vasc Endovasc Surg. 2003;  25 6-15
• 46 Longest P W, Kleinstreuer C. Particle-hemodynamics modeling of the distal end-to-side femoral bypass: effects of graft caliber and graft-end cut.  Med Engineer Physics. 2003;  25 843-858
• 47 Hashimoto S, Maeda H, Sasada T. Effect of shear rate on clot growth at foreign surfaces.  Artif Organs. 1985;  9 345-350
• 48 Bellemans J, Stockx L, Peerlinck K, Vermylen J, Lacroix H, Suy R. Arterial occlusion and thrombus aspiration after total knee arthroplasty.  Clin Orthop. 1999;  1 164-168
• 49 Mamode N, Scott R N. Graft type for femoro-popliteal bypass surgery. Cochrane Peripheral Vascular Diseases Group.  Cochrane Database Syst Rev. 2000;  (2) CD001487 , Review
• 50 Green R M, Ouriel K, Ricotta J J, DeWeese J A. Revision of failed infrainguinal bypass graft: principles of management.  Surgery. 1986;  100 646-654
• 51 Ascer E, Collier P, Gupta S K, Veith F J. Reoperation for polytetrafluorethylene bypass failure: the importance of distal outflow site and operative technique in determining outcome.  J Vasc Surg. 1987;  5 298-310
• 52 Younger A SE, Kalla T P, McEwen J A, Inkpen K. Survey of tourniquet use in orthopaedic foot and ankle surgery.  Foot Ankle Internat. 2005;  26 208-217
• 53 Ostman B, Michaelsson K, Rahme H, Hillered L. Tourniquet-induced ischemia and reperfusion in human skeletal muscle.  Clin Orthop. 2004;  418 260-265
• 54 Tuncali B, Karci A, Bacakoglu A K, Tuncali B E, Ekin A. Controlled hypotension and minimal inflation pressure: a new approach for pneumatic tourniquet application in upper limb surgery.  Anesth Analg. 2003;  97 1529-1532