Venous Thromboembolism: Arteriovenous Foot Pumps in the Prophylaxis of DVT/PE

Published 2002
Citation: J Trauma. 53(1):142-164, July 2002.

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Authors

Rogers, Frederick B. MD; Cipolle, Mark D. MD, PhD; Velmahos, George MD, PhD; Rozycki, Grace MD; Luchette, Fred A. MD

Author Information

From the University of Vermont, Department of Surgery, Fletcher Allen Health Care (F.B.R.), Burlington, Vermont, Department of Surgery, Lehigh Valley Hospital (M.D.C.), Allentown, Pennsylvania, Department of Surgery, Division of Trauma and Critical Care, University of Southern California (G.V.), Los Angeles, California, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, and Department of Surgery, Division of Trauma, Critical Care, and Burns, Loyola University Medical Center (F.A.L.), Maywood, Illinois.

Submitted for publication September 1, 2001.

Accepted for publication March 15, 2002.

Any reference in this guideline to a specific commercial product, process, or service by trade name, trademark, or manufacturer does not constitute or imply an endorsement, recommendation, or any favoritism by the authors or EAST. The views and opinions of the authors do not necessarily state or reflect those of EAST and shall not be used for advertising or product endorsement purposes.

Address for reprints: Frederick B. Rogers, MD, University of Vermont Department of Surgery, Fletcher Allen Health Care, 111 Colchester Avenue, Burlington, VT 05401; email: frederick.rogers@vtmednet.org.

Statement of the Problem

In 1983, Gardner and Fox[23] discovered a venous pump on the sole of the foot that consists of a plexus of veins that fills by gravity and empties on weightbearing, thus increasing femoral blood flow without muscular assistance. A mechanical device, the arteriovenous (A-V) foot pump, has been developed to mimic this effect of weightbearing. The major advantage of this system is that it only requires access to the foot, which enables its use in patients with Jones dressings, casts, or externally fixed limbs that previously were unsuitable for a PCD. One study has shown that the pulsatile action of the A-V foot pump increased venous blood flow velocity in the popliteal vein by 250%.[24]

Process

With the recent clinical introduction of the A-V foot pump, there is a paucity of relevant literature related to this subject. A MEDLINE review dating back to 1980 revealed 12 articles on A-V foot pumps, with 8 articles specifically related to the use of A-V foot pumps in the trauma patient. These eight studies were the basis for the recommendations below (Table 3).

Recommendations

A. Level I: A Level I recommendation for this topic cannot be supported because of insufficient data.

B. Level II: A Level II recommendation for this topic cannot be supported because of insufficient data.

C. Level III: A-V foot pumps may be used as a substitute for pneumatic compression devices in those high-risk trauma patients who cannot wear PCDs because of external fixators or casts and cannot be anticoagulated because of their injuries. It should be noted that in trauma patients, A-V foot pumps have not been shown to be as efficacious as PCDs and are associated with some significant complications.[12][25][26]

Scientific Foundation

Most of the studies involving the use of A-V foot pumps are found in the orthopedic literature, and many of these series involve small numbers of patients. Although little has been documented on the effects of A-V footpumps on DVT in trauma patients, other beneficial effects have been observed. In 71 patients who had operations or casts for traumatic lower extremity injuries, Gardner and Fox[27] showed a significant decrease in pain, swelling, and measurement of compartment pressures in the affected extremities with the use of the A-V foot pumps. In the discussion to this article, the authors hypothesized that the increased blood flow seen with the pumps was because of hyperemia mediated by endothelial-derived relaxing factor (now thought to be nitric oxide) that was liberated by the endothelium secondary to sudden pressure changes, which could have been caused by the A-V pumps. This endothelial-derived relaxing factor release could encourage the opening of critically closed capillaries, enabling reabsorption of fluid, hence the decrease in compartment pressures. In addition, reports have been documented of A-V foot pumps improving arterial blood flow with the relief of ischemic rest pain.[28][29] In addition to preventing VTE, all of these proposed foot pump mechanisms of action may be potentially beneficial in healing extremity injuries.

In a recent prospective randomized study by Knudson et al.,[12] A-V foot pumps were one arm of a number of prophylactic measures (LMWH and PCDs were the other arms) used to prevent DVT in high-risk trauma patients. Of 372 patients enrolled in the study, the DVT rate was 5.7% for the A-V foot pumps, 2.5% for the PCDs, and 0.8% for the low-molecular-weight heparin as determined on follow-up serial duplex ultrasound. Of note, in 8 of 53 patients who wore foot pumps, severe skin changes, including blistering and wound problems, occurred. This required three patients to be removed early from the study.

Spain et al.[25] compared the use of A-V foot pumps to PCDs in 184 consecutively injured patients. In this nonrandomized study, patients who could not receive a PCD because of lower extremity injuries were placed in A-V foot pumps. Overall, no significant difference was seen in DVT rates between the two groups, with PCDs at 7% and A-V foot pumps at 3%. The authors of this study concluded that A-V foot pumps were a reasonable alternative to PCDs when lower extremity fractures preclude the use of PCDs. Anglen et al.[26]performed a randomized prospective trial comparing A-V foot pumps with PCDs in high-risk orthopedic patients and followed them with serial ultrasound. In 124 patients, the overall incidence of DVT was 4% in those with A-V foot pumps and 0% in those with PCDs. Unfortunately, meaningful analysis of such a study was confounded by the heterogeneity of the two groups and the fact that a sizable number of patients received either aspirin or warfarin postoperatively. In another study by Anglen et al.[30] in a trauma population of ICU and ward patients, the A-V foot pumps were found to be applied properly and functioning correctly only 59% of the time, a problem similar to that reported by Comerota et al.[31] for PCDs.

Summary

Only one clinical series in trauma patients compares A-V foot pumps with other standard techniques of DVT prophylaxis. The results from this series were not definitive in terms of benefits of A-V foot pumps preventing DVT. However, a use of A-V foot pumps may exist in the high-risk trauma patient who has a contraindication to heparin because of injuries or who cannot have PCDs placed on lower extremities secondary to external fixators or large bulky dressings.

Future Investigations

Prospective randomized studies are needed comparing A-V foot pumps to standard prophylactic measures in trauma patients at high risk for the development of DVT.

Acknowledgment

We thank Jody Ciano for her help in the preparation of this article.

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Table

A-V Foot Pumps

First Author

Year

Reference Title

Class

Conclusion

Gardner AMN

1983

The venous pump of the human foot: preliminary

report. Bristol Med Chir J. 98:109–112

III

First description of the physiologic pumping mechanism

on the sole of the foot.

This study demonstrated that A-V foot pump increases

venous blood flow in popliteal vein by 250%.

Laverick MD

1990

A comparison of the effects of electrical calf

muscle stimulation and the venous foot pump

on venous blood flow in the lower leg.

Phlebography. 5:285–290

III

Knudson MM

1996

The use of low molecular weight heparin in

preventing thromboembolism in trauma

patients. J Trauma. 41:446–459

II

A-V foot pumps used as one limb of prospective study

on DVT prophylaxis. Foot pumps had a higher DVT

rate (not significant) than LMWH or PCD and

complications with their use.

Spain DA

1998

Comparison of sequential compression devices

and foot pumps for prophylaxis of deep

venous thrombosis in high-risk trauma

patients. Am Surg. 64:522–526

III

Nonrandomized study of 184 high-risk patients,

incidence of DVT was similar between groups (7%

PCD, 3% A-V foot pumps) as was number of PEs (2

AV foot pumps, 1 PCD).

Anglen JO

1998

A randomized comparison of sequential-gradient

calf compression with intermittent plantar

compression for prevention of venous

thrombosis in orthopedic trauma patients:

preliminary results. Am J Orthop. 33:53–57

II

Prospective, randomized controlled study of high-risk

patients followed with serial duplex. DVT rates: 0%

PCD; 4% A-V foot pump.

Gardner AM

1990

Reduction of post-traumatic swelling and

compartment pressure by impulse

compression of the foot. J Bone Joint Surg

Br. 72:810–815

III

Multicenter trial showed decrease in pain and

compartment pressures with the use of A-V foot

pumps. Hypothesized that this was because of

release of endothelial-derived relaxing factor in

microcirculation.

Morgan RH

1991

Arterial flow enhanced by impulse compression.

Vasc Surg. 25:8–15

III

22 patients with peripheral vascular disease had relief

of ischemic rest pain with use of A-V foot pump.

Abu-Own A

1993

Effects of intermittent pneumatic compression of

the foot on the microcirculatory function in

arterial disease. Eur J Vasc Surg. 7:488–492

                  III

A-V foot pumps increased transcutaneous oxygen and

laser Doppler fluxemetry in patients with severe

claudication.

Anglen JO

1998

Foot pump prophylaxis for deep venous

thrombosis: the rate of effective usage in

trauma patients. Am J Orthop. 580–582

III

Trauma population found that A-V foot pumps were

applied properly and functioning only 59% of the

time.

Comerota AJ

1992

Why does prophylaxis with external pneumatic

compression for deep vein thrombosis fail?

Am J Surg. 164:265–268

III

A-V foot pumps increased transcutaneous oxygen and

laser Doppler fluxemetry in patients with severe

claudication.

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