Cardiovascular Journal of Africa: Vol 32 No 5 (SEPTEMBER/OCTOBER 2021)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 5, September/October 2021 254 AFRICA Can the arterial clamp method be used safely where a tourniquet cannot be used? Ozgur Erdogan, Volkan Gürkan, Cavide Sönmez, Tunay Erden, Sezen Atasoy, Fatih Yildiz, Bekir İ nan, Adile Adilli Abstract Background: Clamp application is safe and widely used in the visceral organs. This raises the question: why not use clamping in orthopaedic, oncological, fracture and revision surgeries of areas where tourniquets are not suitable. This experimental animal study aimed to compare tourniquet and arterial clamp applications with regard to their histological effects and inflammatory responses on a molecular level, on the artery, vein, nerve and muscle tissue. Methods: Twenty-one rabbits were divided into three groups (group I: proximal femoral artery clamp; group II: proximal thigh tourniquet; and group III: control group). In the clamp group, the common femoral artery was clamped with a microvascular clamp for two hours. In the tourniquet group, a 12-inch cuff was applied to the proximal thigh for two hours at 200 mmHg. The common femoral artery, vein, nerve, rectus femoris and tibialis anterior muscles were excised and analysed in all groups. Results: Artery and vein endothelial injuries were found in the clamp and tourniquet groups (relative to the control group, p ≤ 0.001 and p = 0.007, respectively). However, no difference was found between the clamp and tourniquet groups regard- ing vessel wall injury. Conclusion: We found there were no differences in incidence of vessel, muscle and nerve injury when comparing the tourniquet and clamp applications. For surgical procedures that are unsuited to a tourniquet, arterial clamping can be selected, resulting in close-to-tourniquet vessel injury rates but without tourniquet-related complications. Keywords: tourniquet, clamp, haemorragia, artery, vein, injury Submitted 14/12/20, accepted 12/5/21 Published online 7/7/21 Cardiovasc J Afr 2021; 32 : 254–260 www.cvja.co.za DOI: 10.5830/CVJA-2021-023 Blood loss can occur during any surgical procedure. However, certain types of surgery are associated with higher amounts of blood loss, which require transfusion. Some of these procedures are kidney, hepatic, orthopedic and vascular operations. 1 Orthopaedic surgery, especially malignant tumour surgeries of the extremities, results in severe blood loss, which causes difficulty in dissection of the tumour and neurovascular structures, and consequently prolonged surgical times, excessive blood transfusion and transfusion-related complications. Tourniquet use solves this problem, however its use becomes impossible if the surgical field is very proximal, where arterial clamp use could be effective. It should be noted that tourniquet use can be dangerous and in some instances may be contraindicated. 2 Also, there is controversy about the appropriate application time and pressure. Moreover, severe neurological and muscular damage related to the use of a tourniquet has been reported. 3 In radical surgical procedures, arterial clamp application through an additional small incision and vascular dissection, which can quickly close and open the blood supply, may solve these problems. However, orthopaedic surgeons are often unfamiliar with arterial clamp use or they are unsure about its reliability and/or safety. The literature on arterial clamp use in malignant tumour surgeries of the proximal parts of the extremities is lacking. This study aimed to investigate the effectiveness and safety of arterial clamps in terms of possible damage to the arterial wall. The main question motivating this work was why we do not use the clamp method in orthopedic, oncological procedures in patients where tourniquet application is impossible. The hypothesis was that tourniquet use has less adverse effects on the arterial wall than the direct application of an arterial clamp. Methods This animal study proposal was approved by the local ethics committee and local animal experimental ethics committee (HADYEK) of the Bezmialem University, with permit number: 2017/21. According to the guide, Institutional Animal Care and Use Committee (IACUC) 4 for the care and use of laboratory animals, principles and animal rights were protected in this study. A local ethics committee, approved by Bezmialem University Faculty of Medicine Ethics Committe, approved this study: number 2016/154. In the study design, Guide for the Care Department of Orthopaedics, Health Sciences University, Haydarpasa Numune Education and Research Hospital, Istanbul, Turkey Ozgur Erdogan, MD, drozgurerdogan@gmail.com Department of Orthopaedics, Faculty of Medicine, Bezmialem University, Istanbul, Turkey Volkan Gurkan, MD Fatih Yıldız, MD Department of Pathology, Faculty of Medicine, Bezmialem University, Istanbul, Turkey Cavide Sonmez, MD Adila Adıllı, MD Department of Orthopaedics, Fulya Hospital, Acibadem University, Istanbul, Turkey Tunay Erden, MD Division of Genetics, Department of Medical Biology, Istanbul University Cerrahpasa, Istanbul, Turkey Sezen Atasoy, MSc Department of Cardiovascular Surgery, Faculty of Medicine, Bezmialem University, Istanbul, Turkey Bekir Inan, MD