Peripheral arterial disease other diagnostic studies: Difference between revisions

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{{Peripheral arterial disease}}
{{Peripheral arterial disease}}


'''Editors-in-Chief: [[C. Michael Gibson]], M.D., Beth Israel Deaconess Medical Center, Boston, MA; [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]; '''Associate Editor-In-Chief:''' {{CZ}}
{{CMG}}; {{AE}} {{CZ}}; {{VVS}}; [[User:Rim Halaby|Rim Halaby]]
 
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==Overview==
==Overview==
*When symptoms suggestive of [[peripheral artery disease]] are present, '''clinical evaluation''' along with '''non invasive testing''' are enough to establish the diagnosis. Invasive diagnostic studies are anatomic studies that are not used for diagnosis but rather for preoperative evaluation of the anatomy of the [[vessels]].
When symptoms suggestive of [[peripheral artery disease]] are present, clinical evaluation along with non invasive testing are enough to establish the diagnosis. Invasive diagnostic studies are anatomic studies that are not used for diagnosis but rather for preoperative evaluation of the anatomy of the [[vessels]]. The non invasive modality mostly used in the diagnosis of [[peripheral artery disease]] is the measurement of the [[ankle brachial index]] (ABI) at rest and after exercise testing. The non invasive diagnostic studies are functional studies and they include the following: measurement of [[ABI]] at rest and after exercise, pulse volume recording, transcutaneous oxygen pressure measurement and laser doppler fluximetry. The invasive diagnostic studies are anatomic studies and they include the following: conventional [[angiography]], CT angiography, [[MRA]] and duplex [[ultrasound]].
*The non invasive modality mostly used in the diagnosis of [[peripheral artery disease]] is the measurement of the ankle brachial index (ABI) at rest and after exercise testing.
*The '''non invasive''' diagnostic studies are '''functional studies''' and they include the following:
**Measurement of [[ABI]] at rest and after exercise
**Pulse volume recording
**Transcutaneous oxygen pressure measurement
**Laser doppler fluximetry.
*The '''invasive''' diagnostic studies are '''anatomic studies''' and they include the following:
**Conventional [[angiography]].
**CT angiography
**[[MRA]]
**Duplex [[ultrasound]].<ref>Wennberg PW, Rooke TW. Chapter 109. Diagnosis and Management of Diseases of the Peripheral Arteries and Veins. In: Fuster V, Walsh RA, Harrington RA, eds. Hurst's The Heart. 13th ed. New York: McGraw-Hill; 2011.</ref>


== Other Diagnostic Studies ==
== Other Diagnostic Studies ==
*Ankle-Brachial Index, Toe-Brachial Index, and Segmental Pressure Examination
===Ankle-Brachial Index===
*Pulse volume recording
*The [[ankle brachial index]] (ABI) is the ratio of the systolic [[blood pressure]] at the ankle over the [[systolic blood pressure]] measured at the higher arm. ABI is the most commonly diagnostic tool used for the evaluation of [[peripheral artery disease]].
*Treadmill exercise testing with and without ABI assessments and 6 minute walk test
*When vascular stenosis is present peripherally, the [[blood pressure]] in the [[vessel]] decreases and hence the ABI decreases. Thus, the ABI is inversely related to the severity of the peripheral artery disease.
 
====Evaluation of the Severity of the Arterial Occlusive Disease Based on the ABI Done at Rest====
* 1- 1.4: Normal
* 0.8-0.9: Mild
* 0.5-0.8: Moderate
* <0.5: Severe<ref name="Wennberg">Wennberg PW, Rooke TW. Chapter 109. Diagnosis and Management of Diseases of the Peripheral Arteries and Veins. In: Fuster V, Walsh RA, Harrington RA, eds. Hurst's The Heart. 13th ed. New York: McGraw-Hill; 2011.</ref>
 
===Toe-Brachial Index===
*When the vessels are stiff, as in the case of diseases like [[diabetes]], the ABI index is inaccurate in the evaluation of the severity of the arterial occlusive diseases.
* Toe-brachial index is a reliable alternative when the vessels are stiff and non compressible.
*The normal range for the toe-brachial pressure index is values more than 0.70.<ref name="pmid4831541">{{cite journal| author=Hobbs JT, Yao ST, Lewis JD, Needham TN| title=A limitation of the Doppler ultrasound method of measuring ankle systolic pressure. | journal=Vasa | year= 1974 | volume= 3 | issue= 2 | pages= 160-2 | pmid=4831541 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4831541  }} </ref>
 
===ABI in Lower Extremity Exercise Testing===
*Patients with [[peripheral artery disease]] can have normal ABI at rest; however, they show abnormal ABI measurements after stress exercise.
*During exercise, the systolic pressure increases causing an increase in the pressure difference beyond the diseased vessel. Hence, the ABI will decrease.
*Patients who can not tolerate the treadmill exercise can do the tip toe exercise as an alternative.
 
====Evaluation of the Severity of the Arterial Occlusive Disease Based on the ABI After Exercise Testing====
* 0.5-0.9: Mild
* 0.15-0.8: Moderate
* <0.15: Severe.<ref name="Wennberg">Wennberg PW, Rooke TW. Chapter 109. Diagnosis and Management of Diseases of the Peripheral Arteries and Veins. In: Fuster V, Walsh RA, Harrington RA, eds. Hurst's The Heart. 13th ed. New York: McGraw-Hill; 2011.</ref>
 
====Evaluation of the Severity of the Arterial Occlusive Disease Based on the Tolerance to Exercise Testing====
* Exercise tolerance less than 5 minutes: Moderate
* Exercise tolerance less than 3 minutes: Severe<ref name="pmid16534039">{{cite journal| author=Feringa HH, Bax JJ, van Waning VH, Boersma E, Elhendy A, Schouten O et al.| title=The long-term prognostic value of the resting and postexercise ankle-brachial index. | journal=Arch Intern Med | year= 2006 | volume= 166 | issue= 5 | pages= 529-35 | pmid=16534039 | doi=10.1001/archinte.166.5.529 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16534039  }} </ref>
 
===Segmental Pressures Examination===
*Segmental pressure examinations is basically applying the same ABI principle but on different parts of the extremities.
 
===Pulse Volume Recording===
*Pulse volume recording aims to assess the magnitude of the arterial impulse entering a [[vessel]].<ref> Halperin JL. Evaluation of patients with peripheral vascular disease. Thromb Res. 2002;106:V303-V311.</ref>
 
===Transcutaneous Oxygen Measurement===
*Transcutaneous oxygen method aims to evaluate the [[microcirculation]] through the assessment of the oxygen flow through the skin.
*It is is used to monitor the effect of therapy and to assess the chances of healing after amputation.
*When the transcutaneous oxygen measurements exceeds 40 mm Hg it indicated higher chances for healing, whereas measurements less than 20 mm Hg are unlikely to heal.<ref name="pmid1538514">{{cite journal| author=Bacharach JM, Rooke TW, Osmundson PJ, Gloviczki P| title=Predictive value of transcutaneous oxygen pressure and amputation success by use of supine and elevation measurements. | journal=J Vasc Surg | year= 1992 | volume= 15 | issue= 3 | pages= 558-63 | pmid=1538514 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1538514  }} </ref>
 
===Laser Doppler Fluximetry===
*Laser doppler fluximetry assesses skin perfusion.<ref name="pmid10876204">{{cite journal| author=Tsai FW, Tulsyan N, Jones DN, Abdel-Al N, Castronuovo JJ, Carter SA| title=Skin perfusion pressure of the foot is a good substitute for toe pressure in the assessment of limb ischemia. | journal=J Vasc Surg | year= 2000 | volume= 32 | issue= 1 | pages= 32-6 | pmid=10876204 | doi=10.1067/mva.2000.107310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10876204  }} </ref>
 
==Management of Patients With Peripheral Artery Disease (Compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations) : A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines<ref name="pmid23473760">{{cite journal| author=Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss L et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2013 | volume= 61 | issue= 14 | pages= 1555-70 | pmid=23473760 | doi=10.1016/j.jacc.2013.01.004 | pmc=4492473 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23473760 }} </ref>==


== 2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (Updating the 2005 Guideline)(DO NOT EDIT)<ref name="pmid21959305">{{cite journal |author= |title=2011 ACCF/AHA Focused Update of the Guideline for the Management of patients with peripheral artery disease (Updating the 2005 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines |journal=[[Circulation]] |volume=124 |issue=18 |pages=2020–45 |year=2011 |month=November |pmid=21959305 |doi=10.1161/CIR.0b013e31822e80c3 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21959305 |accessdate=2012-10-09}}</ref>==
===Ankle-Brachial Index, Toe-Brachial Index, and Segmental Pressure Examination (DO NOT EDIT)<ref name="pmid21959305">{{cite journal |author= |title=2011 ACCF/AHA Focused Update of the Guideline for the Management of patients with peripheral artery disease (Updating the 2005 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines |journal=[[Circulation]] |volume=124 |issue=18 |pages=2020–45 |year=2011 |month=November |pmid=21959305 |doi=10.1161/CIR.0b013e31822e80c3 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21959305 |accessdate=2012-10-09}}</ref><ref name="pmid16549646">{{cite journal |author=Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>===
=== Recommendations for Ankle-Brachial Index, Toe-Brachial Index, and Segmental Pressure Examination ===


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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' The resting ABI should be used to establish the lower extremity PAD diagnosis in patients with suspected lower extremity PAD, defined as individuals with 1 or more of the following: exertional leg symptoms, nonhealing wounds, age 65 years and older, or 50 years and older with a history of smoking or diabetes.([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' The resting ABI should be used to establish the lower extremity PAD diagnosis in patients with suspected lower extremity PAD, defined as individuals with 1 or more of the following: exertional leg symptoms, nonhealing wounds, age 65 years and older, or 50 years and older with a history of smoking or [[diabetes]].<ref name="pmid9546918">{{cite journal |author=Criqui MH, Denenberg JO, Bird CE, Fronek A, Klauber MR, Langer RD |title=The correlation between symptoms and non-invasive test results in patients referred for peripheral arterial disease testing |journal=[[Vascular Medicine (London, England)]] |volume=1 |issue=1 |pages=65–71 |year=1996 |pmid=9546918 |doi= |url= |accessdate=2012-11-05}}</ref><ref name="pmid11560536">{{cite journal |author=Hirsch AT, Criqui MH, Treat-Jacobson D, Regensteiner JG, Creager MA, Olin JW, Krook SH, Hunninghake DB, Comerota AJ, Walsh ME, McDermott MM, Hiatt WR |title=Peripheral arterial disease detection, awareness, and treatment in primary care |journal=[[JAMA : the Journal of the American Medical Association]] |volume=286 |issue=11 |pages=1317–24 |year=2001 |month=September |pmid=11560536 |doi= |url=http://jama.jamanetwork.com/article.aspx?volume=286&page=1317 |accessdate=2012-11-05}}</ref><ref name="pmid19901192">{{cite journal |author=Diehm C, Allenberg JR, Pittrow D, Mahn M, Tepohl G, Haberl RL, Darius H, Burghaus I, Trampisch HJ |title=Mortality and vascular morbidity in older adults with asymptomatic versus symptomatic peripheral artery disease |journal=[[Circulation]] |volume=120 |issue=21 |pages=2053–61 |year=2009 |month=November |pmid=19901192 |doi=10.1161/CIRCULATIONAHA.109.865600 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=19901192 |accessdate=2012-11-05}}</ref>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>


|-
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' The ABI should be measured in both legs in all new patients with PAD of any severity to confirm the diagnosis of lower extremity PAD and establish a baseline.([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' The ABI should be measured in both legs in all new patients with PAD of any severity to confirm the diagnosis of lower extremity PAD and establish a baseline.<ref name="pmid3042648">{{cite journal |author=Fowkes FG |title=The measurement of atherosclerotic peripheral arterial disease in epidemiological surveys |journal=[[International Journal of Epidemiology]] |volume=17 |issue=2 |pages=248–54 |year=1988 |month=June |pmid=3042648 |doi= |url=http://ije.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=3042648 |accessdate=2012-11-05}}</ref><ref name="pmid8067346">{{cite journal |author=Feigelson HS, Criqui MH, Fronek A, Langer RD, Molgaard CA |title=Screening for peripheral arterial disease: the sensitivity, specificity, and predictive value of noninvasive tests in a defined population |journal=[[American Journal of Epidemiology]] |volume=140 |issue=6 |pages=526–34 |year=1994 |month=September |pmid=8067346 |doi= |url=http://aje.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=8067346 |accessdate=2012-11-05}}</ref><ref name="pmid8924136">{{cite journal |author=Nassoura ZE, Ivatury RR, Simon RJ, Jabbour N, Vinzons A, Stahl W |title=A reassessment of Doppler pressure indices in the detection of arterial lesions in proximity penetrating injuries of extremities: a prospective study |journal=[[The American Journal of Emergency Medicine]] |volume=14 |issue=2 |pages=151–6 |year=1996 |month=March |pmid=8924136 |doi=10.1016/S0735-6757(96)90122-9 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-6757(96)90122-9 |accessdate=2012-11-05}}</ref>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>


|-
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' The toe-brachial index should be used to establish the lower extremity PAD diagnosis in patients in whom lower extremity PAD is clinically suspected but in whom the ABI test is not reliable due to noncompressible vessels (usually patients with long-standing diabetes or advanced age). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' The toe-brachial index should be used to establish the lower extremity PAD diagnosis in patients in whom lower extremity PAD is clinically suspected but in whom the ABI test is not reliable due to noncompressible vessels (usually patients with long-standing [[diabetes]] or advanced age).<ref name="pmid5818299">{{cite journal |author=Carter SA |title=Clinical measurement of systolic pressures in limbs with arterial occlusive disease |journal=[[JAMA : the Journal of the American Medical Association]] |volume=207 |issue=10 |pages=1869–74 |year=1969 |month=March |pmid=5818299 |doi= |url=http://jama.jamanetwork.com/article.aspx?volume=207&page=1869 |accessdate=2012-11-05}}</ref><ref name="pmid8752037">{{cite journal |author=Carter SA, Tate RB |title=Value of toe pulse waves in addition to systolic pressures in the assessment of the severity of peripheral arterial disease and critical limb ischemia |journal=[[Journal of Vascular Surgery]] |volume=24 |issue=2 |pages=258–65 |year=1996 |month=August |pmid=8752037 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0741-5214(96)70101-5 |accessdate=2012-11-05}}</ref><ref name="pmid11296321">{{cite journal |author=Carter SA, Tate RB |title=The value of toe pulse waves in determination of risks for limb amputation and death in patients with peripheral arterial disease and skin ulcers or gangrene |journal=[[Journal of Vascular Surgery]] |volume=33 |issue=4 |pages=708–14 |year=2001 |month=April |pmid=11296321 |doi=10.1067/mva.2001.112329 |url=http://linkinghub.elsevier.com/retrieve/pii/S0741-5214(01)08479-8 |accessdate=2012-11-05}}</ref><ref name="pmid11553180">{{cite journal |author=Brooks B, Dean R, Patel S, Wu B, Molyneaux L, Yue DK |title=TBI or not TBI: that is the question. Is it better to measure toe pressure than ankle pressure in diabetic patients? |journal=[[Diabetic Medicine : a Journal of the British Diabetic Association]] |volume=18 |issue=7 |pages=528–32 |year=2001 |month=July |pmid=11553180 |doi= |url=http://onlinelibrary.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=0742-3071&date=2001&volume=18&issue=7&spage=528 |accessdate=2012-11-05}}</ref><ref name="pmid6833352">{{cite journal |author=Ramsey DE, Manke DA, Sumner DS |title=Toe blood pressure. A valuable adjunct to ankle pressure measurement for assessing peripheral arterial disease |journal=[[The Journal of Cardiovascular Surgery]] |volume=24 |issue=1 |pages=43–8 |year=1983 |pmid=6833352 |doi= |url= |accessdate=2012-11-05}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>


|-
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' Leg segmental pressure measurements are useful to establish the lower extremity PAD diagnosis when anatomic localization of lower extremity PAD is required to create a therapeutic plan. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' Leg segmental pressure measurements are useful to establish the lower extremity PAD diagnosis when anatomic localization of lower extremity PAD is required to create a therapeutic plan.<ref name="pmid2942613">{{cite journal |author=Belcaro G, Nicolaides AN, Bull ML, Groves JH, Williams MA, Possati F, Cotellese R, Cacchio M, Caizzi N |title=The value of segmental pressure measurement in the assessment of peripheral vascular disease |journal=[[International Angiology : a Journal of the International Union of Angiology]] |volume=5 |issue=1 |pages=7–12 |year=1986 |pmid=2942613 |doi= |url= |accessdate=2012-11-05}}</ref><ref name="pmid4344948">{{cite journal |author=Gundersen J |title=Segmental measurements of systolic blood pressure in the extremities including the thumb and the great toe |journal=[[Acta Chirurgica Scandinavica. Supplementum]] |volume=426 |issue= |pages=1–90 |year=1972 |pmid=4344948 |doi= |url= |accessdate=2012-11-05}}</ref><ref name="pmid2956433">{{cite journal |author=Johnston KW, Hosang MY, Andrews DF |title=Reproducibility of noninvasive vascular laboratory measurements of the peripheral circulation |journal=[[Journal of Vascular Surgery]] |volume=6 |issue=2 |pages=147–51 |year=1987 |month=August |pmid=2956433 |doi=10.1067/mva.1987.avs0060147 |url=http://linkinghub.elsevier.com/retrieve/pii/S0741-5214(87)70051-2 |accessdate=2012-11-05}}</ref><ref name="urlcirc.ahajournals.org">{{cite web |url=http://circ.ahajournals.org/content/early/2011/09/29/CIR.0b013e31822e80c3.full.pdf |title=circ.ahajournals.org |format= |work= |accessdate=2012-11-05}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' ABI results should be uniformly reported with noncompressible values defined as greater than 1.40, normal values 1.00 to 1.40, borderline 0.91 to 0.99, and abnormal 0.90 or less. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' ABI results should be uniformly reported with noncompressible values defined as greater than 1.40, normal values 1.00 to 1.40, borderline 0.91 to 0.99, and abnormal 0.90 or less.<ref name="pmid18612117">{{cite journal |author=Fowkes FG, Murray GD, Butcher I, Heald CL, Lee RJ, Chambless LE, Folsom AR, Hirsch AT, Dramaix M, deBacker G, Wautrecht JC, Kornitzer M, Newman AB, Cushman M, Sutton-Tyrrell K, Fowkes FG, Lee AJ, Price JF, d'Agostino RB, Murabito JM, Norman PE, Jamrozik K, Curb JD, Masaki KH, Rodríguez BL, Dekker JM, Bouter LM, Heine RJ, Nijpels G, Stehouwer CD, Ferrucci L, McDermott MM, Stoffers HE, Hooi JD, Knottnerus JA, Ogren M, Hedblad B, Witteman JC, Breteler MM, Hunink MG, Hofman A, Criqui MH, Langer RD, Fronek A, Hiatt WR, Hamman R, Resnick HE, Guralnik J, McDermott MM |title=Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis |journal=[[JAMA : the Journal of the American Medical Association]] |volume=300 |issue=2 |pages=197–208 |year=2008 |month=July |pmid=18612117 |pmc=2932628 |doi=10.1001/jama.300.2.197 |url=http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.300.2.197 |accessdate=2012-11-05}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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==2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Pulse Volume Recording (DO NOT EDIT)<ref name="pmid16549646">{{cite journal |author=Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>==
===Pulse Volume Recording (DO NOT EDIT)<ref name="pmid16549646">{{cite journal |author=Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>===


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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Pulse volume recordings are reasonable to establish the initial lower extremity PAD diagnosis, assess localization and severity, and follow the status of lower extremity revascularization procedures. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Pulse volume recordings are reasonable to establish the initial lower extremity PAD diagnosis, assess localization and severity, and follow the status of lower extremity [[revascularization]] procedures. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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==2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Treadmill Exercise Testing With and Without ABI Assessments and 6-Minute Walk Test (DO NOT EDIT)<ref name="pmid16549646">{{cite journal |author=Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>==
=== Treadmill Exercise Testing With and Without ABI Assessments and 6-Minute Walk Test (DO NOT EDIT)<ref name="pmid16549646">{{cite journal |author=Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref> ===


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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Exercise treadmill tests are recommended to provide the most objective evidence of the magnitude of the functional limitation of claudication and to measure the response to therapy. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Exercise treadmill tests are recommended to provide the most objective evidence of the magnitude of the functional limitation of [[claudication]] and to measure the response to therapy. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>


|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Astandardized exercise protocol (either fixed or graded) with a motorized treadmill should be used to ensure reproducibility of measurements of pain-free walking distance and maximal walking distance. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' A standardized exercise protocol (either fixed or graded) with a motorized treadmill should be used to ensure reproducibility of measurements of pain-free walking distance and maximal walking distance. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>


|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Exercise treadmill tests with measurement of preexercise and postexercise ABI values are recommended to provide diagnostic data useful in differentiating arterial claudication from nonarterial claudication (“pseudoclaudication”). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Exercise treadmill tests with measurement of preexercise and postexercise ABI values are recommended to provide diagnostic data useful in differentiating arterial [[claudication]] from nonarterial claudication (“pseudoclaudication”). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>


|-
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' Exercise treadmill tests should be performed in individuals with claudication who are to undergo exercise training (lower extremity PAD rehabilitation) so as to determine functional capacity, assess nonvascular exercise limitations, and demonstrate the safety of exercise. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' Exercise treadmill tests should be performed in individuals with [[claudication]] who are to undergo exercise training (lower extremity PAD rehabilitation) so as to determine functional capacity, assess nonvascular exercise limitations, and demonstrate the safety of exercise. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' A 6-minute walk test may be reasonable to provide an objective assessment of the functional limitation of claudication and response to therapy in elderly individuals or others not amenable to treadmill testing. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' A 6-minute walk test may be reasonable to provide an objective assessment of the functional limitation of [[claudication]] and response to therapy in elderly individuals or others not amenable to treadmill testing. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
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Latest revision as of 20:26, 6 October 2020

Peripheral arterial disease Microchapters

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AHA/ACC Guidelines on Management of Lower Extremity PAD

Guidelines for Clinical Assessment of Lower Extremity PAD

Guidelines for Diagnostic Testing for suspected PAD

Guidelines for Screening for Atherosclerotic Disease in Other Vascular Beds in patients with Lower Extremity PAD

Guidelines for Medical Therapy for Lower Extremity PAD

Guidelines for Structured Exercise Therapy for Lower Extremity PAD

Guidelines for Minimizing Tissue Loss in Lower Extremity PAD

Guidelines for Revascularization of Claudication in Lower Extremity PAD

Guidelines for Management of CLI in Lower Extremity PAD

Guidelines for Management of Acute Limb Ischemial in Lower Extremity PAD

Guidelines for Longitudinal Follow-up for Lower Extremity PAD

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Vishnu Vardhan Serla M.B.B.S. [3]; Rim Halaby

Overview

When symptoms suggestive of peripheral artery disease are present, clinical evaluation along with non invasive testing are enough to establish the diagnosis. Invasive diagnostic studies are anatomic studies that are not used for diagnosis but rather for preoperative evaluation of the anatomy of the vessels. The non invasive modality mostly used in the diagnosis of peripheral artery disease is the measurement of the ankle brachial index (ABI) at rest and after exercise testing. The non invasive diagnostic studies are functional studies and they include the following: measurement of ABI at rest and after exercise, pulse volume recording, transcutaneous oxygen pressure measurement and laser doppler fluximetry. The invasive diagnostic studies are anatomic studies and they include the following: conventional angiography, CT angiography, MRA and duplex ultrasound.

Other Diagnostic Studies

Ankle-Brachial Index

Evaluation of the Severity of the Arterial Occlusive Disease Based on the ABI Done at Rest

  • 1- 1.4: Normal
  • 0.8-0.9: Mild
  • 0.5-0.8: Moderate
  • <0.5: Severe[1]

Toe-Brachial Index

  • When the vessels are stiff, as in the case of diseases like diabetes, the ABI index is inaccurate in the evaluation of the severity of the arterial occlusive diseases.
  • Toe-brachial index is a reliable alternative when the vessels are stiff and non compressible.
  • The normal range for the toe-brachial pressure index is values more than 0.70.[2]

ABI in Lower Extremity Exercise Testing

  • Patients with peripheral artery disease can have normal ABI at rest; however, they show abnormal ABI measurements after stress exercise.
  • During exercise, the systolic pressure increases causing an increase in the pressure difference beyond the diseased vessel. Hence, the ABI will decrease.
  • Patients who can not tolerate the treadmill exercise can do the tip toe exercise as an alternative.

Evaluation of the Severity of the Arterial Occlusive Disease Based on the ABI After Exercise Testing

  • 0.5-0.9: Mild
  • 0.15-0.8: Moderate
  • <0.15: Severe.[1]

Evaluation of the Severity of the Arterial Occlusive Disease Based on the Tolerance to Exercise Testing

  • Exercise tolerance less than 5 minutes: Moderate
  • Exercise tolerance less than 3 minutes: Severe[3]

Segmental Pressures Examination

  • Segmental pressure examinations is basically applying the same ABI principle but on different parts of the extremities.

Pulse Volume Recording

  • Pulse volume recording aims to assess the magnitude of the arterial impulse entering a vessel.[4]

Transcutaneous Oxygen Measurement

  • Transcutaneous oxygen method aims to evaluate the microcirculation through the assessment of the oxygen flow through the skin.
  • It is is used to monitor the effect of therapy and to assess the chances of healing after amputation.
  • When the transcutaneous oxygen measurements exceeds 40 mm Hg it indicated higher chances for healing, whereas measurements less than 20 mm Hg are unlikely to heal.[5]

Laser Doppler Fluximetry

  • Laser doppler fluximetry assesses skin perfusion.[6]

Management of Patients With Peripheral Artery Disease (Compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations) : A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines[7]

Ankle-Brachial Index, Toe-Brachial Index, and Segmental Pressure Examination (DO NOT EDIT)[8][9]

Class I
"1. The resting ABI should be used to establish the lower extremity PAD diagnosis in patients with suspected lower extremity PAD, defined as individuals with 1 or more of the following: exertional leg symptoms, nonhealing wounds, age 65 years and older, or 50 years and older with a history of smoking or diabetes.[10][11][12](Level of Evidence: B)"
"2. The ABI should be measured in both legs in all new patients with PAD of any severity to confirm the diagnosis of lower extremity PAD and establish a baseline.[13][14][15](Level of Evidence: B)"
"3. The toe-brachial index should be used to establish the lower extremity PAD diagnosis in patients in whom lower extremity PAD is clinically suspected but in whom the ABI test is not reliable due to noncompressible vessels (usually patients with long-standing diabetes or advanced age).[16][17][18][19][20] (Level of Evidence: B)"
"4. Leg segmental pressure measurements are useful to establish the lower extremity PAD diagnosis when anatomic localization of lower extremity PAD is required to create a therapeutic plan.[21][22][23][24] (Level of Evidence: B)"
"5. ABI results should be uniformly reported with noncompressible values defined as greater than 1.40, normal values 1.00 to 1.40, borderline 0.91 to 0.99, and abnormal 0.90 or less.[25] (Level of Evidence: B)"

Pulse Volume Recording (DO NOT EDIT)[9]

Class IIa
"1. Pulse volume recordings are reasonable to establish the initial lower extremity PAD diagnosis, assess localization and severity, and follow the status of lower extremity revascularization procedures. (Level of Evidence: B)"

Treadmill Exercise Testing With and Without ABI Assessments and 6-Minute Walk Test (DO NOT EDIT)[9]

Class I
"1. Exercise treadmill tests are recommended to provide the most objective evidence of the magnitude of the functional limitation of claudication and to measure the response to therapy. (Level of Evidence: B)"
"2. A standardized exercise protocol (either fixed or graded) with a motorized treadmill should be used to ensure reproducibility of measurements of pain-free walking distance and maximal walking distance. (Level of Evidence: B)"
"3. Exercise treadmill tests with measurement of preexercise and postexercise ABI values are recommended to provide diagnostic data useful in differentiating arterial claudication from nonarterial claudication (“pseudoclaudication”). (Level of Evidence: B)"
"4. Exercise treadmill tests should be performed in individuals with claudication who are to undergo exercise training (lower extremity PAD rehabilitation) so as to determine functional capacity, assess nonvascular exercise limitations, and demonstrate the safety of exercise. (Level of Evidence: B)"
Class IIb
"1. A 6-minute walk test may be reasonable to provide an objective assessment of the functional limitation of claudication and response to therapy in elderly individuals or others not amenable to treadmill testing. (Level of Evidence: B)"

References

  1. ↑ 1.0 1.1 Wennberg PW, Rooke TW. Chapter 109. Diagnosis and Management of Diseases of the Peripheral Arteries and Veins. In: Fuster V, Walsh RA, Harrington RA, eds. Hurst's The Heart. 13th ed. New York: McGraw-Hill; 2011.
  2. ↑ Hobbs JT, Yao ST, Lewis JD, Needham TN (1974). "A limitation of the Doppler ultrasound method of measuring ankle systolic pressure". Vasa. 3 (2): 160–2. PMID 4831541.
  3. ↑ Feringa HH, Bax JJ, van Waning VH, Boersma E, Elhendy A, Schouten O; et al. (2006). "The long-term prognostic value of the resting and postexercise ankle-brachial index". Arch Intern Med. 166 (5): 529–35. doi:10.1001/archinte.166.5.529. PMID 16534039.
  4. ↑ Halperin JL. Evaluation of patients with peripheral vascular disease. Thromb Res. 2002;106:V303-V311.
  5. ↑ Bacharach JM, Rooke TW, Osmundson PJ, Gloviczki P (1992). "Predictive value of transcutaneous oxygen pressure and amputation success by use of supine and elevation measurements". J Vasc Surg. 15 (3): 558–63. PMID 1538514.
  6. ↑ Tsai FW, Tulsyan N, Jones DN, Abdel-Al N, Castronuovo JJ, Carter SA (2000). "Skin perfusion pressure of the foot is a good substitute for toe pressure in the assessment of limb ischemia". J Vasc Surg. 32 (1): 32–6. doi:10.1067/mva.2000.107310. PMID 10876204.
  7. ↑ Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss L; et al. (2013). "Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 61 (14): 1555–70. doi:10.1016/j.jacc.2013.01.004. PMC 4492473. PMID 23473760.
  8. ↑ "2011 ACCF/AHA Focused Update of the Guideline for the Management of patients with peripheral artery disease (Updating the 2005 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines". Circulation. 124 (18): 2020–45. 2011. doi:10.1161/CIR.0b013e31822e80c3. PMID 21959305. Retrieved 2012-10-09. Unknown parameter |month= ignored (help)
  9. ↑ 9.0 9.1 9.2 Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B (2006). "ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation". Circulation. 113 (11): e463–654. doi:10.1161/CIRCULATIONAHA.106.174526. PMID 16549646. Retrieved 2012-10-09. Unknown parameter |month= ignored (help)
  10. ↑ Criqui MH, Denenberg JO, Bird CE, Fronek A, Klauber MR, Langer RD (1996). "The correlation between symptoms and non-invasive test results in patients referred for peripheral arterial disease testing". Vascular Medicine (London, England). 1 (1): 65–71. PMID 9546918. |access-date= requires |url= (help)
  11. ↑ Hirsch AT, Criqui MH, Treat-Jacobson D, Regensteiner JG, Creager MA, Olin JW, Krook SH, Hunninghake DB, Comerota AJ, Walsh ME, McDermott MM, Hiatt WR (2001). "Peripheral arterial disease detection, awareness, and treatment in primary care". JAMA : the Journal of the American Medical Association. 286 (11): 1317–24. PMID 11560536. Retrieved 2012-11-05. Unknown parameter |month= ignored (help)
  12. ↑ Diehm C, Allenberg JR, Pittrow D, Mahn M, Tepohl G, Haberl RL, Darius H, Burghaus I, Trampisch HJ (2009). "Mortality and vascular morbidity in older adults with asymptomatic versus symptomatic peripheral artery disease". Circulation. 120 (21): 2053–61. doi:10.1161/CIRCULATIONAHA.109.865600. PMID 19901192. Retrieved 2012-11-05. Unknown parameter |month= ignored (help)
  13. ↑ Fowkes FG (1988). "The measurement of atherosclerotic peripheral arterial disease in epidemiological surveys". International Journal of Epidemiology. 17 (2): 248–54. PMID 3042648. Retrieved 2012-11-05. Unknown parameter |month= ignored (help)
  14. ↑ Feigelson HS, Criqui MH, Fronek A, Langer RD, Molgaard CA (1994). "Screening for peripheral arterial disease: the sensitivity, specificity, and predictive value of noninvasive tests in a defined population". American Journal of Epidemiology. 140 (6): 526–34. PMID 8067346. Retrieved 2012-11-05. Unknown parameter |month= ignored (help)
  15. ↑ Nassoura ZE, Ivatury RR, Simon RJ, Jabbour N, Vinzons A, Stahl W (1996). "A reassessment of Doppler pressure indices in the detection of arterial lesions in proximity penetrating injuries of extremities: a prospective study". The American Journal of Emergency Medicine. 14 (2): 151–6. doi:10.1016/S0735-6757(96)90122-9. PMID 8924136. Retrieved 2012-11-05. Unknown parameter |month= ignored (help)
  16. ↑ Carter SA (1969). "Clinical measurement of systolic pressures in limbs with arterial occlusive disease". JAMA : the Journal of the American Medical Association. 207 (10): 1869–74. PMID 5818299. Retrieved 2012-11-05. Unknown parameter |month= ignored (help)
  17. ↑ Carter SA, Tate RB (1996). "Value of toe pulse waves in addition to systolic pressures in the assessment of the severity of peripheral arterial disease and critical limb ischemia". Journal of Vascular Surgery. 24 (2): 258–65. PMID 8752037. Retrieved 2012-11-05. Unknown parameter |month= ignored (help)
  18. ↑ Carter SA, Tate RB (2001). "The value of toe pulse waves in determination of risks for limb amputation and death in patients with peripheral arterial disease and skin ulcers or gangrene". Journal of Vascular Surgery. 33 (4): 708–14. doi:10.1067/mva.2001.112329. PMID 11296321. Retrieved 2012-11-05. Unknown parameter |month= ignored (help)
  19. ↑ Brooks B, Dean R, Patel S, Wu B, Molyneaux L, Yue DK (2001). "TBI or not TBI: that is the question. Is it better to measure toe pressure than ankle pressure in diabetic patients?". Diabetic Medicine : a Journal of the British Diabetic Association. 18 (7): 528–32. PMID 11553180. Retrieved 2012-11-05. Unknown parameter |month= ignored (help)
  20. ↑ Ramsey DE, Manke DA, Sumner DS (1983). "Toe blood pressure. A valuable adjunct to ankle pressure measurement for assessing peripheral arterial disease". The Journal of Cardiovascular Surgery. 24 (1): 43–8. PMID 6833352. |access-date= requires |url= (help)
  21. ↑ Belcaro G, Nicolaides AN, Bull ML, Groves JH, Williams MA, Possati F, Cotellese R, Cacchio M, Caizzi N (1986). "The value of segmental pressure measurement in the assessment of peripheral vascular disease". International Angiology : a Journal of the International Union of Angiology. 5 (1): 7–12. PMID 2942613. |access-date= requires |url= (help)
  22. ↑ Gundersen J (1972). "Segmental measurements of systolic blood pressure in the extremities including the thumb and the great toe". Acta Chirurgica Scandinavica. Supplementum. 426: 1–90. PMID 4344948. |access-date= requires |url= (help)
  23. ↑ Johnston KW, Hosang MY, Andrews DF (1987). "Reproducibility of noninvasive vascular laboratory measurements of the peripheral circulation". Journal of Vascular Surgery. 6 (2): 147–51. doi:10.1067/mva.1987.avs0060147. PMID 2956433. Retrieved 2012-11-05. Unknown parameter |month= ignored (help)
  24. ↑ "circ.ahajournals.org" (PDF). Retrieved 2012-11-05.
  25. ↑ Fowkes FG, Murray GD, Butcher I, Heald CL, Lee RJ, Chambless LE, Folsom AR, Hirsch AT, Dramaix M, deBacker G, Wautrecht JC, Kornitzer M, Newman AB, Cushman M, Sutton-Tyrrell K, Fowkes FG, Lee AJ, Price JF, d'Agostino RB, Murabito JM, Norman PE, Jamrozik K, Curb JD, Masaki KH, Rodríguez BL, Dekker JM, Bouter LM, Heine RJ, Nijpels G, Stehouwer CD, Ferrucci L, McDermott MM, Stoffers HE, Hooi JD, Knottnerus JA, Ogren M, Hedblad B, Witteman JC, Breteler MM, Hunink MG, Hofman A, Criqui MH, Langer RD, Fronek A, Hiatt WR, Hamman R, Resnick HE, Guralnik J, McDermott MM (2008). "Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis". JAMA : the Journal of the American Medical Association. 300 (2): 197–208. doi:10.1001/jama.300.2.197. PMC 2932628. PMID 18612117. Retrieved 2012-11-05. Unknown parameter |month= ignored (help)


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