Peripheral arterial disease other diagnostic studies
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Peripheral arterial disease Microchapters |
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Differentiating Peripheral arterial disease from other Diseases |
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Diagnosis |
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Treatment |
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Case Studies |
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AHA/ACC Guidelines on Management of Lower Extremity PAD |
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Guidelines for Structured Exercise Therapy for Lower Extremity PAD |
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Guidelines for Minimizing Tissue Loss in Lower Extremity PAD |
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Guidelines for Revascularization of Claudication in Lower Extremity PAD |
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Guidelines for Management of Acute Limb Ischemial in Lower Extremity PAD |
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Guidelines for Longitudinal Follow-up for Lower Extremity PAD |
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Editors-in-Chief: C. Michael Gibson;Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [1]; 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.[1]
Other Diagnostic Studies
Ankle-Brachial Index
- 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.
- 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.[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
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]
2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (Updating the 2005 Guideline) Recommendations for Ankle-Brachial Index, Toe-Brachial Index, and Segmental Pressure Examination (DO NOT EDIT)[7]
| 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.(Level of Evidence: B)" |
| "2. 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. (Level of Evidence: B)" |
2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Ankle-Brachial Index, Toe-Brachial Index, and Segmental Pressure Examination (DO NOT EDIT)[8]
| Class I
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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)[8]
| 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)" |
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)[8]
| 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. 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. (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
- ↑ 1.0 1.1 1.2 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.
- ↑ 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.
- ↑ 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.
- ↑ Halperin JL. Evaluation of patients with peripheral vascular disease. Thromb Res. 2002;106:V303-V311.
- ↑ 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.
- ↑ 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.
- ↑ "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) - ↑ 8.0 8.1 8.2 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)