Noninvasive Diagnosis of Arterial Disease

Noninvasive diagnosis of arterial disease
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file:///F:/med e books and softwares/blueapk_utd_201/UpToDate_20.1...
TOPIC OUTLINE
INTRODUCTION
INDICATIONS FOR TESTING
PHYSIOLOGIC TESTING
Ankle-brachial index
- High ABI
Wrist-brachial index
Toe-brachial index
Segmental pressures
- Lower extremity segmental pressures
- Upper extremity segmental pressures
Pulse volume recordings
- Digit waveforms
Exercise testing
- Protocols
- Interpretation
TRANSCUTANEOUS OXYGEN MEASUREMENTS
ULTRASOUND
Continuous wave Doppler
B-mode imaging
Duplex imaging
- Specific anatomic sites
OTHER IMAGING
INFORMATION FOR PATIENTS
SUMMARY AND RECOMMENDATIONS
REFERENCES
GRAPHICSView All
FIGURES
Segmental pressure examination
PICTURES
Bi-directional Doppler
Four cuff segmental pressures
Pulse volume recordings
Popliteal aneurysm ultrasound
Doppler waveform within stented artery
Aorta Doppler waveform
TABLES
Peak systolic velocity ratios arterial duplex
Normal arterial Doppler velocities
Validated criteria for stenosis in visceral vessels
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RELATED TOPICS
Acute arterial occlusion of the lower extremities (acute limb ischemia)
Basic principles of wound management
Blunt cerebrovascular injury: Mechanisms, screening, and diagnostic evaluation
Chronic mesenteric ischemia
Clinical evaluation of abdominal aortic aneurysm
Clinical features, diagnosis, and natural history of lower extremity peripheral artery disease
Clinical manifestations and diagnosis of the Raynaud phenomenon
Clinical manifestations and evaluation of chronic critical limb ischemia
Creating an arteriovenous fistula for hemodialysis
Definition and pathogenesis of left ventricular hypertrophy in hypertension
Exercise physiology
Management of the severely injured extremity
Nephrogenic systemic fibrosis/nephrogenic fibrosing dermopathy in advanced renal failure
Overview of thoracic outlet syndromes
Patient information: Peripheral artery disease and claudication (Beyond the Basics)
Patient information: Peripheral artery disease and claudication (The Basics)
Percutaneous interventional procedures in the patient with claudication
Popliteal artery aneurysm
Screening for abdominal aortic aneurysm
Screening for asymptomatic carotid artery stenosis
Screening for lower extremity peripheral artery disease
Techniques for lower extremity amputation
Treatment of lower extremity critical limb ischemia
Upper extremity peripheral artery disease
Official reprint from UpToDate www.uptodate.com

2012 UpToDate
Print | Back
Authors
Emile R Mohler, III, MD
Erica Mitchell, MD, FACS
Section Editors
John F Eidt, MD
Joseph L Mills, Sr, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS
Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Tue Jan 31 00:00:00 GMT 2012. | This topic last updated: Thu Jun 16
00:00:00 GMT 2011.
INTRODUCTION The evaluation of the patient with arterial disease begins with a thorough history
and physical examination and uses noninvasive vascular studies as an adjunct to confirm a clinical
diagnosis and further define the level and extent of vascular pathology. Vascular testing may be indicated
for patients with suspected arterial disease based upon symptoms (eg, intermittent claudication), physical
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examination findings (eg, signs of tissue ischemia), or in patients with risk factors for atherosclerosis (eg,
smoking, diabetes mellitus) or other arterial pathology (eg, trauma, peripheral embolism) [1].
A variety of noninvasive examinations are available to assess the presence and severity of arterial disease.
Physiologic tests include segmental limb pressures and the calculation of pressure index values (eg, anklebrachial index, wrist-brachial index), exercise testing, segmental volume plethysmography,
transcutaneous oxygen measurements and photoplethysmography.
Ultrasound is the mainstay for vascular imaging with each mode (eg, B-mode, duplex) providing specific
information that is useful depending upon the vascular disorder. Other studies frequently used to image
the vasculature include computed tomography (CT) and magnetic resonance (MR) imaging. CT and MR
imaging are important alternative methods for vascular assessment; however, the cost and the time
necessary for these studies limit their use for routine testing [2]. Contrast arteriography remains the gold
standard for vascular imaging and at times can be a primary imaging modality, particularly if intervention
is being considered. The role of these imaging in specific vascular disorders are discussed in detail
separately.
INDICATIONS FOR TESTING The need for noninvasive vascular testing to supplement the history
and physical examination depends upon the clinical scenario and urgency of the patients condition. An
exhaustive battery of tests is not required in all patients to evaluate their vascular status. In general, only
tests that confirm the presence of arterial disease or provide information that will alter the course of
treatment should be performed.
Patients can be asymptomatic, have classic symptoms of peripheral artery disease (PAD) such as
claudication, or more atypical symptoms. Symptoms vary depending upon the vascular bed affected, the
nature and severity of the disease and the presence and effectiveness of collateral circulation. The clinical
presentations of various vascular disorders are discussed in separate topic reviews. (See "Clinical features,
diagnosis, and natural history of lower extremity peripheral artery disease" and "Overview of thoracic
outlet syndromes" and "Clinical manifestations and diagnosis of the Raynaud phenomenon" and "Clinical
evaluation of abdominal aortic aneurysm".)
Noninvasive vascular testing may be performed to:
Screen patients who have risk factors for PAD. Patients with asymptomatic lower extremity PAD
have an increased risk of myocardial infarction, stroke, and cardiovascular mortality and benefit
from identification to provide risk factor modification [3-8]. Similarly, asymptomatic patients with
risk factors for aneurysm or cerebrovascular disease may be screened to identify these conditions
and stratify management. (See "Screening for lower extremity peripheral artery disease" and
"Screening for abdominal aortic aneurysm" and "Screening for asymptomatic carotid artery
stenosis".)
Confirm a diagnosis of arterial disease in patients with symptoms or signs consistent with an
arterial pathology. (See "Clinical features, diagnosis, and natural history of lower extremity
peripheral artery disease" and "Upper extremity peripheral artery disease" and "Popliteal artery
aneurysm" and "Chronic mesenteric ischemia" and "Acute arterial occlusion of the lower
extremities (acute limb ischemia)".)
Identify a vascular injury. (See "Management of the severely injured extremity" and "Blunt
cerebrovascular injury: Mechanisms, screening, and diagnostic evaluation".)
Evaluate patients prior to or during planned vascular procedures. (See "Creating an arteriovenous
fistula for hemodialysis" and "Treatment of lower extremity critical limb ischemia".)
Provide surveillance after vascular intervention. (See "Treatment of lower extremity critical limb
ischemia" and "Percutaneous interventional procedures in the patient with claudication".)
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PHYSIOLOGIC TESTING The main purpose of physiologic testing is to verify a vascular origin for a
patients specific complaint. Other goals, depending upon the clinical scenario, are to localize the level of
obstructive lesions and assess the adequacy of tissue perfusion and wound healing potential. These
objectives are met by obtaining one or more tests including segmental limb pressures, calculation of index
values (ankle-brachial index, wrist-brachial index, toe-brachial index), pulse volume recordings, exercise
testing, digit plethysmography and transcutaneous oxygen measurements.
Ankle-brachial index Calculation of the ankle-brachial index (ABI) is a relatively simple and
inexpensive method to confirm the clinical suspicion of lower extremity arterial occlusive disease [3,9].
The resting systolic blood pressure at the ankle is compared with the systolic brachial pressure and the
ratio of the two pressures defines the ankle-brachial (or ankle-arm) index. This index provides a measure
of the severity of disease [10].
The patients must rest for 15 to 30 minutes prior to measuring the ankle pressure. To obtain the ABI,
place a blood pressure cuff just above the ankle. While listening to either the dorsalis pedis or posterior
tibial artery signal with a continuous wave Doppler (picture 1) , insufflate the cuff to a pressure above
which the audible Doppler signal disappears. Slowly release the pressure in the cuff just until the pedal
signal returns and record this systolic pressure. Repeat the measurement in the same manner for the other
pedal vessel in the ipsilateral extremity and repeat the process in the contralateral lower extremity.
Measure the systolic brachial artery pressure bilaterally in a similar fashion with the blood pressure cuff
placed around the upper arm and using the continuous wave Doppler. The ABI for each lower extremity is
calculated by dividing the higher ankle pressure (dorsalis pedis or posterior tibial artery) in each lower
extremity by the higher of the two brachial artery systolic pressures.
Calculation of the ankle-brachial index (ABI) at the bedside is usually performed with a continuous-wave
Doppler probe (picture 1). The disadvantage of using continuous wave Doppler is a lack of sensitivity at
extremely low pressures where it may be difficult to distinguish arterial from venous flow. A venous
signal can be confused with an arterial signal (especially if pulsatile venous flow is present, as can occur
with heart failure) [11,12]. Under these conditions, duplex ultrasound can be used to distinguish between
arteries and veins by identifying the direction of flow. (See 'Continuous wave Doppler' below and 'Duplex
imaging' below.)
The ABI is generally, but not absolutely, correlated with clinical measures of lower extremity function
such as walking distance, speed of walking, balance, and overall physical activity [13-18]. Further
evaluation is dependent upon the ABI value.
The normal ABI is 0.9 to as high as 1.3. Normally, the pressure is higher in the ankle than in the
arm. A normal test generally excludes arterial occlusive disease. Mild disease and arterial
entrapment syndromes can produce false negative tests. If ABIs are normal at rest but symptoms
strongly suggest claudication, exercise testing should be performed [19]. (See 'Exercise
testing' below.)
An ABI >1.3 suggests the presence of calcified vessels and the need for additional vascular studies,
such as pulse volume recordings, measurement of the toe pressures and toe-brachial index, or
arterial duplex studies. (See 'High ABI' below and 'Toe-brachial index' below and 'Duplex
imaging' below.)
An ABI 0.9 is diagnostic of occlusive arterial disease in patients with symptoms of claudication or
other signs of ischemia and has 95 percent sensitivity (and 100 percent specificity) for detecting
arteriogram-positive occlusive lesions associated with 50 percent stenosis in one or more major
vessels [13].
An ABI of 0.4 to 0.9 suggests a degree of arterial obstruction often associated with claudication
[15].
An ABI below 0.4 represents multilevel disease (any combination of iliac, femoral or tibial vessel
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disease) and may be associated with non-healing ulcerations, ischemic rest pain or pedal gangrene.
(See "Clinical manifestations and evaluation of chronic critical limb ischemia".)
A low ABI is associated with a higher risk of coronary heart disease, stroke, transient ischemic attack,
progressive renal insufficiency, and all-cause mortality [20-25]. Screening for asymptomatic PAD is
discussed elsewhere. (See "Screening for lower extremity peripheral artery disease".)
In a prospective study among nearly 1500 women, 5.5 percent had an ABI of <0.9, 67/82 of whom
had no symptoms consistent with peripheral artery disease. Compared with the cohort with an index
>0.9, this group had markedly increased relative risks of 3.1 and 3.7 for death and coronary heart
disease, respectively, at four years [21].
In a report from the Framingham study of 251 men and 423 women (mean age 80 years), 21 percent
had an ABI <0.9 [23]. Those with a low ABI had, at four years, a significantly increased risk of
transient ischemic attack or stroke (13 versus 5 percent).
In a study of 262 patients, the ankle brachial index was measured in patients with type 2 diabetes
[25]. During the 10-year follow-up period, all nonfatal cardiovascular events and mortality were
recorded. The mortality rates for patients with normal and abnormal ABI were 17 and 53 percent,
respectively. The incidence of cardiovascular events (coronary, cerebrovascular) was 27 percent
(95% CI, 20.7-37.3) for the patients with a normal baseline ABI, and 82 percent (95% CI
50.9-131.8) when the baseline ABI was abnormal.
High ABI A potential source of error with the ABI is that calcified vessels may not compress normally,
thereby resulting in falsely elevated pressure measurements. An ABI above 1.3 is suspicious for calcified
vessels and may also be associated with leg pain [18]. The National Health and Nutrition Survey
(NHANES) estimated that 1.4 percent of adults age >40 years in the United States have an ABI >1.4; this
group accounts for approximately 20 percent of all adults with PAD [26].
As with low ABI, abnormally high ABI (>1.3) is also associated with higher cardiovascular risk [22,27].
The Multi-Ethnic Study of Atherosclerosis (MESA) study evaluated 4972 patients without clinical
cardiovascular disease and found a greater left ventricular mass index in patients with high ABI
(>1.4) compared with normal ABI (90 versus 72 g/m2) [27]. Increases in left ventricular mass are
predominantly attributable to an increase in afterload. (See "Definition and pathogenesis of left
ventricular hypertrophy in hypertension".)
The Strong Heart Study followed 4393 Native American patients for a mean of eight years [22].
High ABI (>1.4) was present in 9.2 percent of patients and low ABI (0.9) was found in 4.9 percent
of patients. Adjusted hazard ratios for all-cause mortality and cardiovascular mortality rates were
1.8 and 2.0, respectively, for high ABI and 1.7 and 2.5, respectively, for low ABI relative to normal
ABI (0.9<ABI1.4).
In patients with arterial calcification, such as patients with diabetes, more reliable information is often
obtained using toe pressures and calculation of the toe-brachial index, and pulse volume recordings. (See
'Toe-brachial index' below and 'Pulse volume recordings' below.)
Wrist-brachial index The wrist-brachial index (WBI) is used to identify the level and extent of upper
extremity arterial occlusive disease. Upper extremity disease is far less common than lower extremity
disease and abnormalities in WBI have not been correlated with adverse cardiovascular risk as seen with
ABI. Thus, WBIs are typically measured only when the patient has clinical signs or symptoms consistent
with upper extremity arterial stenosis or occlusion. The WBI is obtained in a manner analogous to the
ABI. (See 'Ankle-brachial index' above.)
Pressure measurements are obtained for the radial and ulnar arteries at the wrist and brachial arteries in
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each extremity. The WBI for each upper extremity is calculated by dividing the highest wrist pressure
(radial artery or ulnar artery) by the higher of the two brachial artery pressures. The normal value for the
WBI is 1.0.
Incompressibility can also occur in the upper extremity. The radial or ulnar arteries may have a
supranormal wrist-brachial index. This finding may indicate the presence of medial calcification in the
patient with diabetes.
Toe-brachial index The toe-brachial index (TBI) is a more reliable indicator of limb perfusion in
patients with diabetes because the small vessels of the toes are frequently spared from medial
calcification.
The TBI is obtained by placing a pneumatic cuff on one of the toes. The great toe is usually chosen but in
the face of amputation the second or other toe is used. A photo-electrode is placed on the end of the toe to
obtain a photoplethysmographic (PPG) arterial waveform using infrared light. The infrared light is
transmitted into the superficial layers of the skin and the reflected portion is received by a photosensor
within the photo-electrode. The signal is proportional to the quantity of red blood cells in the cutaneous
circulation.
Analogous to the ankle and wrist pressure measurements, the toe cuff is inflated until the PPG waveform
flattens and then the cuff is slowly deflated. The systolic pressure is recorded at the point in which the
baseline waveform is re-established. The ratio of the recorded toe systolic pressure to the higher of the
two brachial pressures gives the TBI.
A pressure gradient of 20 to 30 mmHg normally exists between the ankle and the toe, and thus, a normal
toe-brachial index is 0.7 to 0.8. An absolute toe pressure >30 mmHg is favorable for wound healing [28],
although toe pressures >45 to 55 mmHg may be required for healing in patients with diabetes [29-31].
Toe pressures are useful to define perfusion at the level of the foot, especially in patients with
incompressible vessels, but they provide no indication of the site of occlusive disease. In addition to
measuring toe systolic pressures, the toe Doppler arterial waveforms should also be evaluated. (See 'Pulse
volume recordings' below.)
Segmental pressures Once arterial occlusive disease has been verified using the ankle-brachial index
(ABI) measurements (resting or post-exercise) (see 'Exercise testing' below), the level and extent of
disease can be determined using segmental limb pressures which are performed using specialized
equipment in the vascular laboratory. Blood pressures are obtained at successive levels of the extremity,
localizing the level of disease fairly accurately. Segmental pressures can be obtained for the upper or
lower extremity.
Lower extremity segmental pressures The patient is placed in a supine position and rested for 15
minutes. Three or four standard-sized blood pressure cuffs are placed at several positions on the
extremity. A three-cuff technique uses above knee, below knee, and ankle cuffs. A four-cuff technique
(picture 2) uses two narrower blood pressure cuffs rather than one large cuff on the thigh and permits the
differentiation of aortoiliac and superficial femoral artery disease [32].
The pedal vessel (dorsalis pedis, posterior tibial) with the higher systolic pressure is used, and the
pressure that occludes the pedal signal for each cuff level is measured by first inflating the cuff until the
signal is no longer heard and then progressively deflating the cuff until the signal resumes. The pressure at
each level is divided by the higher systolic arm pressure to obtain an index value for each level (figure 1).
A 20 mmHg or greater reduction in pressure is indicative of a flow-limiting lesion if the pressure
difference is present either between segments along the same leg or when compared with the same level
in the opposite leg (ie, right thigh/left thigh, right calf/left calf) (figure 1). Well-developed collateral
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vessels may diminish the observed pressure gradient and obscure a hemodynamically significant lesion.
Successive significant (>20 mmHg) decrements in the same extremity indicate multilevel disease.
Pressure gradients may be increased in the hypertensive patient and decreased in patients with low cardiac
output. When performing serial examinations over time, changes in index values >0.15 from one study to
the next are considered significant and suggest progression of disease.
With a four cuff technique, the high-thigh pressure should be higher than the brachial pressure, though in
the normal individual, these pressures would be nearly equal if measured by invasive means. The
four-cuff technique introduces artifact because the high-thigh cuff is often not appropriately 120 percent
the diameter of the thigh at the cuff site. A >30 mmHg decrement between the highest systolic brachial
pressure and high-thigh pressure is considered abnormal.
A normal high-thigh pressure excludes occlusive disease proximal to the bifurcation of the common
femoral artery. If the high-thigh systolic pressure is reduced compared with the brachial pressure, then the
patient has a lesion at or proximal to the bifurcation of the common femoral artery. If the high-thigh
pressure is normal but the low-thigh pressure is decreased, the lesion is in the superficial femoral artery.
In one prospective study, the four-cuff technique correctly identified the level of the occlusive lesion in 78
percent of extremities [32].
For patients with claudication, the localization of the lesion may have been suspected from their history.
The site of pain and site of arterial disease correlates with pressure reductions seen on segmental
pressures [3,33]:
Buttock, hip or thigh pain Pressure gradient between the brachial artery and the upper thigh is
consistent with arterial occlusive disease at or proximal to the bifurcation of the common femoral
artery.
Calf pain Pressure gradient from the high to lower thigh indicates superficial femoral artery
disease. Pressure gradient from the lower thigh to calf reflects popliteal disease.
Low calf pain Pressure gradient from the calf and ankle is indicative of infrapopliteal disease.
Foot pain Pressure gradient from the ankle and toe suggests digital artery occlusive disease.
As with ABI measurements, segmental pressure measurements in the lower extremity may be artifactually
increased or not interpretable in patients with non-compressible vessels [3]. Patients with diabetes who
have medial sclerosis and patients with chronic kidney disease often have nonocclusive pressures with
ABIs >1.3, limiting the utility of segmental pressures in these populations. Pulse volume recordings
which are independent of arterial compression are preferentially used instead. (See 'Pulse volume
recordings' below.)
Upper extremity segmental pressures Segmental pressures may also be performed in the upper
extremity. Generally, three cuffs are used with above and below elbow cuffs and a wrist cuff. Index values
are calculated at each level. In the patient with possible upper extremity occlusive disease, a difference of
10 mmHg between the left and right brachial systolic pressures suggests innominate, subclavian,
axillary, or proximal brachial arterial occlusion. Differences of more than 10 to 20 mmHg between
successive arm levels suggest intervening occlusive disease.
Pulse volume recordings Modern vascular testing machines use air plethysmography to measure
volume changes within the limb, in conjunction with segmental limb pressure measurement. The same
pressure cuffs are used for each test (picture 2). (See 'Segmental pressures' above.)
Cuffs are placed and inflated, one at a time, to a constant standard pressure. Volume changes in the limb
segment beneath the cuff are reflected as changes in pressure within the cuff, which is detected by a
pressure transducer and converted to an electrical signal to produce an analog pressure pulse contour
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known as a pulse volume recording (PVR).

A normal PVR waveform is composed of a systolic upstroke with a sharp systolic peak followed by a
downstroke that contains a prominent dicrotic notch (picture 3). Alterations in the pulse volume contour
and amplitude indicate proximal arterial obstruction. The degree of these changes reflects disease severity
[34,35]. Mild disease is characterized by loss of the dicrotic notch and an outward bowing of the
downstroke of the waveform (picture 3). With severe disease, the amplitude of the waveform is blunted
(picture 3). Pulse volume recordings are most useful in detecting disease in calcified vessels which tend to
yield falsely elevated pressure measurements. (See 'High ABI' above.)
Since the absolute amplitude of plethysmographic recordings is influenced by cardiac output and
vasomotor tone, interpretation of these measurements should be limited to the comparison of one
extremity to the other in the same patient and not between patients. The dicrotic notch may be absent in
normal arteries in the presence of low resistance, such as after exercise.
Digit waveforms Patients with distal extremity small artery occlusive disease (eg, Buergers disease,
Raynauds, end-stage renal disease, diabetes mellitus) often have normal ankle-brachial index and wristbrachial index values. Arterial occlusion distal to the ankle or wrist can be detected using digit
plethysmography, which is performed by placing small pneumatic cuffs on each of the digits of the hands
or feet depending upon the disease being investigated. In a manner analogous to pulse volume recordings
described above, volume changes in the digit segment beneath the cuff are detected and converted to
produce an analog digit waveform. (See 'Pulse volume recordings' above.)
Exercise testing Segmental blood pressure testing, toe-brachial index measurements and PVR
waveforms can be obtained before and after exercise to unmask occlusive disease not apparent on resting
studies. Exercise testing is a sensitive method for evaluating patients with symptoms suggestive of arterial
obstruction when the resting extremity systolic pressures are normal.
Exercise testing is most commonly performed to evaluate lower extremity peripheral artery disease
(PAD). Exercise testing is generally not needed to diagnose upper extremity arterial disease, though, on
occasion, it may play a role in the evaluation of subclavian steal syndrome. The discussion below focuses
on lower extremity exercise testing. The principles of testing are the same for the upper extremity, except
that a tabletop arm ergometer (hand crank) is used instead of a treadmill.
The dynamics of blood flow across a stenotic lesion depend upon the severity of the obstruction and
whether the individual is at rest or exercising. Exercise normally increases systolic pressure and decreases
peripheral vascular resistance. The effects of exercise on the cardiovascular system are discussed
elsewhere. (See "Exercise physiology".)
Exercise augments the pressure gradient across a stenotic lesion. An arterial stenosis less than 70 percent
may not be sufficient to alter blood flow or produce a systolic pressure gradient at rest; however,
following exercise, a moderate stenosis may be unmasked and the augmented gradient reflected as a
reduction from the resting ankle-brachial index (ABI) following exercise. Repeat ABIs demonstrate a
recovery to the resting, baseline ABI value over time.
Protocols There are many protocols for treadmill testing including fixed routines, graded routines and
alternative protocols for patients with limited exercise ability [36].
With a fixed routine, patients are exercised with the treadmill at a constant speed with no change in
the incline of the treadmill over the course of the study. A common fixed protocol involves walking
on the treadmill at 2 mph at a 12 percent incline for five minutes or until the patient is forced to stop
due to pain (not due to SOB or angina). The walking distance, time to the onset of pain, and nature
of any symptoms are recorded. The ABI is recorded at rest, one minute after exercise, and every
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minute thereafter (up to 5 minutes) until it returns to the level of the resting ABI. The ABI in
patients with severe disease may not return to baseline within the allotted time period.
Graded routines may increase the speed of the treadmill, but more typically the percent incline of
the treadmill is increased during the study. A metaanalysis of eight studies compared continuous
versus graded routines in 658 patients in whom testing was repeated several times [37]. The
estimated reliability in determining the intermittent claudication distance (initial distance to calf
pain) and absolute claudication distance (patient can no longer walk) as assessed by the intraclass
correlation coefficient was found to be significantly better for the graded protocol for absolute but
not intermittent claudication distance. The reliability of a continuous protocol using a 12 percent
grade approached the reliability of the graded protocol.
For patients with limited exercise ability, alternative forms of exercise can be used. Plantar flexion
exercises or toe ups involve having the patient stand on a block and raise onto the balls of the feet
to exercise the calf muscles. This form of exercise has been verified against treadmill testing as
accurate for detecting claudication and PAD.
For patients who cannot exercise, reactive hyperemia testing or the administration of pharmacologic
agents such as papaverine or nitroglycerin are alternatives testing methods to imitate the
physiologic effect of exercise (vasodilation) and unmask a significant stenosis. Reactive hyperemia
testing involves placing a pneumatic cuff at the thigh level and inflating it to a supra-systolic
pressure for three to five minutes. This produces ischemia and compensatory vasodilation distal to
the cuff; however, the test is painful, and thus, it is not commonly used.
Interpretation A normal response to exercise is a slight increase or no change in the ABI compared
with baseline. If the patient develops symptoms with walking on the treadmill and does not have a
corresponding decrease in ankle pressure, arterial obstruction as the cause of symptoms is essentially
ruled out and the clinician should seek other causes for the leg symptoms.
A fall in ankle systolic pressure by more than 20 percent from its baseline value, or below an absolute
pressure of 60 mmHg that requires >3 minutes to recover is considered abnormal. Severe claudication can
be defined as an inability to complete the treadmill exercise due to leg symptoms and post-exercise ankle
systolic pressures below 50 mmHg. Single-level disease is inferred with a recovery time that is <6
minutes, while a 6 minute recovery time is associated with multilevel disease, particularly a combination
of supra-inguinal and infrainguinal occlusive disease [13].
TRANSCUTANEOUS OXYGEN MEASUREMENTS Transcutaneous oxygen measurement (TcPO2)
may provide supplemental information regarding local tissue perfusion and the values have been used to
assess the healing potential of lower extremity ulcers or amputation sites. (See "Basic principles of wound
management" and "Techniques for lower extremity amputation".)
Platinum oxygen electrodes are placed on the chest wall and legs or feet. The absolute value of the
oxygen tension at the foot or leg, or a ratio of the foot value to chest wall value can be used. A normal
value at the foot is 60 mmHg and a normal chest/foot ratio is 0.9 [38,39]. Local edema, skin temperature,
emotional state (sympathetic vasoconstriction), inflammation, and pharmacologic agents limit the
accuracy of the test.
The level of TcPO2 that indicates tissue healing remains controversial. It is generally accepted that in the
absence of diabetes and tissue edema, wounds are likely to heal if oxygen tension is greater than 40
mmHg. A higher value is needed for healing a foot ulcer in the patient with diabetes.
ULTRASOUND Ultrasound is the mainstay for noninvasive vascular imaging with each mode (eg,
B-mode, duplex) providing specific information. Ultrasonography is used to evaluate the location and
extent of vascular disease, arterial hemodynamics, and lesion morphology [10].
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Real-time ultrasonography uses reflected sound waves (echoes) to produce images and assess blood
velocity. Two ultrasound modes are routinely used in vascular imaging: the B (brightness) mode and the
Doppler mode (B mode imaging + Doppler flow detection = duplex ultrasound). Duplex ultrasonography
has gained a prominent role in the noninvasive assessment of the peripheral vasculature overcoming the
limitations (need for intravenous contrast) of other noninvasive methods and providing precise anatomic
localization and accurate grading of lesion severity [40,41].
Both B-mode and Doppler mode take advantage of pulsed sound waves. Pulsed-wave technology uses a
row of crystals, each of which alternately send and receive pulse trains of sound waves with a slight time
delay with respect to their adjacent crystals. The time and intensity differences of the transmitted and
received sound waves are converted to an image that displays depth and intensity for each crystal in the
row. A pulse Doppler also permits localization of Doppler shifts induced by moving objects (red blood
cells).
Continuous wave Doppler A continuous wave Doppler continually transmits and receives sound waves
and, therefore, it cannot be used for imaging or to identify Doppler shifts. It is used primarily for blood
pressure measurement (picture 1). (See 'Ankle-brachial index' above and 'Wrist-brachial index' above and
'Segmental pressures' above.)
The continuous wave hand-held ultrasound probe uses two separate ultrasound crystals, one for sending
and one for receiving sound waves. Continuous wave ultrasound provides a signal that is a summation of
all the vascular structures through which the sound has passed and is limited in the evaluation of a
specific vascular structure when multiple vessels are present. However, the intensity and quality of the
continuous wave Doppler signal can give an indication of the severity of vascular disease proximal to the
probe. The quality of the arterial signal can be described as triphasic (like the heartbeat), biphasic
(bum-bum), or monophasic.
Biphasic signals may be normal in patients older than 60 because of decreased peripheral vascular
resistance; however, monophasic signals unquestionably indicate significant pathology. Monophasic
signals must be distinguished from venous signals, which vary with respiration and increase in intensity
when the surrounding musculature is compressed (augmentation). It is often quite difficult to obtain
ankle-brachial index values in patients with monophasic continuous wave Doppler signals. (See 'Anklebrachial index' above.)
B-mode imaging The B-mode provides a grey scale image useful for evaluating anatomic detail
(picture 4). The quality of a B-mode image depends upon the strength of the returning sound waves
(echoes). Echo strength is attenuated and scattered as the sound wave moves through tissue. Angles of
insonation of 90 maximize the potential return of echoes. Higher frequency sound waves provide better
lateral resolution compared with lower frequency waves. Thus, high-frequency transducers are used for
imaging shallow structures at 90 of insonation.
Duplex imaging Duplex scanning can be used to evaluate the vasculature preoperatively,
intraoperatively, and postoperatively for stent or graft surveillance and is very useful in identifying
proximal arterial disease. A meta-analysis of 14 studies found that sensitivity and specificity of this
technique for 50 percent stenosis or occlusion were 86 and 97 percent for aortoiliac disease and 80 and
98 percent for femoropopliteal disease [42].
The identification of vascular structures from the B-mode display is enhanced in the color mode, which
displays movement (blood flow) within the field (picture 5). The shift in sound frequency between the
transmitted and received sound waves due to movement of red blood cells is analyzed to generate velocity
information (Doppler mode). Flow toward the transducer is standardized to display as red and flow away
from the transducer is blue; the colors are semi-quantitative and do not represent actual arterial or venous
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flow.
Accurate measurements of Doppler shift and, therefore, velocity measurements require proper positioning
of the ultrasound probe relative to the direction of flow. An angle of insonation of sixty degrees is ideal;
however, an angle between 30 and 70 is acceptable. The severity of stenosis is best assessed by
positioning the Doppler probe directly over the lesion. The ratio of the velocity of blood at a suspected
stenosis to the velocity obtained in a normal portion of the vessel is calculated. Velocity ratios >4.0
indicate a >75 percent stenosis in peripheral arteries (table 1).
A normal arterial Doppler velocity waveform is triphasic with a sharp upstroke, forward flow in systole
with a sharp systolic peak, sharp downstroke, reversed flow component at the end of systole, and forward
flow in late diastole (picture 5) [43,44]. The spectral band is narrow and a characteristic lucent spectral
window can be seen between the upstroke and downstroke. Normal velocities vary with the artery
examined and decrease as one proceeds more distally in an extremity (table 2). For example, velocities in
the iliac artery vary between 100 and 200 cm/s and peak systolic velocities in the tibial artery are 40 and
70 cm/s.
Different velocity waveforms are obtained depending upon whether the probe is proximal or distal to a
stenosis. Progressive obstruction proximal to the Doppler probe results in a decrease in systolic peak,
elimination of the reversed flow component and an increase in the flow seen in late diastole. Decreased
peripheral vascular resistance is responsible for the loss of the reversed flow component and this finding
may be normal in older patients or reflect compensatory vasodilation in response to an obstructive
vascular lesion.
A delayed upstroke, blunted peak, and no second component signify progressive obstruction proximal to
the probe, and a flat waveform indicates severe obstruction.
The pitch of the duplex signal changes in proportion to the velocity of the blood with high-pitched harsh
sounds indicative of stenosis. Proximal to a high-grade stenosis with minimal compensatory
collateralization, a thumping sound is heard.
Specific anatomic sites
Aortoiliac Aortoiliac imaging requires the patient to fast for about 12 hours to reduce interference
by bowel gas. It is therefore most convenient to obtain these studies early in the morning.
Satisfactory aortoiliac Doppler signals (picture 6) can be obtained from approximately 90 percent of
individuals who have been properly prepared. Complete examination involves the visceral aorta,
iliac bifurcation, and iliac arteries distally.
Extremities For the lower extremity, examination begins at the common femoral artery and is
routinely carried through the popliteal artery. The tibial arteries can also be evaluated. In the upper
extremities, the extent of the examination is determined by the clinical indication. Visualization of
the subclavian artery is limited by the clavicle.
Any areas of stenosis are initially localized with color Doppler and then quantified and assessed by
measuring Doppler velocities. In general, the ratio of the peak systolic velocity (PSV) within an
area of stenosis is compared with the PSV in the vessel just proximal to it to estimate the degree of
stenosis. For the lower extremity, the percent stenosis can be estimated. A PSV ratio that is 1.5 to
2.0 indicates a 50 percent arterial stenosis and a ratio >4.0 indicates >75 percent stenosis (table 1).
The same general principles apply when determining the degree of stenosis within a lower
extremity bypass graft.
There are no generally agreed upon criteria for determining stenosis in upper extremity arteries, and
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most vascular laboratories tend to extrapolate criteria from lower extremity arteries to upper
extremity arteries.
Visceral arteries Duplex examination of visceral arteries, especially the renal arteries, requires the
use of low frequency transducers to penetrate to the depth of these vessels. Fasting is required prior
to examination to minimize overlying bowel gas. Validated velocity criteria for determining the
degree of stenosis in visceral vessels are given in the table (table 3).
OTHER IMAGING Contrast arteriography remains the gold standard for vascular imaging and, under
some circumstances (eg, acute ischemia), is the primary imaging modality because it offers the benefit of
potential simultaneous intervention. However, because arteriography exposes the patient to radiation and
other complications associated with percutaneous arterial access and iodinated contrast, other modalities
including computed tomography and magnetic resonance imaging have become important alternative
methods for vascular assessment.
The development of multidetector computed tomography (MDCT) allows rapid acquisition of high
resolution, contrast-enhanced arterial images [45-48]. However, the examination is expensive and also
involves radiation exposure and the intravenous contrast agents. A meta-analysis of 20 studies in which
MDCT was used to evaluate 19,092 lower extremity arterial segments in 957 symptomatic patients
compared test performance with DSA [49]. The sensitivity and specificity for detecting a stenosis of 50
percent with MDCT and DSA were 95 and 96 percent, respectively. Six studies evaluated diagnostic
performance according to anatomic region of the arterial system. Arterial occlusions were correctly
identified in 94 percent of segments and the absence of a significant stenosis correctly identified in 96
percent of segments. Specificity was lower in the tibial arteries compared with the aortoiliac and
femoropopliteal segment, but the difference was not significant. MDCT has been used to guide the need
for intervention. In a series of 58 patients with claudication, none of 29 patients in whom conservative
management was indicated by MDCT required revascularization at a mean follow-up of 501 days [50].
Magnetic resonance angiography (MRA), using rapid three-dimensional imaging sequences combined
with gadolinium contrast agents, has shown promise to become a time-efficient and cost-effective tool for
the assessment of lower extremity peripheral artery disease [1,51-53]. MRA is usually only performed if
revascularization is being considered. A potential, severe complication associated with use of gadolinium
in patients with renal failure is nephrogenic systemic sclerosis/nephrogenic fibrosing dermopathy, and
therefore gadolinium is contraindicated in these patients. (See "Nephrogenic systemic
fibrosis/nephrogenic fibrosing dermopathy in advanced renal failure", section on 'Gadolinium'.)
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The
Basics and Beyond the Basics. The Basics patient education pieces are written in plain language, at the
5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a
given condition. These articles are best for patients who want a general overview and who prefer short,
easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and
more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients
who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on patient info and the keyword(s) of interest.)
Basics topics (see "Patient information: Peripheral artery disease and claudication (The Basics)")
Beyond the Basics topics (see "Patient information: Peripheral artery disease and claudication
(Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
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Noninvasive vascular testing is an extension of the vascular history and physical examination and is
used to confirm a diagnosis of arterial disease and determine the level and extent of disease.
Available studies include physiologic tests that correlate symptoms with site and severity of arterial
occlusive disease, and imaging studies that further delineate vascular anatomy. (See
'Introduction' above.)
Noninvasive vascular testing may be indicated to screen patients with risk factors for arterial
disease, establish a diagnosis in patients with symptoms or signs consistent with arterial disease,
identify a vascular injury, or evaluate the vasculature preoperatively, intraoperatively, or for
surveillance following a vascular procedure (eg, stent, bypass). (See 'Indications for testing' above.)
Physiologic tests include segmental limb pressure measurements and the determination of pressure
index values (eg, ankle-brachial index, wrist-brachial index, toe-brachial index), exercise testing,
segmental volume plethysmography, and transcutaneous oxygen measurements. These tests
generally correlate to clinical symptoms and are used to stratify the need for further evaluation and
treatment. (See 'Physiologic testing' above.)
The comparison of the resting systolic blood pressure at the ankle to the systolic brachial pressure is
referred to as the ankle-brachial (ABI) index. The analogous index in the upper extremity is the
wrist-brachial index (WBI). (See 'Ankle-brachial index' above and 'Wrist-brachial index' above.)
For the lower extremity:
ABI of 0.91 to 1.30 is normal.
ABI 0.90 is diagnostic of arterial obstruction.
ABI >1.30 suggests the presence of calcified vessels
Further evaluation is dependent upon the ABI value.
For patients with a normal ankle-brachial index (ABI) who have typical symptoms of claudication,
we suggest exercise testing. An ABI that decreases by 20 percent following exercise is diagnostic
of arterial obstruction whereas a normal ABI following exercise eliminates a diagnosis of arterial
obstruction and suggests the need to seek other causes for the leg symptoms. (See 'Exercise
testing' above.)
For symptomatic patients with an ABI 0.9 who are possible candidates for intervention, we
perform additional noninvasive vascular studies to further define the level and extent of disease.
Depending upon the clinical scenario, additional testing may include additional physiologic tests,
duplex ultrasonography, or other imaging such as angiography using computed tomography or
magnetic resonance imaging, or conventional arteriography. (See 'Ankle-brachial index' above and
'Physiologic testing' above and 'Ultrasound' above and 'Other imaging' above.)
For patients with an ABI >1.3, the toe-brachial index (TBI) and pulse volume recordings (PVRs)
should be performed. A normal toe-brachial index is 0.7 to 0.8. The normal PVR waveform is
composed of a systolic upstroke with a sharp systolic peak followed by a downstroke that contains
a prominent dicrotic notch. Progressive obstruction alters the normal waveform and blunts its
amplitude. (See 'High ABI' above and 'Toe-brachial index' above and 'Pulse volume
recordings' above.)
Transcutaneous oxygen measurement may supplement other physiologic tests by providing
information regarding local tissue perfusion. A normal value at the foot is 60 mmHg and a normal
chest/foot ratio is 0.9. (See 'Transcutaneous oxygen measurements' above.)
For patients with a normal ankle- or wrist-brachial index and distal extremity ischemia, individual
digit waveforms and digit pressures can be used to identify small vessel occlusive arterial disease.
(See 'Digit waveforms' above.)
Ultrasound is routinely used for vascular imaging. B-mode imaging is the primary modality for
evaluating and following aneurysmal disease, while duplex scanning is used to define the site and
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severity of vascular obstruction. Areas of stenosis localized with Doppler can be quantified by
comparing the peak systolic velocity (PSV) within a narrowed area to the PSV in the vessel just
proximal to it (PSV ratio). The percent stenosis in lower extremity native vessels and vascular
grafts can be estimated (table 1). A PSV ratio >4.0 indicates a >75 percent stenosis. These criteria
can also be used for the upper extremity. Validated criteria for the visceral vessels are given in the
table (table 3). (See 'Ultrasound' above.)
Contrast arteriography remains the gold standard for vascular imaging and, under some
circumstances (eg, acute ischemia), is the primary imaging modality because it offers the benefit of
potential simultaneous intervention. Other imaging modalities include multidetector computed
tomography (MDCT) and magnetic resonance imaging and angiography (MRA). (See 'Other
imaging' above.)
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