In advanced peripheral arterial disease (PAD), medial arterial calcification is known to inflate the ankle-brachial index. An alternative method of evaluating symptomatic patients is toe-brachial indexes (TBI), where a ratio less than .7 indicates PAD and less than .4 indicates a severe form. The objective of this retrospective analysis was to investigate the association between TBIs less than .7 and angiographically verified PAD. Patients were required to have either a leg angiogram 13 months prior to or 12 months after a 6-minute walk test. Of the 174 included patients, the mean overall TBI was .450. The mean TBI by location was highest at iliac and infra-geniculate with .544 and lowest at supra-geniculate with .372. Infra-geniculate lesions were also the most frequent (n = 46). A TBI less than .4 was found in 47.7% of patients. TBIs greater than .7 were present in 36 patients; however, only 16 had significant angiographic stenosis. In conclusion, the majority of patients with angiographic PAD had a TBI less than .7, especially less than .4. Contrary to suspicion, infra-geniculate lesions were the most common and had the highest TBI.
NorgrenLHiattWRDormandyJA, et al.Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg2007; 33(suppl l): S1–S75.
2.
DiehmCAllenbergJRPittrowD, et al.Mortality and vascular morbidity in older adults with asymptomatic versus symptomatic peripheral arterial disease. Circulation2009; 120: 2053–2061.
3.
DiehmNShangASilvestroA, et al.Association of cardiovascular risk factors with pattern of lower limb atherosclerosis in 2659 patients under- going angioplasty. Eur J Vasc Endovasc Surg2006; 31: 59–63.
RookeTWHirschATMisraS, et al.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. J Am Coll Cardiol2011; 58: 2020–2045.
6.
WilliamsDTHardingKGPriceP. An evaluation of the efficacy of methods used in screening for lower-limb arterial disease in diabetes. Diabetes Care2005; 28: 2206–2210.
7.
OkamotoKOkaMMaesatoK, et al.Peripheral arterial occlusive disease is more prevalent in patients with hemodialysis: comparison with the findings of multidetector-row computed tomography. Am J Kidney Dis2006; 48: 269–276.
8.
EverhartJEPettittDJKnowlerWCRoseFABennettPH. Medial arterial calcification and its association with mortality and complications of diabetes. Diabetologia 1988 Jan; 31(1): 16–23.
9.
AerdenDMassaadDvon KempK, et al.The ankle-brachial index and the diabetic foot: a troublesome marriage. Ann Vasc Surg2011; 25: 770–777.
10.
AboyansVHoEDenenbergJOHoLANatarajanLCriquiMH. The association between elevated ankle systolic pressures and peripheral occlusive arterial disease in diabetic and nondiabetic subjects. J Vasc Surg2008; 48: 1197–1203.
11.
TehanPBrayAKeechR, et al.Sensitivity and specificity of the toe‐brachial index for detecting peripheral arterial disease. J Ultrasound Med2015; 34(10): 1737–1743.
12.
HirschATHaskalZJHertzerNR, et al.ACC/AHA guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the american associations 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)—summary of recommendations. J Vasc Intervent Radiol2006; 17: 1383–1397.
13.
CarterSALezackJD. Digital systolic pressures in the lower limb in arterial disease. Circulation1971; 43: 905–914.
14.
RamseyDEMankeDASumnerDS. Toe blood pressure: a valuable adjunct to ankle pressure measurement for assessing peripheral arterial disease. J Cardiovasc Surg1983; 24: 43–48.
15.
BrooksBDeanRPatelSWuBMolyneauxLYueDK. TBI or not TBI: that is the question. Is it better to measure toe pressure than ankle pressure in diabetic patients?Diabet Med2001; 18: 528–532.
16.
OhtakeTOkaMIkeeR, et al.Impact of lower limbs’ arterial calcification on the prevalence and severity of PAD in patients on hemodialysis. J Vasc Surg2011; 53: 676–683.
17.
MukherjeeDEagleK. The importance of early diagnosis and treatment in peripheral arterial disease: insights from the PARTNERS and REACH registries. Curr Vasc Pharmacol2010; 8: 293–300.
18.
SuominenVUurtoISaarinenJVenermoMSaleniusJ. PAD as a risk factor for mortality among patients with elevated ABI – a clinical study. Eur J Vasc Endovasc Surg2010; 39: 316–322.
19.
RookeTWHirschATMisraS, et al.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, developed in collaboration with the society for cardiovascular angiography and interventions, society of interventional radiology, society for vascular medicine, and society for vascular surgery. Cathet Cardiovasc Interv2011; 79: 501–531.2012
United States Department of Health & Human Services. Medical privacy—national standards to protect the privacy of personal health information. Available at:, www.hhs.gov/ocr/hipaa, (Accessed 29 December 2020).
22.
SawkaAMCarterSA. Effect of temperature on digital systolic pressures in lower limb in arterial disease. Circulation1992; 85: 1097–1101.
23.
PandeRLPerlsteinTSBeckmanJA, et al.Secondary prevention and mortality in peripheral artery disease: National Health and Nutrition Examination Study, 1999 to 2004. Circulation2011; 124: 17–23.
24.
McDermottMMLiuKFerrucciL, et al.Decline in functional performance predicts later increased mobility loss and mortality in peripheral arterial disease. J Am Coll Cardiol2011; 57: 962–970.
25.
McDermottMMGreenlandPTianL, et al.Association of 6-minute walk performance and physical activity with incident ischemic heart disease events and stroke in peripheral artery disease. J Am Heart Assoc2015; 4: e001846.
26.
PollySMontgomeryMSGardnerAW. The clinical utility of a six-minute walk test in peripheral arterial occlusive disease patients. JAGS1998; 46: 706–711.
