Noninvasive diagnosis of arterial disease
- Emile R Mohler III, MD
Emile R Mohler III, MD
- Section Editor — Vascular Medicine
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Erica Mitchell, MD, FACS
Erica Mitchell, MD, FACS
- Associate Professor of Surgery
- Division of Vascular Surgery
- Oregon Health & Science University
- Section Editors
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular Surgery
- Professor of Surgery
- University of South Carolina School of Medicine Greenville
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular Surgery
- Professor of Surgery
- University of Arizona Health Sciences Center
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 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) .
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, ankle-brachial 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 . 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 (See "Clinical features and diagnosis of abdominal aortic aneurysm".).
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 patient’s 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 and diagnosis of lower extremity peripheral artery disease" and "Overview of thoracic outlet syndromes" and "Clinical manifestations and diagnosis of the Raynaud phenomenon" and "Clinical features and diagnosis of abdominal aortic aneurysm".)
- Spittell JA Jr. Diagnosis and management of occlusive peripheral arterial disease. Curr Probl Cardiol 1990; 15:1.
- Rofsky NM, Adelman MA. MR angiography in the evaluation of atherosclerotic peripheral vascular disease. Radiology 2000; 214:325.
- Hirsch AT, Haskal ZJ, Hertzer NR, et al. 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 2006; 113:e463.
- Criqui MH, Langer RD, Fronek A, et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med 1992; 326:381.
- Leng GC, Fowkes FG, Lee AJ, et al. Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study. BMJ 1996; 313:1440.
- O'Hare AM, Katz R, Shlipak MG, et al. Mortality and cardiovascular risk across the ankle-arm index spectrum: results from the Cardiovascular Health Study. Circulation 2006; 113:388.
- Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007; 45 Suppl S:S5.
- American Diabetes Association. Standards of medical care in diabetes--2008. Diabetes Care 2008; 31 Suppl 1:S12.
- PASCARELLI EF, BERTRAND CA. COMPARISON OF BLOOD PRESSURES IN THE ARMS AND LEGS. N Engl J Med 1964; 270:693.
- Olin JW, Kaufman JA, Bluemke DA, et al. Atherosclerotic Vascular Disease Conference: Writing Group IV: imaging. Circulation 2004; 109:2626.
- Taylor-Piliae RE, Fair JM, Varady AN, et al. Ankle brachial index screening in asymptomatic older adults. Am Heart J 2011; 161:979.
- Nead KT, Cooke JP, Olin JW, Leeper NJ. Alternative ankle-brachial index method identifies additional at-risk individuals. J Am Coll Cardiol 2013; 62:553.
- Aboyans V, Criqui MH, Abraham P, et al. Measurement and interpretation of the ankle-brachial index: a scientific statement from the American Heart Association. Circulation 2012; 126:2890.
- Nead KT, Cooke JP, Olin JW, et al. Commentary on: “Alternate ankle-brachial index method identifies additional at-risk individuals”,. J Am Coll Cardiol 2013; 62:560.
- Belch JJ, Topol EJ, Agnelli G, et al. Critical issues in peripheral arterial disease detection and management: a call to action. Arch Intern Med 2003; 163:884.
- Hiatt WR. Medical treatment of peripheral arterial disease and claudication. N Engl J Med 2001; 344:1608.
- Kuller LH, Shemanski L, Psaty BM, et al. Subclinical disease as an independent risk factor for cardiovascular disease. Circulation 1995; 92:720.
- Vogt MT, Cauley JA, Newman AB, et al. Decreased ankle/arm blood pressure index and mortality in elderly women. JAMA 1993; 270:465.
- Resnick HE, Lindsay RS, McDermott MM, et al. Relationship of high and low ankle brachial index to all-cause and cardiovascular disease mortality: the Strong Heart Study. Circulation 2004; 109:733.
- Murabito JM, Evans JC, Larson MG, et al. The ankle-brachial index in the elderly and risk of stroke, coronary disease, and death: the Framingham Study. Arch Intern Med 2003; 163:1939.
- O'Hare AM, Rodriguez RA, Bacchetti P. Low ankle-brachial index associated with rise in creatinine level over time: results from the atherosclerosis risk in communities study. Arch Intern Med 2005; 165:1481.
- Bundó M, Muñoz L, Pérez C, et al. Asymptomatic peripheral arterial disease in type 2 diabetes patients: a 10-year follow-up study of the utility of the ankle brachial index as a prognostic marker of cardiovascular disease. Ann Vasc Surg 2010; 24:985.
- Mohler ER 3rd. Peripheral arterial disease: identification and implications. Arch Intern Med 2003; 163:2306.
- Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg 1997; 26:517.
- Wolf EA Jr, Sumner DS, Strandness DE Jr. Correlation between nutritive blood flow and pressure in limbs of patients with intermittent claudication. Surg Forum 1972; 23:238.
- McDermott MM, Greenland P, Liu K, et al. The ankle brachial index is associated with leg function and physical activity: the Walking and Leg Circulation Study. Ann Intern Med 2002; 136:873.
- McDermott MM, Ferrucci L, Guralnik JM, et al. The ankle-brachial index is associated with the magnitude of impaired walking endurance among men and women with peripheral arterial disease. Vasc Med 2010; 15:251.
- Wang JC, Criqui MH, Denenberg JO, et al. Exertional leg pain in patients with and without peripheral arterial disease. Circulation 2005; 112:3501.
- McPhail IR, Spittell PC, Weston SA, Bailey KR. Intermittent claudication: an objective office-based assessment. J Am Coll Cardiol 2001; 37:1381.
- Resnick HE, Foster GL. Prevalence of elevated ankle-brachial index in the United States 1999 to 2002. Am J Med 2005; 118:676.
- Ix JH, Katz R, Peralta CA, et al. A high ankle brachial index is associated with greater left ventricular mass MESA (Multi-Ethnic Study of Atherosclerosis). J Am Coll Cardiol 2010; 55:342.
- Carter SA, Tate RB. Value of toe pulse waves in addition to systolic pressures in the assessment of the severity of peripheral arterial disease and critical limb ischemia. J Vasc Surg 1996; 24:258.
- Vitti MJ, Robinson DV, Hauer-Jensen M, et al. Wound healing in forefoot amputations: the predictive value of toe pressure. Ann Vasc Surg 1994; 8:99.
- Apelqvist J, Castenfors J, Larsson J, et al. Prognostic value of systolic ankle and toe blood pressure levels in outcome of diabetic foot ulcer. Diabetes Care 1989; 12:373.
- http://www.iwgdf.org/index.php?option=com_content&task=view&id=43&Itemid=63 (Accessed on June 02, 2011).
- Heintz SE, Bone GE, Slaymaker EE, et al. Value of arterial pressure measurements in the proximal and distal part of the thigh in arterial occlusive disease. Surg Gynecol Obstet 1978; 146:337.
- Sumner DS, Strandness DE Jr. The relationship between calf blood flow and ankle blood pressure in patients with intermittent claudication. Surgery 1969; 65:763.
- Darling RC, Raines JK, Brener BJ, Austen WG. Quantitative segmental pulse volume recorder: a clinical tool. Surgery 1972; 72:873.
- Kempczinski RF. Segmental volume plethysmography in the diagnosis of lower extremity arterial occlusive disease. J Cardiovasc Surg (Torino) 1982; 23:125.
- Hiatt WR, Hirsch AT, Regensteiner JG, Brass EP. Clinical trials for claudication. Assessment of exercise performance, functional status, and clinical end points. Vascular Clinical Trialists. Circulation 1995; 92:614.
- Nicolaï SP, Viechtbauer W, Kruidenier LM, et al. Reliability of treadmill testing in peripheral arterial disease: a meta-regression analysis. J Vasc Surg 2009; 50:322.
- Bowers BL, Valentine RJ, Myers SI, et al. The natural history of patients with claudication with toe pressures of 40 mm Hg or less. J Vasc Surg 1993; 18:506.
- Byrne P, Provan JL, Ameli FM, Jones DP. The use of transcutaneous oxygen tension measurements in the diagnosis of peripheral vascular insufficiency. Ann Surg 1984; 200:159.
- Arsenault KA, McDonald J, Devereaux PJ, et al. The use of transcutaneous oximetry to predict complications of chronic wound healing: a systematic review and meta-analysis. Wound Repair Regen 2011; 19:657.
- Moneta GL, Yeager RA, Lee RW, Porter JM. Noninvasive localization of arterial occlusive disease: a comparison of segmental Doppler pressures and arterial duplex mapping. J Vasc Surg 1993; 17:578.
- AbuRahma AF, Khan S, Robinson PA. Selective use of segmental Doppler pressures and color duplex imaging in the localization of arterial occlusive disease of the lower extremity. Surgery 1995; 118:496.
- Koelemay MJ, den Hartog D, Prins MH, et al. Diagnosis of arterial disease of the lower extremities with duplex ultrasonography. Br J Surg 1996; 83:404.
- Kohler TR, Nance DR, Cramer MM, et al. Duplex scanning for diagnosis of aortoiliac and femoropopliteal disease: a prospective study. Circulation 1987; 76:1074.
- Zierler RE. Duplex and color-flow imaging of the lower extremity arterial circulation. Semin Ultrasound CT MR 1990; 11:168.
- Ota H, Takase K, Igarashi K, et al. MDCT compared with digital subtraction angiography for assessment of lower extremity arterial occlusive disease: importance of reviewing cross-sectional images. AJR Am J Roentgenol 2004; 182:201.
- Romano M, Mainenti PP, Imbriaco M, et al. Multidetector row CT angiography of the abdominal aorta and lower extremities in patients with peripheral arterial occlusive disease: diagnostic accuracy and interobserver agreement. Eur J Radiol 2004; 50:303.
- Adriaensen ME, Kock MC, Stijnen T, et al. Peripheral arterial disease: therapeutic confidence of CT versus digital subtraction angiography and effects on additional imaging recommendations. Radiology 2004; 233:385.
- Edwards AJ, Wells IP, Roobottom CA. Multidetector row CT angiography of the lower limb arteries: a prospective comparison of volume-rendered techniques and intra-arterial digital subtraction angiography. Clin Radiol 2005; 60:85.
- Met R, Bipat S, Legemate DA, et al. Diagnostic performance of computed tomography angiography in peripheral arterial disease: a systematic review and meta-analysis. JAMA 2009; 301:415.
- Schernthaner R, Fleischmann D, Lomoschitz F, et al. Effect of MDCT angiographic findings on the management of intermittent claudication. AJR Am J Roentgenol 2007; 189:1215.
- Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA 2001; 286:1317.
- McDermott MM, Kerwin DR, Liu K, et al. Prevalence and significance of unrecognized lower extremity peripheral arterial disease in general medicine practice*. J Gen Intern Med 2001; 16:384.
- Menke J, Larsen J. Meta-analysis: Accuracy of contrast-enhanced magnetic resonance angiography for assessing steno-occlusions in peripheral arterial disease. Ann Intern Med 2010; 153:325.
- 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
- Continuous wave Doppler
- B-mode imaging
- Duplex imaging
- - Specific anatomic sites
- OTHER IMAGING
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS