Ankle Brachial Pressure Index Exam Flashcards
Questions to ask patient
If in any pain
If have diabetes
Why do you ask if patient has diabetes
Calcified vessels can cause misleadingly high ABPI results
Ideally would use toe pressure using special cuff
Brachial pressure
Just use systolic pressure when calculating ABPI
Do brachial pressure on BOTH arms- use the higher of the 2 systolic readings for use when calculating
Ankle pressure
Place cuff around ankle and position stethoscope over posterior tibial artery
Keep cuff in same position but now position stethoscope over dorsalis pedis artery of same foot
Assess systolic pressure in dorsalis pedis artery
Record highest of two pressures obtained for use when calculating left ABPI
Repeat for right foot
Calculating left ABPI
highest pressure of either left PTA or DP/highest brachial pressure
Right ABPI
highest pressure of either right PTA or DP/ highest brachial pressure
ABPI >1.2
Calcified vessels resulting in unusually high ABPI
Use Doppler US and angiography to accurately assess perfusion
ABPI 1-1.2
Normal result
ABPI 0.9-1
Acceptable
ABPI 0.8-9
Mild arterial disease
Typical presenting features include mild claudication
ABPI 0.5-79
Moderate arterial disease
Typical presenting features include severe claudication
ABPI <0.5
Severe arterial disease (critical ischaemia)
Typically presenting include rest pain, ulceration and gangrene
URGENT REFERRAL
Irregular pulse
AF
Calcified vessels
Diabetes
Advanced age
Further exams
Peripheral vascular exam CV exam Bloods (FBC, EST/CRP (exclude arteritis), U+Es, lipid profile, thrombophilia screen) ECG Doppler US CT/MRI angiography
Peripheral arterial disease symptoms
Cramping pain in calf, thigh or buttock after walking four a given distance (caudication distance) and relieved by rest
Calf —> femoral disease
buttock —> iliac disease
Cardinal features of critical ischaemia
Ulceration and gangrene
Foot pain at rest (relieve at night by hanging legs off bed)
Signs of peripheral arterial disease
Absent femoral, popliteal or foot pulses Cold, white legs Atrophied skin Punched out (arterial) ulcers (often painful) Postural/dependent colour change Severe ischaemia
Severe ischaemia
Buerger’s angle (angle that leg goes pale when raised off couch) <20
Capillary refill time >15s
Fontaine Classification
- Asymptomatic
- Intermittent claudication
- Ischaemic rest pain
- Ulceration/gangrene (critical ischaemia)
Lifestyle changes for PAD
Quit smoking
Treat HTN and hypercholesterolaemia with a statin
Prescribe antiplatelet agent (unless contraindicated)- clopidogrel 1st line
Management of Claudication
Supervised exercise programme (2h/wk for 3 months) - reduce symptoms by improving collateral blood flow; exercise to point of maximal pain
Vasoactive Drugs e.g. naftidrofuryl oxalate - modest benefit, recommended only in those who do not wish to undergo revascularisation and if exercise fails to improve symptoms
Percutaneous transluminal angioplasty (PTA)
Used for disease limited to a single arterial segment
Balloon is inflated in narrowed segment
Stents can be used to maintain arterial patency
Surgical Reconstruction (arterial reconstruction itch bypass graft)
If atheromatous disease is extensive but distal run-offs are good (i.e. distal arteries filled by collateral vessels)
Autologous vein grafts superior to prosthetic grafts when knee joint is crossed
Amputation
<3% of patients with intermittent claudication require major amputation within 5 years (increase in DM)
May relieve intractable pain and death from sepsis and gangrene
Knee should be preserved ideally as it improves mobility and rehabilitation potential
Start rehab early but balance with healing
Gabapentin can be used for phantom limb pain
