Ankle Brachial Pressure Index Exam

Question 1

Questions to ask patient

Answer 1

If in any pain

If have diabetes

Question 2

Why do you ask if patient has diabetes

Answer 2

Calcified vessels can cause misleadingly high ABPI results

Ideally would use toe pressure using special cuff

Question 3

Brachial pressure

Answer 3

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

Question 4

Ankle pressure

Answer 4

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

Question 5

Calculating left ABPI

Answer 5

highest pressure of either left PTA or DP/highest brachial pressure

Question 6

Right ABPI

Answer 6

highest pressure of either right PTA or DP/ highest brachial pressure

Question 7

ABPI >1.2

Answer 7

Calcified vessels resulting in unusually high ABPI

Use Doppler US and angiography to accurately assess perfusion

Question 8

ABPI 1-1.2

Answer 8

Normal result

Question 9

ABPI 0.9-1

Answer 9

Acceptable

Question 10

ABPI 0.8-9

Answer 10

Mild arterial disease

Typical presenting features include mild claudication

Question 11

ABPI 0.5-79

Answer 11

Moderate arterial disease

Typical presenting features include severe claudication

Question 12

ABPI <0.5

Answer 12

Severe arterial disease (critical ischaemia)
Typically presenting include rest pain, ulceration and gangrene
URGENT REFERRAL

Question 13

Irregular pulse

Answer 13

AF

Question 14

Calcified vessels

Answer 14

Diabetes

Advanced age

Question 15

Further exams

Answer 15

Peripheral vascular exam
CV exam
Bloods (FBC, EST/CRP (exclude arteritis), U+Es, lipid profile, thrombophilia screen)
ECG
Doppler US
CT/MRI angiography

Question 16

Peripheral arterial disease symptoms

Answer 16

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

Question 17

Cardinal features of critical ischaemia

Answer 17

Ulceration and gangrene

Foot pain at rest (relieve at night by hanging legs off bed)

Question 18

Signs of peripheral arterial disease

Answer 18

Absent femoral, popliteal or foot pulses
Cold, white legs
Atrophied skin
Punched out (arterial) ulcers (often painful)
Postural/dependent colour change
Severe ischaemia

Question 19

Severe ischaemia

Answer 19

Buerger’s angle (angle that leg goes pale when raised off couch) <20
Capillary refill time >15s

Question 20

Fontaine Classification

Answer 20

1. Asymptomatic
2. Intermittent claudication
3. Ischaemic rest pain
4. Ulceration/gangrene (critical ischaemia)

Question 21

Lifestyle changes for PAD

Answer 21

Quit smoking
Treat HTN and hypercholesterolaemia with a statin
Prescribe antiplatelet agent (unless contraindicated)- clopidogrel 1st line

Question 22

Management of Claudication

Answer 22

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

Question 23

Percutaneous transluminal angioplasty (PTA)

Answer 23

Used for disease limited to a single arterial segment
Balloon is inflated in narrowed segment
Stents can be used to maintain arterial patency

Question 24

Surgical Reconstruction (arterial reconstruction itch bypass graft)

Answer 24

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

Question 25

Amputation

Answer 25

<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