An Evaluation of the Efficacy of Methods Used in Screening for Lower-Limb Arterial Disease in Diabetes

Abstract

OBJECTIVE -Foot-related disease is the most common cause for hospital admission among the diabetic population. Lower-limb peripheral arterial occlusive disease (PAOD) is a major risk factor in diabetic foot disease. Screening for PAOD commonly includes foot pulses and the ankle-brachial pressure index (ABPI) and/or the toe-brachial pressure index (TBI), but concerns persist regarding their accuracy. We evaluated the efficacy of several commonly used screening methods in different subject populations.RESEARCH DESIGN AND METHODS -We studied 130 limbs in 68 individuals with no critical ischemia over 8 months. Limbs were grouped on the basis of the presence or absence of diabetes, clinically detectable peripheral neuropathy, and PAOD identified on color duplex imaging. Comparative analyses of foot pulses, the ABPI, the TBI, and distal Doppler waveform analysis were performed.RESULTS -Foot pulses, the TBI, and qualitative waveform analyses were highly sensitive screening methods in individuals with and without diabetes. However, detectable peripheral neuropathy was associated with a reduced sensitivity and poor specificity of foot pulses, a reduction in sensitivity of the ABPI (71 to 38%), and a reduction in specificity of the TBI (81 to 61%) and qualitative waveform analysis (96 to 66%). Quantitative analysis failed to detect disease with severely damped and low-intensity signals.CONCLUSIONS -Screening tools that are effective in screening for lower-limb PAOD in the nondiabetic population are less efficacious in diabetes, particularly in the presence of detectable peripheral neuropathy. Qualitative waveform analysis and the TBI were demonstrated to be more effective screening methods than the ABPI and foot pulses particularly in high-risk limbs with detectable peripheral neuropathy. Diabetes Care 28:2206 -2210, 2005F oot-related disease is the most common cause for hospital admission among the diabetic population and is recognized as the most common cause of nontraumatic lower-limb amputation in the western world. People with diabetes are Ͼ20 times more likely to undergo an amputation than the rest of the population (1). The main risk factors for the development of diabetic foot disease are peripheral neuropathy and peripheral arterial occlusive disease (PAOD). The detection of significant arterial disease is vital to the prevention and treatment of foot disease. The unreliable nature of the symptoms and signs of lower-limb arterial insufficiency in diabetes means that noninvasive tests are essential to achieve effective screening (2,3). The European Working Group on Critical Leg Ischaemia recommends an additional, noninvasive vascular assessment for patients with diabetes and foot ulceration (4).Screening techniques commonly used in assessing lower-limb perfusion are the palpation of foot pulses and calculation of the ankle-brachial pressure index (ABPI) and/or the toe-brachial pressure index (TBI). There is continued debate regarding the influence of peripheral neuropathy and arterial calcification on the reliabil...

Comparison of ankle brachial pressure index to arterial doppler USG in the diagnosis of peripheral vascular disease in diabetes mellitus

“…The results in the non-diabetic control group were almost similar (sensitivity 83% and specificity 100%). 12 Alnaeb et al reported a correlation of −0.81 between an ABI <0.9 and arterial DUS in the same type of diabetic patients.…”

Peripheral arterial disease, type 2 diabetes and postprandial lipidaemia: Is there a link?

“…The prevalence of diabetes in the group with an ABI > 1.4 was 58%, compared with 18% and 48% in those with a normal ABI or those with an ABI < 0.9 [37] . It has long been known that the sensitivity of the ABI to correctly diagnose PAD is considerably reduced in the presence of arterial media calcification and that, clinically, this calcification is associated with the presence of peripheral neuropathy [38,39] . Accordingly, in the presence of peripheral neuropathy it is recommended to use an alternative method, such as flow wave analysis using Doppler colour ultrasound [40,41] .…”

The Diabetic Foot in End Stage Renal Disease

“…[72] Certainly its use in patients with diabetes mellitus has been criticized because arterial medial calcification may cause spuriously elevated ankle pressures, even more so in patients with ESRD. [70,71,73,74] This potential underestimation of peripheral arterial disease may be circumvented by measuring toe pressures, but such measurement requires more sophisticated equipment and trained personnel. [70,71,73,74] Transcutaneous oxygen pressure (TcPO 2 ), Duplex imaging, and angiography represent further modalities used in a more comprehensive evaluation of peripheral circulation, especially prior to revascularization.…”

“…[70,71,73,74] This potential underestimation of peripheral arterial disease may be circumvented by measuring toe pressures, but such measurement requires more sophisticated equipment and trained personnel. [70,71,73,74] Transcutaneous oxygen pressure (TcPO 2 ), Duplex imaging, and angiography represent further modalities used in a more comprehensive evaluation of peripheral circulation, especially prior to revascularization. [33,70,71] Diabetic neuropathy is also diagnosed clinically.…”