Noninvasive Localization of Infrainguinal Arterial Occlusive Disease in Diabetics

Abstract

A retrospective review of 101 diabetics without aortoiliac disease was carried out to analyze the ability of various noninvasive tests to predict the level of significant (>50% stenosis) infrainguinal arterial disease. Patients were studied with anklebrachial indices (ABI), toebrachial indices (TBI), segmental pulse volume recordings (PVR), segmental pressures (SEGP), segmental Doppler waveforms (DWF), and arteriography. Results were classified as normal, disease at the femoropopliteal level, infrapopliteal level, or both levels (multilevel), or noninterpretable. Our findings for the entire study showed that, as a single test, DWF appears to have the best angiographic correlation, although the summed diagnosis of combined DWF and PVR data is superior in distinguishing multilevel disease from isolated tibial disease. SEGP are of very limited use in diabetics, even in multimodality testing, and we no longer include that test in our routine evaluation of diabetics.

The Limitations of Ankle Brachial Index when used Alone for the Detection/Screening of Peripheral Arterial Disease in a Population with an Increased Prevalence of Diabetes

“…This group can be subdivided into three categories: 31% triphasic waveforms (normal) 1,6,12 ; 44% biphasic waveforms (mild-to-moderate arterial insufficiency) 1,6,12 ; and 25% monophasic waveforms (moderate-to-severe arterial insufficiency). 1,6,12 In this group, 69% of segments that were noncompressible were positive for peripheral arterial disease by Doppler evaluation. A total of 1% of the ankle pressures performed were in the normal ABI range; however, they demonstrated a corresponding abnormal Doppler signal.…”

“…For optimum accuracy, Doppler waveform analysis should be used to determine the presence or absence of disease in segments with noncompressible ABIs. 6,12 However, some screening programs do not perform Doppler waveform analysis. Therefore, we are left with the choice of categorizing noncompressible ABI's as equivocal, positive or negative.…”

“…No further demographic or medical history information was available. Because waveform analysis is more accurate at detecting peripheral arterial disease than ankle brachial indices alone, 6,12 waveform analysis was used to determine the presence or absence of PAD in patients with noncompressible ankle pressures.…”

“…The ankle brachial index (ABI) is commonly used when screening patients for peripheral arterial disease (PAD). Although the ABI is an established and reliable means of determining the presence or absence of PAD, 1–6 its effectiveness is decreased in a population with a high percentage of diabetes because of a higher incidence of medial arterial calcification. 7–9…”

Vascular Problems in the Diabetic Foot

“…Toursarkissian and coworkers 45 retrospectively reviewed the ability of various noninvasive tests to predict the level of significant infrainguinal arterial disease in 101 diabetic subjects. The author noted that Doppler waveform, as a single test, appears to have the best angiographic correlation, although the summed diagnosis of combined Doppler waveform with PVR data is superior in distinguishing multilevel disease from isolated tibial disease.…”