Reliability of common femoral artery hemodynamics in assessing the severity of aortoiliac inflow disease

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...

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“…However, the accuracy of waveform analysis alone in assessing the severity of lower-limb arterial disease is uncertain (12,13).…”

mentioning

confidence: 99%

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

2005

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“…Other experts, however, used biphasic to describe waveforms with forward flow in systole, zero diastolic flow reversal, and pandiastolic forward flow (Figure 4). 5,74,79 To further complicate this issue, some authors characterized biphasic as "normal," 1,66,70 whereas others labeled this waveform "abnormal." 50,54,74 These contradictory characterizations are a plausible explanation for the omission of biphasic terminology by the majority of the publications reviewed in this study.…”

Section: Discussionmentioning

confidence: 97%

“…5,74,79 To further complicate this issue, some authors characterized biphasic as "normal," 1,66,70 whereas others labeled this waveform "abnormal." 50,54,74 These contradictory characterizations are a plausible explanation for the omission of biphasic terminology by the majority of the publications reviewed in this study. Similar inconsistencies are found when describing waveform phasicity.…”

Section: Discussionmentioning

confidence: 97%

“…Furthermore, specific definitions for these waveforms were inconsistent, and references considered authoritative characterized or illustrated biphasic and monophasic differently ( Figure 1). 1,74,76,79 A triphasic waveform with three componentsforward flow in systole, reverse flow (late systole/ early diastole), and forward flow (late diastole)-was the most uniformly defined descriptor ( Figure 2). In an investigation assessing the reliability of femoral artery hemodynamics to classify aortoiliac disease, however, waveforms with two or three phases were also defined as triphasic.…”

Section: Discussionmentioning

confidence: 99%

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Confusion of Peripheral Arterial Doppler Waveform Terminology

Scissons

Comerota

2009

Journal of Diagnostic Medical Sonography

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185Doppler instruments are widely used for the noninvasive evaluation of peripheral arterial disease. Auditory descriptors and graphic displays of waveforms characterize the hemodynamics of the vessel being examined. Descriptions of normal Characterization of peripheral arterial waveforms is basic to the diagnosis of vascular disease. Surveys indicate inconsistent application of traditional waveform descriptors. This study reviews literature to identify areas of confusion. Publications were reviewed to determine whether triphasic, biphasic, and monophasic terms were defined; if biphasic was linked with diastolic flow reversal; whether pandiastolic flow was associated with biphasic or monophasic terminology; and whether waveform illustrations had a zero baseline. Ninety-four publications were reviewed. Triphasic and monophasic were defined in 81%, biphasic in 48%. Biphasic was classified with flow reversal in 38%. Pandiastolic flow was not addressed in 57% but associated with monophasic in 47% and biphasic in 5%. Twenty-one percent of the publications had an illustration without a zeroflow baseline. This review suggests a lack of consensus when classifying arterial blood flow with traditional waveform descriptors. Waveform characterization inconsistencies are undermining comprehension of Doppler principles and may lead to inappropriate testing. A multisocietal consensus panel should accept responsibility for resolving this issue.

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“…However, in the studies included in the systematic review results were mostly reported by arterial segment, although some studies presented results by artery 32,36,65 or limb 21,23,31,63 as the unit of analysis. Consequently, the units of analysis tested were not independent of each other because one patient could have several segments or arteries evaluated, and either one or both legs.…”

Section: Accuracy Of the Testsmentioning

confidence: 99%

A systematic review of duplex ultrasound, magnetic resonance angiography and computed tomography angiography for the diagnosis and assessment of symptomatic, lower limb peripheral arterial disease

2008

Clinical Governance: An International Journal

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Reliability of common femoral artery hemodynamics in assessing the severity of aortoiliac inflow disease

Cited by 49 publications

References 60 publications

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

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

Confusion of Peripheral Arterial Doppler Waveform Terminology

A systematic review of duplex ultrasound, magnetic resonance angiography and computed tomography angiography for the diagnosis and assessment of symptomatic, lower limb peripheral arterial disease

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