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Approximation of the Ankle-Brachial Index in the Setting of Medial Arterial Calcific Sclerosis

Published:September 08, 2021DOI:https://doi.org/10.1053/j.jfas.2021.09.001

      Abstract

      The presence of medial arterial calcific sclerosis is known to cause inaccuracy in the interpretation of noninvasive vascular testing. This substantially limits the utility of an important baseline diagnostic test for peripheral arterial disease. Therefore, the objective of this investigation was to derive a method to effectively factor out calcification in the interpretation of the ankle and digital brachial indices. The noninvasive vascular testing results of 160 subjects were stratified into the absence of calcification, mild calcification, moderate calcification, and severe calcification based on plain film radiographic findings of the infrageniculate vessels. Measurements were then performed of the pulse volume recording (PVR) waveforms at brachial, ankle and digital anatomic levels to include PVR wavelength and PVR upstroke length, with a calculation of the ratio of PVR upstroke length to PVR wavelength. These measurements were compared between groups and then correlated to the ankle and digital brachial indices. A significant difference was observed in the PVR upstroke ratio between the 3 anatomic levels (0.1818 vs 0.2622 vs 0.3191; p < .001), but not between the 4 calcification groups (0.2457 vs 0.2363 vs 0.2694 vs 0.2631; p = .242). A significant negative correlation was observed between the PVR upstroke ratio and the ankle brachial index (ABI) (Pearson -0.454; p = .002) with linear regression indicating the relationship is defined by the formula: Effective ankle brachial index = 1.17 – (1.33 × PVR upstroke ratio at ankle level). A significant negative correlation was also observed between the PVR upstroke ratio and the digital brachial index (Pearson -0.553; p < .001) with linear regression indicating the relationship is defined by the formula: Effective toe brachial index = 1.04 – (1.61 × PVR upstroke ratio at digital level). The results of this investigation demonstrate the feasibility of, and provide equations to approximate, the effective ankle brachial and toe brachial indices in the setting of medial arterial calcification.

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      References

        • Hingorani A
        • LaMuraglia GM
        • Henke P
        • Meissner MH
        • Loretz L
        • Zinszer KM
        • Driver VR
        • Frykberg R
        • Carman TL
        • Marston W
        • Mills Sr, JL
        • Murad MH
        The management of the diabetic foot: a clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine.
        J Vasc Surg. 2016; 63: 3S-21S
        • Boulton AJ.
        The diabetic foot: grand overview, epidemiology and pathogenesis.
        Diabetes Metab Res Rev. 2008; 24: S3-S6
        • Markakis K
        • Bowling FL
        • Boulton AJ.
        The diabetic foot in 2015: an overview.
        Diabetes Metab Res Rev. 2016; 32: 169-178
        • Carls GS
        • Gibson TB
        • Driver VR
        • Wrobel JS
        • Garoufalis MG
        • Defrancis R
        • Wang S
        • Bagalman JE
        • Christina JR.
        The economic value of specialized lower-extremity medical care by podiatric physicians in the treatment of diabetic foot ulcers.
        J Am Podiatr Med Assoc. 2011; 101: 93-115
        • Harrington C
        • Zagari MJ
        • Corea J
        • Klitenic J.
        A cost analysis of diabetic lower-extremity ulcers.
        Diabetes Care. 2000; 23: 1333-1338
        • Faglia E.
        Characteristics of peripheral arterial disease and its relevance to the diabetic population.
        Int J Low Extrem Wounds. 2011; 10: 152-166
        • Jude EB
        • Eleftheriadou I
        • Tentolouris N.
        Peripheral arterial disease in diabetes – a review.
        Diabet Med. 2010; 27: 4-14
        • Allison MA
        • Criqui MH
        • Wright CM.
        Patterns and risk factors for systemic calcified atherosclerosis.
        Arterioscler Thromb Vasc Biol. 2004; 24: 331-336
        • Wu M
        • Rementer C
        • Giachelli CM.
        Vascular calcification: an update on mechanisms and challenges in treatment.
        Calcif Tissue Int. 2013; 93: 365-373
        • Aerden D
        • Massaad D
        • von Kemp K
        • van Tussenbroek F
        • Debing E
        • Keymeulen B
        • Van den Brande P
        The ankle-brachial index and the diabetic foot: a troublesome marriage.
        Ann Vasc Surg. 2011; 25: 770-777
        • Aboyans V
        • Ho E
        • Denenberg O
        • Ho LA
        • Natarajan L
        • Criqui MH.
        The association between elevated ankle systolic pressures and peripheral occlusive arterial disease in diabetic and nondiabetic subjects.
        J Vasc Surg. 2008; 48: 1197-1203
        • Zhang H
        • Li XY
        • Si YJ
        • Lu XL
        • Luo XS
        • Liu ZY.
        Manifestation of lower extremity arthrosclerosis in diabetic patients with high ankle-brachial index.
        Chin Med J (Engl). 2010; 123: 890-894
        • Apelqvist J
        • Castenfors J
        • Larsson J
        • Stenström A
        • Agardh CD.
        Prognostic value of systolic ankle and toe blood pressure levels in outcome of diabetic foot ulcer.
        Diabetes Care. 1989; 12: 373-378
        • Brownrigg JR
        • Hinchliffe RJ
        • Apelqvist J
        • Boyko EJ
        • Fitridge R
        • Mills JL
        • Reekers J
        • Shearman CP
        • Zierler RE
        • Schaper NC.
        Performance of prognostic markers in the prediction of wound healing or amputation among patients with foot ulcers in diabetes: a systematic review.
        Diabetes Metab Res Rev. 2016; 32: 128-135
        • Gibbons GW
        • Wheelock Jr, FC
        • Hoar Jr, CS
        • Rowbotham JL
        • Siembieda C.
        Predicting success of forefoot amputations in diabetics by noninvasive testing.
        Arch Surg. 1979; 114: 1034-1036
        • Lew E
        • Nicolosi N
        • Botek G.
        Lower extremity amputation risk factors associated with elevated ankle brachial indices and radiogrpahic arterial calcification.
        J Foot Ankle Surg. 2015; 54: 473-477
        • Everhart JE
        • Pettitt DJ
        • Knowler WC
        • Rose FA
        • Bennett PH.
        Medial arterial calcification and its association with mortality and complications of diabetes.
        Diabetologia. 1988; 31: 16-23
        • Guzman RJ
        • Bian A
        • Shintani A
        • Stein CM.
        Association of foot ulcer with tibial artery calcification in independent of peripheral occlusive disease in type 2 diabetes.
        Diabetes Res Clin Pract. 2013; 99: 281-286
        • Edmonds ME
        • Morrison N
        • Laws JW
        • Watkins PJ.
        Medial arterial calcification and diabetic neuropathy.
        Br Med J (Clin Res Ed). 1982; 284: 928-930
        • Young MJ
        • Adams JE
        • Anderson GF
        • Boulton AJ
        • Cavanagh PR.
        Medial arterial calcification in the feet of diabetic patients and matches non-diabetic control subjects.
        Diabetologia. 1993; 36: 615-621
        • Silvestro A
        • Diehm N
        • Savolainen H
        • Do DD
        • Vogelea J
        • Mahler F
        • Zwicky S
        • Baumgartner I.
        Falsely high ankle-brachial index predicts major amputation in critical limb ischemia.
        Vasc Med. 2006; 11: 69-74
        • Smith DC
        • Gavin Bilmen J
        • Iqbal S
        • robbery S
        • Pereira M
        Medial artery calcification as an indicator of diabetic vascular disease.
        Foot Ankle Int. 2008; 29: 185-190
        • Chantelau E
        • Lee KM
        • Jungblut R.
        Association of below-knee atherosclerosis to medial arterial calcification in diabetes mellulitus.
        Diabetes Res Clin Pract. 1995; 29: 169-172
        • Mayfield JA
        • Caps MT
        • Boyko EJ
        • Ahroni JH
        • Smith DG.
        Relationship of the medial arterial calcinosis to autonomic neuropathy and adverse outcomes in a diabetic veteran population.
        J Diabetes Complications. 2002; 16: 165-171
        • Arain FA
        • Ye Z
        • Bailey KR
        • Chen Q
        • Liu G
        • Leibson CL
        • Kullo IJ.
        Survival in patients with poorly compressible leg arteries.
        J Am Coll Cardiol. 2012; 59: 400-407
        • Guzman RJ
        • Brinkley DM
        • Schumacher PM
        • Donahue RM
        • Beavers H
        • Qin X.
        Tibial artery calcification as a marker of amputation risk in patients with peripheral arterial disease.
        J Am Coll Cardiol. 2008; 51: 1967-1974
        • Adragao T
        • Pires A
        • Branco P
        • Castro R
        • Oliveira A
        • Nogueira C
        • Bordalo J
        • Curto JD
        • Prata MM.
        Ankle-brachial index, vascular calcifications and mortality in dialysis patients.
        Nephrol Dial Transplant. 2012; 27: 318-325
        • Aragon-Sanchez J
        • Lazaro-Martinez JL
        Factors associated with calcification in the pedal arteries in patients with diabetes and neuropathy admitted for foot disease and its clinical significance.
        Int J Low Extrem Wounds. 2013; 12: 252-255
        • Young MJ
        • Adams JE
        • Anderson GF
        • Boulton AJ
        • Cavanagh PR.
        Medial arterial calcification in the feet of diabetic patients and matched non-diabetic control subjects.
        Diabetologia. 1993; 36: 615-621
        • Sharma A
        • Scammell BE
        • Fairbairn KJ
        • Seagrave MJ
        • Game FL
        • Jeffcoate WJ.
        Prevalence of calcification in the pedal arteries in diabetes complicated by foot disease.
        Diabetes Care. 2010; 33: e66
        • Cardenas V
        • Seo K
        • Sheth S.
        Prevalence of lower-extremity arterial calcification in patients with diabetes mellitus complicated by foot disease at an urban US tertiary care center.
        J Am Podiatr Med Assoc. 2018; 108: 267-271
        • Skoklnik Weiss R
        • Meyr AJ
        • Dhanisetty R
        • Choi ET
        • Cunningham-Hill M
        • Rubin D
        • Oresanya L
        Evaluating the impace of medial arterial calcification on outcomes of infrageniculate endovascular interventions for treatment of diabetic foot ulcers.
        Vasc Endovasc Surg. 2021; 55: 382-388
        • Morrison LB
        • Bogan IK.
        Calcification of the vessels in diabetes: A roentgenographic study of the legs and feet.
        JAMA. 1929; 92: 1424-1426