Ankle Systolic Pressure Research Articles

Comparison of Standard One-Minute Treadmill Exercise and Strandness Test (Absolute Walking Distance) in Relation to Site of Lesion, Walking Distance, and Diastolic Blood Flow Velocity (Doppler Curves)

In 215 outpatients suffering from occlusive arterial disease of the lower limbs the authors compared the decrease in the ratio of ankle systolic pressure to brachial systolic pressure according to whether the treadmill exercise was limited to one minute or extended until pain forced the patient to stop. After a one-minute walk the pressure index always decreased significantly, especially when walking was restricted. The decrease in the pressure index was generally greater when the exercise was continued until the absolute walking distance, and the recovery time was usually twice as long. The fall in the pressure index was significantly greater for patients with single and multiple iliac stenoses than for those with stenoses at lower levels. In patients having a diastolic blood flow velocity on Doppler curves at rest, not modified by walking, a maximum drop in peripheral pressure was recorded after walking for one minute. In this instance there was no intensification of the decrease in peripheral pressure, unlike in patients without a diastolic blood flow velocity at rest. This one-minute test is not a maximal hemodynamic response, but it is sufficient for the appreciation of ischemia during exercise, according to the different parameters measured.

Flow motion waves with high and low frequency in severe ischaemia before and after percutaneous transluminal angioplasty

STUDY OF OBJECTIVE: The aim was to evaluate skin flux and prevalence of low and high frequency flow motion waves in patients with severe ischaemia due to peripheral arterial occlusive disease before and after percutaneous transluminal angioplasty (PTA) with and without local thrombolysis. Flow motion was recorded by the laser Doppler technique at the dorsum of the foot before, one day, and one month after PTA. The results were separately analysed in patients with successful and unsuccessful treatment. 18 patients with rest pain or incipient gangrene were included. Mean pretreatment systolic ankle pressure was 55.8(SD 25.5) mm Hg, and mean transcutaneous PO2 at 43 degrees C was 5.2(9.4) mm Hg. Arteriography revealed relevant stenoses or occlusions of the femoropopliteal and calf arteries. Before treatment two patterns of flow motion with characteristic frequency ranges were observed at the foot dorsum and at a probe temperature of 32 degrees C: low frequency (LF) waves with a mean frequency of 2.2(0.5) cycles.min-1 and a mean amplitude of 0.73(0.42) arbitrary units (AU) and high frequency (HF) waves with a mean frequency of 22.6(4.2) cycles.min-1 and a mean amplitude of 0.39(0.33) AU. PTA was successful in 11 of the 18 patients. After successful treatment, prevalence of HF waves decreased from 10/11 to 4/11 cases (p less than 0.001), but remained nearly unchanged after failed procedure. Prevalence of LF waves before and after PTA did not differ significantly. Our data support the hypothesis that HF waves represent a reaction of skin microcirculation to severe ischaemia. With reference to animal studies it is proposed that HF waves originate from terminal arterioles. They may function as a compensatory mechanism of flow regulation involved in pathophysiology of ischaemia.

Oscillotonometry: A simple non‐invasive method of differentiating proximal arterial obstruction from distal microangiopathy in the vascular assessment of diabetics

AbstractIn diabetic patients with ischaemic feet a frequent clinical problem is the differentiation between those with distal microangiopathy alone and those with proximal arterial inflow obstruction.Doppler pressure measurement is of assistance but there is a significant subgroup who have proximal obstruction despite the findings of a high ankle systolic pressure. These patients have stiff arterial walls and the Doppler cuff does not compress them normally.If oscillotonometry is performed, a low range of swing suggests an inflow obstruction whereas a high range suggests a good inflow. This differentiation enables suitable patients to be selected for angiography and possible angioplasty or bypass surgery.

Stenotic intimal thickening of the external lliac artery in competition cyclists

Twenty-three cases of an arterial disease that affects competition cyclists are reported. Patients complained of intermittent acute claudication appearing on one lower limb only at the time of a maximal strain while cycling. Doppler hemodynamic investigation on an ergometric bicycle revealed a collapse of the ankle systolic pressure. Arteriography showed a sinuous lengthening and moderate stenosis of the external iliac artery. Pathologic examination of the artery disclosed a stenotic intimal thickening due to moderately cellular loose connective tissue with a variable distribution of collagen and elastic fibers. The cells in the affected zone were readily labeled with anti-actin and anti-myosin antibodies, and electron microscopy revealed features of synthetic smooth muscle cells. The lesion observed differs from intimal fibrodysplasia and from artherosclerosis. Abnormal local hemodynamic conditions may lead to this type of lesion. Thus, stenotic intimal thickening of the external iliac artery appears to be a new arterial disease defined by clinical, arteriographic, and pathologic features.

A haemodynamic evaluation of the femoro-femoral cross-over bypass

The femoro-femoral cross-over bypass has become a popular choice for the management of unilateral iliac artery disease, being used in preference to aorto-femoral or extraperitoneal ilio-femoral bypasses. It is a relatively minor procedure and associated with a small incidence of side effects, the main one being the risk of development of a steal of blood from the donor limb by the bypass. Although this problem has been widely discussed, haemodynamic studies have been limited by the use of indirect measurements of blood flow, such as ankle systolic pressures or by the use of electromagnetic flowmetry at the time of surgery. No study employing volumetric blood flow measurements to identify and quantify blood steal in the postoperative patient has been reported to date. With aims of studying the haemodynamic effects of a femoro-femoral cross-over bypass on the circulation in both the recipient and donor limbs, and of identifying preoperatively, problems likely to lead to haemodynamic problems or to graft failure, the present study of 31 patients undergoing femoro-femoral bypass was undertaken. The patients, 18 of whom had rest pain and 13 intermittent claudication, were studied preoperatively using arteriography and a non-invasive assessment. At 3 months from the operation, all received a clinical assessment and a further non-invasive assessment, including a measurement of blood volume flow. Flow measurements were made in the bypass at rest and during a reactive hyperaemia test. In addition, flow measurements were made in the donor limb below the bypass origin at rest and during hyperaemic testing of the recipient limb in order to assess any steal effect the bypass might cause to the donor limb circulation. All 31 patients were improved by surgery, but five developed donor limb claudication which was attributed to steal in three cases. Resting blood flow in the bypasses, 161 (65-282)ml/min [median (range)], rose by 116% (5-428%) to 300 (82-1114)ml/min after hyperaemic testing. Simultaneously, bypass hyperaemia caused a fall in donor limb blood flow of 32% (0-74%). Of the preoperative non-invasive tests, only donor femoral artery pulse rise time was related to the later development of objective evidence of steal. Successful Gruntzig dilatation of four major stenoses resulted in a satisfactory outcome.

Skin Perfusion Pressure Assessed by Measuring the External Pressure Required To Stop Blood Cell Flux

Laser Doppler flowmetry (LDF) was used to determine the point at which blood flow cessation is achieved under circumferentially applied external counter pressure at the ankle level. In 13 individuals with a normal ankle index, the flow of cessation external pressure (FCEP) was, on average, 28 mmHg lower than the systolic ankle pressure (range: 7-62). In 19 patients with an ankle index below 1.0, FCEP correlated with the ankle pressure (rs = 0.76) and even more closely with the ankle index (rs = 0.82). In patients with a more pronounced degree of arterial occlusive disease, FCEP can be equal to or even higher than the ankle pressure. This may be due to a release of sympathetic vasoconstrictor tone and possibly to the presence of a collateral circulation supplying the skin. Individual LDF values from the skin at rest do not reflect the degree of peripheral circulatory insufficiency.

Walking ability and ankle systolic pressures: Observations in patients with intermittent claudication in a short-term walking exercise program

Walking ability and ankle systolic pressures: Observations in patients with intermittent claudication in a short-term walking exercise program

Walking ability and ankle systolic pressures: Observations in patients with intermittent claudication in a short-term walking exercise program

Walking ability and limb hemodynamics were studied in 56 patients with intermittent claudication in an exercise program. Patients walked 1 hour 3 times a week for 3 to 6 months. Ankle and brachial pressures were measured at rest and after a standard walk, and walking ability on the treadmill and during free walking was determined. Average maximal distance on the treadmill increased from 0.59 to 1.00 km after training (p less than 0.0001). Also, after training 84% of patients were able to walk continuously more than 2 km without severe discomfort. The attained walking ability of individual patients could not be predicted from pressure measurements. Small pressure changes after training suggested that factors other than increased development of collateral vessels were important in determining walking ability. Practically useful walking ability was achieved in patients with aortoiliac and femoropopliteal arterial obstruction in the presence or absence of coronary disease and in patients taking beta-blockers. The results indicate that walking exercise is a valuable treatment for many patients with claudication who are not candidates for arterial reconstruction.

Cystic myxomatous degeneration of the right common and external iliac artery

• Please address all correspondence to: W. E. Tuinebreijer, Vondellaan 13, Rode Kruis Ziekenhuis, 1942 LE Beverwijk, The Netherlands, tory of intermittent claudication affecting the right upper and lower leg. Her exercise tolerance, which was initially 100m, became normal with exercise therapy but two months before admission her complaints reappeared suddenly and worsened progressively. The patient had been a smoker until 12 months prior to admission (10-12 cigarettes a day), but otherwise there were no risk factors for atherosclerosis. On examination the pulse in the right groin was found to be diminished and no distal pulses were palpable. In the left leg normal peripheral pulses were palpable. The ankle systolic pressure index at rest was 0.55 in the right leg and 1.03 in the left leg. Arteriography showed a smooth walled stenosis of the right common iliac artery, and complete occlusion of the right external lilac and common femoral arteries (Fig. 1). At operation the right common and external iliac arteries and the common femoral artery were exposed and seen to contain a clear liquid and to be dilated. Through arteriotomies in the common femoral and common iliac arteries mucoid liquid under pressure escaped and the intima was found to be dissected by the fluid. An endarterectomy of the common femoral and iliac arteries was easily performed. At the distal end of the mucoid degeneration the intima was well attached. The arteriotomies were closed by direct suture. The patient remained symptom-free 20 months after the operation, with a normal arteriogram and a normal ankle systolic pressure index.

Prognostic value of systolic ankle and toe blood pressure levels in outcome of diabetic foot ulcer.

The prognostic value of distal blood pressure measurements has been studied in 314 consecutive diabetic patients with foot ulcers. Systolic toe blood pressure was measured with a strain-gauge technique, and ankle pressure was measured with strain-gauge or Doppler techniques. Wound healing was defined as intact skin for at least 6 mo. One hundred ninety-seven patients healed primarily, 77 had amputations, and 40 died before healing had occurred. In 294 of 300 patients, it was possible to measure either ankle or toe pressure. Fourteen patients were not available for pressure measurements. Of these, 10 patients healed primarily, and 4 died before healing occurred. Both ankle and toe pressures were higher (P less than .001) among patients who healed without amputation compared with those who underwent amputation or died before healing. No differences were seen in ankle or toe pressure levels among those who had amputations or died. No patient healed primarily with an ankle pressure less than 40 mmHg. An upper limit above which amputation was not required could not be defined. Primary healing was achieved in 139 of 164 patients (85%) with a toe pressure level greater than 45 mmHg, whereas 43 of 117 patients (36%; P less than .001) healed without amputation when toe pressure was less than or equal to 45 mmHg. In conclusion, a combination of ankle and toe pressure measurements is a useful tool to predict primary healing in diabetic foot ulcers.

Early detection of stenosis of femoro-distal grafts. A surveillance study using colour-duplex scanning

The development of stenoses following femoro-distal bypass procedures may jeopardise graft function. In a prospective study serial assessment of femoro-distal grafts in 77 patients was performed over a period of 13 months. Forty-eight of the bypasses were in situ, 18 were reversed veingrafts and 11 were modified sheep collagen grafts. Colour coded duplex scanning of all grafts was performed in addition to physical examination, ankle systolic pressure measurements and pulse volume recordings. Stenotic areas were detected in the graft in 16 cases and at the site of the proximal anastomosis in one case. In one graft a residual valve leaflet was found. In addition eleven arterio-venous communications were observed in in situ veingrafts and one aneurysmal degeneration in a collagen graft was noted. All stenoses were detected by colour duplex scanning and confirmed by arteriography or operative exploration. Only 38% of the stenoses over 50% was associated with recurrent symptoms or could be detected by diminished palpable pulses. Ankle blood-pressure measurements and pulse volume recordings indicated the presence of a stenosis over 50% in only 46% of the cases. Twelve of 13 patients with graft stenosis over 50% were revised by vein patch plasty with a good result in all cases. The primary and secondary two year cumulative patency rates of all in situ bypasses were 63% and 79% respectively. Close surveillance of femoro-distal grafts appears justified by this study. Colour duplex scanning was superior to systolic ankle pressure measurements and pulse volume recording in detecting the development of graft stenosis.

Fluorescein angiography for predicting healing of foot ulcers.

Fluorescein angiography (FA) was performed on 83 patients (68 diabetics) with foot ulcer or gangrene. Densitometric measurements were made on the FA images, and different FA parameters were defined. These parameters, as well as systolic ankle and toe blood pressures, were evaluated for predicting the future course, i.e., whether healing would occur or whether major amputation below or above the knee had to be performed. The toe slope (i.e., the rate of increase of fluorescence on the big toe during the first 10 seconds after its appearance on the toe) predicted healing correctly in 0.83 and major amputation in 0.88. The ankle and toe pressures had only slightly lower predictive value. The combination of ankle pressure and toe slope predicted healing correctly in 0.91 and major amputation in 0.88. When ankle pressure cannot be measured, FA is the method of choice. Further, FA provides information on regional blood flow unobtainable by any other method.

Microvascular circulatory changes in the lower extremities after reconstructive vascular surgery for intermittent claudication

We have studied the circulatory changes in the lower extremities after reconstructive vascular surgery in ten patients with intermittent claudication. The following examinations were carried out 3 days before, 3 days, and 28 days after the operation: measurement of ankle systolic blood pressure, calf plethysmography, resting calf muscle blood flow and resting subcutaneous foot blood flow. The vasoconstrictor response (veno-arteriolar reflex) was also assessed. On the night before the operation and on the 28th night after aorto-bifemoral bypass surgery, subcutaneous adipose tissue blood flow in the forefoot was measured during sleep. The ankle systolic blood pressure and the ankle index rose significantly. The former increased from 57 +/- 16.4 mmHg to 93 +/- 24.0 mmHg (mean +/- S.E.M.) and was still elevated on the 28th postoperative day. The total limb blood flow, the muscle blood flow and the blood flow in the subcutaneous tissue of the forefoot during daytime were unchanged. In contrast, the blood flow in the forefoot during sleep increased significantly from 3.5 +/- 1.63 ml x (min x 100 g)-1 to 5.2 +/- 2.14 ml x (min x 100 g)-1 (mean +/- S.E.M.) on the 28th night. The vasoconstrictor response was potentiated, and increased from 27% before the operation to 45% on the third postoperative day. This change was maintained 28 days postoperatively. In conclusion the increase in arterial blood pressure was only reflected in the vasoconstrictor response which had returned to normal by the third postoperative day and nocturnal blood flow in the subcutaneous adipose tissue which did likewise.

The Role of Percutaneous Transluminal Angioplasty and Femoropopliteal Bypass in Patients with Threatened Limb

Fifty-two patients with no history of percutaneous transluminal angioplasty (PTA) or vascular surgery presented with a threatened limb and arteriographic findings showing suitability for femoropopliteal arterial reconstruction. Twenty-seven patients were treated by PTA (Group 1) and 25 were treated by femoropopliteal bypass (Group 2). The technical success rate was 85% for PTA and 100% for surgery. The hemodynamic success rate was 63% for PTA and 88% for surgery; the mean increase in ankle systolic pressure index (ASPI) was 0.34 following PTA and 0.57 following surgery. Complications occurred in 11 % of patients following PTA and 32% of patients following surgery. Follow-up ranged from six months to five years with a mean of two years. A clinically successful result was evident in 67% of patients having PTA and 76% of oper ated patients. The overall amputation rate for Group 1 was 7.4% and for Group 2 was 20%. It is concluded that, in the management of femoropopliteal occlusive disease, surgery is more likely to be initially successful than PTA and will give rise to a greater increase in ASPI and a higher incidence of clinically successful outcome; however, because the complication rate is higher for surgery, and fail ure is more likely to lead to amputation, PTA should be considered as a first-line treatment, particularly in patients who are at increased risk for surgery.

Variability of ankle and brachial systolic pressures in the measurement of atherosclerotic peripheral arterial disease.

The aim of this study was to determine the variability of measurements of ankle and brachial systolic pressures and ankle brachial ratios in order to assess their suitability for use in epidemiological studies of arterial disease in the lower limbs. Thirty-six subjects had repeat measurements taken by four observers on two separate days using a Doppler probe and random zero sphygmomanometer. The variability in the measurement of ankle systolic pressure was comparable to that for brachial systolic pressure. The 95% confidence limits of one measurement of the ankle brachial ratio was estimated to be +/- 16%, reducing to +/- 10% for the mean of four measurements taken by two observers on two days. Analysis of variance indicated that the variability in the measurement of ankle brachial ratios attributable to observers, days, timing of measurements on the same day, and repeat measurements was considerably less than the "biological" variability between subjects and between legs. These results suggest that repeatability of the ankle brachial ratio is such that a single measurement is suitable for most epidemiological studies of atherosclerotic peripheral arterial disease.

Age- and sex-related changes in the ratio between ankle and brachial systolic pressure in normal subjects.

The ratio between ankle (ASP) and brachial (BSP) systolic pressure was studied by using Doppler ultrasound in 198 normal subjects aged between twenty and ninety years: 97 males and 101 females. The ASP/BSP ratio decreased significantly with age both in males (r = -0.64; p less than 0.001) and in females (r = -0.72; p less than 0.001). In males, the decrease in the ratio with age was due to a significant decrease in ASP with age (r = -0.52; p less than 0.001), whereas BSP did not increase significantly with age. In females, a different result was observed, since only BSP (and not ASP) was significantly (and positively) correlated with age. In both sexes, the diameter of the terminal abdominal aorta measured by echocardiography was significantly increased with age, and full examination with Doppler ultrasound excluded any significant arterial stenosis of the lower limbs. The study provided evidence that age- and sex-related changes in arterial wave transmission do exist in normal subjects.

Effects of Naftidrofuryl in Patients With Intermittent Claudication

In a randomized, double-blind, placebo-controlled study in patients with peripheral arterial occlusive disease stage IIb of Fontaine's classification, the efficacy of naftidrofuryl, a vasoactive substance, was investigated. Forty patients--31 men and 9 women with an average age of 62.98 +/- 10.65 years--were admitted to the study. All had a history of claudication for at least six months. The duration of the trial was eighteen weeks. After a washout period of two weeks the patients received either two times 400 mg naftidrofuryl or two identical placebo tablets daily for eight weeks. Subsequently a crossover from verum to placebo and vice versa was carried out and the alternative medication was administered for another eight weeks. Clinical results were evaluated by measuring painfree and maximal walking distance by treadmill test at a speed of 3.2 km/h and an inclination of 12 degrees. Systolic ankle pressure and brachial pressure were measured by Doppler ultrasound, and ankle/arm pressure ratio was calculated. Treadmill test, Doppler ultrasound examination, and laboratory data analysis were performed at the beginning of every study period, every four weeks during and at the end of the study. Results. The patients in both groups showed an initial homogeneity of age, risk factors, concomitant diseases, walking distance, and Doppler indices. After eight weeks naftidrofuryl resulted in a statistically significant increase in painfree (p less than 0.02) and maximal walking distance (p less than 0.05). The placebo-treated group showed only a slight, statistically nonsignificant increase in both painfree and maximal walking distance.(ABSTRACT TRUNCATED AT 250 WORDS)

Buttock claudication from isolated bilateral internal iliac arterial stenoses

An unusual case is reported of severe buttock claudication in a woman with normal ankle systolic pressures after exercise, for which the cause was eventually found to be isolated bilateral hypogastric arterial stenosis. Although a normal ankle pressure response to exercise usually rules out vascular obstruction in patients with symptoms suggestive of intermittent claudication, the diagnosis of isolated hypogastric arterial disease should be entertained when a neurogenic or orthopedic explanation can be excluded.

Transcutaneous oxygen monitoring as an indication of prognosis in critical ischaemia of the lower limb

Critical ischaemia in the chronically ischaemic limb has proved difficult to define both in clinical and objective terms. This has meant that assessment of patients has in the past relied heavily on the angiographic appearances of the vessels which is also an unreliable technique. Attempts have been made to define critical ischaemia objectively in terms of the ankle systolic pressure but recent studies have shown that although the definition produced in 1982 was highly specific, the sensitivity was low with many patients with the clinical features of critical ischaemia having ankle pressures which were higher than the recommended values. Recently the transcutaneous measurement of oxygen tension has been used to assess patients with peripheral vascular disease and has proved of use in assessing distal tissue perfusion in chronically ischemic limbs. This study compares ankle systolic pressure measurements with the transcutaneous oxygen tension results from the ischaemic foot with the patient sitting and found that the latter gave a more accurate guide to the severity of ischaemia and a more accurate prediction of the short-term results in individual cases.

The ratio between ankle and brachial systolic pressure in patients with sustained uncomplicated essential hypertension.

1. The ratio between ankle (ASP) and brachial (BSP) systolic pressures was studied using Doppler ultrasound in 66 male subjects, 33 with sustained uncomplicated essential hypertension and 33 age-matched normal controls. 2. Based on covariance analysis, the ASP-BSP relationship was significantly different in the two populations, the ASP/BSP ratio (mean +/- SEM) being significantly lower in hypertensive subjects (106 +/- 1 vs 132 +/- 2; P less than 0.001). 3. While the ASP/BSP ratio was negatively correlated with age in normal subjects, no significant correlation was observed in hypertensive subjects. 4. The diameter of the terminal abdominal aorta measured by echography was significantly greater in hypertensive subjects, while full examination with Doppler ultrasound excluded any significant arterial stenosis of the lower limbs. 5. The study suggested that, in patients with sustained uncomplicated essential hypertension, the lower ASP/BSP ratio is related to changes in arterial wave transmission.