Pulse Volume Recordings Research Articles

Acute Limb Ischemia Management and Complications: From Catheter-Directed Thrombolysis to Long-Term Follow-up.

Acute limb ischemia (ALI) is a vascular emergency that needs to be diagnosed and treated quickly to prevent permanent tissue damage and amputation. Catheter-directed thrombolysis is a possible treatment option for mild to moderate ALI, with improved results from endovascular procedures and thrombolytic drugs. However, patients receiving thrombolysis may experience higher rates of distal embolization, serious bleeding events, and stroke than those undergoing surgery. The review article emphasizes the need for postoperative and extended management of ALI patients, including monitoring for compartment syndrome, managing reperfusion damage, and reducing changeable cardiovascular risk factors such as lipid-lowering therapy, diabetes management, and smoking cessation. Complications that can arise from thrombolytic therapy are also discussed, including hemorrhagic complications, minor bleeding, and reperfusion damage, with recommendations to monitor patients closely during treatment and discontinue therapy immediately if any abnormalities are detected. Follow-up evaluations for patients, including Doppler ultrasound, ankle brachial index, pulse volume recordings, and laboratory tests, are recommended to ensure the best possible outcome for patients with ALI.

Long-term limb salvage and functional outcomes for patients undergoing partial calcanectomy.

Partial calcanectomy (PC) can be performed to treat chronic heel ulcers in patients with calcaneal osteomyelitis. Patients undergoing PC often have multiple comorbidities, limited mobility, and face high risk of major limb amputation. This study examined the extent of vascular diagnostic testing and interventions as well as long-term outcomes in patients undergoing PC. A retrospective analysis was performed on patients who underwent PC for non-healing calcaneal ulcer over a ten-year period. Demographics, comorbidities, vascular testing, and procedural data were recorded. Additional subgroup analysis was performed according to presence or absence of peripheral arterial disease (PAD). Primary outcomes were major limb amputation (above or below the knee) and mortality. Secondary outcomes included successful wound healing, time to complete wound healing, re-interventions, and change in ambulatory status. A total of 157 patients underwent partial calcanectomies on 162 limbs. 78.3% of patients had diabetes mellitus and 47.8% were diagnosed with PAD. Ankle brachial index with pulse volume recording (ABI/PVR) was performed for 46.5% (73/157) of patients, arterial duplex in 44.6% (70/157), and 19.7% (31/157) had a computed tomography angiogram. Lower extremity revascularization was performed in 28.4% of limbs (46/162). Independent ambulatory status was reported in 40.1% prior to PC and decreased to 17.9% by the time of last recorded follow-up (p < .00001). Long-term amputation-free survival was significantly higher in patients without PAD at 7 years (78.4% vs 57.1%, p = .02). Multivariate logistic regression analysis demonstrated that PAD and end-stage renal disease (ESRD) increased the odds of major limb amputation (OR 3.5 and 2.8, respectively), whereas ESRD and adjuvant podiatric procedures were associated with increased mortality (OR 4.8 and 4.8, respectively). Non-invasive vascular testing should be obtained in all patients undergoing PC, in order to stratify risk of amputation and identify candidates for revascularization. Over the long-term, patients undergoing PC face significant risk of prolonged wound healing, decline in ambulatory status, and major limb amputation.

Peripheral artery disease diagnosis based on deep learning-enabled analysis of non-invasive arterial pulse waveforms

This paper intends to investigate the feasibility of peripheral artery disease (PAD) diagnosis based on the analysis of non-invasive arterial pulse waveforms. We generated realistic synthetic arterial blood pressure (BP) and pulse volume recording (PVR) waveform signals pertaining to PAD present at the abdominal aorta with a wide range of severity levels using a mathematical model that simulates arterial blood circulation and arterial BP-PVR relationships. We developed a deep learning (DL)-enabled algorithm that can diagnose PAD by analyzing brachial and tibial PVR waveforms, and evaluated its efficacy in comparison with the same DL-enabled algorithm based on brachial and tibial arterial BP waveforms as well as the ankle-brachial index (ABI). The results suggested that it is possible to detect PAD based on DL-enabled PVR waveform analysis with adequate accuracy, and its detection efficacy is close to when arterial BP is used (positive and negative predictive values at 40 % abdominal aorta occlusion: 0.78 vs 0.89 and 0.85 vs 0.94; area under the ROC curve (AUC): 0.90 vs 0.97). On the other hand, its efficacy in estimating PAD severity level is not as good as when arterial BP is used (r value: 0.77 vs 0.93; Bland-Altman limits of agreement: −32%-+32 % vs −20%-+19 %). In addition, DL-enabled PVR waveform analysis significantly outperformed ABI in both detection and severity estimation. In sum, the findings from this paper suggest the potential of DL-enabled non-invasive arterial pulse waveform analysis as an affordable and non-invasive means for PAD diagnosis.

Percentage of mean arterial pressure as a marker of atherosclerosis for detecting patients with coronary artery disease

The percentage of mean arterial pressure (%MAP) is the height of the mean arterial waveform divided by the peak amplitude of the waveform of pulse volume recording. The purpose of this study was to determine whether the cutoff value of 45% for %MAP at the ankle, which is recommended for the diagnosis of lower extremity artery disease, in combination with ankle-brachial index (ABI) is useful for detecting patients with clinical coronary artery disease (CAD) and investigate the optimal cutoff value of %MAP to diagnose patients with CAD. We measured ABI and %MAP in 2213 subjects (mean age: 61.2 ± 15.5 years). Multivariate analysis revealed that %MAP ≥ 45% was significantly associated with a higher risk of CAD after adjusting for traditional cardiovascular risk factors (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.43–3.21; p < 0.001). However, the association was no longer significant after adjusting for ABI (OR, 1.39; 95% CI, 0.83–2.33; p = 0.21), whereas ABI was significantly associated with CAD (OR, 0.98; 95% CI, 0.97–0.99; p = 0.005). The optimal cutoff value of %MAP derived from a receiver operating characteristic curve to diagnose CAD was 40.3%. Multivariate analysis revealed that %MAP ≥ 40.3% was significantly associated with a higher risk of CAD (OR, 1.63; 95% CI, 1.19–2.24; p = 0.002) independent of ABI (OR, 0.98; 95% CI, 0.97–0.99; p = 0.002). The cutoff value of 40.3%, but not 45%, for %MAP may be useful for detecting patients with advanced atherosclerosis and for cardiovascular risk assessment independent of ABI.Registration Informationhttp://www.umin.ac.jp (University Hospital Medical Information Network Clinical Trials Registry) (UMIN000039512)

Mönckeberg's Medial Calcific Sclerosis Makes Traditional Arterial Doppler's Unreliable in High-Risk Patients with Diabetes.

To assess Mönckeberg's medial calcific sclerosis (MMCS) severity in patients with a diabetic foot infection. This was an analysis of 2 randomized clinical trials in which we evaluated the treatment of 233 patients admitted to the hospital for moderate and severe foot infections. Arterial calcification was defined as visible radiopaque arteries on foot and ankle radiographs, recorded as the most distal visible artery involved (toes, metatarsals, and ankle/hindfoot). Most subjects (57.1%, n = 133) had MMCS, with extension to toes in 79 (59.4%), to metatarsals in 32 (24.1%), and to ankle/hindfoot in 22 patients (16.5%). In 7 patients (5.2%) MMCS was solely seen in dorsalis pedis (DP) artery, in 13 patients (9.8%) in posterior tibialis (PT) artery, and in 113 patients (85.0%) MMCS was seen in both arteries. Only 29.2% (n = 68) of DP arteries and 34.8% (n = 81) of PT arteries were not compressible by Doppler. DP and PT arteries were not compressible more often in MMCS (DP 34.3% vs 20.4%, P = .02 and PT 43.1% vs 21.4%, P < .01), toe-brachial indices of ≥0.7 were significantly more common in people without MMCS (46.0% vs 67.4%, P < .01). In contrast, there were no differences in skin perfusion pressure measurements (>50 mmHg; 67.7% vs 68.0%, P = .96), waveforms (biphasic/triphasic 83.5% vs 77.0%, P = .22), and pulse volume recording (9.6 ± 3.3 vs 13.7 ± 36.0) between patients with and without MMCS. MMCS is common in patients with diabetic foot infections. MMCS is associated with noncompressible arterial Doppler studies and likely interferes with the accuracy of arterial Doppler studies.

Abstract No. 210 Correlation between Quantitative Perfusion Using Catheter-Directed Computed Tomography and Pulse Volume Recording Tests in Patients with Critical Limb-Threatening Ischemia

Abstract No. 210 Correlation between Quantitative Perfusion Using Catheter-Directed Computed Tomography and Pulse Volume Recording Tests in Patients with Critical Limb-Threatening Ischemia

MetfOrmin BenefIts Lower Extremities with Intermittent Claudication (MOBILE IC): randomized clinical trial protocol

BackgroundPeripheral artery disease (PAD) affects over 230 million people worldwide and is due to systemic atherosclerosis with etiology linked to chronic inflammation, hypertension, and smoking status. PAD is associated with walking impairment and mobility loss as well as a high prevalence of coronary and cerebrovascular disease. Intermittent claudication (IC) is the classic presenting symptom for PAD, although many patients are asymptomatic or have atypical presentations. Few effective medical therapies are available, while surgical and exercise therapies lack durability. Metformin, the most frequently prescribed oral medication for Type 2 diabetes, has salient anti-inflammatory and promitochondrial properties. We hypothesize that metformin will improve function, retard the progression of PAD, and improve systemic inflammation and mitochondrial function in non-diabetic patients with IC.Methods200 non-diabetic Veterans with IC will be randomized 1:1 to 180-day treatment with metformin extended release (1000 mg/day) or placebo to evaluate the effect of metformin on functional status, PAD progression, cardiovascular disease events, and systemic inflammation. The primary outcome is 180-day maximum walking distance on the 6-min walk test (6MWT). Secondary outcomes include additional assessments of functional status (cardiopulmonary exercise testing, grip strength, Walking Impairment Questionnaires), health related quality of life (SF-36, VascuQoL), macro- and micro-vascular assessment of lower extremity blood flow (ankle brachial indices, pulse volume recording, EndoPAT), cardiovascular events (amputations, interventions, major adverse cardiac events, all-cause mortality), and measures of systemic inflammation. All outcomes will be assessed at baseline, 90 and 180 days of study drug exposure, and 180 days following cessation of study drug. We will evaluate the primary outcome with linear mixed-effects model analysis with covariate adjustment for baseline 6MWT, age, baseline ankle brachial indices, and smoking status following an intention to treat protocol.DiscussionMOBILE IC is uniquely suited to evaluate the use of metformin to improve both systematic inflammatory responses, cellular energetics, and functional outcomes in patients with PAD and IC.Trial Registration: The prospective MOBILE IC trial was publicly registered (NCT05132439) November 24, 2021.

Evaluation of the role of combining inter-arm systolic pressure difference and derivatives of pulse volume recording in detecting subclavian artery stenosis.

BackgroundSubclavian artery stenosis (SAS) is a peripheral arterial disease of asymptomatic appearance and disastrous consequences. The traditional screening method remains unsatisfactory.ObjectiveThe study aimed to assess the diagnostic performances of inter-arm systolic pressure difference (IASBPD), derivatives of pulse volume recording (PVR), and their combination in detecting subclavian artery stenosis.Materials and methodsThe present study was a retrospective analysis of clinical data from inpatients suspected of supra-arch artery stenosis in Fuwai hospital during 1 year, who underwent selective arterial angiographies. We obtained simultaneous blood pressure measurements on four limbs and pulse waves for calculating IASBPD and PVR derivatives prior to the angiographies. We utilized the receiver operating characteristic curve (ROC) to calculate the optimal cut-off value of IASBPD, upstroke time (UT), and upstroke time per cardiac cycle (UTCC) for detecting SAS. Moreover, we compared the sensitivity and specificity of IASBPD, UT, UTCC, and their combinations for diagnosing SAS (Clinical trial number: NCT03521739).ResultsWe consecutively enrolled 320 eligible patients. Based on SAS’s definition of stenosis above 50%, the area under the curve of IASBPD, UT, and UTCC were 0.84, 0.76, and 0.80 (P < 0.001). And their corresponding cut-off points were 9 mmHg, 202 milliseconds, and 23.2%. The sensitivity and specificity of IASBPD ≥ 9 mmHg were 57.0 and 94.1%. UT ≥ 202 ms and UTCC ≥ 23.2% yielded similar sensitivity (72.6 vs. 72.6%, P > 0.05), but UTCC had higher specificity (81.1 vs. 72.4%, P < 0.05). The sensitivity of the combination of IASBPD and UT (85.2%) or UTCC (78.5%) was significantly higher than IASBPD alone (57%, P < 0.05). The specificity of either combination decreased to 67.6 and 76.8% (P < 0.05).ConclusionsThis present study showed that the combinations of IASBPD and PVR-derived parameters promoted diagnostic sensitivity and preserved adequate specificity than those alone for detecting SAS.

Comparison of duplex ultrasound and hemodynamic assessment with computed tomography angiography in patients with arterial thoracic outlet syndrome.

Thoracic outlet syndrome (TOS) presents with a variety of neurovascular symptoms, and its diagnosis cannot be established purely on the basis of clinical assessments. Computed tomography angiography (CTA) is currently the most useful investigative modality for patients with suspected vascular TOS. However, CTA facilities are limited, and CTA itself is an expensive and a resource-intensive technique associated with risks such as radiation exposure and contrast toxicity. Therefore, a screening test to identify the need for CTA may facilitate clinical management of patients with suspected TOS. Data for patients with suspected arterial TOS who underwent duplex ultrasound with arterial hemodynamic assessment (HDA) (pulse-volume recording and Doppler arterial pressure measurement) at King Saud University Medical City Vascular Lab between 2009 and 2018 were collected. The sensitivity, specificity, positive and negative predictive values (NPV), and area under the curve for duplex ultrasound and arm arterial HDA with CTA were reviewed. The data for 49 patients (mean age, 31 ± 14 years) were reviewed, of which 71% were female. The sensitivity, specificity, positive predictive value, and NPV of duplex ultrasound were 86.7%, 49.3%, 26.5%, and 94.6%, respectively. For arm arterial HDA, these values were 73.3%, 78.9%, 42.3%, and 93.3%, respectively. The combination of arm arterial HDA with duplex ultrasound scores yielded sensitivity, specificity, positive predictive value, and NPV of 93.3%, 42.3%, 25.5%, and 96.8%, respectively. The combination of duplex ultrasound with arm arterial HDA showed higher sensitivity and NPV than either test alone. The specificity of arm arterial HDA was significantly higher than that of the other measurements. When suspected, arterial TOS could be ruled out using duplex ultrasound and arm arterial HDA. These 2 investigations may help determine the need for CTA.

The Role of Imaging in Peripheral Interventions

Patient evaluation is critical to identify and quantitate patient's disease. Aside from the patient's history and physical examination, imaging can help confirm and determine the extent of disease. Imaging can aid in treatment planning once the decision to proceed to intervention has been made. This chapter will discuss the role of imaging before and after peripheral arterial interventions and how it may improve intervention outcomes. It will discuss the value of the arterial noninvasive examinations (ankle-brachial index, toe-brachial index, pulse volume recordings, and arterial duplex ultrasound), computed tomographic angiograms, magnetic resonance angiogram, and intravascular ultrasound.

EHypertension: A prospective longitudinal multi‐omics essential hypertension cohort

eHypertension: A prospective longitudinal multi‐omics essential hypertension cohort

Abnormal photoplethysmography waveforms are associated with chemotherapy induced neuropathy.

Background: Chemotherapy-induced peripheral neuropathy (CIPN) is a dose-dependent adverse event of many chemotherapy agents that affects autonomic, motor, and sensory nerve fibers. The purpose of this study is to describe abnormal photoplethysmography waveforms (PPGs) in the setting of CIPN in cancer patients screened for peripheral arterial disease (PAD), which to our knowledge has not been previously described. Patients and methods: 147 patients who underwent vascular physiologic testing in evaluation for PAD with an ankle brachial index (ABI) or toe brachial index (TBI), segmental pressures, pulse volume recordings, and toe PPGs, in a tertiary cancer center's vascular lab between January 1, 2019 and January 31, 2021 were included in the study. Results: Odds ratio analysis demonstrates 3 times increased odds of abnormal PPGs in patients with PAD (OR 3.2256 95% CI 1.523-6.832, p=0.002), 7 times increased odds of abnormal PPGs in patients with CIPN (OR 7.802 95% CI 3.606-16.880, p<0.001), 9 times increased odds of abnormal PPGs in patients with both CIPN and PAD (9.895 95% CI 2.643-37.043, p=0.001), and 7 times increased odds of abnormal PPGs in patients with chemotherapy agent known to cause CIPN (7.821 95% CI 3.619-16.902, p<0.001). Logistic regression demonstrated that PAD (coefficient 1.171 std. error 0.383 wald 9.354 p=0.002), CIPN (coefficient 2.054 std. error 0.394 wald 27.227 p<0.001), and chemo agent known to cause CIPN (coefficient 2.057 std. error 0.393 wald 27.370 p<0.001) were all predictors of abnormal PPGs. Conclusions: CIPN had greater odds for abnormal PPGs than PAD. Additional larger studies are needed to assess if PPG analysis could be utilized to assess for early diagnosis of CIPN.

Automated Measurements of Ankle-Brachial Index: A Narrative Review

Peripheral artery disease (PAD) is an atherosclerotic disease that causes obstruction in lower limb arteries. It increases cardiovascular risk even in asymptomatic patients. Accurate diagnostic tools for identification of affected individuals are needed. Recently, there have been attempts to establish a reliable method of automated ankle-brachial index (ABI) identification. A search of PubMed database to identify studies assessing automatic ABI measurements in agreement with standard PAD diagnosis methods was conducted in December 2020. A total of 57 studies were analyzed in the review. The majority of analyzed studies found ABI measured by automatic oscillometric devices to be potentially feasible for use. Some note that, even though the Doppler and oscillometric methods are not fully interchangeable, the oscillometric devices could be used in screening. Significantly fewer publications are available on automatic plethysmographic devices. For photoplethysmography, most studies reported either good or moderate agreement with reference standards. For air plethysmography, poorer agreement with Doppler ABI is suggested. It is noted that pulse volume recording (PVR) function may improve the diagnostic accuracy of the devices.

Responsiveness and Inter-Rater Reliability of the Pulse Volume Recording Upstroke Ratio (PVRr)

The objective of this study was to evaluate a measure of the responsiveness and reliability of the pulse volume recording upstroke ratio (PVRr). A database of 389 subjects undergoing lower extremity revascularization was analyzed. Subjects were included in the analysis if they had undergone pedal radiographs, had PVRs performed pre- and postlower extremity revascularization, and had regular pulsatile digital waveforms with a pressure recording on both PVRs. The responsiveness of the PVRr was assessed by means of the postoperative percent change in comparison to the digital pressures. A statistically significant negative correlation was observed (Pearson -0.421; p = .007) indicating that as digital pressures increased, the PVRr decreased. Further, measurement of the reliability of the PVRr was performed on a selection of 10 recordings by 2 residents and 3 board-certified surgeons. The observed intraclass correlation coefficient of measurements was 0.960. Results of this investigation provide evidence in support of the responsiveness and inter-rater reliability in the calculation of the pulse volume recording upstroke ratio.

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

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.

Upstroke Time Is a Useful Vascular Marker for Detecting Patients With Coronary Artery Disease Among Subjects With Normal Ankle-Brachial Index.

BackgroundUpstroke time is the transit time from the nadir to peak of the waveform of pulse volume recording. The purpose of this study was to determine whether upstroke time at the ankle is a useful vascular marker for detecting patients with advanced atherosclerosis in combination with ankle‐brachial index (ABI).Methods and ResultsWe measured upstroke time and ABI in 2313 subjects (mean age, 61.2±15.3 years). The prevalence of coronary artery disease (CAD) was significantly higher in patients with prolonged upstroke time (≥180 ms) than in subjects with normal upstroke time (<180 ms) (29.6% versus 11.8%; P<0.001), with a significant association between prolonged upstroke time and an increased risk of CAD (odds ratio [OR], 1.61; 95% CI, 1.07–2.44; P=0.02). In 1954 subjects with normal ABI (1.00 ≤ ABI ≤ 1.40), the prevalence of CAD was significantly higher in patients with prolonged upstroke time than in subjects with normal upstroke time (29.5% versus 10.6%; P<0.001), with a significant association between prolonged upstroke time and CAD (OR, 2.33; 95% CI, 1.41–3.87; P=0.001), whereas there was no significant association between upstroke time and CAD in subjects with low ABI (<1.00) (OR, 1.24; 95% CI, 0.72–2.16; P=0.44).ConclusionsUpstroke time may be a useful vascular marker for detecting patients with CAD, especially in subjects with normal ABI who are usually considered not to have advanced atherosclerosis by ABI measurement alone. More attention should be paid to upstroke time for detecting patients with advanced atherosclerosis.RegistrationURL: https://www.umin.ac.jp; Unique identifier: UMIN000039512.

Abstract No. 484 Ankle pulse volume recording in the patient with occlusive infrapopliteal disease: does the degree of abnormality correlate with the severity of occlusive disease?

Abstract No. 484 Ankle pulse volume recording in the patient with occlusive infrapopliteal disease: does the degree of abnormality correlate with the severity of occlusive disease?

Novel vascular laboratory technique in the assessment of peripheral artery occlusive disease

This paper highlights the need for a more accurate noninvasive test to measure perfusion in patients with peripheral artery disease and medial calcinosis from diabetes, age, or chronic kidney disease.1 Traditional ankle-brachial index measurements (ABIs) lack reliability in these patients, and even normal values can be misleading. Correlation with pulse volume recordings or Doppler waveforms can provide insight into an underlying arteriopathy with “normal” ABIs. The adjunctive use of toe pressures is sometimes helpful but is limited in patients with severe disease or in the setting of prior toe amputations.

Association of Pulse Volume Recording at Ankle with Total and Cardiovascular Mortality in Hemodialysis Patients.

Pulse volume recording is an accurate modality for detecting arterial occlusion in the lower extremities. There are two indexes of pulse volume recording measured at ankle, percentage of mean arterial pressure (%MAP) and upstroke time (UT). The aim of the study was to examine the ability of %MAP and UT for the prediction of overall and cardiovascular mortality in hemodialysis (HD) patients. In 197 routine HD patients, ankle %MAP, ankle UT, and ankle–brachial index (ABI) were automatically measured by Colin VP-1000 instrument. Fourteen cardiovascular mortality and 29 overall mortalities were documented during 2.7 ± 0.6 years follow-up. In the univariate analysis, in addition to co-morbidities and traditional clinical parameters, increased total mortality was associated with decreased ABI, ABI < 0.9, increased %MAP and UT, %MAP > 50%, and UT > 169 ms (p ≤ 0.041) and increased cardiovascular mortality was associated with increased UT and %MAP > 50% (p ≤ 0.022). After multivariate analysis, increased %MAP and %MAP > 50% (p ≤ 0.047) were still the predictors of total mortality and %MAP > 50% (p = 0.024) was still the predictor of cardiovascular mortality. In HD patients, we found that ankle %MAP and %MAP > 50% could predict total mortality and ankle %MAP > 50% could predict cardiovascular mortality in the multivariate analysis. Hence, assessment of %MAP from pulse volume recording at ankle might be helpful in identifying the high-risk group for poor prognosis in HD patients.

Noninvasive Arterial Testing: What and When to Use.

Peripheral arterial disease (PAD) represents a growing public health issue that continues to be underdiagnosed. In its most severe form, critical limb ischemia, it contributes to expanding morbidity with minor and major limb amputations. PAD is strongly associated with increased mortality, as it is known to be concomitant with coronary and cerebrovascular disease. Diagnosis of PAD relies on noninvasive arterial testing, a class of tests that can provide physiologic or morphologic information. Physiologic tests such as ankle-brachial index, toe-brachial index, pulse volume recordings, and arterial duplex evaluation are the mainstay of gateway evaluation and surveillance. Morphologic exams such as computer tomographic angiography and magnetic resonance angiography are appropriate for preprocedural anatomic evaluation in patients with established vascular disease. This review focuses on physiologic exams.