Toe Systolic Blood Pressure Research Articles

The use of a novel toe-thumb pressure index for assessing arterial status in the lower limb. A reliability and validity study.

This study explored the reliability, validity and perceived comfort of a novel thumb pressure measure and calculation of a toe-thumb index to identify their suitability as an adjunct or alternatives to ankle-brachial and toe-brachial indices. Repeated manual thumb and toe systolic blood pressures were conducted using two raters, over two time points, on 34 healthy participants. Concurrent automated toe, thumb and brachial systolic blood pressures as well as comfort ratings for these measures (using a 10mm visual analogue scale) were captured once by a research assistant. Automated thumb and brachial measures showed fair correlation (ρ=0.36, p=0.03) and a toe-thumb index and toe-brachial index good correlation (ρ=0.62, p<0.01). Intraclass correlation coefficients (ICC) identified moderate intra-rater reliability for manual thumb pressures for Rater 1 and 2 (ICC 0.57, 95% CI [0.14, 0.79] and ICC 0.74, 95% CI [0.49, 0.87], respectively), while inter-rater reliability was poor (ICC=0.16, 95% CI [-0.85, 0.47]). Concurrent validity comparing manual and automated measures for thumb pressure was also poor (ICC -0.05, 95% CI [-1.06, 0.72] and ICC 0.42, 95% CI [-0.16, 0.72] Rater 1 and 2 respectively). Thumb measures were significantly more comfortable than brachial measures (5mm, p<0.00). Thumb systolic pressures are correlated with brachial systolic pressures, with reasonable intra-rater reliability, however, correlation is only fair and measurement error wider than clinically acceptable. Furthermore, manual measures are poorly correlated with automated units. Consequently, caution is required in applying these techniques. As thumb measures were perceived as significantly more comfortable than brachial measures and have an advantage where brachial pressures cannot, or should not, be obtained, further evaluation is warranted.

Variability of toe pressures during haemodialysis: comparison of people with and without diabetes; a pilot study

BackgroundDiabetes, end stage renal disease (ESRD), and peripheral arterial disease (PAD) are associated with a higher risk of diabetes-related lower limb amputation. Timely identification of PAD with toe systolic blood pressure (TSBP) and toe-brachial pressure index (TBPI) is critical in order to implement foot protection strategies to prevent foot complications in people with ESRD. There is limited evidence describing the effect of haemodialysis on TSBP and TBPI. This study aimed to determine the variability of TSBP and TBPI during haemodialysis in people with ESRD, and to determine whether any observed variability differed between people with and without diabetes.MethodsTSBP and TBPI were taken before dialysis (T1), one hour into dialysis (T2) and in the last 15 min of dialysis (T3) during a single dialysis session. Linear mixed effects models were undertaken to determine the variability in TSBP and TBPI across the three time points and to determine whether this variability differed between people with and without diabetes.ResultsThirty participants were recruited, including 17 (57%) with diabetes and 13 (43%) with no diabetes. A significant overall reduction in TSBP was observed across all participants (P < 0.001). There was a significant reduction in TSBP between T1 and T2 (P < 0.001) and between T1 and T3 (P < 0.001). There was no significant overall change in TBPI over time (P = 0.62). There was no significant overall difference in TSBP between people with diabetes and people with no diabetes (mean difference [95% CI]: -9.28 [-40.20, 21.64], P = 0.54). There was no significant overall difference in TBPI between people with diabetes and people with no diabetes (mean difference [95% CI]: -0.01 [-0.17, 03.16], P = 0.91).ConclusionTSBP and TBPI are an essential part of vascular assessment of the lower limb. TBPI remained stable and TSBP significantly reduced during dialysis. Given the frequency and duration of dialysis, clinicians taking toe pressures to screen for PAD should be aware of this reduction and consider how this may have an impact on wound healing capacity and the development of foot related complications.

Toe-brachial index and toe systolic blood pressure for the diagnosis of peripheral arterial disease

Toe-brachial index and toe systolic blood pressure for the diagnosis of peripheral arterial disease

Do toe blood pressures predict healing after minor lower limb amputation in people with diabetes? A systematic review and meta-analysis.

Purpose of study:To investigate toe systolic blood pressure and/or toe-brachial pressure index in predicting healing post minor diabetic foot amputations.Key methods:A systematic search of EMBASE and PubMed (including Medline and The Cochrane Library) was conducted from database inception to 9 March 2020. Two authors independently reviewed and selected relevant studies. Quality was assessed with a modified Critical Appraisal Skill Programme checklist.Main results:Ten studies met the inclusion criteria. Nine studies investigating toe systolic blood pressure reported healing occurred at mean toe systolic blood pressure values ⩾30 mmHg, ranging between 30 and 83.6 mmHg. The meta-analysis (four studies) found toe systolic blood pressure <30 mmHg had 2.09 times the relative risk of non-healing post amputation, compared to toe systolic blood pressure ⩾30 mmHg (relative risk = 2.09, 95% confidence interval: 1.37–3.20, p = 0.001). Two studies investigating toe-brachial pressure index report successful healing where toe-brachial pressure index >0.2, with one study reporting a higher value of 0.8.Main conclusions:Successful post-amputation healing outcomes were reported at mean toe systolic blood pressure ⩾30 mmHg, and the results varied considerably between the studies. Further research should identify whether variables, including amputation level, method of wound closure and length of post-operative follow-up periods, affect the values of toe systolic blood pressure and toe-brachial pressure index observed in this review.

Toe Pressure in Predicting Diabetic Foot Ulcer Healing: A Systematic Review and Meta-analysis

Foot ulceration is the most frequently recognized lower extremity complication in diabetic patients. Predicting wound healing is an essential step in the management of diabetic foot ulcers (DFUs), as it is estimated that early detection and appropriate treatments may prevent up to 85% of amputations. Toe systolic blood pressure (TBP) is a quick and portable bedside assessment and is less affected by medial sclerosis of arteries present in the diabetic population compared to other measurements like ankle-brachial index. This systematic review seeks to evaluate the sensitivity and specificity of toe pressure in prediction of DFU wound healing. PubMed/MEDLINE and EMBASE databases were systematically searched up to September 20, 2017 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All randomized control, prospective and retrospective trials were considered for inclusion if they reported healing rates of DFUs with respect to different TBP readings. Healing was defined to be intact skin for at least 6 months or at time of death. Quality assessment of articles was performed using the RevMan Quality Assessment. Information on healing rates with respect to different TBP values was extracted. Summary estimates of sensitivity and specificity of TBP in predicting healing of DFU wounds were obtained using a bivariate model. A total of 580 articles were screened. Eight studies (6 prospective and 2 retrospective) inclusive of 909 patients were eligible for inclusion. It was found that a TBP of more than 30mm Hg is associated with a sensitivity and specificity of 0.86 and 0.58 respectively for healing of DFUs. A TBP of more than 30mm Hg is sensitive but not specific in the prediction of healing of DFUs. Due to its portability and quick analysis, TBP may be used as a bedside assessment to complement current clinical parameters to aid in predicting the healing of diabetic foot ulcers.

Consistency of Toe Systolic Pressures, Brachial Systolic Pressures, and Toe-Brachial Indices in People with and without Diabetes.

Toe Systolic Blood Pressures (TSPs) and Toe-Brachial Indices (TBIs) have been identified as useful adjuncts in the identification of pedal ischemia, peripheral artery occlusive diseases, and risk for either nonhealing of lower extremity wounds or for amputation. Valid measurement of TSPs and TBIs is therefore essential. However, it could be jeopardized by rater, instrument, and intratestee inconsistency. These three sources of inconsistency were examined in this research. Five publications addressing TSP and TBI consistency were identified and their results were analyzed using intraclass correlation coefficients. Moderate variability in TSPs was found across all studies; greater variability was evidenced in brachial systolic pressure, particularly for people who had diabetes; and TBI values also exhibited considerable variability, but little difference between people who did and did not have diabetes. These findings provide qualified evidence of consistency regarding measurement of TSPs but challenge TBI as a valid and useful indicator in screening, prognostic, and monitoring contexts, particularly for people who have diabetes. However, there is a prospect that TBI assessment could be improved by adherence to standardized protocols and by obtaining multiple measurements from toes and arms on a single occasion as well as on different occasions.

Intermittent vacuum treatment with VacuMed does not improve peripheral artery disease or walking capacity in patients with intermittent claudication

To assess distal blood pressures (BPs) in ankle and toe, walking capacity, intermittent claudication symptoms, physical activity and self-rated health after intermittent vacuum treatment (IVT) for peripheral artery disease (PAD). Forty-eight patients with PAD were randomised to either a control (C)-group with lifestyle changes or lifestyle changes in combination with VacuMed® treatment thrice weekly for 6 weeks. Ankle and toe BPs were measured before, after 6 weeks of intervention and after 6 weeks follow-up. Walking capacity, intermittent claudication symptoms, physical activity and self-rated health (Likert scale) were also assessed. The ankle to brachial index (ABI) and BPs in the ankle and toe decreased after 6 and 12 weeks in both groups with no difference between the groups. In the legs with the lowest ABI at baseline in each patient, there were no differences regarding ABI, BPs and toe-systolic BP index between the groups after either the intervention or the follow-up period. The BPs decreased in both groups. The walking distance and the time to pain were unchanged in the IVT-group and increased in the C-group after the follow-up period, but without any significant differences between the groups. The level of objectively tested physical activity and self-rated health remained unchanged throughout the study in both the IVT- and the C-group. There were no differences between the changes of the self-rated health data during the study period between the IVT- and the C-group. VacuMed® had no effect per se on distal blood pressures, walking capacity, intermittent claudication symptoms, physical activity and self-rated health.

Discrimination of hie and hiesho using toe blood pressure in young women

ObjectiveIn Western medicine, hie (cold sensation) is thought as a subjective complaint. Consequently, despite women's complaints of health problems due to hie, such as distress and decreased quality of life, it is not diagnosed as a disease or given active treatment. However, hie sometimes requires emergency treatment or is a symptom of other disorders. Thus, diagnosing hie and eliminating distress due to hie are clinically significant. This research aimed to discriminate between hie and hiesho (cold disorder) and quantify hie by using objective assessments in addition to subjective assessments. MethodsA questionnaire was administered to 159 healthy young women without any underlying disease that could cause hie, followed by assessment of vascular function. These data were examined through exploratory factor analysis, exploratory cluster analysis, and multivariate logistic analysis. Two- and three-group comparisons were made using the Mann-Whitney test and Kruskal-Wallis test, respectively, followed by multiple comparisons using Scheffé's method. ResultsThe hie (including hiesho) and normal groups comprised 81 (51%) and 78 (49%) subjects, respectively. The questionnaire was a low reliability screening method for determining the severity of hie symptoms. As an index of discrimination of hie and hiesho, we determined the toe-brachial index (TBI) to be 0.81 and toe systolic blood pressure (SBP) to be 87.73 mmHg with a linear function (TBI=0.007 5×toe SBP+0.152, adjusted R2=0.829, F(1,79)=388.79, P<0.001). ConclusionToe SBP and TBI were suggested to be capable of discriminating and quantifying symptoms when used in combination with a questionnaire.

The effect of pretest rest time on automated measures of toe systolic blood pressure and the toe brachial index.

Evaluation of peripheral blood supply is fundamental to risk categorization and subsequent ongoing monitoring of patients with lower extremity peripheral arterial disease. Toe systolic blood pressure (TSBP) and the toe brachial index (TBI) are both valid and reliable vascular screening techniques that are commonly used in clinical practice. However, the effect of pretest rest duration on the magnitude of these measurements is unclear. Eighty individuals meeting current guidelines for lower extremity peripheral arterial disease screening volunteered to participate. The Systoe and MicroLife automated devices were used to measure toe and brachial systolic blood pressures, respectively, following 5, 10 and 15 min of rest in a horizontal supine position. A ratio of TSBP to brachial pressure was used to calculate the TBI and change in TBI at each time interval was investigated. A significant increase in TSBP [3.66 mmHg; 95% confidence interval (CI): 1.44-5.89; P≤0.001] and the TBI (0.03; 95% CI: 0.01-0.05; P≤0.001) occurred between 5 and 10 min. Between 10 and 15 min, there was a nonsignificant decrease in TSBP (-0.73 mmHg; 95% CI: -1.48 to 2.93; P=1.000) and the TBI (0.00; 95% CI: -0.02 to 0.02; P=1.000). Ten minutes of pretest rest is recommended for measurement of TSBP and for both pressure measurements used in the calculation of a TBI to ensure that stable pressures are measured.

Inter-rater reliability of automated devices for measurement of toe systolic blood pressure and the toe brachial index.

The aim of this study was to determine the inter-rater reliability of automated devices for the measurement of toe systolic blood pressure (TSBP) and the toe brachial index (TBI). Toe and brachial systolic blood pressures were measured in 40 participants by two podiatrists using SysToe and MicroLife automated devices. Intraclass correlation coefficients (ICC) with a 95% confidence interval (CI) and 95% limits of agreement (LOA) were determined for TSBP, brachial systolic blood pressure and the TBI. The inter-rater reliability of all measurements was excellent, with ICCs ranging from 0.82 to 0.85. TSBP had the greatest reliability (ICC: 0.85, 95% CI: 0.74-0.92, 95% LOA: -14.4 to 21.1 mmHg) and brachial blood pressures had the lowest reliability (ICC: 0.82, 95% CI: 0.68-0.90, 95% LOA: -21.2 to 22.9 mmHg). The inter-rater reliability of the TBI fell between the TSBP and the brachial blood pressure reliability (ICC: 0.83, 95% CI: 0.70-0.90, 95% LOA: -0.16 to 0.20). We showed that automated devices for the measurement of toe and brachial systolic blood pressure and the TBI in a clinical setting produce measurements with high inter-rater reliability. These findings support the use of these automated devices for ongoing monitoring of lower extremity vascular status.

Is additional hyperbaric oxygen therapy cost‐effective for treating ischemic diabetic ulcers? Study protocol for the Dutch DAMOCLES multicenter randomized clinical trial 对缺血性糖尿病溃疡患者额外进行高压氧治疗的成本效益如何？荷兰DAMOCLES多中心随机临床试验的研究方案

The value of hyperbaric oxygen therapy (HBOT) in the treatment of diabetic ulcers is still under debate. Available evidence suggests that HBOT may improve the healing of diabetic ulcers, but it comes from small trials with heterogeneous populations and interventions. The DAMOCLES-trial will assess the (cost-)effectiveness of HBOT for ischemic diabetic ulcers in addition to standard of care. In a multicenter randomized clinical trial, including 30 hospitals and all 10 HBOT centers in the Netherlands, we plan to enroll 275 patients with Types 1 or 2 diabetes, a Wagner 2, 3 or 4 ulcer of the leg present for at least 4 weeks, and concomitant leg ischemia, defined as an ankle systolic blood pressure of <70 mmHg, a toe systolic blood pressure of <50 mmHg or a forefoot transcutaneous oxygen tension (TcpO2) of <40 mmHg. Eligible patients may be candidates for revascularization. Patients will be randomly assigned to standard care with or without 40 HBOT-sessions. Primary outcome measures are freedom from major amputation after 12 months and achievement of, and time to, complete wound healing. Secondary endpoints include freedom from minor amputations, ulcer recurrence, TcpO2 , quality of life, and safety. In addition, we will assess the cost-effectiveness of HBOT for this indication. The DAMOCLES trial will be the largest trial ever performed in the realm of HBOT for chronic ulcers, and it is unique for addressing patients with ischemic diabetic foot ulcers who may also receive vascular reconstructions. This matches the treatment dilemma in current clinical practice.

Effect of pre‐test rest duration on toe and ankle systolic blood pressure measurements

Background Measurement of toe and ankle blood pressure is used to evaluate the peripheral arterial status of patients, yet the pre-test rest period is inconsistent in published studies and among practitioners, and could affect results. The aim of this systematic review was to evaluate all research that has investigated the effect of different periods of pre-test rest on toe and ankle systolic blood pressure. Methods MEDLINE (from 1946), EMBASE (from 1947), CINAHL (from 1937), and Cochrane Central Register of Controlled Trials (CENTRAL) (from 1800) were searched up to April 2012. No language or publication restrictions were applied. Eighty-eight content experts and researchers in the field were contacted by email to assist in the identification of published, unpublished, and ongoing studies. Studies evaluating the effect of two or more pretest rest durations on toe or ankle systolic blood pressure were eligible for inclusion. No restrictions were placed on participant characteristics or the method of blood pressure measurement. Outcomes included toe or ankle systolic blood pressure and adverse effects. Abstracts were independently assessed by two reviewers for potential inclusion. Results 1658 abstracts were identified by electronic searching. Thirty three of the 88 content experts and researchers in the field replied, identifying five potentially relevant studies. No studies were eligible for inclusion. Conclusion There is no evidence of the effect of different periods of pre-test rest duration on toe and ankle systolic blood pressure measurements. Rigorous trials evaluating the effect of different durations of pre-test rest are required to direct clinical practice and research.

Why Critical Limb Ischemia Criteria are Not Applicable to Diabetic Foot and What the Consequences are

Neuropathy, peripheral arterial occlusive disease and microvascular disturbances are important factors contributing to foot problems in diabetic patients. In the diabetic foot with ischemia, the alterations in skin microvascular function are pronounced including severely reduced capillary circulation and abolished hyperaemic responses. These microvascular disturbances, which are superimposed on the already existing structural diabetic microangiopathy, are compatible with a state of "chronic capillary ischemia" and an increased shunting of blood through arteriovenous channels. This maldistribution of blood in skin microcirculation is not detected by measurement of peripheral blood pressure (systolic ankle blood pressure, systolic toe blood pressure). As indicated in several studies toe blood pressure is a poor predictor of local tissue perfusion, tissue survival and healing of chronic foot ulcers. Consequently, the disturbances in peripheral tissue perfusion of the diabetic foot may be underestimated leading to delayed vascular interventions and/or medical treatment. Thus, measurements of peripheral blood pressure, e.g. toe blood pressure, should be combined with investigations of local tissue perfusion in order to get an adequate estimation of peripheral tissue perfusion in diabetic patients. For this purpose local skin microcirculation can be investigated by transcutaneous oxygen tension of the forefoot. Also, due to these reasons, the threshold for revascularization should be lower in diabetic patients with foot ulcer.

Preliminary assessment of an automatic screening device for peripheral arterial disease using ankle–brachial and toe–brachial indices

Ankle-brachial index (ABI) is currently recommended for the screening of peripheral arterial disease. However, this method becomes less reliable in the presence of calcified, incompressible arteries, as they result in an erroneously elevated ABI, and an additional measure termed the toe-brachial index (TBI) is recommended. The evaluation of ABI, and in particular TBI, typically requires significant technical skill and often involves referral to a vascular laboratory. This present situation reveals the need for a valid and reliable, automatic, noninvasive device that will provide both ABI and TBI at the level of the primary care physician. The aim of this study was to evaluate the accuracy and reliability of such a device, the Vasera VS-1500AT, in the assessment of toe, ankle, and brachial systolic blood pressures. This study involved the assessment of 80 limbs from 40 normotensive and hypertensive individuals (17 men and 23 women) with a mean age of 45 ± 18 years. There was a statistically significant correlation (r=0.92) between toe systolic blood pressures obtained manually with photoplethysmography compared with those obtained through the automated device. The same significant correlation was also seen between the two with ankle (r=0.87) and brachial (r=0.88) systolic blood pressures. These strong correlations demonstrate that further investigation of this device is warranted regarding its use as a screening tool for the assessment of peripheral arterial disease. The automation provided by this device could potentially eliminate variability in these measurements thereby allowing for screening and diagnosis to be done without referral to a vascular laboratory.

Plasma osteoprotegerin is related to carotid and peripheral arterial disease, but not to myocardial ischemia in type 2 diabetes mellitus

BackgroundCardiovascular disease (CVD) is frequent in type 2 diabetes mellitus patients due to accelerated atherosclerosis. Plasma osteoprotegerin (OPG) has evolved as a biomarker for CVD. We examined the relationship between plasma OPG levels and different CVD manifestations in type 2 diabetes.MethodsType 2 diabetes patients without known CVD referred consecutively to a diabetes clinic for the first time (n = 305, aged: 58.6 ± 11.3 years, diabetes duration: 4.5 ± 5.3 years) were screened for carotid arterial disease, peripheral arterial disease, and myocardial ischemia by means of carotid artery ultrasonography, peripheral ankle and toe systolic blood pressure measurements, and myocardial perfusion scintigraphy (MPS). In addition, plasma OPG concentrations and other CVD-related markers were measured.ResultsThe prevalence of carotid arterial disease, peripheral arterial disease, and myocardial ischemia was 42%, 15%, and 30%, respectively. Plasma OPG was significantly increased in patients with carotid and peripheral arterial disease compared to patients without (p < 0.001, respectively), however, this was not the case for patients with myocardial ischemia versus those without (p = 0.71). When adjusted for age, HbA1c and U-albumin creatinine ratio in a multivariate logistic regression analysis, plasma OPG remained strongly associated with carotid arterial disease (adjusted OR: 2.12; 95% CI: 1.22-3.67; p = 0.008), but not with peripheral arterial disease or myocardial ischemia.ConclusionsIncreased plasma OPG concentration is associated with carotid and peripheral arterial disease in patients with type 2 diabetes, whereas no relation is observed with respect to myocardial ischemia on MPS. The reason for this discrepancy is unknown.Trial registration numberat http://www.clinicaltrial.gov: NCT00298844

Does comprilan bandage have any influence on peripheral perfusion in patients with oedema?

Comprilan bandage may be an attractive treatment of leg oedema, but theoretically bandage could compromise peripheral circulation. The present study was undertaken to investigate circulation in the first toe before, during, and after treatment with comprilan bandage. Blood flow rate was measured by the heat-washout method in the pulp of the first toe of 10 patients (eight women, two men, aged 75-94) with leg oedemas, and systolic toe blood pressure was determined by the strain gauge method. Oedema was scored according to a visual scale, and the patients were treated with comprilan (short stretch) bandage for 1 week. Toe blood flow rate was measured before, during and after the use of the bandages, and toe blood pressure was measured before and after the use of bandages. According to the visual scale, all subject benefited from the treatment by reduction of oedema, and they reported increased well-being after. Blood flow rate was not significantly altered during and after the treatment. Systolic toe pressure was normal in all patients (R/L = 94/83 mmHg), and no significant change took place during and after the use of the bandages (92/90 mmHg). Comprilan bandage has a positive effect on legs oedemas, visually as well as according to the patients well-being. The treatment does not have any significant influence on toe blood pressure. It cannot, however, be excluded that the use of comprilan bandage may compromise toe blood flow rate slightly (<5%). A larger study with more subjects has to be made to come this closer, and additional capillary blood flow rate should be measured in an area without arteriovenous anastomoses.

Myocardial ischemia, carotid, and peripheral arterial disease and their interrelationship in type 2 diabetes patients

BackgroundCardiovascular disease (CVD) is the leading cause of death in type 2 diabetes mellitus (T2DM) patients. We examined the relationship between CVD in different vascular territories. MethodsT2DM patients without known or suspected CVD (n = 305) referred consecutively to a diabetes clinic for the first time and age-matched nondiabetic reference subjects (n = 40) were screened for myocardial ischemia, carotid, and peripheral arterial disease by means of myocardial perfusion scintigraphy, carotid artery ultrasonography, and peripheral ankle and toe systolic blood pressure measurements. ResultsIn the T2DM patients, the prevalence of myocardial ischemia, carotid, and peripheral arterial disease was 30%, 42%, and 15%, respectively, almost three times higher than in the reference subjects (P = 0.007, P = 0.001, and P = 0.09, respectively). T2DM patients with myocardial ischemia, carotid, or peripheral arterial disease had a significantly increased risk of CVD in other vascular territories as well (OR: 1.99, 2.09, and 3.09, respectively). However, 40%, 52%, and 22% of the T2DM patients with myocardial ischemia, carotid, or peripheral arterial disease demonstrated exclusively this particular type of CVD manifestation. ConclusionsIn T2DM patients, signs of CVD in one vascular territory carry a significantly increased risk of CVD in other territories, although many patients only presented one manifestation.

Toe Blood Pressure Measurements in Patients Suspected of Leg Ischaemia: A New Laser Doppler Device Compared with Photoplethysmography

Objectives. To study the usefulness of a new laser Doppler (LD) device as compared with photoplethysmography (PPG) to measure toe systolic blood pressures (TBP) in patients suspected of arterial insufficiency of the legs.Design. Prospective comparative clinical study.Materials and Methods. Seventy patients (121 legs) referred to our vascular laboratory for TBP measurements were investigated using a standard PPG and a new LD instrument, incorporating a cuff inflator and probe heater.Results. Mean toe pressures with the PPG, unheated LD, and heated LD (37 °C) were 68.1, 67.2, and 75.5 mmHg, respectively. TBP with heated LD was systematically higher than with PPG (7.7 mmHg; p<0.001). Intra-class correlations between PPG vs. unheated LD and PPG vs. heated LD were good: 0.91 and 0.93, respectively. However, a considerable variation existed between PPG and LD (95% confidence interval: 45 mmHg), which were unrelated to the value of the TBP. Kappa values of agreement between PPG and unheated and heated LD to detect critical ischaemia (TBP below 30 mmHg) were good (κ=0.77 and 0.63, respectively).Conclusions. The new LD device appears a good alternative to standard PPG measurements to assess TBP, despite a rather wide variation.

Influence of lipoprotein(a) on restenosis after femoropopliteal percutaneous transluminal angioplasty in Type 2 diabetic patients.

The influence of vascular morphology and metabolic parameters including lipoprotein(a) (Lp(a)) on restenosis after peripheral angioplasty has been compared in Type 2 diabetes (DM) vs. non-diabetic patients (ND). The clinical course and risk profile of 132 (54 DM vs. 78 ND) patients with peripheral arterial occlusive disease (PAD) were observed prospectively following femoropopliteal angioplasty (PTA). Clinical examination, oscillometry, ankle brachial blood pressure index (ABI) and the toe systolic blood pressure index (TSPI) were used during follow-up. Duplex sonography and reangiography were also used to verify suspected restenosis or reocclusion. At the time of intervention patients with DM had a lower median Lp(a) of 9 vs. 15 mg/dl (P < 0.01) in patients without diabetes. Recurrence within 1 year after PTA occurred in 25 diabetic (= 46%, Lp(a) 12 mg/dl) and 30 non-diabetic (= 38%, Lp(a) 48 mg/dl) patients. DM patients with 1 year's patency had a median Lp(a) of 7 vs. 11 mg/dl in non-diabetic patients (P < 0.05). However, 12 months after angioplasty Lp(a) correlated negatively with the ABI (r = -0.44, P < 0.01) in diabetic and in non-diabetic patients (r = -0.20, P < 0.05). The probability of recurrence after PTA continuously increased with higher levels of Lp(a) in each subgroup of patients. Our data indicate that Lp(a) is generally lower in those with peripheral arterial occlusive disease and Type 2 diabetes than in non-diabetic individuals. The increased risk for restenosis with rising levels of Lp(a) is set at a lower Lp(a) in diabetes and may be more harmful for diabetic patients.

The usefulness of a laser Doppler in the measurement of toe blood pressures

Objective: The purpose of this study was to evaluate the clinical value and reproducibility of laser Doppler (LD) versus photoplethysmography (PPG) in the measurement of the systolic toe blood pressure. Methods: Toe blood pressure was measured in 60 patients in different stages of peripheral vascular disease with simultaneous digital sampling of PPG and two LD signals, each with a different filter setting (3 second [LD3] and 0.03 second [LD0.03]), and cuff pressure. These measurements were repeated after 1 week. The signals were analyzed with previous results ignored. The agreement of the PPG and LD pressures and reproducibility after 1 week were assessed by calculating the intraclass correlation coefficient (ICC). The agreement variation across the range of pressure values was visually explored by means of difference plots. Results: In 19 legs with a very low pressure only LD could adequately measure the pressure, whereas PPG did not. The ICCs between PPG and LD3 and LD0.03 were 0.95 or more. The ICCs of the 1-week reproducibility of the PPG, LD3, and LD0.03 pressures were 0.92, 0.88, and 0.86, respectively. The variation was equally distributed across the range of pressures in all three methods. Conclusion: LD is a reliable alternative to PPG to measure toe blood pressures. Furthermore, LD is able to measure low pressures, which is relevant in the assessment of the presence of critical ischemia. (J Vasc Surg 2000;32:1172-9.)