Toe Systolic Pressure Research Articles

Urgent need to clarify the definition of chronic critical limb ischemia - a position paper from the European Society for Vascular Medicine.

Chronic critical lower limb ischemia (CLI) has been defined as ischemia that endangers the leg. An attempt was made to give a precise definition of CLI, based on clinical and hemodynamic data (Second European Consensus). CLI may be easily defined from a clinical point of view as rest pain of the distal foot or gangrene or ulceration. It is probably useful to add leg ulcers of other origin which do not heal because of severe ischemia, and to consider the impact of frailty on adverse outcome. From a hemodynamic viewpoint there is no consensus and most of the existing classifications are not based upon evidence. We should thus propose a definition and then validate it in a prospective cohort in order to define the patients at major risk of amputation, and also to define the categories of patients whose prognosis is improved by revascularisation. From today's available data, it seems clear that the patients with a systolic toe pressure (STP) below 30 mmHg must be revascularised whenever possible. However other patients with clinically suspected CLI and STP above 30 mmHg must be evaluated and treated in specialised vascular units and revascularisation has to be discussed on a case by case basis, taking into account other data such as the WiFi classification for ulcers.In conclusion, many useful but at times contradictory definitions of CLI have been suggested. Only a few have taken into account evidence, and none have been validated prospectively. This paper aims to address this and to give notice that a CLI registry within Europe will be set up to prospectively validate, or not, the previous and suggested definitions of CLI.

Prevalence and severity of peripheral arterial disease among patient with heel pressure ulcer: a retrospective study of 42 patients.

Heel pressure ulcer is a major complication in elderly hospitalized patients. The association with peripheral arterial disease (PAD) which is also a frequent disease in this population is poorly known. The aim of this study was to assess the prevalence of PAD and critical limb ischemia (CLI) in patients with heel pressure ulcer. Patients referred to the vascular medicine department for heel pressure ulcer from October 2014 to June 2015 were included in the study. The assessment of peripheral arterial disease was made with the results of ankle brachial index and/or doppler ultra sound of lower limb arteries. Toe systolic pressure and transcutaneous pressure (TcPO2) were also recorded, and the diagnosis of critical limb ischemia was made according to the TASC 2 criteria. The population was composed with 42 patients (women 43%, men 57%). The mean age was 81±11 years. Heel pressures ulcers were diagnosed in the following situations: lower limb fracture (31%), acute medical illness (21%), multiple chronic conditions (28%) and critical care unit hospitalization (7%). A peripheral arterial disease was present in 31 patients (73%), and a critical limb ischemia in 7 patients. For 18 patients, PAD was not known in their past medical history, and this was the case of 5 patients among those with critical limb ischemia. A revascularization was performed in 12 patients, and 5 patients undergo a lower limb amputation. 12 patients were died at 3 months. PAD is frequent among patients with heel pressure ulcer, and is often unknown. The functional and vital prognostic are poor, and the results of our study emphasize the importance of screening PAD in the evaluation of heel pressure ulcer risk.

Diagnostic accuracy of resting systolic toe pressure for diagnosis of peripheral arterial disease in people with and without diabetes: a cross-sectional\xa0retrospective case-control study

BackgroundThe resting systolic toe pressure (TP) is a measure of small arterial function in the periphery. TP is used in addition to the ankle-brachial index when screening for peripheral arterial disease (PAD) of the lower limb in those with diabetes, particularly in the presence of lower limb medial arterial calcification. It may be used as an adjunct assessment of lower limb vascular function and as a predictor of wound healing. The aim of this study was to determine the diagnostic accuracy of TP for detecting PAD in people with and without diabetes.MethodsThis was a retrospective case-control study. Two researchers extracted information from consecutive patient records, including TP measurements, colour Duplex ultrasound results, demographic information, and medical history. Measures of diagnostic accuracy were determined by receiver operating curve (ROC) analysis, and calculation of sensitivity, specificity, and positive and negative likelihood ratios.ResultsThree hundred and nintey-four participants with suspected PAD were included. In the diabetes group (n = 176), ROC analysis of TP for detecting PAD was 0.78 (95%CI: 0.69 to 0.84). In the control group (n = 218), the ROC of TP was 0.73 (95%CI: 0.70 to 0.80). TP had highest sensitivity when anatomical distribution of disease was both proximal and distal (diabetes group: 79.49%, the control group: 82.61%). TP yielded highest sensitivity in mild disease (50–75% stenosis) in diabetes group, (81.82%) and moderate disease (>75% stenosis) in control group (80.77%).ConclusionsOur findings indicate that TPs are useful to assist in diagnosing PAD in clinical practice, however, results should be interpreted with caution due to the small probability of PAD being present with a negative test.

Pre-measurement rest time affects magnitude and reliability of toe pressure measurements

Objectives. Toe pressures are used to evaluate lower extremity healing capacity and screen for peripheral arterial disease (PAD). Although toe pressures are commonly used clinically both as an independent measure and in the calculation of the toe–brachial index, the effect of pre-measurement rest duration on the magnitude and reliability of toe pressures is unknown. This study investigated the effect of pre-measurement rest duration on toe pressures. Methods. Seventy community-based participants meeting guidelines for PAD screening were recruited. Systolic toe pressures either at the left or right hallux were manually measured using photoplethysmography following 5, 10 and 15 min of rest in a supine horizontal position. Testing was repeated 7–10 days later. Results. A significant drop in toe pressure (3.86 mmHg) occurred between 5 and 10 min (p = 0.001). No significant change occurred between 10 and 15 min. Reliability after 5 min was excellent (intra-class correlation coefficient, ICC = 0.80, 95% CI 0.68–0.89), increasing slightly at 10 and 15 min (ICC = 0.86, 95% CI 0.77–0.92 and ICC = 0.82, 95% CI 0.69–0.89). Conclusions. Toe pressures stabilize after 10 min of rest in a supine horizontal position. Longer periods of pre-measurement rest did not improve reliability significantly.

Highly Purified Eicosapentaenoic Acid Improves Decreased Toe-Brachial Index in Japanese Patients with Type 2 Diabetes Mellitus

Eicosapentaenoic acid (EPA), which is an important polyunsaturated fatty acid in fish oil, improves blood coagulability and prevents thrombosis. EPA is usually available for treatment of patients with obliterating arteriosclerosis in Japan, but its usefulness for microcirculation in the foot has not been established. We studied the effect of highly purified ethyl eicosapentaenoate on decreased microcirculation in the foot in Japanese patients with type 2 diabetes mellitus. Changes in ankle-brachial index (ABI), toe systolic pressure, and toe-brachial index (TBI) with administration of EPA were evaluated in outpatients. Individual comparison of mean values before and after treatment was performed by using paired Student t test. Both decreased toe systolic pressure and TBI significantly improved with administration of ethyl eicosapentaenoate for 4 weeks in patients who had decreased TBI; decreased TBI was normalized in 24 of 35 big toes (68.6%). In addition, treatment improved decreased ABI; decreased ABI was normalized in 4 of 6 lower limbs (66.7%). This study confirmed that administration of highly purified ethyl eicosapentaenoate improves peripheral microcirculation in diabetic patients with decreased TBI and ABI.

Intratester and Intertester Reliability of Toe Pressure Measurements in People with and Without Diabetes Performed by Podiatric Physicians.

Toe pressures and the toe brachial index (TBI) represent possible screening tools for peripheral arterial disease; however, limited evidence is available regarding their reliability. The aim of this study was to determine intratester and intertester reliability of toe systolic pressure and the TBI in participants with and without diabetes performed by podiatric physicians. Two podiatric physicians performed toe and brachial pressure measurements on 80 participants, 40 with and 40 without diabetes, during two testing sessions using photoplethysmography and Doppler probe. Intraclass correlation coefficients (ICCs) and 95% limits of agreement were determined. In people with diabetes, intratester reliability of toe pressure measurement was excellent for both testers (ICCs, 0.84 and 0.82). Reliability of the TBI was good (ICCs, 0.72 and 0.75) and brachial pressure fair (ICCs, 0.43 and 0.55). The intertester reliability of toe pressure (ICC, 0.82) and the TBI (ICC, 0.80) was excellent. Intertester reliability of brachial pressure was reduced in people with diabetes (ICC, 0.49). In age-matched participants, intratester reliability of toe pressure measurement was excellent for both testers (ICCs, 0.83 and 0.87), and reliability of the TBI (ICCs, 0.74 and 0.80) and brachial pressure (ICCs, 0.73 and 0.78) was good to excellent. Intertester reliability of toe pressure (ICC, 0.84), the TBI (ICC, 0.81), and brachial pressure (ICC, 0.77) was excellent. Toe pressures and the TBI demonstrated excellent reliability in people with and without diabetes and can be an effective component of lower-extremity vascular screening. However, wide limits of agreement relative to blood pressure values for both cohorts indicate that results should be interpreted with caution.

Second Toe Systolic Pressure Measurements are Valid Substitutes for First Toe Systolic Pressure Measurements in Diabetic Patients: A Prospective Study

Toe systolic pressure is a component of the standard vascular and diabetic foot assessment. Until now, clinicians have measured only first toe pressure given a lack of evidence for measurements of the other toes. In diabetic patients, first toe measurements are often not possible because of ulceration or amputation. It was hypothesized that the adjacent second toe systolic pressure measurements would be interchangeable with those of the first toe. A prospective study was performed on 100 participants with diabetes mellitus. Duplicate systolic toe pressures were measured in the first toe and adjacent second toe using the Systoe Automated Toe Pressure System, Systoe Photophlethysmograph Sensor Cuff, and occlusion cuffs measuring 120 × 25 mm for the first toe and 90 × 15 mm for the second toe. Correlation analysis was followed by Ordinary Least Products regression to detect and distinguish fixed and proportional bias between the two toe measurements. The acceptable limits of interchangeable results were defined as 5–10 mmHg. Correlation coefficient r = 0.908; p < 0.001. Eighty-two percent of the variations in the second toe measurements were accounted for by knowing the first toe measurements and vice versa. Ordinary Least Products regression showed no fixed or proportional bias between the two methods of measurement: second toe systolic pressure = (−0.579) + (1.038) ∗ first toe systolic pressure. Repeatability analysis showed a 0.5% variation between duplicate measurements. This is the first study which demonstrates that second toe systolic pressures are interchangeable with those of the first toe. Second toe pressures can be used in diabetic patients whose first toe pressures cannot be assessed.

Abstract 19419: A Phase IIa Randomized Double-Blind, Placebo Controlled Study to Evaluate Plasmid Stromal Cell-Derived Factor-1 for Treatment of Critical Limb Ischemia - The STOP-CLI Trial

Background: Stromal cell-derived factor-1 (SDF-1) promotes tissue repair by increasing cell survival, endogenous stem cell recruitment and vasculogenesis. Preclinical studies demonstrated that non-viral DNA plasmid encoding human SDF-1 (pSDF-1) is safe and increased vessel density in animal models of hindlimb ischemia versus placebo. Additionally, clinical studies have demonstrated safety of pSDF-1 and evidence of neovascularization at the microvascular level. A Phase IIa multi-center double blind randomized placebo-controlled dose escalation study (STOP-CLI) was initiated to evaluate the safety and efficacy of pSDF-1 administered via direct intramuscular injection in patients with critical limb ischemia (CLI). Methods: Forty eight CLI (Rutherford 4 or 5) patients who were poor candidates for surgical revascularization on stable medical therapy with ankle systolic pressure ≤70 mmHg or toe systolic pressure ≤50 mmHg were enrolled into 4 cohorts (n=12 each). Within each cohort, subjects were randomized 3:1 to receive a single set of direct intramuscular injections (8 or 16) to the ischemic limb of escalating doses of 1 mg/ml pSDF-1 (4, 8, 8 or 16mg) or placebo and were followed for 12 months post-dosing. Efficacy endpoints include: quality of life via SF-36, visual analog scale (VAS), Rutherford class, time to first/number of amputations, wound healing, and survival. Results: Enrollment was completed in July 2013. At baseline, patients were, 58.6±13.7 years, 88% male, and had an equal number of Rutherford 4 and 5 (n=24 each). To date, 482 follow up months have been completed with 36 Serious Adverse Events reported, none drug-related. Interim 12 month efficacy results show patients who received 8 injections (8 x 1 mg) totaling 8 mg pSDF-1 improved in rest pain (VAS -3.3±2.5 cm vs. -0.8±2.4 cm; 8 x 1 mg injections vs. placebo, p=0.12) and demonstrate improvements in SF-36 Overall Physical (22.4 ± 27 vs. -2.6 ± 29.7, p=0.22) and Mental (21.0 ± 12.7 vs. 0.26 ± 28.2, p=0.16) Health. Final 12 month data will be available in September 2014. Conclusions: STOP-CLI tests the hypothesis that delivery of pSDF-1 is safe and will improve the clinical status of patients with CLI. The interim results of STOP-CLI demonstrate safety and bioactivity of pSDF-1 for treatment of CLI.

Second Toe Systolic Pressure Measurements are Valid Substitutes for First Toe Systolic Pressure Measurements in Diabetic Patients: A Prospective Study

Toe systolic pressure is a component of the standard vascular and diabetic foot assessment. Until now,clinicians have measured only first toe pressure given a lack of evidence for measurements of the other toes. In diabetic patients, first toe measurements are often not possible because of ulceration or amputation. It was hypothesized that the adjacent second toe systolic pressure measurements would be interchangeable with those of the first toe. A prospective study was performed on 100 participants with diabetes mellitus. Duplicate systolic toe pressures were measured in the first toe and adjacent second toe using the Systoe Automated Toe Pressure System, Systoe Photophlethysmograph Sensor Cuff, and occlusion cuffs measuring 120 x 25 mm for the first toe and 90 x 15 mm for the second toe. Correlation analysis was followed by Ordinary Least Products regression to detect and distinguish fixed and proportional bias between the two toe measurements. The acceptable limits of interchangeable results were defined as 5-10 mmHg. Correlation coefficient r ¼ 0.908; p < 0.001. Eighty-two percent of the variations in the second toe measurements were accounted for by knowing the first toe measurements and vice versa. Ordinary Least Products regression showed no fixed or proportional bias between the two methods of measurement: second toe systolic pressure = (-0.579) + (1.038) * first toe systolic pressure. Repeatability analysis showed a 0.5%variation between duplicate measurements. This is the first study which demonstrates that second toe systolic pressures are interchangeable with those of the first toe. Second toe pressures can be used in diabetic patients whose first toe pressures cannot be assessed.

Artériopathie des membres inférieurs : problèmes diagnostiques en 2014

Diagnosis of peripheral occlusive arterial disease still raises many problems in 2014. Early detection is crucial and a very good tool is available: ankle brachial index. In some patients, toe systolic pressure measurement might be useful (patients with diabetes mellitus or renal failure). As far as walking symptoms are concerned, treadmill test usually gives the answer about the reason for pain. In some cases, other tests may be useful, i.e. treadmill TcPO2in low back pain. Critical ischaemia is a major issue for treatment when revascularization has failed but diagnosis also raises concerns. Objective testing for ischaemia is mandatory (TcPO2, toe systolic pressure). Ankle pressure measurement is not sufficient in those patients. Patients suspected for critical limb ischaemia have to be investigated and treated in vascular centers. Many problems still concern diagnosis of peripheral occlusive arterial disease in 2014.

Measuring systolic ankle and toe pressure using the strain gauge technique – a comparison study between mercury and indium-gallium strain gauges

Background. Measurement of the ankle and toe pressures are often performed using a plethysmograph, compression cuffs and a strain gauge. Usually, the strain gauge contains mercury but other alternatives exist. From 2014, the mercury-containing strain gauge will no longer be available in the European Union. The aim of this study was to compare an indium-gallium strain gauge to the established mercury-containing strain gauge. Methods. Consecutive patients referred to the Department of Clinical Physiology and Nuclear Medicine at Bispebjerg and Frederiksberg Hospitals for measurements of systolic ankle and toe pressures volunteered for the study. Ankle and toe pressures were measured twice with the mercury and the indium-gallium strain gauge in random order. Comparison of the correlation between the mean pressure using the mercury and the indium-gallium device and the difference between the two devices was performed for both toe and ankle level. Results. A total of 53 patients were included (36 male). Mean age was 69 (range, 45–92 years). Mean pressures at toe and ankle level with the mercury and the indium-gallium strain gauges were 77 (range, 0–180) mm Hg and 113 (range, 15–190) mm Hg, respectively. Comparison between the mercury and the indium-gallium strain gauge showed a difference in toe blood pressure values of − 0.7 mm Hg (SD: 7.0). At the ankle level, a difference of 2.0 mm Hg (SD: 8.6) was found. Conclusion. The two different devices agree sufficiently in the measurements of systolic ankle and toe pressure for the indium-gallium strain gauge to replace the mercury strain gauge.

Outcome of Ischemic Foot Ulcer in Diabetic Patients Who Had no Invasive Vascular Intervention

There is limited information regarding outcome in patients not available for revascularisation. Our aim was to identify factors related to ulcer healing in diabetic patients with severe peripheral arterial disease who were not available for revascularisation. Diabetic patients with a foot ulcer, consecutively presenting at a multidisciplinary foot centre with systolic toe pressure <45 mmHg or an ankle pressure <80 mmHg were prospectively included. Patients who received revascularisation were excluded. All patients had continuous follow-up until healing or death. Out of 602 patients (median age: 76 years) included in this study, 50% healed either primarily (76%) or with a minor amputation (24%). Seventeen percent of patients healed after major amputation and 33% died unhealed. By regression analysis, rest pain, impaired renal function, ischemic heart disease, cerebral vascular disease, extent of tissue destruction, and ankle pressure >50 mmHg affected the outcome of the ulcers. Diabetic patients with ischemic foot ulcers not available for revascularisations are not excluded from healing without major amputation. Factors strongly related to outcome were co-morbidity, severity of peripheral arterial disease, and extent of tissue destruction. Our findings reinforce the need for a classification system considering these factors at decision-making for vascular intervention.

Foot Care

Foot Care

Factors related to outcome of neuroischemic/ischemic foot ulcer in diabetic patients

Peripheral vascular disease (PVD) is an important limiting factor for healing in neuroischemic or ischemic diabetic foot ulcer. The purpose of this study was to identify factors related to healing in patients with diabetes with foot ulcers and severe PVD. Patients with diabetes with a foot ulcer, consecutively presenting at a multidisciplinary foot center with a systolic toe pressure <45 mm Hg or an ankle pressure <80 mm Hg were prospectively included, followed according to a preset program, and with the exception of specified exclusions, subjected to angiography offered vascular intervention when applicable. All patients had continuous follow-up until healing or death irrespective of the type of vascular intervention. One thousand one hundred fifty-one patients were included. Eighty-two percent had a toe pressure <45 mm Hg and 49% had an ankle pressure <80 mm Hg. Eight hundred one patients (70%) underwent an angiography. Out of these, 63% had vascular intervention, either percutaneous transluminal angioplasty (PTA; 39%) or reconstructive surgery (24%). Nine percent of the patients had one or more complications after angiography. PTA was multisegmental in 46% and to the crural arteries in 46%. Reconstructive surgery was distal in 51%. Age (P < .001), renal function impairment (P = .005), congestive heart failure (P = .01), number and type of ulcer (P < .001), and severity of PVD (P = .003) affected the outcome of ulcers. PTA and reconstructive vascular surgery increased the probability of healing without amputation (odds ratio [OR], 1.77 and 2.05, respectively). Probability of ulcer healing is strongly related to comorbidity, extent of tissue involvement, and severity of PVD in patients with diabetes with severe PVD.

The reliability of toe systolic pressure and the toe brachial index in patients with diabetes

The reliability of toe systolic pressure and the toe brachial index in patients with diabetes

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.

The reliability of toe systolic pressure and the toe brachial index in patients with diabetes.

BackgroundThe Ankle Brachial Index is a useful clinical test for establishing blood supply to the foot. However, there are limitations to this method when conducted on people with diabetes. As an alternative to the Ankle Brachial Index, measuring Toe Systolic Pressures and the Toe Brachial Index have been recommended to assess the arterial blood supply to the foot. This study aimed to determine the intra and inter-rater reliability of the measurement of Toe Systolic Pressure and the Toe Brachial Index in patients with diabetes using a manual measurement system.MethodsThis was a repeated measures, reliability study. Three raters measured Toe Systolic Pressure and the Toe Brachial Index in thirty participants with diabetes. Measurement sessions occurred on two occasions, one week apart, using a manual photoplethysmography unit (Hadeco Smartdop 45) and a standardised measurement protocol.ResultsThe mean intra-class correlation for intra-rater reliability for toe systolic pressures was 0.87 (95% LOA: -25.97 to 26.06 mmHg) and the mean intra-class correlation for Toe Brachial Indices was 0.75 (95% LOA: -0.22 to 0.28). The intra-class correlation for inter-rater reliability was 0.88 for toe systolic pressures (95% LOA: -22.91 to 29.17.mmHg) and 0.77 for Toe Brachial Indices (95% LOA: -0.21 to 0.22).ConclusionDespite the reasonable intra-class correlation results, the range of error (95% LOA) was broad. This raises questions regarding the reliability of using a manual sphygmomanometer and PPG for the Toe Systolic Pressure and Toe Brachial Indice.

Detection of Imminent Vein Graft Occlusion: What is the Optimal Surveillance Program?

The prediction of infrainguinal vein bypass failure remains an inexact judgment. Patient demographics, technical factors, and vascular laboratory graft surveillance testing are helpful in identifying a high-risk graft cohort. The optimal surveillance program to detect the bypass at risk for imminent occlusion continues to be developed, but required elements are known and include clinical assessment for new or changes in limb ischemia symptoms, measurement of ankle and/or toe systolic pressure, and duplex ultrasound imaging of the bypass graft. Duplex ultrasound assessment of bypass hemodynamics may be the most accurate method to detect imminent vein graft occlusion. The finding of low graft flow during intraoperative assessment or at a scheduled surveillance study predicts failure; and if associated with an occlusive lesion, a graft revision can prolong patency. The most common abnormality producing graft failure is conduit stenosis caused by myointimal hyperplasia; and the majority can be repaired by an endovascular intervention. Frequency of testing to detect the failing bypass should be individualized to the patient, the type of arterial bypass, and prior duplex ultrasound scan findings. The focus of surveillance is on identification of the low-flow arterial bypass and timely repair of detected critical stenosis defined by duplex velocity spectra criteria of a peak systolic velocity 300 cm/s and peak systolic velocity ratio across the stenosis >3.5-correlating with >70% diameter-reducing stenosis. When conducted appropriately, a graft surveillance program should result in an unexpected graft failure rate of <3% per year.

Surveillance After Lower Extremity Arterial Bypass

The elements of a surveillance program after lower limb bypass grafting to enhance graft patency continue to evolve. Graft evaluation should include clinical assessment for new or changes in limb ischemia symptoms, measurement of ankle or toe systolic pressure, or both, and duplex ultrasound imaging of the bypass graft, which in the early postoperative period is predictive of the subsequent need for bypass graft revision. The natural history of moderate graft stenosis is known, and these lesions can be safely monitored using serial testing to identify progression. The testing frequency should be individualized to the patient, type of arterial bypass, and duplex scan findings. Graft surveillance should focus on the identification and repair of critical stenosis (peak systolic velocity exceeding 300 cm/s, and peak systolic velocity ratio across the stenosis exceeding 3.5) correlating with more than 70% diameter-reducing stenosis. A graft surveillance program should result in a graft failure rate of less than 3% per year.

Influence of peripheral arterial disease on capillary pressure in the foot.

Capillary perfusion and transmural pressure are delicately regulated by microvascular constriction mechanisms, which are activated upon a change in posture. Capillary flow is known to be disturbed in patients with severe peripheral arterial disease. To date, however, the influence of this disease on capillary pressure is unknown. Capillary pressure in the nail fold of the hallux, ankle, and toe blood pressures were measured in the sitting and supine positions in 8 patients with intermittent claudication (F2), in 7 patients with rest pain and/or ischemic ulcers (F3-4), and in 12 age-matched healthy controls (F0). Red blood cell velocity, laser Doppler flux, and continuous blood pressure of the second toe were measured simultaneously. Toe, ankle, and brachial pressure were measured after the experiment in both positions. Capillary pressure did not increase significantly with increasing disease severity (F0, F2, and F3-4) in supine (P =.37; medians, 17, 21, and 14 mm Hg, respectively) and sitting (P =.96; medians, 59, 60, and 60 mg Hg, respectively) positions, whereas toe systolic pressure did, both in supine (P <.001; medians, 91, 49, and 14 mm Hg, respectively) and sitting (140, 104, and 64 mm Hg, respectively) positions. Nutritive skin perfusion (red blood cell velocity) decreased with increasing disease severity (F0, F2, and F3-4) while supine (P =.005; medians,.19,.20, and.04 mm/s, respectively) and while sitting (P =.06; medians,.22,.15, and.04 mm/s, respectively). An increase in orthostatic pressure increases both toe and capillary pressures. Arterial insufficiency of the leg seems to leave the capillary pressure unscathed. Apparently, arteriolar vasodilation compensates for the lower arterial pressure in both positions, even in patients with rest pain and low nutritive perfusion.