Continuing Education Activity

The ankle-brachial index is a non-invasive tool for the assessment of vascular status. It consists of the ratio between the systolic blood pressure of the lower extremity, specifically the ankle, and the upper extremity. This ratio compares the resistance of the blood vessels, with one of the primary factors being the diameter of the vessels. This diameter is narrowed either from internal factors (plaque, intimal tear) or external factors such as compression by soft tissues. The activity reviews the noninvasive diagnostic procedure: the ankle-brachial index. It reviews the role of healthcare providers in using the tool for screening, diagnosis, treatment, and guidance for patients with various vascular-related conditions.

Objectives:

• Explain how ankle-brachial index is useful in various clinical situations in both the acute trauma setting and the chronic clinical setting.

• Review the differences between normal and abnormal values for ankle-brachial index.

• Identify the steps for an appropriate evaluation of the potential complications and clinical significance of arterial insufficiency.

• Describe interprofessional team strategies for improving care coordination and communication to advance and improve outcomes using ankle-brachial index as a diagnostic tool.

Introduction

The ankle-brachial index (ABI) is a non-invasive tool for the assessment of vascular status. It consists of the ratio between the systolic blood pressure of the lower extremity, specifically the ankle, and the upper extremity. This ratio compares the resistance of the blood vessels, with one of the primary factors being the diameter of the vessels. This diameter is narrowed either from internal factors (plaque, intimal tear) or external factors such as compression by soft tissues.

Anatomy and Physiology

The ABI is measured using 3 arteries: the brachial artery for the upper extremity and the dorsalis pedis and or posterior tibial artery at the ankle.

• Dorsalis pedis artery: The dorsalis pedis artery arises primarily from the anterior tibial artery and starts higher in the anterior compartment of the leg between the tibialis anterior and extensor hallucis longus (EHL). In most cases, the vessel above the ankle passes under the EHL to reside between EHL and the extensor digitorum longus (EDL). Other variations include later crossing sites either at the ankle or distal.[1] Ranging the great toe can help identify the EHL for guidance about finding the dorsalis pedis pulse, especially in a patient with faint pulses. Additionally, the artery can be traced proximally from the first dorsal metatarsal artery extending into the great toe webspace or distally from the supplying artery.
• Posterior tibial artery: The posterior tibial artery passes posterior to the medial malleolus at the ankle between the tibialis posterior and flexor digitorum longus tendons.[2]
• Brachial artery: The brachial artery is palpable medial to the biceps tendon in the antecubital fossa.[3]

Indications

The ABI has uses in screening, diagnosis, treatment, guidance, and prognosis. See the clinical relevance section for further information.

Contraindications

The contraindications for ABI include the following:

• Deep vein thrombosis: The American Heart Association guidelines recommend avoiding compression of the extremity with known or suspected deep vein thrombosis due to concern for breaking and embolizing a thrombus.[4]
• Severe leg pain: Performing ABI measurement requires significant pressure to be applied to the leg. Whether related to leg ischemia, fracture/swelling, or wounds, this procedure can cause significant pain for the patient.

Equipment

The 2 techniques used for ABI include the following:

Manual Technique

• Compression device: Blood pressure cuff (sphygmomanometer); appropriate size is  “width at least 40% of the limb circumference”[4]
• Pulse detection device: doppler or stethoscope

Automated Technique

Oscillometer: Use regular cuff for calf diameter less than 35 cm and large cuff for over 35 cm. Take note: there are limits to using an automated device as the device has difficulty reading low blood pressure. Also, there is a concern the value is less accurate as the device detects the point of maximum impulse, which is more consistent with the mean arterial pressure.[5]

Personnel

An ABI is a tool that can be used by many medical providers, including physicians, nurse practitioners/physician extenders, and nurses. Resuts from one study showed in the general practice setting that nurses were the highest utilizer of this diagnostic tool.[6][7]

This tool plays a valuable clinical role across many specialties, including:

• Medicine
• Primary care
• Vascular surgery
• Plastic surgery
• Trauma
• Orthopedic surgery
• Podiatry
• Emergency medicine
• Wound care

Preparation

The steph for preparing for an ABI include the following:

• Rest patient: Different guidelines suggest the patient should have a specific rest period before assessing ABI, ranging from 10 to 30 minutes.
• Avoid nicotine: Study results show that smoking selectively affects the ankle but not the brachial systolic pressure, resulting in artificially elevated values.[4]
• Supine position: There is a documented increase in the ABI value by approximately 0.3 with sitting instead of the supine position.[8]
• Quiet space: Avoid underestimating systolic pressure due to difficulty with the audibility of systolic sounds.
• Supported limbs: Reduces motion, and the patient is more likely to be relaxed.
• Cover wounds: Reduce the risk of contaminating wounds or equipment.

Technique or Treatment

Cuff Application Sites for ABI

• Arm: Mid-arm
• Ankle: Above level of malleoli
• For the manual method, apply a stethoscope or Doppler to sites of brachial, dorsalis pedis (DP), and posterior arteries as described in the anatomy section.
• Inflate cuff 20 to 30mm Hg above the last heard sound, then slowly release pressure. The first heart sound is the pressure that should be recorded as the systolic pressure at that site.
• Order: The American Heart Association suggests performing the order of measurements as follows: First arm, same side ankle, opposite leg, and opposite arm.[4]
• If there is a 10 mm Hg difference in the arm, it is recommended to recheck the initial arm to address the “white coat effect” of blood pressure measurement.[9]

Calculation: The calculation is the ratio of the systolic pressure at the ankle over the systolic pressure at the arm. The appropriate value to use for systolic ankle pressure has been a subject of debate. The most commonly used is the highest value of the ankle values.[10] One study looked at alternative methods, including average values, dorsalis pedis only, posterior tibial only, and lowest values. This study suggests all have prognostic value. The difference is the “threshold” for abnormal values and varies slightly (0.87 to 0.95).

Complications

Studies demonstrate value variability based on experience and the same patient on different days and between offices/specialties.[11] Results from one study suggests repeatability is the best when using a high ankle/highest arm.[12] A suggested minimal significant difference between recorded ABI values is 0.15. Also, consider training. About one-third of providers who reported performing procedures demonstrated “correct” use per study.[7]

Clinical Significance

The following provides the clinical significance for ABI:

Values

• Normal: 0.9 to 1.4 [13]
• High: greater than 1.4, typically indicative of vessel stiffening
• Low: less than 0.9 means narrowing of vessels
• Non-measurable: Unable to occlude blood vessels at 300 mm Hg of pressure application

Minimal variations in ABI value occur with race, sex, age, and height, but the overall predictability of peripheral artery disease (PAD) is similar among groups.[13][14] Special considerations for the pediatric population: In early infancy, ABI values average lower values than adults (58% below 0.9); however, ABI reaches normal values after 12 months.[15] Studies support use in the pediatric population to reduce radiation exposure to more invasive tests with good reliability.[16] In general, the variation in measurements is less in young, healthy individuals.

Clinical Uses

Peripheral arterial disease 

The American Heart Association suggests clinicians consider evaluating patients who smoke, are over 50, patients with diabetes, or older than 70 for peripheral arterial disease.[4] In one screening study involving patients who were asymptomatic and at least 50, 20% were identified to have PAD.[17] One study suggested that providers in the general medical community use the information to initiate cardiovascular risk reduction interventions.[7] Peripheral arterial disease results suggest that ABI is better at detecting greater than 50% stenosis and proximal lesions better than distal lesions.[18] Both low and high ABI values have an independent association with cardiovascular events.[14] Also, abnormal ABI correlates with the risk of chronic kidney disease.[19]

Several studies have used ABI for predicting additional risk due to low invasiveness and relative ease of performance to the test:

• Studies show correlations of ABI less than 0.9 with increased risk for peripheral vascular disease, myocardial infarction, renal disease, and hypertension.[20]
• Lower ABI also correlates with a high carotid plaque score.[21]
• There is a higher risk of recurrent stroke (hazard ratio [HR] 1.7) and vascular events/death (2.22).[22]

Ulcer management

Traditionally, ABI was thought to have a role in wound healing. One study evaluating heel wounds showed that ABI was not reliable for heel pressure sores.[23] Another study suggested that ABI is predictive of further need for amputation in diabetic wounds but not in wound healing itself.[24] An ABI under 0.5 increased the likelihood of amputation by 40%.[25] ABI is useful in the evaluation of critical limb ischemia. One management protocol suggests that a normal or inability to perform ABI warrants more invasive evaluation in the setting of critical limb ischemia. If there is an abnormality in the ABI, promote surveillance if there is no tissue loss/gangrene and revascularization in the case of tissue loss or gangrene.[26] After revascularization, there is a correlation between change in ABI value and ulcer wound healing (ABI delta greater than or equal to 0.23, HR 1.87 for wound healing).[27]

ForPpost-surgical Healing

Surgical healing prediction:

• ABI has been reported useful in total knee arthroplasty procedures. Lower ABI (less than 0.7) shows an increased chance of total knee arthroplasty failure.[28]
• Patients with lower ABI are more likely to have delayed healing when undergoing heart surgery.[29]
• Evaluation of flap placement in foot/ankle trauma 0.9 to 1.2.[30]

Trauma

ABI has a role in the initial evaluation and management of blunt trauma and knee dislocations as a method of assessing for vascular injury.[31][32][33][34] The widely used criterion is an ABI less than 0.9 as an abnormal value for knee dislocations. For low values (less than 0.9), further evaluation is warranted, including methods such as ultrasound, magnetic resonance imaging, computed tomography, and angiography. For values greater than 0.9, serial monitoring is recommended (48 to 72 hours).[35][36] ABI can be correlated with physical exam monitoring, exhibiting good reliability (sensitivity ABI 49.5% vs ABI + exam 100%); however, if the 2 do not agree, further evaluation may be warranted.[37][38]

Claudication

Occult PAD in 20% of patients referred to orthopedic surgery for leg pain in patients over 50 years old.[17] Results from one study found that the value of the ABI was not necessarily predictive of current functional status. Still, there is a prognostic value with a greater likelihood of decreased functional status over time with lower baseline values.[20][39] Also, there are conditions associated with claudication unrelated to arterial disease. These conditions include functional popliteal syndrome and exercise-induced leg pain.[40][41] In these individuals, muscle hypertrophy of the soft tissues can lead to vessel occlusion, which is important to note/consider when evaluating a patient for exertional compartment syndrome, as these patients would not be expected to improve after fasciotomy.

Enhancing Healthcare Team Outcomes

The use of ABI for patient care requires knowledgeable individuals who are trained to do so. Training is necessary for the full team of providers, including clinicians, mid-level practitioners, nurses, and ultrasonographers. One randomized control trial evaluated the optimal way to teach the ABI procedure to medical students. The study compared didactic versus experiential learning. Results showed that experiential learning significantly improved the ability to perform the test correctly and accurately.[42] Performance, application, and interpretation of ABI require an interprofessional team approach, including physicians, specialists, specialty-trained nurses, and ultrasound techs, all collaborating across disciplines to achieve optimal patient results.

Nursing, Allied Health, and Interprofessional Team Interventions

Performing an ABI assessment does take time; the estimated time is 15 minutes. As such, it will often fall on the duty of the nurse or ultrasound technician to perform the test to assist in clinical flow.

Wound Care Providers

Guidelines exist for monitoring wound care applications:

• Avoid compression dressing with ABI 0.5 and refer to the specialist/supervising provider
• Values 0.5 to 0.8 apply low compression only
• Greater than 0.8 may apply high compression [7][43]

Nursing, Allied Health, and Interprofessional Team Monitoring

The key to monitoring is establishing protocols for ABI. An appropriate protocol for nursing monitoring should address the following three questions: Which values should I use? What periods to perform the test? When should I notify someone?  Routine trauma monitoring for injuries such as knee dislocations has been suggested at intervals of every 2 hours. This approach should consist of clinical assessment and determination if ABI is necessary at the same time with every clinical evaluation.  Other options include ABI at specific periods (ie, a clinical exam every 2 hours and ABI every 4 hours) or only if there is a change in the clinical exam.