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Ghirardini F, Martini R. Current Opinion on Diagnosis of Peripheral Artery Disease in Diabetic Patients. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1179. [PMID: 39064610 PMCID: PMC11279131 DOI: 10.3390/medicina60071179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 07/16/2024] [Accepted: 07/18/2024] [Indexed: 07/28/2024]
Abstract
Peripheral arterial disease (PAD) prevalence and diabetes mellitus (DM) prevalence are continuously increasing worldwide. The strong relationship between DM and PAD is highlighted by recent evidence. PAD diagnosis in diabetic patients is very important, particularly in patients with diabetic foot disease (DFD); however, it is often made difficult by the characteristics of such diseases. Diagnosing PAD makes it possible to identify patients at a very high cardiovascular risk who require intensive treatment in terms of risk factor modification and medical therapy. The purpose of this review is to discuss the diagnostic methods that allow for a diagnosis of PAD in diabetic patients. Non-invasive tests that address PAD diagnosis will be discussed, such as the ankle-brachial index (ABI), toe pressure (TP), and transcutaneous oxygen pressure (TcPO2). Furthermore, imaging methods, such as duplex ultrasound (DUS), computed tomography angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA), are described because they allow for diagnosing the anatomical localization and severity of artery stenosis or occlusion in PAD. Non-invasive tests will also be discussed in terms of their ability to assess foot perfusion. Foot perfusion assessment is crucial in the diagnosis of critical limb ischemia (CLI), the most advanced PAD stage, particularly in DFD patients. The impacts of PAD diagnosis and CLI identification in diabetic patients are clinically relevant to prevent amputation and mortality.
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Affiliation(s)
| | - Romeo Martini
- Department of Angiology, San Martino Hospital, 32100 Belluno, Italy;
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2
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:2497-2604. [PMID: 38752899 DOI: 10.1016/j.jacc.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1313-e1410. [PMID: 38743805 DOI: 10.1161/cir.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Chuter V, Schaper N, Mills J, Hinchliffe R, Russell D, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, van den Berg JC, Venermo M, Fitridge R. Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: A systematic review. Diabetes Metab Res Rev 2024; 40:e3683. [PMID: 37477087 DOI: 10.1002/dmrr.3683] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/22/2023]
Abstract
As a progressive disease process, early diagnosis and ongoing monitoring and treatment of lower limb peripheral artery disease (PAD) is critical to reduce the risk of diabetes-related foot ulcer (DFU) development, non-healing of wounds, infection and amputation, in addition to cardiovascular complications. There are a variety of non-invasive tests available to diagnose PAD at the bedside, but there is no consensus as to the most diagnostically accurate of these bedside investigations or their reliability for use as a method of ongoing monitoring. Therefore, the aim of this systematic review was to first determine the diagnostic accuracy of non-invasive bedside tests for identifying PAD compared to an imaging reference test and second to determine the intra- and inter-rater reliability of non-invasive bedside tests in adults with diabetes. A database search of Medline and Embase was conducted from 1980 to 30 November 2022. Prospective and retrospective investigations of the diagnostic accuracy of bedside testing in people with diabetes using an imaging reference standard and reliability studies of bedside testing techniques conducted in people with diabetes were eligible. Included studies of diagnostic accuracy were required to report adequate data to calculate the positive likelihood ratio (PLR) and negative likelihood ratio (NLR) which were the primary endpoints. The quality appraisal was conducted using the Quality Assessment of Diagnostic Accuracy Studies and Quality Appraisal of Reliability quality appraisal tools. From a total of 8517 abstracts retrieved, 40 studies met the inclusion criteria for the diagnostic accuracy component of the review and seven studies met the inclusion criteria for the reliability component of the review. Most studies investigated the diagnostic accuracy of ankle -brachial index (ABI) (N = 38). In people with and without DFU, PLRs ranged from 1.69 to 19.9 and NLRs from 0.29 to 0.84 indicating an ABI <0.9 increases the likelihood of disease (but the extent of the increase ranges from a small to large amount) and an ABI within the normal range (≥0.90 and <1.3) does not exclude PAD. For toe-brachial index (TBI), a threshold of <0.70 has a moderate ability to rule PAD in and out; however, this is based on limited evidence. Similarly, a small number of studies indicate that one or more monophasic Doppler waveforms in the pedal arteries is associated with the presence of PAD, whereas tri- or biphasic waveform suggests that PAD is less likely. Several forms of bedside testing may also be useful as adjunct tests and 7 studies were identified that investigated the reliability of bedside tests including ABI, toe pressure, TBI, transcutaneous oxygen pressure (TcPO2 ) and pulse palpation. Inter-rater reliability was poor for pulse palpation and moderate for TcPO2. The ABI, toe pressure and TBI may have good inter- and intra-rater reliability, but margins of error are wide, requiring a large change in the measurement for it to be considered a true change rather than error. There is currently no single bedside test or a combination of bedside tests that has been shown to have superior diagnostic accuracy for PAD in people with diabetes with or without DFU. However, an ABI <0.9 or >1.3, TBI of <0.70, and absent or monophasic pedal Doppler waveforms are useful to identify the presence of disease. The ability of the tests to exclude disease is variable and although reliability may be acceptable, evidence of error in the measurements means test results that are within normal limits should be considered with caution and in the context of other vascular assessment findings (e.g., pedal pulse palpation and clinical signs) and progress of DFU healing.
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Affiliation(s)
- Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Sydney, Australia
| | - Nicolaas Schaper
- Division of Endocrinology, Department of Internal Medicine, MUMC+, Maastricht, The Netherlands
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco (UCSF) Medical Centre, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland, Bern, Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Supelnic MN, Ferreira AF, Bota PJ, Brás-Rosário L, Plácido da Silva H. Benchmarking of Sensor Configurations and Measurement Sites for Out-of-the-Lab Photoplethysmography. SENSORS (BASEL, SWITZERLAND) 2023; 24:214. [PMID: 38203076 PMCID: PMC10781263 DOI: 10.3390/s24010214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/17/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024]
Abstract
Photoplethysmography (PPG) is used for heart-rate monitoring in a variety of contexts and applications due to its versatility and simplicity. These applications, namely studies involving PPG data acquisition during day-to-day activities, require reliable and continuous measurements, which are often performed at the index finger or wrist. However, some PPG sensors are susceptible to saturation, motion artifacts, and discomfort upon their use. In this paper, an off-the-shelf PPG sensor was benchmarked and modified to improve signal saturation. Moreover, this paper explores the feasibility of using an optimized sensor in the lower limb as an alternative measurement site. Data were collected from 28 subjects with ages ranging from 18 to 59 years. To validate the sensors' performance, signal saturation and quality, wave morphology, performance of automatic systolic peak detection, and heart-rate estimation, were compared. For the upper and lower limb locations, the index finger and the first toe were used as reference locations, respectively. Lowering the amplification stage of the PPG sensor resulted in a significant reduction in signal saturation, from 18% to 0.5%. Systolic peak detection at rest using an automatic algorithm showed a sensitivity and precision of 0.99 each. The posterior wrist and upper arm showed pulse wave morphology correlations of 0.93 and 0.92, respectively. For these locations, peak detection sensitivity and precision were 0.95, 0.94 and 0.89, 0.89, respectively. Overall, the adjusted PPG sensors are a good alternative for obtaining high-quality signals at the fingertips, and for new measurement sites, the posterior pulse and the upper arm allow for high-quality signal extraction.
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Affiliation(s)
- Max Nobre Supelnic
- Department of Bioengineering (DBE), Instituto Superior Técnico (IST), 1049-001 Lisbon, Portugal; (P.J.B.); (H.P.d.S.)
| | - Afonso Fortes Ferreira
- Instituto de Engenharia de Sistemas e Computadores—Microsistemas e Nanotecnologias (INESC MN), 1000-029 Lisbon, Portugal;
| | - Patrícia Justo Bota
- Department of Bioengineering (DBE), Instituto Superior Técnico (IST), 1049-001 Lisbon, Portugal; (P.J.B.); (H.P.d.S.)
- Instituto de Telecomunicações (IT), 1049-001 Lisbon, Portugal
| | - Luís Brás-Rosário
- Cardiology Department, Santa Maria University Hospital (CHLN), Lisbon Academic Medical Centre, 1649-028 Lisbon, Portugal;
- Cardiovascular Centre of the University of Lisbon, Lisbon School of Medicine, 1649-028 Lisbon, Portugal
| | - Hugo Plácido da Silva
- Department of Bioengineering (DBE), Instituto Superior Técnico (IST), 1049-001 Lisbon, Portugal; (P.J.B.); (H.P.d.S.)
- Instituto de Telecomunicações (IT), 1049-001 Lisbon, Portugal
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Heitner TJ, Livneh A, Landesberg A. Novel Peripheral Perfusion Dynamics Indices for Detecting and Grading Arterial Stenosis. Cardiovasc Eng Technol 2023; 14:774-785. [PMID: 37985616 DOI: 10.1007/s13239-023-00686-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/11/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE Peripheral artery disease causes severe morbidity, especially in diabetics and the elderly. There is a need for accurate noninvasive detection of peripheral arterial stenosis. The study has tested the hypothesis that arterial stenosis and the associated adaptation of the downstream circulation yield characteristic changes in the leg perfusion dynamics that enable early diagnosis, utilizing impedance plethysmography. METHODS The arterial perfusion dynamic was derived from impedance plethysmography (IPG). Two degrees of arterial stenosis were emulated by inflating a blood-pressure cuff around the thigh to 45 and 90 mmHg, in healthy volunteers (n = 30). IPG signals were acquired continuously throughout the experiment. Ankle and brachial blood pressures were measured at the beginning of each experiment and at the end of each emulated stenosis phase. RESULTS Thigh compressions did not affect the pulse-transit time, but prolonged the time to the peak perfusion wave. Segmentation of the perfusion upstroke into two phases, at the time point of maximum acceleration (MAT), revealed that arterial compression prolonged only the initial slow phase duration (SPd). The MAT and SPd were proportional to the emulated stenosis severity and detected the arterial stenosis with high sensitivity (> 93%) and specificity (100%). The SPd increased from 46.4 ± 21.2 ms at baseline to 75.4 ± 38.5 ms and 145 ± 39 ms under 45 mmHg and 90 mmHg compressions (p < 0.001), without affecting the pulse-transit time. CONCLUSIONS The novel method and indices can identify and grade the emulated arterial stenosis with high accuracy and may assist in differentiating between focal arterial stenosis and widespread arterial hardening.
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Affiliation(s)
- Tomer Joshua Heitner
- Faculty of Biomedical Engineering, Technion-Israel Institute of Technology, Technion City, 32000, Haifa, Israel
| | - Amit Livneh
- Faculty of Biomedical Engineering, Technion-Israel Institute of Technology, Technion City, 32000, Haifa, Israel
| | - Amir Landesberg
- Faculty of Biomedical Engineering, Technion-Israel Institute of Technology, Technion City, 32000, Haifa, Israel.
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Brouwers JJ, Willems SA, Goncalves LN, Hamming JF, Schepers A. Reliability of bedside tests for diagnosing peripheral arterial disease in patients prone to medial arterial calcification: A systematic review. EClinicalMedicine 2022; 50:101532. [PMID: 35812995 PMCID: PMC9256539 DOI: 10.1016/j.eclinm.2022.101532] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/04/2022] [Accepted: 06/08/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Medial arterial calcification (MAC), frequently associated with diabetes mellitus (DM) and chronic kidney disease (CKD), is a systemic vascular disorder leading to stiffness and incompressible arteries. These changes impede the accuracy of bedside tests to diagnose peripheral arterial disease (PAD). This review aimed to evaluate the reliability of bedside tests for the detection of PAD in patients prone to MAC. METHODS A systematic search (Pubmed, Embase, Web of Science, Cochrane, and Emcare) was performed according to the PRISMA guidelines to identify relevant studies providing data on the performance of bedside tests for the detection of PAD in patients prone to MAC. Studies were included when bedside test were compared to a reference standard. Primary endpoints were the positive and negative likelihood ratios (PLR, NLR). Methodological quality and risk of bias were evaluated using the QUADAS-2 tool. FINDINGS In total, 23 studies were included in this review. The most commonly evaluated test was the ankle-brachial index (ABI), followed by toe-brachial index (TBI), toe pressure (TP) measurements, and continuous wave Doppler (CWD). The majority of patients were older, male, and had DM. We found that ABI <0·9 was helpful to diagnose PAD, but failed to rule out PAD (NLR >0·2). The same applied for TP (NLR >0·3) and TBI (5 out of 6 studies revealed an NLR >0·2). CWD (loss of triphasic pattern) is reliable to exclude PAD (NLR 0-0·09), but was only validated in two studies. Overall, methodological quality was poor which led to risk of bias in 20 studies. INTERPRETATION The diagnosis of PAD in patients prone to MAC remains challenging. The ABI performed reasonably in the diagnosis of PAD, while the CWD (loss of triphasic signal) can be used to rule out PAD. This systematic review showed that test performances were generally poor with serious concerns in methodological quality of the included studies. We therefore counsel against the use of a single bedside test. FUNDING None to declare.
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Affiliation(s)
- Jeroen J.W.M. Brouwers
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Surgery, Haga Teaching Hospital, the Hague, the Netherlands
- Corresponding author at: Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands.
| | - Siem A. Willems
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Surgery, Haga Teaching Hospital, the Hague, the Netherlands
| | - Lauren N. Goncalves
- Department of Surgery, Haaglanden Medical Center, the Hague, the Netherlands
| | - Jaap F. Hamming
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Abbey Schepers
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands
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Kashetsky N, Sachdeva M, Lu JD, Mufti A, Kim P, Bagit A, Sibbald RG. Diagnostic Accuracy of Ankle-Brachial Pressure Index Compared with Doppler Arterial Waveforms for Detecting Peripheral Arterial Disease: A Systematic Review. Adv Skin Wound Care 2022; 35:195-201. [PMID: 35311767 DOI: 10.1097/01.asw.0000822628.82131.1d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
GENERAL PURPOSE To present the results of a research study evaluating the diagnostic accuracy of the ankle-brachial pressure index (ABPI) compared with that of Doppler arterial waveforms (DAWs) to detect peripheral arterial disease (PAD). TARGET AUDIENCE This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES After completing this continuing education activity, the participant will:1. Summarize the evidence the authors considered when comparing the diagnostic accuracy of the ABPI with that of Doppler arterial waveforms to detect PAD.2. Select the characteristics of the participants in the studies the authors analyzed.3. Identify the results of the authors' study comparing the diagnostic accuracy of the ABPI with that of Doppler arterial waveforms to detect PAD.4. Distinguish the authors' conclusions about the advantages of using Doppler arterial waveforms to detect PAD.
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Charlton PH, Paliakaitė B, Pilt K, Bachler M, Zanelli S, Kulin D, Allen J, Hallab M, Bianchini E, Mayer CC, Terentes-Printzios D, Dittrich V, Hametner B, Veerasingam D, Žikić D, Marozas V. Assessing hemodynamics from the photoplethysmogram to gain insights into vascular age: A review from VascAgeNet. Am J Physiol Heart Circ Physiol 2021; 322:H493-H522. [PMID: 34951543 PMCID: PMC8917928 DOI: 10.1152/ajpheart.00392.2021] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
The photoplethysmogram (PPG) signal is widely measured by clinical and consumer devices, and it is emerging as a potential tool for assessing vascular age. The shape and timing of the PPG pulse wave are both influenced by normal vascular aging, changes in arterial stiffness and blood pressure, and atherosclerosis. This review summarizes research into assessing vascular age from the PPG. Three categories of approaches are described: 1) those which use a single PPG signal (based on pulse wave analysis), 2) those which use multiple PPG signals (such as pulse transit time measurement), and 3) those which use PPG and other signals (such as pulse arrival time measurement). Evidence is then presented on the performance, repeatability and reproducibility, and clinical utility of PPG-derived parameters of vascular age. Finally, the review outlines key directions for future research to realize the full potential of photoplethysmography for assessing vascular age.
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Affiliation(s)
- Peter H Charlton
- Department of Public Health and Primary Care, University of Cambridge, United Kingdom.,Research Centre for Biomedical Engineering, City, University of London, London, United Kingdom
| | - Birutė Paliakaitė
- Biomedical Engineering Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Kristjan Pilt
- Department of Health Technologies, Tallinn University of Technology, Tallinn, Estonia
| | - Martin Bachler
- Biomedical Systems, Center for Health and Bioresources, AIT Austrian Institute of Technology, Vienna, Austria
| | - Serena Zanelli
- Laboratoire Analyse, Géométrie et Applications (LAGA), University Sorbonne Paris Nord, Paris, France.,Axelife, 44460 Saint Nicolas de Redon, France
| | - Daniel Kulin
- Institute of Translational Medicine, Semmelweis University, Budapest, Hungary.,E-Med4All Europe Ltd., Budapest, Hungary
| | - John Allen
- Research Centre for Intelligent Healthcare, Coventry University, Coventry, United Kingdom.,Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Magid Hallab
- Axelife, 44460 Saint Nicolas de Redon, France.,Centre de recherche et d'Innovation, Clinique Bizet, Paris, France
| | | | - Christopher C Mayer
- Biomedical Systems, Center for Health and Bioresources, AIT Austrian Institute of Technology, Vienna, Austria
| | - Dimitrios Terentes-Printzios
- Hypertension and Cardiometabolic Unit, First Department of Cardiology, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Bernhard Hametner
- Biomedical Systems, Center for Health and Bioresources, AIT Austrian Institute of Technology, Vienna, Austria
| | - Dave Veerasingam
- Department of Cardiothoracic Surgery, Galway University Hospitals, Ireland
| | - Dejan Žikić
- Institute of Biophysics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vaidotas Marozas
- Biomedical Engineering Institute, Kaunas University of Technology, Kaunas, Lithuania
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10
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Chuter VH, Searle A, Barwick A, Golledge J, Leigh L, Oldmeadow C, Peterson B, Tehan P, Twigg SM. Estimating the diagnostic accuracy of the ankle-brachial pressure index for detecting peripheral arterial disease in people with diabetes: A systematic review and meta-analysis. Diabet Med 2021; 38:e14379. [PMID: 32740980 DOI: 10.1111/dme.14379] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/16/2020] [Accepted: 07/27/2020] [Indexed: 12/18/2022]
Abstract
AIM To systematically evaluate research investigating the accuracy of the ankle-brachial index (ABI) for diagnosing peripheral artery disease (PAD) in people with diabetes, as the accuracy is thought to be reduced in this cohort. METHODS A database search of EBSCO Megafile Premier, Embase and The Cochrane Library was conducted to 28 February 2019. Prospective and retrospective investigations of the diagnostic accuracy of the ABI for PAD in people with diabetes using an imaging reference standard were eligible. Sensitivity and specify of the ABI and bivariate meta-analysis against reference tests, or a standard summary receiver operating curve analysis (SROC) was performed. RESULTS Thirty-three studies met the inclusion criteria. ABI was compared with angiography in 12 studies and with colour duplex ultrasound (CDUS) in 21 studies. A SROC analysis of studies using angiography as the reference standard found a diagnostic odds ratio (DOR) of 9.06 [95% confidence interval (CI) 3.61 to 22.69], and area under the curve (AUC) of 0.76 (95% CI 0.66 to 0.86). Bivariate analysis of studies using CDUS demonstrated mean sensitivity of 0.60 (95% CI 0.48 to 0.71; P = 0.097) and mean specificity of 0.87 (95% CI 0.78 to 0.92; P < 0.001) with a DOR of 9.76 (95% CI 5.24 to 18.20; P < 0.0001) and AUC 0.72. CONCLUSIONS These results suggest the ABI has a high specificity but lower sensitivity in detecting imaging diagnosed PAD in people with diabetes. The low probability of the testing being able to rule diagnosis in or out suggest that the ABI has limited effectiveness for early detection of PAD in this cohort.
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Affiliation(s)
- V H Chuter
- School of Health Sciences, Townsville, QLD, Australia
- Priority Research Centre for Physical Activity and Nutrition, The University of Newcastle, Townsville, QLD, Australia
| | - A Searle
- School of Health Sciences, Townsville, QLD, Australia
| | - A Barwick
- School of Health Sciences, Townsville, QLD, Australia
| | - J Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, QLD, Australia
| | - L Leigh
- Hunter Medical Research Institute, Newcastle, Australia
| | - C Oldmeadow
- Hunter Medical Research Institute, Newcastle, Australia
| | - B Peterson
- School of Health Sciences, Townsville, QLD, Australia
| | - P Tehan
- School of Health Sciences, Townsville, QLD, Australia
| | - S M Twigg
- Sydney Medical School (Central), Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Herraiz-Adillo Á, Cavero-Redondo I, Álvarez-Bueno C, Pozuelo-Carrascosa DP, Solera-Martínez M. The accuracy of toe brachial index and ankle brachial index in the diagnosis of lower limb peripheral arterial disease: A systematic review and meta-analysis. Atherosclerosis 2020; 315:81-92. [DOI: 10.1016/j.atherosclerosis.2020.09.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 09/05/2020] [Accepted: 09/24/2020] [Indexed: 12/24/2022]
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12
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Cooper K, Majdalany BS, Kalva SP, Chandra A, Collins JD, Francois CJ, Ganguli S, Gornik HL, Kendi AT, Khaja MS, Minocha J, Norton PT, Obara P, Reis SP, Sutphin PD, Rybicki FJ. ACR Appropriateness Criteria ® Lower Extremity Arterial Revascularization-Post-Therapy Imaging. J Am Coll Radiol 2019; 15:S104-S115. [PMID: 29724414 DOI: 10.1016/j.jacr.2018.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/04/2018] [Indexed: 02/07/2023]
Abstract
Peripheral arterial disease (PAD) affects millions across the world and in the United States between 9% to 23% of all patients older than 55 years. The refinement of surgical techniques and evolution of endovascular approaches have improved the success rates of revascularization in patients afflicted by lower extremity PAD. However, restenosis or occlusion of previously treated vessels remains a pervasive issue in the postoperative setting. A variety of different imaging options are available to evaluate patients and are reviewed within the context of asymptomatic and symptomatic patients with PAD who have previously undergone endovascular or surgical revascularization. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Kyle Cooper
- Research Author, University of Michigan Health System, Ann Arbor, Michigan
| | - Bill S Majdalany
- Principal Author and Panel Vice-Chair, University of Michigan Health System, Ann Arbor, Michigan.
| | | | - Ankur Chandra
- Scripps Green Hospital, La Jolla, California; Society for Vascular Surgery
| | | | | | | | - Heather L Gornik
- Cleveland Clinic Heart and Vascular Institute, Cleveland, Ohio; American College of Cardiology
| | | | | | - Jeet Minocha
- University of California, San Diego, San Diego, California
| | | | - Piotr Obara
- Loyola University Medical Center, Maywood, Illinois
| | | | | | - Frank J Rybicki
- Specialty Chair, Ottawa Hospital Research Institute and the Department of Radiology, The University of Ottawa, Ottawa, Ontario, Canada
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Bentham M, Stansby G, Allen J. Innovative Multi-Site Photoplethysmography Analysis for Quantifying Pulse Amplitude and Timing Variability Characteristics in Peripheral Arterial Disease. Diseases 2018; 6:diseases6030081. [PMID: 30227612 PMCID: PMC6165367 DOI: 10.3390/diseases6030081] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 09/01/2018] [Accepted: 09/05/2018] [Indexed: 11/17/2022] Open
Abstract
Photoplethysmography (PPG) is a simple-to-perform vascular optics measurement technique that can detect blood volume changes in the microvascular bed of tissue. Beat-to-beat analysis of the PPG waveform enables the study of the variability of pulse features, such as the amplitude and the pulse arrival time (PAT), and when quantified in the time and frequency domains, has considerable potential to shed light on perfusion changes associated with peripheral arterial disease (PAD). In this pilot study, innovative multi-site bilateral finger and toe PPG recordings from 43 healthy control subjects and 31 PAD subjects were compared (recordings each at least five minutes, collected in a warm temperature-controlled room). Beat-to-beat normalized amplitude variability and PAT variability were then quantified in the time-domain using two simple statistical measures and in the frequency-domain bilaterally using magnitude squared coherence (MSC). Significantly reduced normalized amplitude variability (healthy control 0.0384 (interquartile range 0.0217–0.0744) vs. PAD 0.0160 (0.0080–0.0338) (p < 0.0001)) and significantly increased PAT variability (healthy control 0.0063 (0.0052–0.0086) vs. PAD 0.0093 (0.0078–0.0144) (p < 0.0001)) was demonstrated for the toe site in PAD using the time-domain analysis. Frequency-domain analysis demonstrated significantly lower MSC values across a range of frequency bands for PAD patients. These changes suggest a loss of right-to-left body side coherence and cardiovascular control in PAD. This study has also demonstrated the feasibility of using these measurement and analysis methods in studies investigating multi-site PPG variability for a wide range of cardiac and vascular patient groups.
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Affiliation(s)
- Michael Bentham
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK.
| | - Gerard Stansby
- Northern Vascular Centre, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK.
| | - John Allen
- Northern Medical Physics and Clinical Engineering, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK.
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Shabani Varaki E, Gargiulo GD, Penkala S, Breen PP. Peripheral vascular disease assessment in the lower limb: a review of current and emerging non-invasive diagnostic methods. Biomed Eng Online 2018; 17:61. [PMID: 29751811 PMCID: PMC5948740 DOI: 10.1186/s12938-018-0494-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/02/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Worldwide, at least 200 million people are affected by peripheral vascular diseases (PVDs), including peripheral arterial disease (PAD), chronic venous insufficiency (CVI) and deep vein thrombosis (DVT). The high prevalence and serious consequences of PVDs have led to the development of several diagnostic tools and clinical guidelines to assist timely diagnosis and patient management. Given the increasing number of diagnostic methods available, a comprehensive review of available technologies is timely in order to understand their limitations and direct future development effort. MAIN BODY This paper reviews the available diagnostic methods for PAD, CVI, and DVT with a focus on non-invasive modalities. Each method is critically evaluated in terms of sensitivity, specificity, accuracy, ease of use, procedure time duration, and training requirements where applicable. CONCLUSION This review emphasizes the limitations of existing methods, highlighting a latent need for the development of new non-invasive, efficient diagnostic methods. Some newly emerging technologies are identified, in particular wearable sensors, which demonstrate considerable potential to address the need for simple, cost-effective, accurate and timely diagnosis of PVDs.
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Affiliation(s)
- Elham Shabani Varaki
- The MARCS Institute for Brain, Behaviour & Development, Western Sydney University, Penrith, NSW, 2750, Australia.
| | - Gaetano D Gargiulo
- The MARCS Institute for Brain, Behaviour & Development, Western Sydney University, Penrith, NSW, 2750, Australia
| | - Stefania Penkala
- School of Science and Health, Western Sydney University, Penrith, NSW, 2750, Australia
| | - Paul P Breen
- The MARCS Institute for Brain, Behaviour & Development, Western Sydney University, Penrith, NSW, 2750, Australia.,Translational Health Research Institute, Western Sydney University, Penrith, NSW, 2750, Australia
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BHAT SHREYA, ADAM MUHAMMAD, HAGIWARA YUKI, NG EDDIEY. THE BIOPHYSICAL PARAMETER MEASUREMENTS FROM PPG SIGNAL. J MECH MED BIOL 2017. [DOI: 10.1142/s021951941740005x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Early investigation on blood circulation by Hertzman (1937) leads to the observation of vital body signs such as respiration rate, heart rate (HR), blood oxygenation and vascular assessment using photoplethysmographic (PPG) device. PPG is a noninvasive, painless optical technique used to monitor the pulsations linked to alteration in the blood volume. The PPG waveform is a summation of pulsatile and nonpulsatile components and contains useful information about the physiological systems. With the breakthrough in technology and development of powerful analytical tools, PPG devices are constantly being used in advanced medical equipments such as smart-watches and smart-wristbands for HR monitoring, pulse oximeters for measuring respiratory rate and noncontact PPG device for blood oxygen saturation measurement. This paper presents description on PPG and its characteristic waveform and working principle. It also includes brief explanation on nonlinear analysis of PPG signals and salient applications of PPG followed by its advantages and limitations.
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Affiliation(s)
- SHREYA BHAT
- Department of Psychiatry, St John’s Research Institute, Bangalore, India
| | - MUHAMMAD ADAM
- Department of Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore
| | - YUKI HAGIWARA
- Department of Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore
| | - EDDIE Y. K. NG
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore
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16
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Tehan PE, Chuter VH. A targeted screening method for non-invasive vascular assessment of the lower limb. J Foot Ankle Res 2016; 9:48. [PMID: 27980685 PMCID: PMC5142395 DOI: 10.1186/s13047-016-0181-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 11/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Podiatrists routinely perform non-invasive lower limb vascular assessment, however frequently cite time as a major barrier in performing regular assessment. The aim of this study was to develop an evidence-based vascular assessment method to guide podiatrists' decision-making processes to aid in timely vascular assessment in at risk populations. METHOD The sample underwent brachial pressure measurement, ankle pressures, toe pressure and Doppler waveform with colour duplex ultrasound (CFDU) used as the reference standard. Both the targeted screening method and the American Heart Association (AHA) guideline for vascular screening were then applied to the data set and sensitivity and specificity of each method was calculated. RESULTS One hundred nineteen participants were included. Sensitivity of the targeted screening method (62%, 95% CI 47.17-75.35) was higher than the AHA method (49%, 95% CI 34.75-63.40), however, specificity of the AHA method (94%, 95% CI 85.62-98.37) was higher than the targeted screening method (85%, 95% CI 74.26-92.60). Diagnostic accuracy was similar with the AHA method yielding 74% diagnostic accuracy and the targeted screening method 73%. CONCLUSION The targeted screening method and the broad international guideline demonstrated similar accuracy, however clinicians may save time using the targeted screening method. This study highlights the difficulties in obtaining accuracy in lower limb vascular assessment in general.
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Affiliation(s)
- Peta Ellen Tehan
- School of Health Sciences, Faculty of Health, University of Newcastle, Ourimbah, NSW 2258 Australia
| | - Vivienne Helaine Chuter
- School of Health Sciences, Faculty of Health, University of Newcastle, Ourimbah, NSW 2258 Australia
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Lewis JE, Williams P, Davies JH. Non-invasive assessment of peripheral arterial disease: Automated ankle brachial index measurement and pulse volume analysis compared to duplex scan. SAGE Open Med 2016; 4:2050312116659088. [PMID: 27493755 PMCID: PMC4959301 DOI: 10.1177/2050312116659088] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 06/14/2016] [Indexed: 11/17/2022] Open
Abstract
Objectives: This cross-sectional study aimed to individually and cumulatively compare sensitivity and specificity of the (1) ankle brachial index and (2) pulse volume waveform analysis recorded by the same automated device, with the presence or absence of peripheral arterial disease being verified by ultrasound duplex scan. Methods: Patients (n=205) referred for lower limb arterial assessment underwent ankle brachial index measurement and pulse volume waveform recording using volume plethysmography, followed by ultrasound duplex scan. The presence of peripheral arterial disease was recorded if ankle brachial index <0.9; pulse volume waveform was graded as 2, 3 or 4; or if haemodynamically significant stenosis >50% was evident with ultrasound duplex scan. Outcome measure was agreement between the measured ankle brachial index and interpretation of pulse volume waveform for peripheral arterial disease diagnosis, using ultrasound duplex scan as the reference standard. Results: Sensitivity of ankle brachial index was 79%, specificity 91% and overall accuracy 88%. Pulse volume waveform sensitivity was 97%, specificity 81% and overall accuracy 85%. The combined sensitivity of ankle brachial index and pulse volume waveform was 100%, specificity 76% and overall accuracy 85%. Conclusion: Combining these two diagnostic modalities within one device provided a highly accurate method of ruling out peripheral arterial disease, which could be utilised in primary care to safely reduce unnecessary secondary care referrals.
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Affiliation(s)
- Jane Ea Lewis
- Cardiff School of Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | - Paul Williams
- Department of Medical Physics, University Hospital of Wales, Cardiff, UK
| | - Jane H Davies
- South East Wales Trials Unit, Cardiff University, Cardiff, UK
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Cooper KJ, Peña C, Benenati J. Determining End Points for Critical Limb Ischemia Interventions. Tech Vasc Interv Radiol 2016; 19:104-12. [PMID: 27423992 DOI: 10.1053/j.tvir.2016.04.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Critical limb ischemia is a condition that has increased in prevalence and carries a high degree of morbidity. Although endovascular therapy for treatment of patients with critical limb ischemia has undergone significant advances with improved outcomes over the past decade, these patients often have multilevel disease, and it may take weeks or months for ulceration healing. For this reason, the acceptable therapeutic end points during and immediately following revascularization remain somewhat obscure. There are multiple tools available to guide the treating vascular specialist in this regard. Establishment of in-line flow to the foot and the angiosome containing the ulceration, appearance of a "wound blush," restoration of pulses, and bleeding at the ulcer site are basic tenets intraprocedurally. Postprocedural noninvasive testing including the ankle-brachial and toe-brachial indices, segmental pressure measurements, pulse volume recordings, transcutaneous oxygen tension, skin perfusion pressures (SPPs), and toe pressures all play a role in determining the likelihood of clinical improvement. Newer technologies such as two-dimensional (2D) perfusion angiography, fluorescence angiography, and tissue oxygen saturation mapping may allow better real-time assessment of flow restoration. In combination with close clinical follow-up and wound care, these tools provide treating physicians with a better grasp of the necessary end points to optimize patients for clinical improvement.
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Tehan PE, Bray A, Chuter VH. Non-invasive vascular assessment in the foot with diabetes: sensitivity and specificity of the ankle brachial index, toe brachial index and continuous wave Doppler for detecting peripheral arterial disease. J Diabetes Complications 2016; 30:155-60. [PMID: 26281971 DOI: 10.1016/j.jdiacomp.2015.07.019] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/15/2015] [Accepted: 07/19/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND & AIMS Non-invasive lower limb vascular assessment in people at risk of peripheral arterial disease (PAD) including those with diabetes is crucial. There is evidence that standard assessment techniques such as the ankle-brachial index (ABI) may be less effective in people with diabetes. However there is limited evidence for other frequently used tests including continuous wave Doppler (CWD), and the toe-brachial index (TBI). The aim of this study was to determine the sensitivity and specificity of, ABI, CWD and TBI in a population with, and without diabetes. METHODS Participants with and without diabetes who met current guidelines for vascular screening were recruited, and CWD waveforms, an ABI and a TBI were obtained from the right lower limb. Diagnostic accuracy was determined using colour duplex ultrasound (CFDU). Receiver operating characteristic curves were calculated. RESULTS 117 participants were recruited, seventy-two with diabetes and forty-five without diabetes. CWD had the highest sensitivity in people with diabetes (74%) and without (84%). CWD also had the highest specificity in people with diabetes (74%) and without (84%) compared to both TBI and ABI. In participants with diabetes, the ABI was a poor test, area under the curve: 0.58 (p=0.27). CONCLUSIONS CWD waveform is more likely to detect significant PAD compared to ABI and TBI in people with and without diabetes.
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Affiliation(s)
- Peta Ellen Tehan
- School of Health Sciences, Faculty of Health, University of Newcastle, Australia.
| | - Alan Bray
- Vascular Health Care, Gateshead, Australia
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Affiliation(s)
- Sevket Balta
- Department of Cardiology, Eskişehir Military Hospital, Eskişehir, Turkey
| | - Sait Demirkol
- Department of Cardiology, Gulhane Medical Academy, Ankara, Turkey
| | - Mustafa Demir
- Department of Cardiology, Gulhane Medical Academy, Ankara, Turkey
| | - Cengiz Ozturk
- Department of Cardiology, Gulhane Medical Academy, Ankara, Turkey
| | - Mustafa Aparcı
- Department of Cardiology, Etimesgut Military Hospital, Ankara, Turkey
| | - Turgay Celik
- Department of Cardiology, Gulhane Medical Academy, Ankara, Turkey
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Argyriou C, Giannoukas AD. Ankle-brachial index remains the most powerful tool for peripheral arterial disease detection in epidemiological studies. Angiology 2013; 64:483-4. [PMID: 23620312 DOI: 10.1177/0003319713485408] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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