Ankle-Brachial Index

The ankle-brachial index (ABI) is considered the primary diagnostic test for PAD. An ABI < 0.9 is up to
95% sensitive and 99% specific for the detection of angiographically confirmed PAD [19]. A simple ABI
test can be performed in the office setting, using a hand-held Doppler device (5- or 10-MHz) with
acoustic gel and appropriately sized (10-12 cm) blood pressure cuffs. With the patient resting in a supine
position, the ABI is obtained by measuring the systolic pressure at the bilateral brachial, anterior tibial,
and posterior tibial arteries. The ABI for each leg is calculated by dividing the higher of the two ankle
systolic pressures by the higher of the two brachial pressures [20]. The ABI measurement technique is
illustrated in FIGURE 1.
An ABI < 0.9 establishes the PAD diagnosis. The ABI is also considered an adequate measure of overall
lower extremity perfusion and therefore can be readily used to quantify disease severity as shown in the
table:

Limitations of the ABI:

 Medial arterial calcification resulting in non-compressible arteries may lead to false elevation
(ABI > 1.4) or artificial normalization of ABI

 ABI may be normal or borderline at rest in patients with aortoiliac disease

Exercise ABI

In the case of normal resting ABIs in patients with a high clinical suspicion for PAD, an exercise ABI is
helpful to establish the PAD diagnosis. Exercise ABI testing is performed in the vascular laboratory using
a treadmill at a 12% grade at 1.5-2mph for at least 5 minutes with the goal of reproducing exertional leg
symptoms. A 15-20% drop in the ABI following exercise is diagnostic of PAD. Exercise ABI testing is also
useful for objective assessment of functional limitation in patients who report exertional leg symptoms.

References

19. Fowkes FG. The measurement of atherosclerotic peripheral arterial disease in epidemiologic surveys.
Int J Epidemiol. 1998;17:248-254.

20. Ouriel K, Zarins CK. Doppler ankle pressure: An evaluation of three methods of expression. Arch Surg.
1982;117:1297-1300.