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Ankle-brachial index

Article  in  Canadian family physician Medecin de famille canadien · March 2013

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Top 10 Forgotten Diagnostic Procedures
Ankle-brachial index
David Ponka MD CM CCFP(EM) FCFP  Faisal Baddar MD CM CCFP

Contraindications
Acute ischemic limb.

Applications
Provisional diagnosis of peripheral arterial disease.

Equipment necessary
• A 5- to 10-MHz vascular Doppler probe with a narrow
head. (In a pinch, a fetal probe can be used.)
• Acoustic gel
• Sphygmomanometer

Set-up
The patient lies in the supine position for this pro-
cedure. Take the patient’s systolic pressure in each
arm with the sphygmomanometer and Doppler probe
(placed at the level of the radial or brachial artery) and
record. Next, affix the cuff on the leg at the level of
the calf and repeat, following the procedure described
below. Avoid errors by keeping the probe on the artery
while inflating the cuff. for verification bias. This corresponds to a stenosis
greater than 50% anywhere in a lower extremity. 
Procedure
1. Using the Doppler probe, locate the artery with the Diagnostic confirmation
strongest signal (either dorsalis pedis or posterior tib- Formal Doppler studies and angiography can confirm
ial); this is the one you will use for the test. To deter- the diagnosis. Consider referring the patient for vascular
mine the pressure, the probe must be consistently at surgery if the ankle-brachial index is less than 0.80 or if
an angle over the artery in the direction of the signal. clinical suspicion persists. 
2. Apply the sphygmomanometer and inflate until the Dr Ponka is Associate Professor in the Department of Family Medicine at the
University of Ottawa in Ontario. Dr Baddar is a staff hospitalist at Pembroke
foot signal disappears. Deflate until the signal is audi- Regional Hospital and a community preceptor in the Department of Family
ble in the foot and record this value. Medicine at the University of Ottawa.

3. Repeat on the contralateral side. Reference

1. Lijmer JG, Hunink MG, van den Dungen JJ, Loonstra J, Smit AJ. ROC analy-
4. Now you can calculate the ankle-brachial index for sis of noninvasive tests for peripheral arterial disease. Ultrasound Med Biol
either leg by dividing the leg systolic pressure by the 1996;22(4):391-8.

arm systolic pressure.

Evidence
In examining the femoral and popliteal pulsatility indi-
ces, ankle-brachial index, and, when available, angi-
ography results, it was shown that a likelihood
ratio of 3.0 could be attained for an ankle-brachial
index threshold of 0.77 1 (or less), after correction
The physical examination is facing extinction in modern
medicine. The Top Ten Forgotten Diagnostic Procedures
series was developed as a teaching tool for residents in family
medicine to reaffirm the most important examination-
based diagnostic procedures, once commonly used in
everyday practice. For a complete pdf of the Top Ten
Forgotten Diagnostic Procedures, go to http://dl.dropbox.
com/u/24988253/bookpreview%5B1%5D.pdf.

270  Canadian Family Physician • Le Médecin de famille canadien | Vol 59:  march • mars 2013
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