Ankle Brachial Index:

Best Practice for Clinicians

Wound
Ostomy and
Continence

Nurses
Society
 Ankle Brachial Index: Best Practice for Clinicians BestPracti
Definition
Ankle brachial index (ABI) is a noninvasive vascular screening
screening test to identi- This tool may be used to support the diagnosis of vascular disease by pro-
fy large vessel peripheral arterial disease by comparing systolic blood pres- viding an objective indicator of arterial perfusion to a lower extremity.
extremity. In the
sures in the ankle to the
t he higher of the brachial systolic blood pressures
pressures,, which presence of diabetes mellitus, the reading may not be accurate.
is the best&estimate
Vowden Vowden,of1996,
central systolic blood pressure (Sacks et al., 2002;
2001). ABI is also known as ankle/arm index (AAI) and resting pressure index (RPI).

Purpose
ABI
• detects large vessel peripheral
peripheral arterial disease in lower extremities
extremities (Criqui et al, 1989; Sacks
Sacks et al., 2002)
• determines adequate
adequate arterial blood flow in the lower extremities
extremities
• provides documentation
documentation of adequate arterial blood flow in lower extremities before using compression
compression therapy.
therapy.
History/Physical Finding

Assessment and Physical Findings

Before performing ABI, it is important to obtain a thorough history and physical that includes, but is not limited to the following considerations.

History/Physical Finding Considerations Decision to Proceed with ABI

Diabetes Noncompressible blood vessels or calcified ves-
sels may not give an accurate reading with the
use of a blood vessel cuff.
Taking toe pressures (TP) for patients with dia-
betes in whom lower-extremity arterial disease
(LEAD) is suspected (TP ≤ 30 indicates LEAD) is
recommended. Toe pressures are recommended if
ABI >1.3 (WOCN Society, 2002).

Pain, including • Pain may make obtaining blood pressures at • Proceed with ABI, but continuously
continuously monitor
• intermittent claudication
claudication (pain that
that occurs with ankles impossible if patient cannot tolerate pro- pain level by encouraging patient to notify a
activity and is relieved by a period of rest) cedure. (To rate pain levels, use a validated clinician if unable to tolerate the procedure.
• nocturnal leg pain
pain (pain that occurs when in bed) pain scale [e.g., Wong-Baker Faces Pain Rating • Refer to healthcare
healthcare provider for further evalua-
• resting leg pain (pain that occurs in the absence
absence Scale]). tion if unable to perform ABI because of pain.
of activity and with the legs in the dependent • Clinician should ask patient what
what has helped
position) alleviate pain.
• painf
painful
ul ulcer • Patient may need to be premedicated before ABI.
• any painful condition, such as arthritis.
arthritis.

Acute deep vein thrombosis (DVT) Applying compression with the blood pressure Do not proceed with ABI; refer to healthcare
cuff may dislodge clot. provider for further evaluation of acute DVT.

Cellulitis May not be able to obtain ankle pressure
because of patient discomfort and/or edema.
• Proceed with ABI,
ABI, but continuously monitor
monitor dis-
comfort level by encouraging the patient to notify
the clinician if unable to tolerate the procedure.
• Refer to healthcare
healthcare provider for further evalua-
tion if unable to perform ABI due to discomfort
and/or edema.

History/Physical Finding
Lower-extremity
Lower-extremity edema, lymphedema, and/or
obesity
Previous trauma or surgery to lower extremities
Absence of dorsalis pedis artery pulse and pos-
terior tibial artery pulse (with Doppler)
History of leg ulcers and/or alterations in skin
integrity
History of tobacco, caffeine, and/or alcohol
intake
Assessment and Physical Findings
Considerations Decision to Proceed with ABI
• Extremity edema, lymphedema, and/or obesity Proceed with ABI if able to obtain audible sig-
can result in diminished sound transmission. nal for pressure readings.
• Obtaining Doppler signal (sound of pulse) may
be difficult.
• May need
cuff to to use a large
accommodate larlarger
ge adult blood pressure
pressure
extremity.
• Scar tissue may
may interfere in obtaining pulses. Proceed with ABI if able to obtain signal
• May increase lower-extremi
lower-extremity ty edema. audible for pressure readings.
• Locate pulses using
using palpation or Doppler.
Doppler. Proceed with ABI if able to obtain signal audi-
Doppler is more sensitive in the presence of low ble for pressure readings.
flow or edema and in some cases you can hear
by Doppler when palpation is unable
unable to detect
pulse. Measure both dorsalis pedis and posteri-
or pulse and use the higher to calculate ABI.
ABI.
• Presence of palpable
palpable pulses does not rule
rule out
LEAD.
• Absence of dorsalis pedis artery pulse
pulse and pos-
terior tibial artery pulse is indicative of LEAD.
• Approximately 12% of the population
population has a
congenital absence of the dorsalis pedis pulse.
• ABI is obtained using a Doppler and sphyg-
momanometer to measure systolic pressures
in the brachial, dorsalis pedis, and/or poste-
rior tibial arteries.
• Previous ABI
ABI readings may be be available for Proceed with ABI.
comparison.
• Use a protective
protective barrier on the patient’s extrem-
extrem-
ity when any alterations in skin integrity are
present.
• Note degree of smoking, alcohol, and/or
and/or caf- Proceed with ABI if the patient has taken blood
feine use before assessment. Patient should be pressure medication if prescribed. Make a nota-
encouraged to be free of stimuli that elevate tion if the patient has used nicotine, caffeine, or
blood pressure, such as nicotine, caffeine, and alcohol prior to the test if it is not feasible or prac-
alcohol prior to the ABI procedure. tical to reschedule the test.
• There may already
already be a documented history of
vascular insufficiency
insufficiency..
3
 Assessment and Physical Findings
History/Physical Finding Considerations Decision to Proceed with ABI
Findings consistent with chronic venous insuf- • Previous ABI
ABI readings may be
be available for Proceed with ABI.
ficiency, including
ficiency, comparison.
• atrophy of subcutaneous
subcutaneous tissue
tissue • Cleanse, moisturize,
moisturize, and protect affected
affected area.
• hardened, thickened
thickened scaly skin (lipoder- May need to apply a protective dressing to

matosclerosis)
• brown discoloration of lower leg;
discoloration leg; brown sock openuniversal
use areas to precautions.
protect blood pressure cuff and
appearance (hemosiderin)
• braw
brawny
ny edema
edema..

Findings consistent with arterial insufficiency,

insufficiency, • May have difficulty
difficulty locating pulses with either Proceed with ABI if able to obtain signal
including palpation or Doppler.
Dopp ler. audible for pressure readings.
• loss of hair on lower
lower leg, foot, or toes
toes • May require
require further vascular evaluation.
• thinning, shiny,
shiny, taut skin
• cyano
cyanosis/pa
sis/pallor
llor on elevation
• depend
dependent
ent rubo
ruborr
• paresthesias (subjective
(subjective sensation of “pins and
needles” or other changes in sensation)
• skin temperature
temperature changes (cool lower extremi-
ties/feet/toes)
• dimini
diminished/decr
shed/decreased
eased pulses of lower extremities.
extremities.

Hypertension • Hypertensi
Hypertension
on often has no sympt
symptoms.
oms. • Proceed with ABI if hypertension is controlled.
• Take caution, if brachial blood pressure read-
read- • Refer to healthcar
healthcaree provider for evaluation of
ings are consistent with >140 mmHg systolic or uncontrolled hypertension.
>90 mmHg diastolic.

Dementia Cognitive impairment may interfere with a • Proceed with ABI if patient has ability
ability to cooperate.
patient’s ability to comprehensively interpret and • Refer to healthcar
healthcaree provider if unable to per-
follow ABI procedural instructions. form ABI due to dementia.

4
 ABI Procedure
The best ABI results are obtained when the patient is relaxed, comfortable, and • Place the patient in a flat, supine
supine position for a minimum
minimum of 10 minutes prior
prior
has an empty bladder. to the test. Place one small pillow behind the patient’s head for comfort.
To enhance the patient’s relaxation and comfort • Ask patients about recent caffeine
caffeine intake, alcohol intake, smoking, pain, and
• Expla
Explain
in the procedure
procedure.. heavy activity as these can all affect blood pressure readings.
readings.
• Remove tight clothing
clothing so that the blood pressure
pressure cuff can be easily applied
to the arms and lower legs.

Follow-Up
If the ABI is >0.9, continue to monitor clinical presentation of circulatory sta- Periodic measurements of the ABI are indicated for nonhealing leg wounds.
tus and/or wound. If the ABI is > 1.3, this may be indicative of noncompress-
noncompress- Patients with arterial insufficiency should have the ABI periodically reevaluat-
ible blood vessels, as in diabetes. Suggest alternate testing methods (e.g., tran- ed (every 3 months) as it may decrease over time.
scutaneous oximetry).
Referral
• Recommend
Recommend that referring healthcare provider
provider consider referral to vascular • Notify referring healthcare
healthcare provider of any significant inconsistency
inconsistency between
surgeon if ABI results are borderline (<0.6 to 0.8) or severe ischemia (<0.5). ABI readings and clinical observations.
• Refer if there is a falsely elevated reading due to noncompressible blood ves- • Alert referring healthcare provider
provider if there is inability to perform ABI for any
sels,including
ods which frequently accompanies diabetes.
photoplethysmography (PPG) orSuggest alternativeoximetry.
transcutaneous testing meth- reason.

Documentation
• Document all brachial and ankle B/P readings in the medical record,
record, noting • Describe the patient’s
patient’s tolerance of the procedure.
procedure.
any differences between extremities (>5–10 mmHg). If subclavian stenosis is • Document the ABI ABI value by perfusion status—normal,
status—normal, LEAD, borderline,
present, systolic pressure differences
differences of >15–20 mmHG or greater may occur. severe, or critical ischemia perfusion (WOCN Society,
Society, 2002). Include an indi-
• If a waveform is obtained
obtained with the procedure,
procedure, it must be interpreted
interpreted by a cation of the patient’s understanding.
qualified clinician and should be placed in the medical record with the ABI • Request for
for a vascular referral,
referral, if applicable.
results. • Schedule follow-up appointment(s)
appointment(s)..