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Approximation of the Ankle-Brachial Index in the Setting of Medial Arterial Calcific Sclerosis
Andrew J Meyr1, Sara Mateen2, Jennifer Skolnik2
1Clinical Professor, Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.
Insights
Medial arterial calcific sclerosis can affect peripheral arterial disease testing. This study introduces a method using pulse volume recording (PVR) waveforms to correct ankle and digital brachial indices for calcification, improving diagnostic accuracy.
Area of Science:
- Vascular Medicine
- Noninvasive Vascular Testing
- Medical Imaging Analysis
Background:
- Medial arterial calcific sclerosis (MACS) is a common condition that significantly impairs the accuracy of noninvasive vascular testing.
- This inaccuracy limits the diagnostic utility of ankle-brachial index (ABI) and digital-brachial index (DBI) for peripheral arterial disease (PAD).
- A method is needed to account for arterial calcification in the interpretation of these crucial vascular diagnostic tests.
Purpose of the Study:
- To develop and validate a method for correcting ankle-brachial index (ABI) and digital-brachial index (DBI) measurements in the presence of medial arterial calcification.
- To investigate the relationship between pulse volume recording (PVR) waveform characteristics and the degree of arterial calcification.
- To derive equations for calculating effective ABI and DBI that are adjusted for arterial calcification.
Main Methods:
- 160 subjects' noninvasive vascular testing results were analyzed, stratified by the severity of infrageniculate arterial calcification.
- Pulse volume recording (PVR) waveforms were measured at brachial, ankle, and digital levels, focusing on waveform wavelength and upstroke length.
- The ratio of PVR upstroke length to PVR wavelength was calculated and correlated with ABI and DBI.
Main Results:
- A significant difference in the PVR upstroke ratio was observed across different anatomical levels (p < .001), but not across calcification severity groups (p = .242).
- A significant negative correlation was found between the PVR upstroke ratio and ABI (Pearson r = -0.454, p = .002).
- Linear regression yielded an equation for effective ABI: 1.17 - (1.33 × PVR upstroke ratio at ankle level). Similar significant negative correlation and equation were found for effective DBI.
Conclusions:
- The study demonstrates the feasibility of using PVR waveform analysis to adjust for medial arterial calcification in vascular testing.
- Derived linear regression equations allow for the approximation of effective ABI and DBI, enhancing diagnostic accuracy in calcified arteries.
- This method offers a potential solution to overcome the limitations imposed by MACS on peripheral arterial disease assessment.
Abstract:
The presence of medial arterial calcific sclerosis is known to cause inaccuracy in the interpretation of noninvasive vascular testing. This substantially limits the utility of an important baseline diagnostic test for peripheral arterial disease. Therefore, the objective of this investigation was to derive a method to effectively factor out calcification in the interpretation of the ankle and digital brachial indices. The noninvasive vascular testing results of 160 subjects were stratified into the absence of calcification, mild calcification, moderate calcification, and severe calcification based on plain film radiographic findings of the infrageniculate vessels. Measurements were then performed of the pulse volume recording (PVR) waveforms at brachial, ankle and digital anatomic levels to include PVR wavelength and PVR upstroke length, with a calculation of the ratio of PVR upstroke length to PVR wavelength. These measurements were compared between groups and then correlated to the ankle and digital brachial indices. A significant difference was observed in the PVR upstroke ratio between the 3 anatomic levels (0.1818 vs 0.2622 vs 0.3191; p < .001), but not between the 4 calcification groups (0.2457 vs 0.2363 vs 0.2694 vs 0.2631; p = .242). A significant negative correlation was observed between the PVR upstroke ratio and the ankle brachial index (ABI) (Pearson -0.454; p = .002) with linear regression indicating the relationship is defined by the formula: Effective ankle brachial index = 1.17 - (1.33 × PVR upstroke ratio at ankle level). A significant negative correlation was also observed between the PVR upstroke ratio and the digital brachial index (Pearson -0.553; p < .001) with linear regression indicating the relationship is defined by the formula: Effective toe brachial index = 1.04 - (1.61 × PVR upstroke ratio at digital level). The results of this investigation demonstrate the feasibility of, and provide equations to approximate, the effective ankle brachial and toe brachial indices in the setting of medial arterial calcification.
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