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UVMFLOWNET  January 2010

UVMFLOWNET January 2010

Subject:

Re: Toe pressures

From:

"Johnson, Bill" <[log in to unmask]>

Reply-To:

UVM Flownet <[log in to unmask]>

Date:

Sat, 9 Jan 2010 17:57:49 -0800

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (80 lines)

Bill Johnson, Port Townsend, WA

Kris, your question intrigued me since I have not looked at this issue in a long time.  I was taught a toe/brachial index above 0.70 is normal, less than 0.50 consistent with claudication or worse (i.e. abnormal) and a toe pressure less than 30 mmHg was bad news for healing.  I have seen other criteria.  I did a brief search and was not impressed with the number of papers about this issue, although perhaps I am not going back far enough in the literature.  Since toe pressures are an important tool to assess disease in the presence of medial calcification and distal small vessel disease, perhaps we should revisit this issue?  Particularly with the increasing number of diabetics we are seeing.  The second abstract below states toe pressures are more useful in excluding critical ischemia, and I agree with that statement.  I do not think there are any absolute values or index numbers, and as with most of what we do, clinical correlation is important.

If I have missed any other good articles on this subject, I would appreciate knowing about them.  I have not searched the textbooks, and I am sure they would lend light on this subject.  

Ramsey DE, Manke DA, Sumner DS. Toe blood pressure. A valuable adjunct to ankle pressure measurement for assessing peripheral arterial disease. J Cardiovasc Surg (Torino). 1983 Jan-Feb;24(1):43-8

Ankle pressure measurements fail to reflect the severity of peripheral ischemia when the underlying vessels are calcified or when there is extensive pedal or digital arterial disease. These problems may be obviated by measuring pressures at toe level. In this study, toe pressures were correlated with ankle pressures, clinical symptoms, and the presence or absence of diabetes in 294 limbs. The relationship of toe pressures to healing of ulcers or amputations of the foot was investigated in 58 limbs. Measurements were made with a digital pneumatic cuff and a photoplethysmograph. The ability of absolute toe pressure, ankle/brachial index, toe/brachial index, toe/ankle index, and the brachial pressure minus the toe pressure to differentiate between asymptomatic, claudicating, and ischemic limbs was determined. The toe/brachial index, arm minus toe pressure, and the absolute toe pressure had an average sensitivity and specificity of 85% and 88% for asymptomatic limbs and 89% and 86% for ischemic limbs. A toe pressure greater than 30 mmHg was indicative of a good healing potential, and ankle pressure less than 80 mmHg was associated with poor healing. The correlation between ankle and toe pressures was essentially the same in both diabetic (r = 0.60) and non-diabetic limbs (r = 0.62).

 

More recent (edited for space considerations)

 

Kröger K, Stewen C, Santosa F, et al.  Toe pressure measurements compared to ankle artery pressure measurements. Angiology. 2003 Jan;54(1):39-44.

The Trans-Atlantic Inter-Society Consensus (TASC)-recommended absolute toe pressure is < 30-50 mm Hg for definition of chronic critical limb ischemia (CLI). Toe pressures can be measured by different techniques. The authors analyzed the clinical use of the Doppler technique and an automatic device with optical sensors and estimated their value in documentation of chronic critical limb ischemia compared to ankle artery pressures. 

    ... (3) In 175 patients the toe pressures were measured at 1 toe and the ankle artery pressures were determined. In this group they estimated the clinical use of the toe pressure in regard to the definition of CLI (toe pressure < 50 mm Hg) compared to the ankle pressure < 70 mm Hg.     ... Defining systolic ankle artery pressure < or = 50 to 70 mm Hg as the golden standard for CLI, the sensitivity of optical toe pressure measurement for the detection of CLI was 8%, the specificity was 96%, the positive predictive value 12%, and the negative predictive value was 94%.  ...toe pressure measurements are more useful to exclude CLI than to prove it.

 

________________________________

From: UVM Flownet on behalf of Duane Williams
Sent: Fri 1/8/2010 12:02 PM
To: [log in to unmask]
Subject: Toe pressures


Any thing less than 50 mmHg will not heal,  Any thing greater than 50 mmHg will heal.
 
Duane Williams R.V.S.
Technical Director 
Vascular Lab
North Dallas Surgical Specialists
972-487-6400 wk
972-800-3407 mobile
[log in to unmask] 


Above all, we must realize that no arsenal, or no weapon in the arsenals
of the world, is so formidable as the will and moral courage of free men
and women. It is a weapon our adversaries in today's world do not have.
Ronald Reagan 


________________________________

From: Kristian A Engstrom <[log in to unmask]>
To: [log in to unmask]
Sent: Fri, January 8, 2010 9:07:07 AM
Subject: 



Would anyone be willing to share with me their criteria for toe pressures?

Thanks

 

Kris Engstrom

 

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