The “theoretical patient” has incompressible ankle arteries and borderline
low toe pressures. In our place, 40-50 mmHg in toe pressures gradients in
relation to the brachial blood pressure are at the lower normal range. 
Below, at one of Chris labs, small vessel disease would be proposed.
However, no one can distinguish between macro- and micro vessel disease when
it is impossible to assess ankle pressures due to medial sclerosis. The
critical opening toe pressure can be lower as normal in vasospasm, organic
small vessel disease, as well as in proximal arterial obstructions. To
minimize vasospastic effects, it is important to warm up the toes before,
and to document the toe temperatures during the measurements. When
clinically indicated, i.e. in case of severe claudication or ulcerations we
would propose a Duplex investigation at least of the proximal femoral
(iliac) arteries instead of thigh/calf blood pressure measurements, since
pressure measurements at that levels are difficult to standardize and also
time consuming. 
Also the pulsatile characteristics of the blood flows were discussed:
However, biphasic flow pattern might be changed to monophasic ones of quite
different reasons such as proximal collateral flows, diabetic precapillary
AV-shunting (resulting in a warm but ischemic toe) or peripheral
vasodilation due to ischemia. 

In this "theoretical" patient without symptoms, our statement would have
been: Incompressible ankle arteries probably due to medial sclerosis. Toe
pressures borderline low but no sign of impaired wound healing.

If the "theoretical" patient was referred due to claudication or
ulcerations, the outcome from the distal pressure measurements would have
been ambiguous and a short exercise text not of greater help. In that case a
Duplex investigation would have been recommended.

Kind regards and the best wished for the year 2009

On Wed, 7 Jan 2009 14:07:47 -0500, Chris S. (RVT) <[log in to unmask]> wrote:

>Hi everyone. I am a little confused on how to best interpret toe pressures in 
>the case of a patient who has non-compliant vessels.   This applies to
either a 
>segmental pressure exam, or an arterial duplex with ABI's.  Let me give a 
>hypothetical example for you all to better understand:
>Patient: John Doe, 70 y/o male, insulin dependent diabetes mellitus.
>Exam:   Segmental Pressures
>Rt Brachial: 140                        Lt Brachial: 140
>High thigh: >250                       High thigh:  >250
>Low thigh:  >250                        Low thigh:  >250
>Calf:          >250                               Calf:   >250
>Post Tib:    >250                          Post Tib:   >250
>Dors Ped:   > 250                        Dors Ped:   >250
>Great toe:   112                      Great Toe:     106
>ABI- 1.79                                   ABI- 1.79
>TBI- 0.80                                   TBI- 0.76
>Triphasic waves at all segments Bilaterally.
>Then, Patient was exercised for two minutes and pressures were taken once 
>Post Exercise Pressures
>Rt Brachial: 150               
>Rt Post Tib:  >250                 Lt Post Tib:   >250
>Rt Dors Ped:  >250                Lt Dors Ped:   >250
>Rt Great Toe:  84                Lt Great Toe:    80
>ABI- 1.7                              ABI- 1.7
>TBI- 0.56                            TBI- 0.53
>Now, here is the dilemna..   I work at two different vascular labs, and both 
>labs would give different results based on this test data.
>Lab #1 would say this:
>Moderate arterial disease post exercise in the lower extremities bilaterally, 
>with a toe-brachial index of 0.56 on the right, and 0.53 on the left.  The 
>segmental pressures are unreliable due to non-compliant (calcific) vessels.
>Lab #2 would say this:
>Abnormal examination.  There is essentially no evidence of arterial 
>insufficiency in the large vessels of the lower extremities bilaterally.  
Note is 
>made of decreased toe pressures, suggestive of small vessel disease.
>OKAY....SO WHAT DO YOU GUYS MAKE OF ALL THIS?  LOL!   Do you all agree 
>with one finding, but not the other?   How does your lab interpret results
>as these?
>Thanks, Chris
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