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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 Reinhard 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 > >AT REST 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 >more: > >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 such >as these? > >Thanks, Chris > >To unsubscribe or search other topics on UVM Flownet link to: >http://list.uvm.edu/archives/uvmflownet.html To unsubscribe or search other topics on UVM Flownet link to: http://list.uvm.edu/archives/uvmflownet.html