Eur J Vasc Endovasc Surg 18, 133–137 (1999)
Article No. ejvs.1999.0854
The Toe Pole Test for Evaluation of Arterial Insufficiency in
Diabetic Patients*
H.-I. Paˆ hlsson1, E. Wahlberg†2, P. Olofsson2 and J. Swedenborg2
1Department of Radiology, University Hospital, Linkoping, and 2Department of Surgery,
Division of Vascular Surgery, Karolinska Hospital, Stockholm, Sweden
Objectives: to evaluate if the pole test at the toe level can be used for assessment of arterial insufficiency in diabetic
patients.
Methods: twenty-five legs in 23 diabetic patients suffering from leg ischaemia were examined prospectively. A laser
Doppler probe was attached to the pulp of the first toe to monitor perfusion continuously before and after occluding the
arterial inflow with a cuff and during elevation of the leg until perfusion disappeared (the pole test). At ankle level the
examinations were made similarly but with an ankle cuff and a hand-held Doppler.
Results: in the 44% (11/25) of the legs where it was possible to compare cuff blood pressure at ankle level with the pole
test, the cuff measurements were significantly higher (p<0.01). In 13 of the remaining 14, maximal elevation did not
result in disappearance of the Doppler signal. At toe level where 76% (19/25) of the legs could be compared, there was
no significant difference between the two methods.
Conclusion: the pole test can be used at the toe level to evaluate arterial insufficiency in diabetes. When used in the toe,
the pole test can assess pressures below 55–70 mmHg, while only pressures below 45 mmHg can be determined at the
ankle level. Falsely elevated blood pressure in diabetics is probably of less importance in digital arteries than in ankle
arteries, which makes cuff pressure at toe level a more acceptable approximation.
Key Words: Ankle blood pressure; Toe blood pressure; Limb ischaemia; Pole test; Diabetes.

On Tue, Jun 15, 2021 at 10:50 AM Steve Knight <[log in to unmask]> wrote:
The pole test comes from England I believe. I'm surprised it isn't embraced here. Perhaps our litigenous society insists on dials and meters to provide data.

Sent from my T-Mobile 4G LTE Device

From: UVM Flownet <[log in to unmask]> on behalf of Craig Hume <[log in to unmask]>
Sent: Monday, June 14, 2021 5:18:31 PM
To: [log in to unmask] <[log in to unmask]>
Subject: Re: Non compressiblility - tissue vs vessel
 
What about pole pressures? Never done them but im making a pole to start. Only good for pressures <=70mmhg ish.

On Thu, Jun 3, 2021 at 1:14 AM Jill Sommerset <[log in to unmask]> wrote:
Thank you for  sharing your thoughts, Bill.  PAT has only been validated in the  inframalleolar region of the foot. So we cannot apply this criteria to the distal  PTA, ATA, or peroneal Artery. 
  

We are encountering more and more pedal arch disease and variant Pedal anatomy 
. The value of PAT is evaluating the artery leading right to the wound bed. We call this “target artery PAT”  - this is especially helpful in the diabetic or renal failure patient with CLTI. When we evaluate PAT of the foot we can also obtain pedal flow hemodynamics and understand flow direction in the arch. This can be very helpful when we need to indirectly revascularization the patient.   As far as probe selection we generally always use a standard linear probe on the bottom of the foot and even on the top of the foot however in a thin foot or if scanning the dorsal metatarsal arteries one can use a high frequency probe.   

Jill 


On Jun 2, 2021, at 6:50 AM, Bill Schroedter <[log in to unmask]> wrote:



Thanks so much Jill. Clearly this is a useful, perhaps even critical parameter, especially in those patients with CLI. And I really liked your comment about its use in decision making for grading compression for venous ulcerations.  

Another question arose in my mind with the discussion of the high frequency transducer to obtain a waveform from the metatarsals or at the edge of the wound.  Is there any data or even in your experience, is there a significant difference (I suppose that means changing healing potential) when this is obtained from the the ankle versus out on the foot or at the wound margins?

Thanks.

Bill   

 

From: UVM Flownet <[log in to unmask]> On Behalf Of Jill Sommerset
Sent: Wednesday, June 2, 2021 9:00 AM
To: [log in to unmask]
Subject: Re: Non compressiblility - tissue vs vessel

 

Thanks for the question Nicole. I’ve attached the criteria.  Like anything, correct technique is key in the accuracy of PAT. 

 

Have a great day,

Jill 

<image001.png>



On Jun 2, 2021, at 4:39 AM, Nicole Ball <[log in to unmask]> wrote:



[log in to unmask]">

Hi all.  Interesting discussion.  I personally have not done PAT but have printed some articles to research.  Question...What are the diagnostic criteria for AT in the pedal arteries...normal AT vs abnormal AT?  Thank you.

 

Sincerely,



Nicole Ball, BS, RVT

Technical Director, Vascular Lab

Concord Hospital

250 Pleasant Street

Concord, NH  03301

 

[log in to unmask]">

>>> Jill Sommerset <[log in to unmask]> 6/1/2021 4:57 PM >>>

 

 

 

* CAUTION - This is an EXTERNAL email - DO NOT open attachments or links in unexpected emails or from unknown senders *

 

 

 

Thank you Denise and Harvey. Yes, we use PAT on the dorsal and plantar metararsal arteries. The hockey stick is nice for the dorsal metatarsal arteries right at the edge of the wound bed.

 

 

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<IMAGE.jpeg>

> On Jun 1, 2021, at 1:50 PM, Harvey Wilson <[log in to unmask]> wrote:

>

> Thanks so much, Jill. Your talk for the NWVT was my favourite by far! I will try more practice for sure. One thing helpful is the MVI or micro vascular imaging on the GE LE10 it is quite sensitive to low flow states and I also use it for temporal arteritis so as not to override the vessel wall. I was curious about using a hockey stick probe and that to look at the digital artery - has anyone ever done a digital acceleration time?

>

>> On Tue, 1 Jun 2021 12:10:24 -0700, Jill Sommerset <[log in to unmask]> wrote:

>>

>> Great conversation here! I’ve attached our publications on PAT. We find it valuable not only in the arterial/CLTI pt but also on the venous wound pt where there is question of compression can be applied. The lateral plantar and Arcuate are fairly easy to image and obtain at PAT however like anything there is education and practice that comes along with it. Please reach out with any questions or thoughts. I’d love to hear them.

>>

>> Kindly,

>> Jill Sommerset

>>

>>

>>

>>

>>>> On Jun 1, 2021, at 12:03 PM, Harvey Wilson <[log in to unmask]> wrote:

>>>

>>> Very interesting folks! I was only hoping for a bit of speculation on tissue compressibility and got a bonus!

>>> We typically will fall back on getting waveforms if possible and a TBI -  but as Bart states they are not always possible, those short, fat toes, etc. As for the toe clamp, we use tape still and if I need to get good PPG contact on those greasy ones, I will place Saran wrap very lightly around just to hold the PPG on without pressure.

>>> I have only tried a couple of times to get a PAT since watching a lecture on it at the NWVT. I find those little guys in the plantar foot quite tricky to find and our Radiologists and vascular surgeons might have never heard of it.  Are PAT's well validated and widely used?

>>> Partially compressible, yeah, what to do with that possibility? What bugs me is to take obviously monophasic waveforms in the tibials but an ABI of 1.0 and then see it reported as "no evidence of arterial insufficiency" :( :(

>>>

>>> Harvey

>>>

>>>> On Tue, 1 Jun 2021 11:10:22 -0700, Barton Bean <[log in to unmask]> wrote:

>>>>

>>>> Hi Bill,

>>>> There are so many variables - cuff to toe sizes, what pressure is on the

>>>> PPG (very difficult to be precise in my experience) - except perhaps with

>>>> tape which we no longer use (clamp with unknown pressure is provided by

>>>> current equipment manufacturer), is the light on in the room, does the

>>>> patient have and small vessel calcifications.

>>>> Don't get me wrong they are a part of our protocol and we do them. I just

>>>> no longer believe the results particularly since a large part of our work

>>>> is with diabetic wound care.

>>>> PAT has been  wonderful for us (even though it has limitations too).

>>>> Fond regards,

>>>> Bart

>>>>

>>>> On Tue, Jun 1, 2021 at 10:54 AM Bill Schroedter <

>>>> [log in to unmask]> wrote:

>>>>

>>>>> Hey Bart,

>>>>> Absolutely PAT's but could you please elaborate on your reservations re:

>>>>> toe pressures?

>>>>> Thanks,

>>>>> Bill

>>>>>

>>>>> -------- Original message --------

>>>>> From: Barton Bean <[log in to unmask]>

>>>>> Date: 6/1/21 1:41 PM (GMT-05:00)

>>>>> Subject: Re: Non compressiblility - tissue vs vessel

>>>>>

>>>>> PAT's (pedal acceleration times)are invaluable in a patient like this (and

>>>>> for that matter in our lab all wound care patients).

>>>>> In my experience ankle/toe pressure have some limited value but we are

>>>>> moving to PAT studies pre and post intervention.

>>>>> I cannot seem to be consistent with toe pressure even though I have

>>>>> performed thousands - I don't trust them any more.

>>>>> Best,

>>>>> Bart

>>>>>

>>>>> On Tue, Jun 1, 2021 at 4:35 AM Bill Schroedter <

>>>>> [log in to unmask]> wrote:

>>>>>

>>>>>> Good question Harvey. I agree with Denise. For wound care patients, many

>>>>>> of which are diabetic, this is an issue and toe pressures are really a

>>>>>> must.

>>>>>>

>>>>>> That said, I am trying to wrap my head around your question about the

>>>>>> effect of tissue edema – seems like that should transmit the pressure to

>>>>>> the vessel. Elaphantiasis Nostras would likely result in a similar

>>>>>> situation to that is much more common, lipodermatosclerosis. The resultant

>>>>>> tissue fibrosis / sclerosis in my mind would be more likely make a

>>>>>> difference in pressure transmission to the vessel. If you are 30-40 mmHg

>>>>>> above brachial pressure, no problem - your question is answered. But for

>>>>>> nearly my whole career I have wondered about what I call partially

>>>>>> compressible vessels – ones that are stiff and could in fact require more

>>>>>> than the transmitted tissue pressure to compress. What if the vessel in

>>>>>> fact does compress so that we obtain a falsely elevated pressure but is

>>>>>> impossible to determine the presence or degree – we really have no way of

>>>>>> knowing that. Our solution - when doing these, we always keep in mind that

>>>>>> we also have the Doppler waveform which should be strongly considered in

>>>>>> the interpretation of ankle pressures. A monophasic signal (or one with a

>>>>>> delayed upstroke) is unlikely to have a normal arterial pressure. The great

>>>>>> strength of our technology – a lot of clues – they should all point to the

>>>>>> same thing.

>>>>>>

>>>>>> Regards,

>>>>>>

>>>>>> Bill

>>>>>>

>>>>>>

>>>>>>

>>>>>> *From:* UVM Flownet <[log in to unmask]> *On Behalf Of *Denise Levy

>>>>>> *Sent:* Tuesday, June 1, 2021 2:09 AM

>>>>>> *To:* [log in to unmask]

>>>>>> *Subject:* Re: Non compressiblility - tissue vs vessel

>>>>>>

>>>>>>

>>>>>>

>>>>>> Hi,

>>>>>>

>>>>>> You will have more success with a metatarsal cuff and a digital toe cuff,

>>>>>> TBI using a PPG for the pressure.

>>>>>>

>>>>>> Very often ABI’s are falsely elevated due to diabetes plus 255 !

>>>>>>

>>>>>> The levels can be found on a search for TBI ranges.

>>>>>>

>>>>>> Thank you for your question,

>>>>>>

>>>>>> Denise Levy, RDMS, RVT

>>>>>>

>>>>>> Hill Vascular and Vein Center

>>>>>>

>>>>>> Vascular Lab Director

>>>>>>

>>>>>>

>>>>>>

>>>>>>

>>>>>>

>>>>>> On Mon, May 31, 2021 at 5:02 PM Bill Johnson <[log in to unmask]>

>>>>>> wrote:

>>>>>>

>>>>>> Harvey i do believe your question is quite valid!

>>>>>>

>>>>>> Personally I can only recount a few cases and I know there was a point

>>>>>> beyond which I would not increase the probe pressure.  "Do no harm seemed a

>>>>>> good idea then and still.

>>>>>>

>>>>>> So, what do you do in these cases?  I assume you do some type of

>>>>>> follow-up?  Any lessons for us still learning?

>>>>>>

>>>>>>

>>>>>>

>>>>>> On Mon, May 31, 2021, 4:24 PM Harvey Wilson <[log in to unmask]>

>>>>>> wrote:

>>>>>>

>>>>>> Hi,

>>>>>>

>>>>>> I've often wondered about getting non comp ABI's on wound clinic patients

>>>>>> who have severe edema or something like  Elaphantiasis Nostras. How much

>>>>>> does hardening and thickening of tissue contribute in cases like these vs

>>>>>> plain old calcification? I thought I'd post this here as I don't have

>>>>>> anyone here to bounce ideas off.

>>>>>>

>>>>>> Thanks,

>>>>>>

>>>>>> Harvey Wilson RVT RDMS RDCS

>>>>>> Victoria

>>>>>>

>>>>>> To unsubscribe or search other topics on UVM Flownet link to:

>>>>>>

>>>>>> To unsubscribe or search other topics on UVM Flownet link to:

>>>>>>

>>>>>> --

>>>>>>

>>>>>> Sent from Gmail Mobile

>>>>>>

>>>>>> To unsubscribe or search other topics on UVM Flownet link to:

>>>>>> To unsubscribe or search other topics on UVM Flownet link to:

>>>>>

>>>>>

>>>>>

>>>>> --

>>>>> Barton A. Bean IV, RVT, FSVU

>>>>> Orange County Vascular Specialists

>>>>> 23236 Via Bahia

>>>>> Mission Viejo, CA 92691-2114

>>>>> E-mail [log in to unmask]

>>>>> (714)803-6288

>>>>> To unsubscribe or search other topics on UVM Flownet link to:

>>>>> To unsubscribe or search other topics on UVM Flownet link to:

>>>>

>>>>

>>>>

>>>> --

>>>> Barton A. Bean IV, RVT, FSVU

>>>> Orange County Vascular Specialists

>>>> 23236 Via Bahia

>>>> Mission Viejo, CA 92691-2114

>>>> E-mail [log in to unmask]

>>>> (714)803-6288

>>>>

>>>> To unsubscribe or search other topics on UVM Flownet link to:

>>>>

>>>

>>> To unsubscribe or search other topics on UVM Flownet link to:

>>

>> To unsubscribe or search other topics on UVM Flownet link to:

>>

>

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