Diagnosis

Diagnosis of PAD is based on the patients symptoms and the physical examination.
The physical examination include comparing blood pressure bilaterally, palpation the pulse of
radial, dorsalis pedis, and posterior tibial artery bilaterally, inspecting the skin color,
temperature, and sensation. Then physician should check if there is history of walking
impairment and specific lifestyle limitation. Based on the guidelines, the measurement that
must be performed to confirm the diagnosis of PAD is Ankle Brachial Index (ABI) (1,2). The
ABI is performed by comparing the systolic blood pressure between ankle and brachial arm
bilaterally. For the ankle, the blood pressures that should be measured are the posterior
tibialis and the dorsalis pedis arteries bilaterally. The highest of those four measurements
divided with the highest of the two measurements from brachial arms. Normal range for ABI
is between 0,90 and 1,30. The ABI value between 0.50 to 0,85 confirm the claudication
diagnosis, and the ABI value lower than 0,30 seen in the patient with resting claudication
pain or gangrene (1,3).
Beside ABI, there are another tests to confirm if the patients really normal. The other
tests that can be performed are Toe Brachial Index (TBI), exercise treadmill test, segmental
limb pressures, or using duplex ultrasound, Computed Tomography (CT), or Magnetic
Resonance Angiography (MRA) (13). TBI performed the same as ABI, but using tiny blood
pressure cuff placed around the toe and photoplethysmograph (PPG) infrared light sensor,
and the value above 0,80 is considered normal (1). If the resting ABI value is at normal range,
physician should measure ABI after exercise, such as exercise treadmill test. In exercise
treadmill test, the patient exercise using a treadmill for five minutes at 2 mph with 12%
inclines, then measured the ABI value. For severe claudication, the patient usually cannot
complete the exercise and the ankle blood pressure is below 50 mmHg (3).
After the ABI result confirm the diagnosis of PAD, segmental limb pressure should be
performed to detect the level and extent of PAD. The reduction of blood pressure is
significant if there are 20 mmHg differences between some segments along the leg or
between the same level at opposite leg. The placement of the cuff in this measurement can
detect the level of PAD (3). The duplex ultrasound can evaluate the blockage of blood vessels
and can determine the severity. This ultrasound using Doppler wave and color Doppler to
evaluate the vessels (1,3). Beside the duplex ultrasound, CT and MRA can be performed to
assess the vessels. There is another test that can be used to assess the vessels anatomy. The
arteriography can show the exact location of stenosis, but it is invasive (1).
 Claudication symptoms

History of walking
impairment and lifestyle
limitation

Physical
examination

Exercise ABI, TBI, segmental

ABI ABI > 0,90 pressure, duplex ultrasound,
CT, MRA

ABI 0,90

Abnormal result Normal result

Confirmed PAD

No PAD

References
1. Muir RL. Peripheral arterial disease: Pathophysiology, risk factors, diagnosis,
treatment, and prevention. J Vasc Nurs [Internet]. 2009;27(2):2630. Available from:
http://dx.doi.org/10.1016/j.jvn.2009.03.001
2. Beckman JA, Findeiss LK, Golzarian J, Gornik HL, Halperin JL, Hirsch AT, et al.
Management of Patients With Peripheral Artery Disease - Lower extremity, Renal,
Mesenteric and Abdominal Aorta. Am Coll Cardiol Found. 2011;(November):166.
3. Boras J, Brkljacic N, Ljubicic A, Ljubic S. Peripheral arterial disease. Diabetol
Croactica. 2010;39(2):6777.