Lower-extremity pressure, staging, and grading thresholds to identify chronic limb-threatening ischemia

Ranked sensitivity estimates for clinical and noninvasive parameters used to identify GLASS stage II or III arterial disease
Figure 1. Sensitivity rates of clinical and noninvasive parameters for identifying Global Limb Anatomic Staging System (GLASS) stage II or III disease. All parameters refer to the index limb; bars span the lower and upper 95% confidence limits around each point estimate. ABI indicates ankle-brachial index; TBI, toe-brachial index; and WIfI, the Society for Vascular Surgery Wound, Ischemia, and foot Infection classification system.

Publication details

Work type Peer-reviewed original research article
Citation Choi JCB, Miranda J, Greenleaf E, Conte MS, Gerhard-Herman MD, Mills JL Sr, Barshes NR. Lower-extremity pressure, staging, and grading thresholds to identify chronic limb-threatening ischemia. Vasc Med. 2023;28(1):45-53.
Authors Justin Chin-Bong Choi; Jorge Miranda; Erin Greenleaf; Michael S. Conte; Marie D. Gerhard-Herman; Joseph L. Mills Sr; and Neal R. Barshes
Publication Vascular Medicine
Publication date February 2023
DOI 10.1177/1358863X221147945
PubMed identification (PMID) number 367-59-932
Intended audience Physicians and trainees involved in diabetic limb salvage, especially vascular surgeons, cardiologists, vascular medicine specialists, and other interventionalists treating peripheral artery disease in patients with foot gangrene or nonhealing foot ulcers

Summary

Alternative noninvasive arterial testing parameters improved sensitivity for detecting peripheral artery disease. A toe-brachial index below 0.7 and the lower of the two ipsilateral ankle-brachial indices below 0.9 were highly sensitive for identifying GLASS stage II or III angiographic disease. Abnormal noninvasive results should prompt consideration of diagnostic angiography to characterize the arterial anatomy of the affected limb.

Contribution and significance

This study directly compared clinical and noninvasive testing parameters with digital subtraction angiography, using GLASS stages and angiosome-level arterial anatomy as the reference. This approach assessed whether commonly used bedside and vascular-laboratory findings reliably identify the arterial disease that limb-salvage specialists consider when deciding whether revascularization is appropriate.

The findings reinforce an important clinical distinction: abnormal noninvasive results can help rule in peripheral artery disease, but normal results do not reliably rule it out. The sensitivity of many parameters was only poor to moderate, and pedal medial artery calcification further reduced the sensitivity of most measurements. Consequently, apparently normal testing should not by itself lead clinicians to dismiss significant arterial disease in a patient with foot ulceration, infection, or gangrene.

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