What are the diagnostic tests for chronic Peripheral Vascular Disease (PVD)?

From the Guidelines

Testing for chronic peripheral vascular disease (PVD) should begin with a thorough clinical assessment, including medical history and physical examination, followed by the ankle-brachial index (ABI) as the primary diagnostic test, as recommended by the most recent guidelines 1. The ABI measures the ratio of systolic blood pressure at the ankle to that in the arm, with a value below 0.9 indicating PVD. For patients with normal ABI but suspected disease, exercise ABI testing can reveal abnormalities that appear only during activity. Some key points to consider in the diagnosis of PVD include:

• The use of noninvasive hemodynamic tests such as ABI, toe-brachial index, segmental pressures, and pulse volume recordings to establish the presence and severity of arterial obstructions 1.
• The role of duplex ultrasound, CT angiography, and MR angiography in providing detailed information about blood flow and vessel structure, and in planning interventions 1.
• The importance of conventional angiography, though invasive, as the gold standard for detailed arterial imaging when planning revascularization procedures 1.
• The consideration of additional tests, such as segmental pressure measurements, pulse volume recordings, and transcutaneous oxygen pressure measurements, to further evaluate PVD 1. Early diagnosis is crucial as PVD increases risk for cardiovascular events and limb complications, and treatment can significantly improve outcomes through risk factor modification, exercise therapy, and in some cases, revascularization procedures 1.

From the Research

Testing for Chronic PVD

• Chronic peripheral vascular disease (PVD) is a manifestation of systemic atherosclerosis that leads to significant narrowing of arteries distal to the arch of the aorta 2.
• The most common symptom of PVD is intermittent claudication, which manifests as pain in the muscles of the legs with exercise 2.
• Physical findings include abnormal pedal pulses, femoral artery bruit, delayed venous filling time, cool skin, and abnormal skin color 2.

Diagnostic Tests

• The standard office-based test to determine the presence of PVD is calculation of the ankle-brachial index (ABI) 2, 3, 4, 5.
• ABI is a non-invasive test that measures the ratio of blood pressure in the ankles to blood pressure in the arms 4, 5.
• Other non-invasive methods for lesion localization include magnetic resonance arteriography, duplex scanning, and hemodynamic localization 2, 3.
• Contrast arteriography is used for definitive localization before intervention 2.

Accuracy of ABI

• The sensitivity and specificity of ABI for diagnosing peripheral artery disease are moderate, with values ranging from 65.5% to 72.3% and 68.8% to 69.3%, respectively 4, 5.
• ABI has a moderate predictive value in the diagnosis of lower extremity arterial disease, but normal range outcomes cannot be taken to infer the absence of disease 4.
• Further non-invasive tests such as exercise studies or pulse volume waveforms should be considered if diagnostic uncertainty exists 4.

Correlation with Symptoms and Health-Related Quality of Life

• Health-related quality of life (HRQL) in patients with PVD correlates weakly with ABI, but exhibits a closer association with vascular symptoms 6.
• Patients with more severe symptoms, such as lifestyle-limiting claudication or limb-threatening ischemia, have lower HRQL scores compared with patients with non-lifestyle-limiting claudication 6.
• Multivariate analysis demonstrates that HRQL scores are better predicted by symptoms than by ABI 6.