From the Guidelines
Peripheral vascular disease (PVD) is diagnosed using a combination of clinical assessment, non-invasive testing, and imaging studies, with the primary diagnostic criterion being an ankle-brachial index (ABI) of less than 0.90, as recommended by the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline 1. The diagnostic criteria for PVD include:
- Clinical symptoms such as intermittent claudication, rest pain, tissue loss, or gangrene
- Physical examination findings like diminished or absent peripheral pulses, bruits over major arteries, cool extremities, pallor on elevation, dependent rubor, and delayed capillary refill
- Non-invasive tests including segmental pressure measurements, pulse volume recordings, duplex ultrasonography, CT angiography, MR angiography, and conventional angiography for definitive anatomical assessment
- The Fontaine classification (stages I-IV) or Rutherford classification (categories 0-6) can be used to grade disease severity based on symptoms and tissue damage According to the 2018 ACC/AHA versus ESC/ESVS guidelines for diagnosis and management of peripheral artery disease, the resting ABI is recommended to establish the diagnosis, with results reported as abnormal (ABI ≤0.90), borderline (ABI 0.91–0.99), normal (1.00–1.40), or noncompressible (ABI >1.40) 1. The most recent guideline from 2024 emphasizes the importance of detecting PAD in most patients through history, physical examination, and resting ankle-brachial index 1. Key points to consider in the diagnosis of PVD include:
- Health disparities in PAD are associated with poor limb and cardiovascular outcomes and must be addressed at the individual patient and population levels 1
- Effective medical therapies for patients with PAD should be prescribed to prevent major adverse cardiovascular events and major adverse limb events for patients with or at risk of developing PAD 1
- The patient population suitable for PAD screening includes those with age ≥65 years, age 50 to 64 years with risk factors for atherosclerosis or a family history of PAD, age <50 years with diabetes and an additional risk factor for atherosclerosis, and individuals with known atherosclerotic disease in another vascular bed 1
From the Research
PVD Diagnostic Criteria
The diagnostic criteria for Peripheral Vascular Disease (PVD) include a combination of medical history, physical examination, and non-invasive tests.
- The ankle-brachial index (ABI) is a widely used non-invasive test to diagnose PVD, with a threshold of ≤ 0.9 indicating the presence of PVD 2.
- Physical findings such as abnormal pedal pulses, femoral artery bruit, delayed venous filling time, cool skin, and abnormal skin color can also indicate PVD 3.
- The medical history, including symptoms of intermittent claudication, can also be used to diagnose PVD, although the correlation between ABI and symptomatology is weak 4.
- A stepwise logistic regression model identified four factors significantly associated with low ABI: absent or diminished peripheral pulses, patient reported history of PVD, age, and venous filling time 5.
Diagnostic Tests
- The ABI is the standard office-based test to determine the presence of PVD, with a sensitivity of 97% and specificity of 89% for oscillometric ABI 2.
- Other non-invasive tests, such as magnetic resonance arteriography, duplex scanning, and hemodynamic localization, can be used to localize lesions and assess disease severity 3.
- Contrast arteriography is used for definitive localization before intervention 3.
Limitations of Diagnostic Criteria
- The ABI has limitations, including a lack of correlation with symptomatology, and decisions should not be made exclusively on the basis of ABI 4.
- Many purportedly useful historical and exam findings need not be elicited in diabetic patients suspected of having severe PVD, as most information related to probability of this disorder may be obtained from patient age, self-reported history of physician diagnosed PVD, peripheral pulse palpation, and venous filling time 5.