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CLINICAL STATEMENTS AND GUIDELINES

June 11, 2024 Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 e1324

3 DIAGNOSTIC TESTING FOR PAD

Diagnostic testing for suspected PAD requires a multifaceted approach that incorporates history and physical examination, ABI, and additional physiological testing, as well as noninvasive and potentially invasive (angiography) imaging (Figure 2). Understanding the indications for the use of these testing modalities can help to efficiently direct resources such as revascularization to patients who may be in urgent need of therapy. Further, and more commonly, understanding the indications for the use of these testing modalities can help to avoid unnecessary testing for patients for whom further delineation of arterial anatomy will not impact plans for therapy (eg, for patients with asymptomatic PAD or chronic symptomatic PAD who are treated with medical therapy and structured exercise).

3.1 Resting ABI and Additional Physiological

Testing Recommendations for Resting ABI and Additional Physiological Testing Referenced studies that support the recommendations are summarized in the Online Data Supplement. Resting ABI COR LOE Recommendations

1 B-NR 1 In patients with history or physical examination find-

ings suggestive of PAD (Table 6), the resting ABI, with or without ankle pulse volume recordings (PVR) and/or Doppler waveforms, is recommended to establish the diagnosis.1,2

1 B-NR 2 The resting ABI should be reported as abnormal

(ABI ≤0.90), borderline (ABI 0.91-0.99), normal (ABI 1.00-1.40), or noncompressible (ABI >1.40).3 2a B-NR 3.	 In patients at increased risk of PAD (Table 5),

screening for PAD with the resting ABI, with or without ankle PVR and/or Doppler waveforms, is reasonable.4–9

3: No Benefit B-NR 4 In patients not at increased risk of PAD (Table 5)

and without history or physical examination findings suggestive of PAD (Table 6), screening for PAD with the ABI is not recommended.10,11

Exercise ABI and Additional Physiological Testing

1 B-NR 5 In patients with suspected PAD, toe pressure/

toe-brachial index (TBI) with waveforms should be performed when the resting ABI is >1.40 (noncompressible).12–17

1 B-NR 6 Patients with suspected chronic symptomatic

PAD (ie, exertional nonjoint-related leg symptoms) and normal or borderline resting ABI (>0.90 and ≤1.40, respectively) should undergo exercise treadmill ABI testing to evaluate for PAD.18,19

2a B-NR 7 In patients with PAD and an abnormal resting ABI

(≤0.90), the exercise treadmill ABI test can be useful to objectively assess the functional status and walking performance.20–25

2a C-LD 8 In patients with chronic symptomatic PAD, it is

reasonable to perform segmental leg pressures with PVR and/or Doppler waveforms in addition to the resting ABI to help delineate the anatomic level of PAD.26,27

2a B-NR 9 In patients with suspected CLTI, it is reasonable

to use toe pressure/TBI with waveforms, transcutaneous oxygen pressure (TcPO2), and/or skin perfusion pressure (SPP) in addition to ABI for assessment of arterial perfusion and to establish the diagnosis of CLTI.13,28–37

Table 7.  Alternative Diagnosis for Leg Pain or Claudication Not Related to PAD (Normal Physiological Testing) Condition Location Characteristic Effect of Exercise Effect of Rest Effect of Position Other Characteristics Hip arthritis Lateral hip, thigh Aching discomfort After variable degree of exercise Not quickly relieved Improved when not bearing weight Symptoms variable; history of degenerative arthritis Foot/ankle arthritis Ankle, foot, arch Aching pain After variable degree of exercise; may also be present at rest Not quickly relieved May be relieved by not bearing weight Symptoms variable Nerve root compression Radiates down leg Sharp lancinating pain Induced by sitting, standing, or walking (variable) Often present at rest Improved by change in position History of back problems; worse with sitting; relief when supine or standing Spinal stenosis (eg, degenerative disc disease or tumor) Often bilateral buttocks, posterior leg Pain and weakness May mimic claudication Variable relief but can take a long time to recover Relief by lumbar spine flexion Worse with standing and extending spine Symptomatic popliteal (Baker’s) cyst Behind knee, down calf Swelling, tenderness With exercise Also present at rest None Not intermittent Venous claudication Entire leg, worse in calf Tight, bursting pain After walking Subsides slowly Relief speeded by leg elevation History of iliofemoral deep vein thrombosis; edema; signs of venous stasis Chronic compartment syndrome Calf muscles Tight, bursting pain After strenuous exercise (jogging) Subsides very slowly Relief with rest Typically heavy muscled athletes Modified from Norgren et al.15 Copyright 2007, with permission from Elsevier. PAD indicates peripheral artery disease.

Recommendations for Resting ABI and Additional Physiological Testing (Continued) COR LOE Recommendations

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