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CLINICAL STATEMENTS AND GUIDELINES

June 11, 2024 Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 e1326

5 Noncompressible tibial arteries occur frequently in

the setting of diabetes or CKD and may result in a falsely elevated ABI of >1.4 even when significant PAD is confirmed by imaging.15–17,39,40,61 Digital arteries are rarely noncompressible, and a TBI can be used to evaluate for PAD.12–14 The TBI is the ratio of the toe (first digit) pressure divided by the higher of the left and right brachial artery systolic pressures. A TBI of ≤0.70 is considered abnormal and allows for the diagnosis of PAD in patients with an ABI >1.4 who have history or physical examination findings suggestive of PAD (Table 6).16,17

6 The exercise treadmill ABI is generally measured

within 1 and 5 minutes after exercise on a motorized treadmill using a Doppler device and a blood pressure cuff. ABI measurements may be further repeated until recovery to baseline. Exercise increases blood flow and the gradient across physiological stenoses to increase the sensitivity of detecting PAD.19 Although evidence supporting the

Figure 2. Algorithm for Diagnostic Testing for PAD. *If not already performed. Colors correspond to Table 3. ABI indicates ankle-brachial index; CLTI, chronic limb-threatening ischemia; CTA, computed tomography angiography; GDMT, guideline-directed management and therapy; MRA, magnetic resonance angiography; PAD, peripheral artery disease; PVR, pulse volume recording, SPP, skin perfusion pressure; TBI, toe-brachial index; and TcPO2, transcutaneous oxygen pressure.

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