CLINICAL UPDATE Understanding the ankle brachial pressure index to treat venous ulceration Measuring ankle systolic and calculating an ankle brachial pressure index (ABPI) is crucial for the non-invasive assessment of peripheral vascular disease (PVD). More recently, the technique has become an important aspect of lower limb wound management, helping clinicians to assess patients with venous ulceration to establish suitable treatment options.

KEY WORDS he measurement of ankle systolic be as long as 25 minutes (Yao, 1970), as blood pressure and the calculation muscle metabolic activity during exercise  Ankle brachial pressure index of an ankle brachial pressure results in local vasodilation induced by the (ABPI) indexT (ABPI) is one of the fundamental release of chemical mediators.  Venous ulceration non-invasive techniques used to assess  Doppler principle peripheral perfusion. The methodology In normal individuals there is an increase  Systolic pressure was established in the 1960s (Vowden in total limb blood flow without a fall in  Diastolic pressure et al, 1996; Caruana et al, 2005) and pressure. However, in the presence of has, for nearly 50 years, been an integral arterial stenotic disease, pressure in the part of vascular assessment, defining distal vascular bed falls and remains low the physiological consequences of until the vasodilators are cleared from atherosclerotic arterial disease, in terms of the limb. Therefore, mild-to-moderate peripheral perfusion pressure. peripheral vascular disease causes a fall in the ABPI after exercise, the recovery More recently, the technique has become period reflecting the severity of the arterial one of the key elements of lower limb disease (Caruana et al, 2005). For a normal wound management, determining subject who has not exercised, a resting treatment options for patients with venous period of five minutes will usually suffice ulceration (Royal College of Nursing, 1998; but if the systolic pressure is reduced and SIGN, 2010). the ABPI of less than 1, readings should be repeated after a further period of five The technique does have limitations but minutes rest or until results are stable. when correctly applied has been shown to offer a valid, reliable and reproducible Choose a sensor measure of lower limb arterial disease A number of different sensors can (Vowden et al, 1996; Caruana et al, 2005). be used to detect the onset of blood movement during occlusive blood pressure Rest the patient measurement. These include: Before undertaking any blood pressure  A traditional stethoscope measurement, the room should be quiet  An ultrasonic detector using the and at a comfortable temperature and the Doppler principle to detect blood cell patient should be relaxed, comfortable movement PETER VOWDEN and have rested for at least five minutes  A strain gauge which calculates blood Consultant Vascular Surgeon and (O’Brien et al, 2003). flow and, hence, pressure by measuring Visiting Professor of Wound Healing electrical resistance changes. It uses Research, Bradford Teaching When taking lower limb systolic pressure an extendable band placed around a Hospitals NHS Foundation Trust readings, the resting period may need to limb or digit to detect small changes in and The University of Bradford be longer. For patients with severe arterial volume (Nielsen and Rasmussen, 1973) disease the resting period may need to  Detectors that register changes

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 Explain procedure (reduce anxiety) – anxiety may falsely elevate systolic pressure  Position subject (supine) ­– limb elevation or dependency in relation to heart level will affect systolic pressure  Rest subject (20 minutes) – exercise can lower leg systolic pressure in claudicants and patients with asymptomatic arterial disease

Measure systolic pressure in both arms using Doppler ultrasound probe (8MHz) and a sphygmomanometer cuff. Remember:  Systolic pressure can vary between arms so record both and use highest  Inappropriate cuff size can affect accuracy  Brachial pressure measurement method can produce slight variation in systolic reading  An irregular pulse and/or too rapid deflation of cuff can affect accuracy of reading

Locate ankle pulses (AT/DP and PT). Measure systolic pressure in both vessels using Doppler ultrasound probe (8MHz) and an appropriately sized sphygmomanom- eter cuff. 0 Using contact gel, position probe at 60 to skin References surface and in line with the artery. Record pressure for Al-Qaisi M, Nott DM, King DH, Kaddoura S each vessel and use the highest pressure at the ankle to (2009). Ankle Brachial Pressure Index (ABPI): calculate the ABPI for that leg. Repeat the process for An update for practitioners. Vasc Health Risk the other limbs. Remember: Management. 5: 833–41  Systolic pressure can vary between ankle vessels so record both pressures and sound type Anderson I (2002) The effect of varying cuff (e.g. monophasic) position on recording ankle systolic blood pres-  Cuff size, position and wound padding can affect sure. J Wound Care 11(5): 185–89 accuracy of reading – position at ankle with only Apelqvist J, Castenfors J, Larsson J, Stenstrom film covering wound A, Agardh CD (1989) Prognostic value of  Non-compressible vessels will falsely elevate systolic ankle and toe blood pressure levels in pressure; be cautious in diabetics and patients with outcome of diabetic foot ulcer. Diabetes Care renal failure 12(6): 373–78  Limb dependency will falsely elevate pressures Belcaro G, Nicolaides AN (1989) Pressure  Select 5MHz probe for deeper vessels and large index in hypotensive or hypertensive patients. J limb size. Cardiovasc Surg 30(4): 614–17 Bianchi J, Zamiri M, Loney M, McIntosh H, Dawe RS, Douglas WS (2008) Pulse oximetry  Document results – record systolic pressure, Highest left ankle systolic pressure index: a simple arterial assessment for patients ABPI = calculate ABPI, using formula (right) L Highest brachial systolic pressure with venous disease. J Wound Care 17(6):

 Discuss results with patient – consider if 253–60

patient requires healthy living advice Highest right ankle systolic pressure ABPIR = Burns PN (1993) Principles of deep Doppler  Clean equipment – follow infection protocol Highest brachial systolic pressure ultrasonography. In: Bernstein EF (ed) Vascular Diagnosis. 4th ed. Mosby, St Louis, Missouri: 249–68 in tissue oxygen (pulse oximetry). No matter which sensor system is used, Carser DG. (2001) Do we need to reappraise our method of interpreting the ankle brachial These have been used to calculate the all these methods record the occlusion pressure index? J Wound Care 10(3): 59–62 Lanarkshire Oximetry Index (LOI), pressure at the site of the cuff, not the Caruana MF, Bradbury AW, Adam DJ (2005). which is derived from pressures pressure at the sensor, and all are subject The validity, reliability, reproducibility and recorded from cuffs at the to the same limitations, in terms of vessel extended utility of ankle to brachial pressure and ankle using oximetry sensors compressibility, pulse pressure variability, index in current vascular surgical practice. Eur placed on the finger and toe to detect patient position and the need to rest J Endovasc Surg 29: 443–51 restoration of pulsatile flow as the cuffs subjects before conducting readings Donnelly R, Emslie-Smith AM, Gardner ID, are deflated. This method has been (Vowden and Vowden, 2006). Morris AD (2000) ABC of arterial and venous disease: vascular complications of diabetes. suggested as a possible alternative to BMJ 320(7241): 1062–66 measuring the ABPI using Doppler All of the methods allow estimation of EWMA (2003) Position Document: equipment (Khalili et al, 2002; Bianchi systolic pressure, but not all register diastolic Understanding compression therapy. MEP et al, 2008). pressure measurement. Ltd, London

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Whichever technique is used to measure superficial. In oedematous limbs or obese blood pressure, readings should be patients, a 5mHz probe may occasionally obtained with the sphygmomanometer be necessary as there is greater depth equipment at heart level to eliminate penetration of the ultrasound at that the effect of hydrostatic pressure on the frequency (Vowden et al, 1996). pressure measurement (O’Brien et al, The brachial pulse should first be located 2003; Pickering el al, 2005). by and ultrasonic gel placed over the identified artery. The gel acts When a comparison is to be made as a coupling medium, allowing transfer between upper and lower limb pressures, of the ultrasound from the probe into readings should be taken with the patient the tissues. The probe should be held in supine to eliminate pressure variations contact with the skin at an angle of about caused by the hydrostatic pressure 60o to the line of the vessel but no pressure difference between the higher and lower should be applied. Once a good signal is limbs in relation to the heart (Vowden, obtained, the cuff should be inflated to 2001a; Vowden, 2001b). above systolic pressure and then slowly released, the pressure at which the signal The difference between the blood pressure returns equates to the systolic pressure. It measured in the arms and that measured is important not to move the probe away in the legs is normally less than 10mmHg, from the vessel and to deflate the cuff pressure in the lower limb generally slowly to obtain an accurate reading. being higher because of augmentation of the pressure by the muscular peripheral To obtain lower limb systolic blood arteries and the summation of reflected pressure, the patient is measured at the pressure waves (Caruana et al, 2005). ankle with the cuff placed immediately But, the difference may be increased in above the malleoli. This allows access the presence of coarctation of the aorta to the posterior tibial, the anterior tibial (Markham et al, 2004) or occlusive lower and its continuation the dorsalis pedis, limb arterial disease or following exercise, and the peroneal arteries. The peroneal especially in the presence of occult or can be difficult to identify and, therefore, symptomatic arterial disease (Vowden et the posterior and anterior tibial arteries Figure 2: This image shows the location al, 1996; Vowden and Vowden, 2001b). are most commonly used for pressure of the posterior tibial artery. An appropriate cuff size should be chosen readings (Vowden et al, 1996; Caruana Figure 3: These markings indicate for each limb when undertaking blood et al, 2005). Figures 2-4 demonstrate where the tibial artery continues as the pressure readings (Caruana et al, 2005). the anatomical location of these vessels. dorsalis pedis in the foot. Whether two or three vessels are used, Using Doppler FOR pressure readings are obtained and FigureFigure 3: 4: Toe This pressure marking shows measurement the site at systolic blood pressure recorded for each artery tested. which the distal peroneal artery can be When using the hand-held Doppler accessed at the ankle. equipment to measure systolic blood Differences in pressure of greater than pressure (Figure 1) the same basic 15mmHg between crural arteries can be methodology set out above for the taken as indicating significant occlusive conventional measurement of blood arterial disease in the vessel with the lower pressure using a sphygmomanometer pressure (Vowden and Vowden, 2001b). should be followed, remembering that This may be relevant when considering the pressure measured relates to the cuff a patient for compression therapy, position and not to the position of the particularly if the pressure is lowest in the sensor. Cuff position and size errors may anterior tibial artery, as the area over the result in inappropriate clinical decision tibialis anterior tendon is more vulnerable making (Caruana, 2005). to pressure damage.

With the subject rested, relaxed and In some patients, lower limb systolic supine, the correct size cuff should be pressure may appear grossly elevated Figure 5: Toe pressure measurement secured around the limb in question. due to the non-compressible nature is taken by placing a cuff around the For the arm, the cuff should be located of their arteries. In such a situation it A suitable sized cuff has been placed around the base ofjust the above the elbow. A variety of probe may be possible to estimate lower limb toe andbase the of Doppler the toe probe and isusing being a used Doppler to detect blood flow in the digitalprobe artery. to detect An alternative blood flow is to in place the the probe overtypes the are available that emit ultrasound systolic pressure by performing a pole tip ofdigital the toe. artery. It is often useful to connect headphones toat the a specific frequency. In general, an test (Smith et al, 1994; Pahlsson et al, Doppler unit to allow more accurate detection of flow onset and therefore toe systolic pressure 8mHz probe is used to evaluate flow in 1999). In this test a reference pulse is peripheral arteries as they tend to be identified in a resting supine patient

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Supplement 8(1)WUK.indd 12 16/03/2012 16:34 Figure 6: Increasing atherosclerotic stenotic arterial disease produces an altered waveform, producing first a biphasic and then a monophasic wave form.

and the limb elevated with the Doppler systolic blood pressure reading and probe held over the artery. The height it has been proposed that readings at which the reference pulse disappears should be taken with a 2.5cm wide cuff above the neutral position in centimetres (Pahlsson et al, 2007). is recorded. Multiplying this figure by References 0.735 (to convert from millimetres of The definition of critical limb ischaemia Hirai M, Shionoya S (1978) Segmental blood blood to millimetres of mercury) gives and the likelihood of wound healing, pressure of the leg and its clinical use. Jpn J Surg the equivalent ankle systolic pressure particularly in the diabetic foot, have 8(2): 102–10 in mmHg (Vowden et al, 1996), but been related to absolute systolic pressure Hugue CJ, Safar ME, Aliefierakis MC, Asmar the range of values is clearly limited by at both the ankle and toe and such RG, London GM (1988) The ratio between limb length and hip mobility. Although readings may, therefore, have value in ankle and brachial systolic pressure in patients not frequently undertaken, pressures treatment planning (Apelqvist et al, 1989; with sustained uncomplicated essential hyper- tension. Clin Sci 74(2): 179–82 derived by leg elevation provide a more Dormandy et al, 1991). Jonsson B, Skau T (2002) Ankle-brachial accurate index of severe leg ischaemia index and mortality in a cohort of question- than sphygmomanometry, although the Obtaining the ABPI naire recorded leg pain on walking. Eur J Vasc technique is limited to assessing pressures Systolic blood pressure can vary widely Endovasc Surg 24(5): 405–10 of less than approximately 60mmHg and to compensate for this and allow a Keen D (2008) Critical evaluation of the reli- (Smith et al, 1994). meaningful comparison of results for ability and validity of ABPI measurement in leg an individual over time, a ratio can be ulcer assessment J Wound Care 17(12): 530–33 An alternative is to measure toe derived that compares the highest arm Khalili GR, Saghaei M, Abedini M (2002) systolic pressure, which is regarded as systolic pressure, taken as the best estimate Blood pressure measurement by pulse oxymet- ric method and comparison with conventional a more reliable measure in diabetics as of central systolic pressure, with the technique. Acta Anaesthesiol Sin 40(1): 3–7 digital vessels are less likely to be non- highest pressure obtained at the ankle. Leng GC, Fowkes FG, Lee AJ, Dunbar J, Hous- compressible. The technique is, however, These readings should, ideally, be taken ley E, Ruckley CV (1996) Use of ankle brachial more difficult. A neonatal or penile blood synchronously and give a separate ABPI pressure index to predict cardiovascular events pressure cuff is placed on the great toe for each leg. Table 1 highlights some of and death: a cohort study BMJ 313(7070): and blood flow detected in the terminal the potential sources of error in systolic 1440–44 phalanx. Figure 5 shows a Doppler probe pressure measurement and, therefore, in Lewis J, Hawkins M, Barree P, Cawley S, being used to detect blood flow in the ABPI calculation. Dayananda S (2010) A comparison between a new automatic system and Doppler method for digital artery. An alternative is to place obtaining ankle brachial pressures. J Foot Ankle the probe over the tip of the toe. It is Al-Qaisi et al (2009) have reviewed the Research 3(Suppl 1): 15 often useful to connect heaphones to literature relating to ABPI and provide Male S, Coull A, Murphy-Black T (2007) the Doppler unit to allow more accurate an update for practitioners, exploring Preliminary study to investigate the normal detection of flow onset and, therefore, the rational for the technique and its range of Ankle Brachial Pressure Index in young adults. J Clin Nurs 16(10): 1878–85 systolic pressure. limitations. Markham LW, Knecht SK, Daniels SR, Mays WA, Khoury PR, Knilans TK (2004) Develop- Toe pressures are lower than arm or ankle Automated systems such as the Huntleigh ment of exercise-induced arm-leg blood pres- systolic pressure and the ‘normal’ range Dopplex ABIlity (Huntleigh Healthcare), sure gradient and abnormal arterial compliance much narrower. It has been found that which uses an integrated pneumatic sensor in patients with repaired coarctation of the cuff width can greatly affect the obtained system rather than traditional Doppler, aorta Am J Cardiol 94(9): 1200–2

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or systems which use the oscilometric degree of non-compressibility in the lower method to record systolic pressure (ABPI limb vessels. If such a result is obtained, MD®; Mesi), are available to synchronously check for possible technical errors that KEY POINTS measure limb systolic pressure in all four may have falsely elevated the lower limb limbs and calculate the ABPI. These have systolic pressure, such as using too small  Before undertaking a blood been shown to be reliable in clinical use but a sphygmomanometer cuff or measuring pressure measurement, the do not all give full information on the pulse ankle pressure with the limb dependent. room should be quiet, at a waveform and pressure at the three ankle comfortable temperature and vessels obtained with the standard Doppler In a young and otherwise fit patient with no the patient should be relaxed, method (Lewis et al, 2010). symptoms of peripheral arterial disease such comfortable and have rested for readings are unlikely to be of significance. at least five minutes. In the elderly, in people with diabetes and in  Waveform and sound, Mild-to-moderate peripheral spectral analysis patients with possible symptoms of arterial vascular disease causes a fall Blood cell velocity varies during the cardiac disease an alternative technique should be in the ABPI after exercise, the cycle and across the sample zone within a used to check lower limb perfusion. recovery period reflecting the blood vessel, with cells in the centre of the severity of the arterial disease. blood vessel moving faster than those on the Individuals with symptoms of intermittent  All methods allow estimation periphery. Ultrasound is reflected from all claudication usually have an ABPI between of systolic pressure but not these cells but as the cell velocities vary so 0.4 and 0.9, while patients with rest pain or all methods allow diastolic does the frequency shift that occurs in the arterial ulceration usually have an ABPI of pressure measurement. reflected ultrasound. The velocity profile <0.4. In patients with mild arterial disease,  Cuff position and size errors for a normal peripheral artery produces particularly that involve the iliac vessels, may result in inappropriate a characteristic triphasic waveform and Doppler systolic pressure measurement clinical decision making. sound. Increasing atherosclerotic stenotic combined with exercise testing can be of arterial disease produces an altered value in revealing occult arterial disease waveform, producing first a biphasic and (Vowden et al, 1996). then a monophasic wave profile and sound (Vowden et al, 1996). Figure 6 illustrates this Segmental pressure measurements along and demonstrates the waveforms produced. a limb, comparing pressures in the thigh, upper calf and at the ankle can also be Signal analysis in its simplest form involves useful in locating the site of any significant operator interpretation of the audible arterial occlusive disease. The systolic References signal derived from the hand-held Doppler. pressure is usually higher in the thigh than Nielsen PE, Rasmussen SM (1973) Indirect More complex analysis of the generated the brachial, with a pressure gradient down measurement of systolic blood pressure by Doppler waveform can be undertaken and the leg (Hirai and Shionoya, 1978), and a strain gauge technique at finger, ankle and toe a Pulsitility Index (PI) derived, the lower the pressure difference of >30mmHg between in diabetic patients without symptoms of oc- clusive arterial disease. Diabetologia 9(1): 25–9 PI the greater the degree of proximal arterial adjacent cuffs indicating significant arterial stenosis (Sumner, 1989; Burns, 1993). disease (Sumner, 1989). Anderson (2002) O’Brien E, Asmar R, Beilin L, Imai Y, Mallion JM, Mancia G, et al (2003) European Society of demonstrated a statistically different systolic Hypertension recommendations for conven- ABPI and general pressure and ABPI between measurements tional, ambulatory and home blood pressure cardiovascular risk taken in the upper and lower calf although measurement. J Hypertens 21(5): 821–48 A reduced ABPI is associated with a general the differences may not have always Pahlsson HI, Laskar C, Stark K, Andersson A, increase in cardiovascular risk (Leng et been clinically significant. Some subjects Jogestrand T, Wahlberg E (2007) The optimal al, 1996; Jonsson and Skau, 2002) with also found the upper cuff position more cuff width for measuring toe blood pressure. Angiology 58(4): 472–6 increasing morbidity rates, and reduced uncomfortable. survival, being linked directly to a reduction Pahlsson HI, Wahlberg E, Olofsson P, Sweden- borg J (1999) The toe pole test for evaluation of in the ABPI (Donnelly et al, 2000). Finding Variations in systolic pressure can also arterial insufficiency in diabetic patients. Eur J a reduced ABPI should, therefore, feed in to influence ABPI and may be important in Vasc Endovasc Surg 18(2): 133–37 an associated cardiovascular risk assessment longitudinal measurement of ABPI. ABPI is Pickering TG, Hall JE, Appel LJ, Falkner BE, and management strategy and if symptoms relatively higher in hypotensive patients and Graves J, Hill MN, et al (2005) Recommen- of peripheral vascular disease are present, low in hypertensive patients (Hugue et al, dations for blood pressure measurement in referral to a vascular surgeon for further 1988; Belcaro and Nicolaides, 1989, Carser, humans and experimental animals. Part 1: blood pressure measurement in humans: a assessment. 2001). statement for professionals from the Subcom- mittee of Professional and Public Education of the American Heart Association Council on ABPI and lower limb ABPI, leg ulceration and High Blood Pressure Research. Hypertension arterial disease compression therapy 45(1): 142–61 In a normal subject the ABPI is usually Taken in isolation an ABPI does not RCN (1998) Clinical Practice Guidelines:The between 1.3 and 0.95, with a ratio of <0.92 establish a diagnosis or define the aetiology management of patients with venous leg ulcers. taken as indicating arterial disease. An of a leg ulcer. The role of ABPI in leg RCN Institute, London ABPI of >1.3 is usually taken to indicate a ulcer management and compression

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Supplement 8(1)WUK.indd 14 16/03/2012 16:34 Table 1 Sources of error in blood pressure measurement and ABPI (Vowden et al, 1996; Khalili et al, 2002; Markham et al, 2004) Some causes of arm blood pressure Systolic effect error Cuff too small +10-40 mmHg Cuff too large -5-25 mmHg Artery line not centered +4-6 mmHg Arm above heart level -2 mmHg/inch Arm below heart level +2 mmHg/inch Cuff placed over clothing/bulky dressings +/- 10-40 mmHg Patient not rested +10-20 mmHg Patient in pain +10-20 mmHg White coat syndrome +11-20 mmHg Lower limb systolic pres- ABPI sure Insufficient period of rest Reduced Reduced Limbs dependent Elevated * Elevated Irregular pulse Variable Variable but usually reduced Leg cuff too small Elevated Elevated Leg cuff to large Reduced Reduced Probe errors Reduced Reduced * Allowance can be made for this by taking the height difference between arm and ankle References pulse in centimetres x 0.735 from the systolic pressure recorded. This should correct Dormandy J, Verstraete M, Andreani D, et al systolic pressure and allow more accurate estimation of the true ABPI. (1991) Second European consensus document on chronic critical leg ischemia. Circulation 84 (suppl 4): 1–26 therapy is two-fold. The first is to support considered a fixed figure, the mean ABPI in SIGN (2010) Guideline 120: Management of the diagnostic process and evaluate the their study population being 1.14 (SD 0.06). chronic venous leg ulceration. SIGN, Edinburgh presence of arterial disease, and the other Smith FC, Shearman CP, Simms MH, Gwynn is to help define the appropriate level of ABPI readings should, therefore, be BR (1994) Falsely elevated ankle pressures in compression therapy. In a clinimetric interpreted in light of the patient’s age, severe leg ischaemia: the pole test — an alter- analysis of the measurement of ABPI by limb size and symptoms of peripheral native approach. Eur J Vasc Surg 8(4): 408–12 Doppler ultrasound, Keen (2008) concluded arterial disease. Decisions about the Sumner DS (1989) Non-invasive assessment that the method was, ‘valid and reliable if appropriateness of hosiery, for example of peripheral arterial occlusive disease. In: the practitioner is competent and able to as part of post deep thrombosis Rutherford KS (ed) . 3rd edn. W.B. Saunders, Philadelphia: 61–111 interpret the result within the context of a limb management, or compression full clinical assessment’. bandaging, should be made accordingly. Vowden KR, Goulding V, Vowden P (1996) Hand-held Doppler assessment for peripheral The International Leg Ulcer Guidelines arterial disease. J Wound Care 5(3): 125–28 Caruana et al (Caruana et al, 2005) (European Wound Management Vowden K, Vowden P (2006) Doppler and emphasise this need for caution in their Association [EWMA], 2003) describe Pulse Oximetry. Wounds UK 2(1): 13–6 review in which they discuss possible causes appropriate management strategies Vowden P, Vowden KR (2001a) Doppler of inappropriate compression therapy in stratified according to ABPI. ABPI readings assessment and ABPI: Interpretation in the chronic venous leg ulcer patients. An ABPI may also indicate appropriate bandage management of leg ulceration. World Wide of ≥0.8 is taken as broad indicator that type selection and several bandage Wounds. Available online at: http://www. worldwidewounds.com/2001/march/Vowden/ a patient will tolerate high compression systems having now been designed to Doppler-assessment-and-ABPI.html (accessed bandaging (sub-bandage resting ankle offer compression therapy to patients with 29 February, 2012) pressure of 40mmHg) or hosiery (European reduced ABPI (Vowden et al, 2011). Vowden KR, Vowden P (2001b) Doppler and Class 2). Concern is often expressed about the ABPI: how good is our understanding? J applying compression to limbs with an Conclusion Wound Care 10(6): 197–202 ABPI >1.3 as such readings may mean that Providing the Doppler assessment Vowden K, Vowden P, Partsch H, Treadwell T the arterial tree is non-compressible. Male principles are followed and the common (2011) 3M Coban 2 Compression made easy. et al (2007), however, emphasise that, for the pitfalls avoided, the ABPI test provides a Wounds Int 2(1) otherwise healthy adults in the 20–40 year simple method for assessing and monitoring Yao ST (1970) Haemodynamic studies in pe- ripheral arterial disease. Br J Surg 57(10): 761–6 age range a ‘normal’ ABPI should not be peripheral arterial disease. Wuk

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