Re: Ask the expert: assessment of peripheral vascular disease in primary care
Dear Editor
We read with the interest article on the assessment of peripheral vascular disease in primary care, published by the esteemed scientist K Paraskevas. Although the article highlights several aspects of an interested issue in diabetic foot ulcers, it needs to be integrated with published findings that are well known in peripheral vascular disease.
According to the author, Ankle Brachial Index (ABI) tends to decrease in patients with vascular claudication, but it can be normal (above 1.0) in patients with spinal claudication. While, the documents demonstrated that 19-31% of those symptomatic peripheral artery disease (PAD) have normal or borderline resting ABI (1). Thus, the role of other tests such as active pedal plantar flexion and toe brachial index (TBI) should also be considered (2).
In another paragraph, it was noted that an attempt at measuring an ABI was unsuccessful as you cannot pick up a Doppler ultrasound signal at the ankle. Other diagnostic tests such as TBI are recommended to be performed in this regard.
Moreover, the early detection and separation of lymphedema from venous involvement in these wounds requires special attention. It is common to develop some discoloration of the skin as a result of the vascular edema. However, lymphedema is a chronic disease that causes the collection of lymphatic fluids to rise, resulting in bilateral swellings. It is important to note that thromboangiitis obliterans (Buerger's disease), is a rare disorder that, in most cases, affects young or middle-aged male cigarette smokers (3,4). Therefore, it is suggested that health care professionals pay extra attention to Buerger's disease in similar situations.
References
1- Mahé G, Lanéelle D, Le Faucheur A. Postexercise Ankle-Brachial Index Testing to Diagnose Peripheral Artery Disease. JAMA. 2021 Jan 5;325(1):89.
2- Tehan PE, Santos D, Chuter VH. A systematic review of the sensitivity and specificity of the toe-brachial index for detecting peripheral artery disease. Vasc Med. 2016 Aug;21(4):382-9.
3- Vijayakumar A, Tiwari R, Kumar Prabhuswamy V. Thromboangiitis Obliterans (Buerger's Disease)-Current Practices. Int J Inflam. 2013;2013:156905.
4- Cacione DG, Macedo CR, Baptista-Silva JC. Pharmacological treatment for Buerger's disease. Cochrane Database Syst Rev. 2016 Mar 11;3(3):CD011033.
Competing interests:
No competing interests
24 July 2024
Soheil Ebrahimpour
Assistant professor in the School of Medicine and Infectious Disease and Tropical Medicine Research Center, Babol University of Medical Sciences, Iran
Mostafa Javanian
Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, I.R. Iran.
Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, I.R. Iran.
Rapid Response:
Re: Ask the expert: assessment of peripheral vascular disease in primary care
Dear Editor
We read with the interest article on the assessment of peripheral vascular disease in primary care, published by the esteemed scientist K Paraskevas. Although the article highlights several aspects of an interested issue in diabetic foot ulcers, it needs to be integrated with published findings that are well known in peripheral vascular disease.
According to the author, Ankle Brachial Index (ABI) tends to decrease in patients with vascular claudication, but it can be normal (above 1.0) in patients with spinal claudication. While, the documents demonstrated that 19-31% of those symptomatic peripheral artery disease (PAD) have normal or borderline resting ABI (1). Thus, the role of other tests such as active pedal plantar flexion and toe brachial index (TBI) should also be considered (2).
In another paragraph, it was noted that an attempt at measuring an ABI was unsuccessful as you cannot pick up a Doppler ultrasound signal at the ankle. Other diagnostic tests such as TBI are recommended to be performed in this regard.
Moreover, the early detection and separation of lymphedema from venous involvement in these wounds requires special attention. It is common to develop some discoloration of the skin as a result of the vascular edema. However, lymphedema is a chronic disease that causes the collection of lymphatic fluids to rise, resulting in bilateral swellings. It is important to note that thromboangiitis obliterans (Buerger's disease), is a rare disorder that, in most cases, affects young or middle-aged male cigarette smokers (3,4). Therefore, it is suggested that health care professionals pay extra attention to Buerger's disease in similar situations.
References
1- Mahé G, Lanéelle D, Le Faucheur A. Postexercise Ankle-Brachial Index Testing to Diagnose Peripheral Artery Disease. JAMA. 2021 Jan 5;325(1):89.
2- Tehan PE, Santos D, Chuter VH. A systematic review of the sensitivity and specificity of the toe-brachial index for detecting peripheral artery disease. Vasc Med. 2016 Aug;21(4):382-9.
3- Vijayakumar A, Tiwari R, Kumar Prabhuswamy V. Thromboangiitis Obliterans (Buerger's Disease)-Current Practices. Int J Inflam. 2013;2013:156905.
4- Cacione DG, Macedo CR, Baptista-Silva JC. Pharmacological treatment for Buerger's disease. Cochrane Database Syst Rev. 2016 Mar 11;3(3):CD011033.
Competing interests: No competing interests