What does an ankle-brachial index (ABI) reveal and when is it indicated?
An ankle-brachial index (ABI) test provides a lot of useful information and is a quick, noninvasive way to check for obstructive peripheral arterial disease (PAD). Before we get into what the ABI represents and when ordering one might be useful, you should be aware that there are two components of an automated ABI report:
- The quantitative portion consisting of the ABI ratio.
- The qualitative portion consisting of the audible and analog waveforms.
The quantitative portion consists of a ratio of the systolic blood pressure taken in the ankle over the systolic blood pressure taken in the arm. This calculation creates the index value.
Figure 1. The quantitative portion of an automated ankle-brachial index (ABI) report consists of a ratio which is calculated by dividing the systolic blood pressure in the ankle by the systolic blood pressure in the arm.
The qualitative component of an ABI test consists of the audible and analog waveforms produced by the Doppler on an automated ABI machine. These waveforms, in conjunction with the ratio, are used to classify the presence and degree of blockage.
It’s important to note that there’s a key difference between manual ABIs (which only require a Doppler pen and blood pressure cuff and pump) and automated ABIs (which require an automated ABI machine). Both the manual and automated methods provide us with ratios and audible waveforms. But, only an automated ABI machine can provide us with analog waveforms.
The most useful part of analog waveforms is that they can be printed in a report and shared. The waveforms are then correlated with the ABI ratios to help with diagnosis.
Figure 2. The qualitative portion of an automated ankle-brachial index (ABI) report consists of audible waveforms, which can only be heard, and analog waveforms, which can be printed in a report.
What does the ABI test mean?
The ABI represents the percentage of blood flow that is traveling from the heart to the ankles. Ideally, the index should be 1, which means that 100% of the blood is reaching the ankles. In fact, the index can be slightly greater than 1 due to hydrostatic pressure that naturally increases from standing during the day.
On the other hand, an ABI of 0.5 means that only 50% of the blood is reaching the ankles, and 50% is blocked by PAD.
Figure 3. When performing an ankle-brachial index (ABI) test, the ABI ratio represents the percentage of blood that is reaching the ankles.
When is an ABI indicated?
An ABI can be used to evaluate a patient for suspected occlusive PAD, but not for a patent aneurysm without obstructive mural thrombus. As well, it would be rare to have enough mural thrombus to show up on an ABI unless an aneurysm was occluded by mural thrombus (then acute limb ischemia would happen).
Keep in mind that PAD is not ruled out by a normal ABI. Rather, the ABI results help differentiate what type of PAD the patient may have.
For example, patients with PAD due to a true aneurysm or even an active pseudoaneurysm will usually have normal ABI results. However, patients who have PAD that is of an occlusive etiology will have abnormal ABI results. Thus, the ABI is mostly used when an occlusive disease is suspected, such as atherosclerosis.
With a patient who has atherosclerotic PAD, one would expect abnormal ABI ratios and abnormal ABI waveforms.
Figure 4. A patient with atherosclerotic peripheral arterial disease would be expected to show abnormal ankle-brachial index (ABI) ratios and abnormal waveforms.
- Aboyans, V, Criqui, MH, Abraham, P, et al. 2012. Measurement and interpretation of the ankle-brachial index: a scientific statement from the American Heart Association. Circulation. 126: 2890–2909. PMID: 23159553
- Cervin, A, Wanhainen, A, and Björck, M. 2020. Popliteal aneurysms are common among men with screening detected abdominal aortic aneurysms, and prevalence correlates with the diameters of the common iliac arteries. Eur J Vasc Endovasc Surg. 59: 67–72. PMID: 31757587
- Cleveland Clinic. 2021. Leg and foot ulcers. Cleveland Clinic. https://my.clevelandclinic.org
- Cleveland Clinic. 2021. Marfan syndrome. Cleveland Clinic. https://my.clevelandclinic.org
- Cleveland Clinic. 2021. Popliteal artery entrapment syndrome (PAES). Cleveland Clinic. https://my.clevelandclinic.org
- Cleveland Clinic. 2021. Statin medications & heart disease. Cleveland Clinic. https://my.clevelandclinic.org
- Collins, L and Seraj, S. 2010. Diagnosis and treatment of venous ulcers. Am Fam Physician. 81: 989–996. PMID: 20387775
- Høyer, C, Sandermann, J, and Peterson, LJ. 2013. The toe-brachial index in the diagnosis of peripheral arterial disease. J Vasc Surg. 58: 231–238. PMID: 23688630
- Jaoude, WA. 2010. Management of popliteal artery aneurysms. SUNY Downstate Department of Surgery. http://www.downstatesurgery.org
- Johns Hopkins Medicine. 2021. Aneurysm. Johns Hopkins Medicine. https://www.hopkinsmedicine.org
- Kassem, MM and Gonzalez, L. 2020. “Popliteal artery aneurysm”. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov
- Moxon, JV, Parr, A, Emeto, TI, et al. 2010. Diagnosis and monitoring of abdominal aortic aneurysm: current status and future prospects. Curr Probl Cardiol. 35: 512–548. PMID: 20932435
- Richert, DL. 2016. Gundersen/Lutheran Ultrasound Department Policy and Procedure Manual. Gundersen Health System. https://www.gundersenhealth.org
- Rivera, PA and Dattilo, JB. 2020. “Pseudoaneurysm”. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov
- Stanford Medicine 25. 2021. Measuring and understanding the ankle brachial index (ABI). Stanford Medicine 25. https://stanfordmedicine25.stanford.edu/
- Teo, KK. 2019. Acute peripheral arterial occlusion. Merck Manuals Professional Edition. https://www.merckmanuals.com
- The Regents of the University of California. 2020. Diabetic foot ulcers. UCSF Department of Surgery. https://surgery.ucsf.edu
- Zwiebel, WJ and Pellerito, JS. 2005. Introduction to Vascular Ultrasonography. 5th edition. Philadelphia: Elsevier Saunders. (Zwiebel and Pellerito 2005, 254–259)