CT sufficient prior to Epidural?

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EruditeDoc

EruditeDoc

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Patient is an elderly female with h/o cardiac stent on anticoagulation also with a pacemaker that is not compatible with MRI. She has lower extremity radicular pain. Ordinarily I would like to have a MRI so that I can see soft tissue pathology. There is a CT scan which notes that there "may be some mild canal and neur foraminal narrowing." Clinically pain is only on ambulation with no associated neurologic deficits by history nor in the office on exam. Would you proceed with intervention from here?
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Agree with Steve. Elderly patient with radicular symptoms symptoms due to neurogenic claudication/stenosis almost never have normal DTR at ankles. Normal neuro exam on the patient makes spine pathology very unlikely. I will say, though, that CT does definitely underestimate stenosis compared to MRI.
 
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CT is sufficient if you want to do an esi. Stenotic patients CAN have normal dtrs. If you can feel a pulse, its not vascular
 
My concern is that CT L spine just might not be showing the extent of possible stenosis. Conversely, I am sure we have all had patients with" relatively" benign looking MRI L spine with radicular pain responsive to ESI. This is why I would consider performing the procedure for her.

I did not however consider possible vascular origin and will explore this.
 
EruditeDoc said:
My concern is that CT L spine just might not be showing the extent of possible stenosis. Conversely, I am sure we have all had patients with" relatively" benign looking MRI L spine with radicular pain responsive to ESI. This is why I would consider performing the procedure for her.

I did not however consider possible vascular origin and will explore this.
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Have you actually reviewed the images? Your original post made it sound like you just read the report. You can often make out disc and to some extent ligamentum flavum on the CT set to a soft tissue window, though not very well.
 
lobelsteve said:
Get an ABI Einstein. Nothing pinched. High risk pt. What are you treating?
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Why do you jump to ABI first?
If they have strong DP & PT foot pulses, they don't have vascular claudication. Diagnosis ruled out in 30 seconds with zero diagnostics.
 
you could proceed with ESI, but you know it probably wouldn't help.

if vascular claudication, wont help at all. but then again, not much would, barring major vascular surgery, and your patient scenario suggests that this would not be a great option (elderly, long term anticoagulation, ischemic cardiac disease with arrhythmias...)
fwiw, debunked 20 years ago:

Peripheral pulse palpation: an unreliable physical sign - PMC

Fifty observers, including two fully trained vascular surgeons, were asked to determine the presence or absence of the femoral and distal pulses of four patients with peripheral vascular disease and one asymptomatic subject (50 pulses assessed). ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

if neurogenic claudication, likewise unlikely to help. and you are not going to be getting a CT myelogram on this patient.



can someone check if lobelsteve has a pulse? or is he related to the Night King?
 
EruditeDoc said:
Patient is an elderly female with h/o cardiac stent on anticoagulation also with a pacemaker that is not compatible with MRI. She has lower extremity radicular pain. Ordinarily I would like to have a MRI so that I can see soft tissue pathology. There is a CT scan which notes that there "may be some mild canal and neur foraminal narrowing." Clinically pain is only on ambulation with no associated neurologic deficits by history nor in the office on exam. Would you proceed with intervention from here?
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If the CT is the best imaging you can get, then you work off of a CT. But I agree with the others that in a patient who's a vasculopath without a glaring radicular finding on imaging, the chances of vascular claudication cannot be ignored. First, check pulses. If feet are warm and well perfused with normal DP and PT pulses, you're done. You've ruled out critical lower extremity arterial occlusion in a vessel big enough to cause claudication. If pulses are weak, but palpable, get ABIs. If no pulse and cold foot, it's an acute arterial occlusion and you call ambulance transport to the ER, so they don't lose their leg in the next 4 hours.

Remember, if you have arterial occlusions, whether it's in the coronaries, legs, brain or elsewhere, you have them everywhere at least to some extent. Patients with history of CVA, CAD and PVD have risk factors that are nearly identical.
 
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lobelsteve said:
Might want to open a book.
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not sure if this is directed at me, but YOU might want to read the book chapters i have written on stenosis.

stenosis typically develops slowly, over the course of decades. in this type of scenario, reflexes can often be preserved.

also, ducttape's article is nonsense. if there is a pulse, the leg is perfused. i have never diagnosed vascular claudication (N=100) when i have found a distal pulse. it usually is pretty clear if their foot is cold and you cant find a pulse
 
SSdoc33 said:
not sure if this is directed at me, but YOU might want to read the book chapters i have written on stenosis.

stenosis typically develops slowly, over the course of decades. in this type of scenario, reflexes can often be preserved.

also, ducttape's article is nonsense. if there is a pulse, the leg is perfused. i have never diagnosed vascular claudication (N=100) when i have found a distal pulse. it usually is pretty clear if their foot is cold and you cant find a pulse
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Shoot me a link. I love reading. Reflexes have nothing to do with stenosis until the roots are compressed.
 
That CT gives you a decent look at a large territory of vasculature. Even I can see massive calcifications/occlusion/aneurysm of the aorta/Iliacs on CT.
 
I think all op is asking is if a CT is sufficient imaging prior to an epidural
 
For the original question, CT is sufficient to rule out most red-flag contraindications to interventional procedures but MRI is preferred when possible

I wouldn't use the cited nonspecific and common CT findings to justify an intervention in this case. There would need to be a clear indication on imaging/exam or significant morbidity as there is a higher risk of cardiac events if you're planning to hold anticoagulation
 
lobelsteve said:
Because strong pulses have great Sn/Sp?
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I wasn't saying I have magic fingers with 99.9% sensitivity and specificity (well....I have been told my fingers are magical, but I digress...)

But yes, positive DP and PT pulses in a competent examiner is a very strong rule out for an ischemic leg. Negative or weak pulses, on the other hand, could be due to ischemic leg, but also benign from edema, obesity or non-ischemic. So, if you want to get technical, If both peripheral foot pulses are present in both lower limbs and there are no femoral bruits, the specificity and NPV of 98.3% and 94.9%, respectively, make the measurement of ABI redundant.

That being said, I did spend 10 years in EDs where ruling ischemic limbs in or out was part of my wheelhouse, so, it's kind of like msk exam being 2nd nature for a physiatrist and epidural access for an anesthesiologist. You go from being an intern on your first month thinking everyone needs a CT angiogram and emergent vascular surgery consult, to being able to rule a lot of the easy ones out very quickly, some at the bedside.

That being said, I've always believed, if you are in doubt, then get a test. But, if you ever see someone where you personally felt strong DP and PT pulses in warm feet, and then still found them to have limb ischemia, I'd like to hear about it. That might be reportable.

(Edit: Added supportive citation)
 
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emd123 said:
I wasn't saying I have magic fingers with 99.9% sensitivity and specificity (well....I have been told my fingers are magical, but I digress...)

But yes, positive DP and PT pulses in a competent examiner is a very strong rule out for an ischemic leg. Negative or weak pulses, on the other hand, could be due to ischemic leg, but also benign from edema, obesity or non-ischemic. So, if you want to get technical, I guess that makes pulse palpation for this clinical question, sensitive but not specific (a positive can rule out, but negatives are non-specific and don't reliably rule it in).

That being said, I did spend 10 years in EDs where ruling ischemic limbs in or out was part of my wheelhouse, so, it's kind of like msk exam being 2nd nature for a physiatrist and epidural access for an anesthesiologist. You go from being an intern on your first month thinking everyone needs a CT angiogram and emergent vascular surgery consult, to being able to rule a lot of the easy ones out very quickly, some at the bedside.

That being said, I've always believed, if you are in doubt, then get a test. But, if you ever see someone where you personally felt strong DP and PT pulses in warm feet, and then still found them to have limb ischemia, I'd like to hear about it. That might be reportable.
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Claudication requires ambulation. Palpating resting legs is not the same thing. I feel pulses all day on severely stenotic 3 vessel leg disease. Pain with walking and better at rest should trigger an ABI. Much more productive to put stents/bypass in these folks when there is age appropriate moderate foraminal stenosis at b/l 4 levels. ESI without a good correlation between history, exam, and imaging is a waste of time and money.
 
In some patients with false-negative examination results (ie, disease is present but pedal pulses are palpable), the pedal pulses disappear during exercise.44-47 Just as exercise testing uncovers significant coronary artery stenoses, exercise of the extremities presumably results in a disproportionate distribution of blood to better-perfused muscle and away from poorly perfused distal tissue, causing the extremity to become symptomatic, the pressure to fall, and the pedal pulse to disappear. Exactly what proportion of diseased extremities with false-negative examination findings become positive with exercise has never been investigated, but a related series of investigations has shown that 2% to 13% of abnormal AAIs occur only after stress.
 
Feeling a pulse in an exam room does not mean that vessel can adequately carry blood in quantities required to meet the metabolic demands of walking. That said, the pt in this scenario doesn't seem to have significant lumbar stenosis so an ABI should be considered. If an ABI is negative you may want to actually look at the CT yourself bc the longer I'm in private practice the more misreads I catch from radiology. Look at your own images and make your own decisions if the pt has spine pathology but you better defer to the radiologist if there is something medical like an aneurysm, cysts, tumor, etc.
 
lobelsteve said:
Claudication requires ambulation. Palpating resting legs is not the same thing. I feel pulses all day on severely stenotic 3 vessel leg disease.
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Those patients had strong pulses, not diminished at all? I said strong pulses.
 
www.ncbi.nlm.nih.gov

Does the clinical examination predict lower extremity peripheral arterial disease? - PubMed

Clinical examination findings must be used in the context of the pretest probability because they are not independently sufficient to include or exclude a diagnosis of PAD with certainty. The PAD screening score using the hand-held Doppler has the greatest diagnostic accuracy.
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

JAMA.
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2006 Feb 1;295(5):536-46.
Does the clinical examination predict lower extremity peripheral arterial disease?
Khan NA1, Rahim SA, Anand SS, Simel DL, Panju A.
Author information

Abstract
CONTEXT:
Lower extremity peripheral arterial disease (PAD) is common and associated with significant increases in morbidity and mortality. Physicians typically depend on the clinical examination to identify patients who need further diagnostic testing.
OBJECTIVE:
To systematically review the accuracy and precision of the clinical examination for PAD.
DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION:
MEDLINE (January 1966 to March 2005) and Cochrane databases were searched for articles on the diagnosis of PAD based on physical examination published in the English language. Included studies compared an element of the history or physical examination with a reference standard of ankle-brachial index, duplex sonography, or angiogram. Seventeen of the 51 potential articles identified met inclusion criteria. Two of the authors independently extracted data, performed quality review, and used consensus to resolve any discrepancies.
DATA SYNTHESIS:
For asymptomatic patients, the most useful clinical findings to diagnose PAD are the presence of claudication (likelihood ratio [LR], 3.30; 95% confidence interval [CI], 2.30-4.80), femoral bruit (LR, 4.80; 95% CI, 2.40-9.50), or any pulse abnormality (LR, 3.10; 95% CI, 1.40-6.60). While none of the clinical examination features help to lower the likelihood of any degree of PAD, the absence of claudication or the presence of normal pulses decreases the likelihood of moderate to severe disease. When considering patients who are symptomatic with leg complaints, the most useful clinical findings are the presence of cool skin (LR, 5.90; 95% CI, 4.10-8.60), the presence of at least 1 bruit (LR, 5.60; 95% CI, 4.70-6.70), or any palpable pulse abnormality (LR, 4.70; 95% CI, 2.20-9.90). The absence of any bruits (iliac, femoral, or popliteal) (LR, 0.39; 95% CI, 0.34-0.45) or pulse abnormality (LR, 0.38; 95% CI, 0.23-0.64) reduces the likelihood of PAD. Combinations of physical examination findings do not increase the likelihood of PAD beyond that of individual clinical findings. However, when combinations of clinical findings are all normal, the likelihood of disease is lower than when individual symptoms or signs are normal. A PAD scoring system, which includes auscultation of arterial components by handheld Doppler, provides greater diagnostic accuracy.
CONCLUSIONS:
Clinical examination findings must be used in the context of the pretest probability because they are not independently sufficient to include or exclude a diagnosis of PAD with certainty. The PAD screening score using the hand-held Doppler has the greatest diagnostic accuracy.
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note the last line - clinical exam findings,,, are not independently sufficient to exclude a diagnosis of PAD with certainty.

and this: Intermittent claudication
Absent or reduced peripheral pulses or the presence of audible bruits supports the diagnosis of intermittent claudication, but some patients with the condition will have normally palpable pulses and no bruits. A low ankle-brachial pressure index (<0.9) also supports the diagnosis. However, the presence of palpable pulses or a normal resting ankle-brachial pressure index (>0.9) does not rule out the diagnosis. If the clinical history is highly suggestive of intermittent claudication and the ankle-brachial pressure index is normal, an exercise ankle-brachial pressure index should be performed.
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Damn. Buncha Fiesty divas. Good read tho. Is the actual question what imaging modality is necessary prior to intervention? I do agree ro vascular claudication . But not sure if thats what youre asking.
 
There is no question. Mri not possible. So ct or xray is all you have to help make decision. Both are pretty lousy. I would forego either if i thought esi would help her stenosis or acute hnp with root compression.
 
Some times vascular vs neurogenic claudication can be difficult to rule out in older folks who can't walk far, PT can be helpful since if they have a stationary bike because this takes the spine portion out of the picture and helps you look into exercise induce claudication, something to think about, but abi is your standard or send to vascular
 
lone commie would say if you think shot helps, do shot, and vote for bernie/hrc/community organizer(hussein), dog catcher
 
EruditeDoc said:
Patient is an elderly female with h/o cardiac stent on anticoagulation also with a pacemaker that is not compatible with MRI. She has lower extremity radicular pain. Ordinarily I would like to have a MRI so that I can see soft tissue pathology. There is a CT scan which notes that there "may be some mild canal and neur foraminal narrowing." Clinically pain is only on ambulation with no associated neurologic deficits by history nor in the office on exam. Would you proceed with intervention from here?
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Is it truly that the pacemaker is not compatible with MRI or just not one of the newer models that is specifically MRI-compatible? We do cardiology supervised pacemaker MRIs where the patient is interrogated before/after and monitored during the study. Might need to send her to a big academic center though. Something to consider if the ABIs are normal.
 
"The clinical examination of the peripheral arterial foot pulses and the auscultation for a femoral bruit has a high degree of accuracy (93.8%) for the detection or exclusion of PAD when compared with the ABI ...If both peripheral foot pulses are present in both lower limbs and there are no femoral bruits, the specificity and NPV of 98.3% and 94.9%, respectively, make the measurement of ABI seem redundant."




The accuracy of the physical examination for the detection of lower extremity peripheral arterial disease

David WJ Armstrong, BScH MSc, Colleen Tobin, RN, and Murray F Matangi, MB ChB FRACP FRCPC FACP FACC
Author information Article notes Copyright and License information Disclaimer
This article has been cited by other articles in PMC.

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Abstract

BACKGROUND:
Peripheral arterial disease (PAD) is a major risk factor for adverse cardiovascular events. There has been a definite push for wider use of the ankle-brachial index (ABI) as a simple screening tool for PAD. Perhaps this has occurred to the detriment of a thorough physical examination.

OBJECTIVE:
To assess the accuracy of the physical examination to detect clinically significant PAD compared with the ABI.

METHODS:
PADfile, the PAD module of CARDIOfile (the Kingston Heart Clinic’s cardiology database [Kingston, Ontario]), was searched for all patients who underwent peripheral arterial testing. Of 1619 patients, 1236 had all of the necessary data entered. Patients’ lower limbs were divided into two groups: those with a normal ABI between 0.91 and 1.30, and those with an abnormal ABI of 0.90 or lower. Peripheral pulses were graded as either absent or present. Absent was graded as 0/3, present but reduced (1/3), normal (2/3) or bounding (3/3). Femoral bruits were graded as either present (1) or absent (0). Using the ABI as the gold standard, the sensitivity, specificity, negative predictive value (NPV), positive predictive value and overall accuracy were calculated for the dorsalis pedis pulse, the posterior tibial pulse, both pedal pulses, the presence or absence of a femoral bruit and, finally, for a combination of both pedal pulses and the presence or absence of a femoral bruit.

RESULTS:
In 1236 patients who underwent PAD testing and who underwent a complete peripheral vascular physical examination (all dorsalis pedis and posterior tibial pulses palpated and auscultation for a femoral bruit), the sensitivity, specificity, NPV, positive predictive value and accuracy for PAD were 58.2%, 98.3%, 94.9%, 81.1% and 93.8%, respectively.

CONCLUSIONS:
The clinical examination of the peripheral arterial foot pulses and the auscultation for a femoral bruit had a high degree of accuracy (93.8%) for the detection or exclusion of PAD compared with the ABI using the cut-off of 0.90 or lower. If both peripheral foot pulses are present in both lower limbs and there are no femoral bruits, the specificity and NPV of 98.3% and 94.9%, respectively, make the measurement of the ABI seem redundant. The emphasis in PAD detection should be redirected toward encouraging a thorough physical examination.
Keywords: Ankle-brachial index, Peripheral arterial disease, Physical examination
Lower extremity peripheral arterial disease (PAD) affects approximately 12% of older patients in the general population (1–3). The diagnosis of PAD is considered to be a major risk factor for future cardiovascular (CV) events and mortality (1,2,4–14). Previous investigations have also shown that the risk of mortality in patients with asymptomatic PAD is similar to those with severe or symptomatic PAD (10,15). Similarly, the health-related quality of life of patients with PAD is similar in patients with other forms of CV disease (CVD) (16), and PAD has even been associated with higher rates of depression (17).
A clinical tool for both the diagnosis of PAD and the assessment of global CV risk stratification is the ankle-brachial index (ABI). The ABI is calculated as the ratio of the highest brachial systolic pressure to the highest systolic pressure in either the dorsalis pedis (DP) or the posterior tibial (PT) artery, and is most often measured using a handheld Doppler ultrasound device. The current ABI reference standard of 0.90 or lower has a sensitivity of 90% and a specificity of 98% for the detection of a hemodynamically significant stenosis of 50% or greater proximally in the lower limb (18,19). In our laboratory, an ABI of 0.96 to 1.30 is considered to be normal. An ABI of between 0.91 and 0.95 is a ‘grey zone’ and in this group, we closely examine the segmental pressures, continuous-wave Dopplers, toe-brachial index and pulse volume recordings to help decide on normality. An ABI of between 0.81 and 0.90 is considered to be mild PAD. An ABI of 0.50 to 0.80 is considered to be moderate PAD and an ABI of lower than 0.50 is considered to be severe PAD. An abnormally high ABI (greater than 1.30) occurs in patients with incompressible arteries, due to calcification of the vascular media. This is most often seen in elderly and diabetic patients. A high ABI (greater than 1.30) is also associated with increased CV risk (20).
Despite the advent of advanced diagnostic techniques, physicians are further required to determine which patients might benefit the most from further testing. Previous studies have investigated the usefulness of the peripheral vascular physical examination to identify patients with an abnormal ABI (0.90 or lower). However, differences in reference standards, patient populations and methodology make drawing conclusions regarding the utility of the physical examination for the detection of PAD difficult. Furthermore, current data are lacking regarding the accuracy of the physical examination in a community-based outpatient setting.
Our objective was to determine the accuracy of the peripheral vascular examination to detect the presence or absence of PAD as defined by an ABI of 0.90 or lower among patients referred to the Kingston Heart Clinic (Kingston, Ontario) for peripheral physiological arterial testing for suspected PAD or for ABI screening in high-risk groups.
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METHODS
Patient population
The Kingston Heart Clinic is a community-based outpatient cardiology practice. PADfile, the PAD module of CARDIOfile (the clinic’s cardiology database), was searched for all patients who underwent peripheral arterial testing. All tests were performed between December 2005 and February 2010. Patients were referred either for suspected PAD or because they were at high risk for PAD (ie, patients older than 70 years of age, diabetic patients 50 to 69 years of age, smokers 50 to 69 years of age or patients with intermediate Framingham risk scores of 10% to 19%). Of the 1619 patients who underwent peripheral arterial testing, 228 were excluded due to an abnormally high ABI (greater than 1.30) in either the left leg, the right leg or both legs. The clinic’s own data indicated, quite clearly, that these patients did not have obstructive PAD. In fact, the high ABI group had a very similar profile to the normal ABI group including the physical examination (Table 1). As expected, the high ABI group had a higher prevalence of diabetes and was, on average, older than the normal ABI group. What was unexpected was that the high ABI group had a much lower prevalence of smoking (12.7% versus 24.2%; P<0.005) (Table 1). Furthermore, the intention of the present study was to compare the accuracy of the physical examination to detect obstructive PAD (ABI 0.90 or lower) with the accuracy of detecting no PAD (ABI 0.91 to 1.30). A further 156 patients were excluded because at least one physical examination field was missing in CARDIOfile. This was due, in large part, to the femoral bruit field being empty (the right in 154 patients, the left in 147 and either in 155). Some foot pulse data were also absent (the right DP in 56 patients, the right PT in 57 and both in 56; and the left DP in 56, the left PT in 57 and both in 56). Absent foot pulses alone only reduced the number of patients by one. The indications for PAD testing are shown in Table 2.


Physiological PAD testing
PAD testing was performed using a Nicolet VasoGuard (CareFusion Corporation, USA) physiological testing system using the four-cuff method for segmental pressures and pulse volume recordings. Proximal vessels were isonated using a 4 MHz transducer. Distal vessels were isonated using an 8 MHz transducer for the continuous-wave Dopplers. The ABI and toe-brachial index were recorded in all patients. Patients’ lower limbs were divided into two groups: those with an ABI of greater than 0.90 and 1.30 or lower, and those with an ABI of 0.90 or lower. The examination of the peripheral pulses, and the auscultation for ileofemoral and femoral bruits were performed by one registered nurse (CT) who was specifically trained in the vascular examination. Peripheral pulses were graded as either absent or present. Absent was graded as 0/3, present but reduced was graded as 1/3, normal was graded as 2/3 and a bounding pulse was graded as 3/3. Femoral bruits were graded as either present or absent based on auscultation. The Edinburgh questionnaire (21) was not specifically used; however, claudication was believed to be present when the patient experienced leg discomfort with exercise that was relieved by rest within 1 min to 5 min.

Data interpretation
Using the ABI as the gold standard, the sensitivity, specificity, positive predictive value, negative predictive value (NPV), accuracy, positive likelihood ratio and negative likelihood ratio were calculated in the usual manner for the DP pulse, the PT pulse, both DP and PT pulses, the presence or absence of a femoral bruit, for a combination of the DP pulse, PT pulse and the presence or absence of a femoral bruit, and for claudication. The ABI data are presented for the total number of legs tested (n=2472). An unpaired t test was used to detect differences between means. Fisher’s exact test was used to detect differences between proportions. The level of significance was adjusted using the Bonferroni correction method for multiple comparisons.
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RESULTS
The mean (± SD) age of the entire population (n=1236) was 66.6±10.5 years. There were 821 men (66.4%) and 415 women (33.6%). A total of 751 patients (60.8%) had a history of CVD (previous myocardial infarction, stroke/transient ischemic attack or revascularization). A total of 900 patients (72.8%) were treated with a statin for dyslipidemia, 862 (69.7%) were being treated for hypertension, 375 (30.3%) had diabetes and 336 (27.2%) were current smokers. A total of 1158 patients (93.7%) had at least one major CV risk factor. Concomitant drug therapy is shown in Table 3.

DISCUSSION
There is little doubt that PAD is a major cause of morbidity and diminished quality of life, and a major risk factor for adverse CV events including mortality. The ABI is a well-validated tool for categorizing disease severity and assessing CV risk.
Previous studies have assessed the use of the vascular physical examination for detecting PAD; however, some studies (22–27) included only symptomatic patients, some (24,28–30) included only asymptomatic patients, and other studies (28,31) exclusively studied patients with diabetes mellitus. Disparities in the reference standard for disease detection (ie, ABI cut-off) also make consensus on the usefulness of the vascular physical examination difficult (32). Current data concerning the accuracy of the physical examination to detect an ABI of 0.90 or lower in a heterogeneous population are lacking.
Our study included a large number of men and women, both with and without diabetes, and both symptomatic and asymptomatic. Only 171 patients (13.8%) were referred for PAD testing due to symptoms associated with PAD, whereas 890 patients (72%) referred had factors associated with increased vascular risk.
Claudication alone had a relatively poor accuracy to detect an abnormal ABI, and was a poor predictor of an abnormal ABI. Only 34.7% of patients with claudication had an ABI of 0.90 or lower. These data are not surprising and, in accordance with previous studies (29,32), reflect the fact that claudication is dependent on the functional demand of the circulation and lower limb pain may be masked by adequate collateral circulation.
The most striking finding from our data was the very high specificity, NPV and accuracy for all pulses present in the absence of a femoral bruit in predicting a normal ABI. The high specificity (98.3%) indicates that patients with an abnormal vascular physical examination should be directed toward ABI measurement. The rather high positive likelihood ratio (odds of an abnormal ABI in a patient with an abnormal versus a normal vascular physical examination) of 34.2 also indicated that patients lacking both DP and PT pulses in the presence of a femoral bruit would likely benefit from having their ABI measured. Previous studies (24,25,27–29) have examined combinations of pulse palpation for detecting an abnormal ABI; however, we are unaware of previous studies investigating a combination of both an abnormal pulse and a femoral bruit. Previous studies (32) investigating combinations of pulse palpation alone have found more modest positive likelihood ratios – similar to those observed in our study.
Conversely, the high NPV indicates that 94.9% of patients with a normal vascular physical examination have a normal ABI. The overall accuracy of an abnormal vascular physical examination was 93.8%. Therefore, our data suggest that a complete vascular physical examination can exclude patients from redundant ABI testing, and ABI measurement should be focused toward patients with an abnormal vascular physical examination.

Limitations
Although the Kingston Heart Clinic is a community-based outpatient cardiac facility, it is a major outpatient cardiac referral centre for CVD in southeastern Ontario. As such, there is a higher prevalence of peripheral vascular disease in those patients referred. Although there is a higher prevalence of PAD, we do not believe this should detract from the most important finding, which is the importance of a complete peripheral arterial examination that includes all four pedal pulses and the auscultation for a femoral bruit before embarking on the measurement of the ABI.
Another issue is the experience of the person (CT) who performed the majority of the clinical examinations and, therefore, the general application of our data to the practicing physician. Surely, this is the wrong message to be sending. The message should be that with the same application and dedication to the peripheral arterial physical examination, anyone can reliably expect to achieve similar results. The registered nurse (CT) had no expertise in the peripheral arterial examination and the first 85 cases were performed under the supervision of a physician (MFM). We believe that anyone can be taught this examination and eliminate unnecessary ABI measurements. We also believe that most physicians have the necessary expertise and all that is needed is the application.
There could be some concern regarding the exclusion of patients with a high ABI (greater than 1.30). First, we would simply say that our intention was to compare a normal ABI (0.91 to 1.30) with an ABI that clearly indicates obstructive PAD (ie, an ABI of 0.90 or lower). Second, there is overwhelming evidence that an ABI of 0.90 or lower has a high sensitivity and specificity for a stenosis of greater than 50% somewhere in the leg proximally, usually the aorto-iliac or superficial femoral systems on the affected side. Third, there is no evidence from our data that a high ABI is associated with obstructive PAD disease proximally. This is supported by showing that a completely normal toe-brachial index (TBI) (0.72 or greater with a strict definition) that is not affected by peripheral arterial calcification was seen in approximately 85% of our high ABI patients. Using the more conservative definition of a normal TBI (0.66 or greater), this percentage of normal TBIs in the high ABI group increases to almost 93%. Furthermore, these percentages are not significantly different from the normal ABI group, and the high ABI group had a similar profile to the normal ABI group including the physical examination (Table 1). It is well known that patients with a high ABI have a higher CV risk, but we believe this is most likely explained by the higher prevalence of diabetes and the higher mean age in this group (Table 1). Therefore, we believe that including the high ABI in the normal ABI group would be methodologically wrong and, even if we had, it would not have affected the overall results of the physical examination.
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CONCLUSION

Vascular physical examination of the lower limbs provides valuable information when investigating lower limb PAD. The clinical examination of the peripheral arterial foot pulses and the auscultation for a femoral bruit has a high degree of accuracy (93.8%) for the detection or exclusion of PAD when compared with the ABI using the cut-off of 0.90 or lower. If both peripheral foot pulses are present in both lower limbs and there are no femoral bruits, the specificity and NPV of 98.3% and 94.9%, respectively, make the measurement of ABI seem redundant. The emphasis in PAD detection should be directed toward encouraging a thorough physical examination.



The accuracy of the physical examination for the detection of lower extremity peripheral arterial disease - PMC

Peripheral arterial disease (PAD) is a major risk factor for adverse cardiovascular events. There has been a definite push for wider use of the ankle-brachial index (ABI) as a simple screening tool for PAD. Perhaps this has occurred to the detriment ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
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Thank you for all your responses. I did actually review the CT myself and could not make out any clear anatomical findings to support her current clinical picture. However, by way of update there are atherosclerotic calcifications and aortic aneurysm just above the bifurcation. I will go ahead and send for ABI. There is seemingly no clear indication for ESI at this time
 
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1. palpation of peripheral pulses alone, what you have said all along (which is palpation of DP and PT pulses) is not what the study looked it. it is palpation of peripheral pulses and examination for femoral bruits. you are changing the goalposts.

2. sensitivity of both is a whopping 58%. that is almost the flip of a coin.

at a sensitivity of 58% when you are looking at the possibility that you have disease with a high pretest probability, that is inadequate to rule out the disease. it does decrease the posttest probability and affects how you interpret the ABIs.

3. finally... what exactly is the risk for obtaining ABIs? if we are doing to do MRIs before we do MBB, why not an ABI?
 
Study was dorsalis pedis and posterior tibial palpation AND femoral bruit with auscultation. Not the same thing.
 
Order the ABI, its noninvasive, makes sense based off the diagnosis and RF, what do you have to lose or just send to vascular surgery
 
DODOCSS said:
lone commie would say if you think shot helps, do shot, and vote for bernie/hrc/community organizer(hussein), dog catcher
Click to expand...

dude.

one's political views have no bearing on their medical treatment. keep the ideas and threads separate, or get lost.

you would be wise to listen to his medical views. disagree with the politics all you like.
 
What about asking if they have the pain just by standing in an extended position? Vascular claudicators shouldn't have leg pain for short standing periods alone right? While Stenotic patients may.
 
SommeRiver said:
Study was dorsalis pedis and posterior tibial palpation AND femoral bruit with auscultation. Not the same thing.
Click to expand...
I have a stethoscope and I'm not afraid to use it.
 
the closest thing i have to a stethoscope is the plastic one that came in my 5 year old's toy veterinarian kit.
 
you are still insistent on not ordering ABIs.

tell me, do you use chloroprep solution or cloth preps to clean off the stethoscope head after they have contacted the groin area?
 
Eilat87 said:
What about asking if they have the pain just by standing in an extended position? Vascular claudicators shouldn't have leg pain for short standing periods alone right? While Stenotic patients may.
Click to expand...

I’ve had people use a recumbent bike. Vascular claudicators will hurt while lumbar claudicators shouldn’t.
 
pmrmd said:
I’ve had people use a recumbent bike. Vascular claudicators will hurt while lumbar claudicators shouldn’t.
Click to expand...
Lumbar claudicators shouldn't claudicate on a recumbent bike? I would think they would since their spine is no longer flexed
 
clubdeac said:
Lumbar claudicators shouldn't claudicate on a recumbent bike? I would think they would since their spine is no longer flexed
Click to expand...

Less likely if they are leaning forward on the handles, not the handles on the seat and leaning back. You are really trying to determine if exercise induced. Poor man's ABI.
 
soccrwz said:
Less likely if they are leaning forward on the handles, not the handles on the seat and leaning back. You are really trying to determine if exercise induced. Poor man's ABI.
Click to expand...
We're talking about a recumbent bike here. When have you ever seen someone leaning forward on a RECUMBENT BIKE?!?
 
clubdeac said:
We're talking about a recumbent bike here. When have you ever seen someone leaning forward on a RECUMBENT BIKE?!?
Click to expand...

If they didn't want you leaning forward why would they put the handles on there. Its not a question of most people lean back, its you can lean forward and have them pedal for a few minutes leaning forward.
 
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