Ankle Brachial Index:

Best Practice for Clinicians

Wound
Ostomy and
Continence
Nurses
Society
 Ankle Brachial Index: Best Practice for Clinicians BP
B e st P ra c t i ce

Definition
Ankle brachial index (ABI) is a noninvasive vascular screening test to identi- This tool may be used to support the diagnosis of vascular disease by pro-
fy large vessel peripheral arterial disease by comparing systolic blood pres- viding an objective indicator of arterial perfusion to a lower extremity. In the
sures in the ankle to the higher of the brachial systolic blood pressures, which presence of diabetes mellitus, the reading may not be accurate.
is the best estimate of central systolic blood pressure (Sacks et al., 2002; ABI is also known as ankle/arm index (AAI) and resting pressure index (RPI).
Vowden & Vowden, 1996, 2001).
Purpose
ABI
• detects large vessel peripheral arterial disease in lower extremities (Criqui et al, 1989; Sacks et al., 2002)
• determines adequate arterial blood flow in the lower extremities
• provides documentation of adequate arterial blood flow in lower extremities before using compression therapy.
History/Physical Finding

Assessment and Physical Findings

Before performing ABI, it is important to obtain a thorough history and physical that includes, but is not limited to the following considerations.

History/Physical Finding Considerations Decision to Proceed with ABI

Diabetes Noncompressible blood vessels or calcified ves- Taking toe pressures (TP) for patients with dia-
sels may not give an accurate reading with the betes in whom lower-extremity arterial disease
use of a blood vessel cuff. (LEAD) is suspected (TP ≤30 indicates LEAD) is
recommended. Toe pressures are recommended if
ABI >1.3 (WOCN Society, 2002).

Pain, including • Pain may make obtaining blood pressures at • Proceed with ABI, but continuously monitor
• intermittent claudication (pain that occurs with ankles impossible if patient cannot tolerate pro- pain level by encouraging patient to notify a
activity and is relieved by a period of rest) cedure. (To rate pain levels, use a validated clinician if unable to tolerate the procedure.
• nocturnal leg pain (pain that occurs when in bed) pain scale [e.g., Wong-Baker Faces Pain Rating • Refer to healthcare provider for further evalua-
• resting leg pain (pain that occurs in the absence Scale]). tion if unable to perform ABI because of pain.
of activity and with the legs in the dependent • Clinician should ask patient what has helped
position) alleviate pain.
• painful ulcer • Patient may need to be premedicated before ABI.
• any painful condition, such as arthritis.

Acute deep vein thrombosis (DVT) Applying compression with the blood pressure Do not proceed with ABI; refer to healthcare
cuff may dislodge clot. provider for further evaluation of acute DVT.

Cellulitis May not be able to obtain ankle pressure • Proceed with ABI, but continuously monitor dis-
because of patient discomfort and/or edema. comfort level by encouraging the patient to notify
the clinician if unable to tolerate the procedure.
• Refer to healthcare provider for further evalua-
tion if unable to perform ABI due to discomfort
and/or edema.
 Assessment and Physical Findings
History/Physical Finding Considerations Decision to Proceed with ABI
Lower-extremity edema, lymphedema, and/or • Extremity edema, lymphedema, and/or obesity Proceed with ABI if able to obtain audible sig-
obesity can result in diminished sound transmission. nal for pressure readings.
• Obtaining Doppler signal (sound of pulse) may
be difficult.
• May need to use a large adult blood pressure
cuff to accommodate larger extremity.

Previous trauma or surgery to lower extremities • Scar tissue may interfere in obtaining pulses. Proceed with ABI if able to obtain signal
• May increase lower-extremity edema. audible for pressure readings.

Absence of dorsalis pedis artery pulse and pos- • Locate pulses using palpation or Doppler. Proceed with ABI if able to obtain signal audi-
terior tibial artery pulse (with Doppler) Doppler is more sensitive in the presence of low ble for pressure readings.
flow or edema and in some cases you can hear
by Doppler when palpation is unable to detect
pulse. Measure both dorsalis pedis and posteri-
or pulse and use the higher to calculate ABI.
• Presence of palpable pulses does not rule out
LEAD.
• Absence of dorsalis pedis artery pulse and pos-
terior tibial artery pulse is indicative of LEAD.
• Approximately 12% of the population has a
congenital absence of the dorsalis pedis pulse.
• ABI is obtained using a Doppler and sphyg-
momanometer to measure systolic pressures
in the brachial, dorsalis pedis, and/or poste-
rior tibial arteries.

History of leg ulcers and/or alterations in skin • Previous ABI readings may be available for Proceed with ABI.
integrity comparison.
• Use a protective barrier on the patient’s extrem-
ity when any alterations in skin integrity are
present.

History of tobacco, caffeine, and/or alcohol • Note degree of smoking, alcohol, and/or caf- Proceed with ABI if the patient has taken blood
intake feine use before assessment. Patient should be pressure medication if prescribed. Make a nota-
encouraged to be free of stimuli that elevate tion if the patient has used nicotine, caffeine, or
blood pressure, such as nicotine, caffeine, and alcohol prior to the test if it is not feasible or prac-
alcohol prior to the ABI procedure. tical to reschedule the test.
• There may already be a documented history of
vascular insufficiency.

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 Assessment and Physical Findings
History/Physical Finding Considerations Decision to Proceed with ABI
Findings consistent with chronic venous insuf- • Previous ABI readings may be available for Proceed with ABI.
ficiency, including comparison.
• atrophy of subcutaneous tissue • Cleanse, moisturize, and protect affected area.
• hardened, thickened scaly skin (lipoder- May need to apply a protective dressing to
matosclerosis) open areas to protect blood pressure cuff and
• brown discoloration of lower leg; brown sock use universal precautions.
appearance (hemosiderin)
• brawny edema.

Findings consistent with arterial insufficiency, • May have difficulty locating pulses with either Proceed with ABI if able to obtain signal
including palpation or Doppler. audible for pressure readings.
• loss of hair on lower leg, foot, or toes • May require further vascular evaluation.
• thinning, shiny, taut skin
• cyanosis/pallor on elevation
• dependent rubor
• paresthesias (subjective sensation of “pins and
needles” or other changes in sensation)
• skin temperature changes (cool lower extremi-
ties/feet/toes)
• diminished/decreased pulses of lower extremities.

Hypertension • Hypertension often has no symptoms. • Proceed with ABI if hypertension is controlled.
• Take caution, if brachial blood pressure read- • Refer to healthcare provider for evaluation of
ings are consistent with >140 mmHg systolic or uncontrolled hypertension.
>90 mmHg diastolic.

Dementia Cognitive impairment may interfere with a • Proceed with ABI if patient has ability to cooperate.
patient’s ability to comprehensively interpret and • Refer to healthcare provider if unable to per-
follow ABI procedural instructions. form ABI due to dementia.

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 ABI Procedure
The best ABI results are obtained when the patient is relaxed, comfortable, and • Place the patient in a flat, supine position for a minimum of 10 minutes prior
has an empty bladder. to the test. Place one small pillow behind the patient’s head for comfort.
To enhance the patient’s relaxation and comfort • Ask patients about recent caffeine intake, alcohol intake, smoking, pain, and
• Explain the procedure. heavy activity as these can all affect blood pressure readings.
• Remove tight clothing so that the blood pressure cuff can be easily applied
to the arms and lower legs.

Follow-Up
If the ABI is >0.9, continue to monitor clinical presentation of circulatory sta- Periodic measurements of the ABI are indicated for nonhealing leg wounds.
tus and/or wound. If the ABI is > 1.3, this may be indicative of noncompress- Patients with arterial insufficiency should have the ABI periodically reevaluat-
ible blood vessels, as in diabetes. Suggest alternate testing methods (e.g., tran- ed (every 3 months) as it may decrease over time.
scutaneous oximetry).
Referral
• Recommend that referring healthcare provider consider referral to vascular • Notify referring healthcare provider of any significant inconsistency between
surgeon if ABI results are borderline (<0.6 to 0.8) or severe ischemia (<0.5). ABI readings and clinical observations.
• Refer if there is a falsely elevated reading due to noncompressible blood ves- • Alert referring healthcare provider if there is inability to perform ABI for any
sels, which frequently accompanies diabetes. Suggest alternative testing meth- reason.
ods including photoplethysmography (PPG) or transcutaneous oximetry.
Documentation
• Document all brachial and ankle B/P readings in the medical record, noting • Describe the patient’s tolerance of the procedure.
any differences between extremities (>5–10 mmHg). If subclavian stenosis is • Document the ABI value by perfusion status—normal, LEAD, borderline,
present, systolic pressure differences of >15–20 mmHG or greater may occur. severe, or critical ischemia perfusion (WOCN Society, 2002). Include an indi-
• If a waveform is obtained with the procedure, it must be interpreted by a cation of the patient’s understanding.
qualified clinician and should be placed in the medical record with the ABI • Request for a vascular referral, if applicable.
results. • Schedule follow-up appointment(s).

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 Guide for Performing ABI Readings
Brachial Pressure with Doppler Ankle Pressure with Doppler Formula for Calculating ABI
Ensure proper blood pressure (BP) cuff place- Ensure proper BP cuff placement on patient’s Divide the higher of the dorsalis pedis or poste-
ment on patient’s upper arm: lower leg: rior tibial systolic pressures for each ankle by the
• BP cuff bladder should be wide enough to cover • BP cuff should be placed around the ankle 2.5 higher of the two upper extremity brachial sys-
40%–50% of the upper arm circumference and cm above the malleolus. tolic pressures to obtain the ABI for each of the
long enough to cover 80% of the arm circumfer- • Use a protective barrier on the patient’s extremity lower extremities. Upon completing calculations,
ence. (A large, adult BP cuff may be needed to when any alterations in skin integrity are present. compare each reading with the interpretations
meet sizing guidelines). • Measure both dorsalis pedis and posterior pres- below.
• BP cuff should be wrapped around the upper sure in each leg and use the higher pressure of
arm without wrinkles and placed firmly enough each leg for the ABI. ABI = Highest ankle pressure
to remain stationary with arm movements. To obtain an audible pulse Highest brachial arm pressure
• Bottom edge of the BP cuff should be placed 2.5 • Apply conducting gel over the pulse site.
cm above the antecubital space. • Place the Doppler probe at a 45º angle over the
• The arm musculature should be relaxed, sup- conducting gel toward the patient’s knee until
ported, and at heart level. ABI Interpretation*
an audible pulse signal is obtained. >1.4 Indicates noncompressible vessels
• Use a protective barrier on the patient’s extremi- • Inflate BP cuff 20–30 mmHg above the point
ty when any alterations in skin integrity are > 1.0 Normal
that the pulse is no longer audible. < 0.9 LEAD
present. • Deflate the BP cuff at a rate of 2–3 mmHg per < 0.6 to 0.8 Borderline
• Palpate brachial pulse, to determine location. second noting the manometer reading at which < 0.5 Severe ischemia
To obtain an audible pulse: the first pulse signal is heard and record this
• Apply conducting gel over the pulse site. systolic value. *Note: In instances where only one extremity
• Place the Doppler at a 45º angle toward the • Cleanse/remove gel from pulse site. can be accessed, use the available systolic
patient’s head until an audible pulse signal is ankle/brachial reading for calculating ABI.
• Remove the BP cuff and repeat the procedure on
obtained. the other ankle.
• Inflate BP cuff 20–30 mmHg above the point
Document the following:
that the pulse is no longer audible.
• ABI
• Deflate the BP cuff at a rate of 2–3 mmHg per
second noting the manometer reading at which • Ankle and brachial systolic readings
the first pulse signal is heard and record this • >5–10 mmHg differences in the brachial read-
systolic value. ings. If subclavian stenosis is present, systolic
• Cleanse/remove gel from pulse site. pressure differences of >15–20 mmHg or greater
may occur.
• Remove the BP cuff and repeat the procedure on
the other arm. • Patient tolerance of procedure
• An assessment of perfusion status (WOCN
Document brachial systolic readings. Society, 2002): normal, LEAD, borderline,
Continue with procedure. severe, or critical ischemia perfusion. Include an
indication of the patient’s understanding.
• Request for a vascular referral, if applicable
• Borderline or severe ischemia
• Any significant inconsistency between ABI read-
ings and clinical observations
• Inability to perform ABI procedure
• Follow-up appointments.

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Glossary
Acute deep vein thrombosis (DVT): A thrombus or the formation of a blood various muscles of the foot and toes. The dorsalis pedis pulse can be palpated
clot that causes an outflow obstruction in the deep veins of the extremity. Veins on the mid-dorsum of the foot, between the first and second metatarsals.
distal to the obstruction become distended; venous pressure increases resulting Noncompressible blood vessels: The process in which organic tissue becomes
in venous stasis. Signs and symptoms include a cold, pale extremity with a hardened by the deposition of calcium salts in the tissues.
bluish discoloration. The pulse below the obstruction is nonpalpable. Edema Pain scale: A means to measure the existence and intensity of pain. A standard-
and erythema of the extremity may also be noted. ized pain assessment instrument, such as the Wong-Baker Faces Pain Rating
Adult blood pressure cuff, large: Upper extremity, large, adult blood pressure Scale, should be utilized.
cuff, which is appropriate for an arm circumference of 32.1–43.4 cm (12.6–17.1 Petechiae: Small, purplish, hemorrhagic spots on the skin that may be present
in.). It has a length of 64.39 cm (25.35 in.) and a width of 17.02 cm (6.70 in.). in certain severe fevers and may be indicative of great prostration, as in typhus.
Arterial insufficiency: Lack of sufficient blood flow in arteries to extremities. Petechiae may also be due to abnormality of the blood-clotting mechanism.
Can be caused by cholesterol deposits (atherosclerosis) or clots (emboli) or by Posterior tibial artery: One of the parts of the popliteal artery of the leg. It
damaged, diseased, or weak vessels. divides into eight branches, which supply blood to different muscles of the
Compression therapy: Application of sustained external pressure to the affect- lower leg, foot, and toes, and is situated midway between the medial malleolus
ed lower extremity to control edema and aid the return of venous blood to the and the medial process of the calcaneal tuberosity. The posterior tibial pulse
heart. May be achieved by wraps or multi-layer, elastic compression therapy can be palpated in the groove behind the medial malleolus.
systems. Purpura: A disorder with bleeding beneath the skin or mucous membranes. It
Doppler scanning: Doppler velocity waveform analysis uses continuous-wave causes black and blue spots (ecchymoses) or pinpoint bleeding.
Doppler ultrasound to record arterial pulsations in various lower-extremity Venous insufficiency: Failure of the valves of the veins to function that leads
arteries. to decreased return of venous blood from the legs to the trunk of the body;
Dorsalis Pedis Artery: The continuation of the anterior tibial artery of the may produce edema.
lower leg. It starts at the ankle joint, divides into five branches, and supplies

References Suggested Reading

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Coughlin, S.S., Barrett-Connor E., et al. (1989). Schatz, I. J., Popper J. S., et al. (2000.) Ankle/brachial Orsted, H., & Sibbald R. (2001). Best practices for the
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Wound This document was developed by the Wound, Ostomy and Continence Clinical Practice Ostomy Subcommittee.
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Continence Copyright© 2005 by the Wound, Ostomy and Continence Nurses Society. This document may be reproduced noncommercially for educational purposes.
Nurses The information and recommendations in this publication are not a substitute for personal medical advice or diagnosis.
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