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Introduction:We investigated whether the toe–brachial index (TBI) is associated with stroke prognosis and evaluated this association in patients with normal ankle–brachial index (ABI).Methods:Acute ischemic stroke patients who underwent TBI measurements were enrolled. Poor functional outcome was defined as modified Rankin Scale score ≥3. Major adverse cardiovascular event (MACE) was defined as stroke recurrence, myocardial infarction, or death. Normal ABI was defined as 0.9 ≤ ABI ≤ 1.4.Results:A total of 1,697 patients were enrolled and followed up for a median 39.7 (interquartile range, 25.7–54.6) months. During the period, 305 patients suffered MACE (18.0%), including 171 (10.1%) stroke recurrences. TBI was associated with hypertension, diabetes, atrial fibrillation, aortic plaque score, ABI, and brachial–ankle pulse wave velocity (allp< 0.05). In multivariable logistic regression, TBI was inversely associated with poor functional outcome in all patients [odds ratio (OR) 0.294, 95% confidence interval (CI) 0.114–0.759], even in patients with normal ABI (OR 0.293, 95% CI 0.095–0.906). In multivariable Cox regression, TBI < 0.6 was associated with stroke recurrence [hazard ratio (HR) 1.651, 95% CI 1.135–2.400], all-cause mortality (HR 2.105, 95% CI 1.343–3.298), and MACE (HR 1.838, 95% CI 1.396–2.419) in all patients. TBI < 0.6 was also associated with stroke recurrence (HR 1.681, 95% CI 1.080–2.618), all-cause mortality (HR 2.075, 95% CI 1.180–3.651), and MACE (HR 1.619, 95% CI 1.149–2.281) in patients with normal ABI.Conclusions:Low TBI is independently associated with poor short- and long-term outcomes in acute ischemic stroke patients despite normal ABI.

Background Podiatric vascular assessment practices in the United Kingdom (UK) are currently unknown. This study aimed to describe the current practices for performing lower limb vascular assessments by podiatrists in the UK, and, to investigate the effect of practitioner characteristics, including education level and practice setting, on the choice of tests used for these assessments. Methods A cross-sectional observational online survey of registered podiatrists in the UK was conducted using SurveyMonkey® between 1st of July and 5th of October 2018. Item content related to: practitioner characteristics, vascular testing methods, barriers to completing vascular assessment, interpretation of vascular assessment techniques, education provision and ongoing management and referral pathways. Descriptive statistics were performed, and multinomial logistic regression analyses were used to determine whether practitioner characteristics could predict the choice of vascular tests used. Results Five hundred and eighty five participants accessed the online survey. After drop-outs and exclusions, 307 participants were included in the analyses. Comprehensive vascular assessments had most commonly been performed once (15.8%) or twice (10.4%) in the past week. The most common indicators for performing vascular assessment were symptoms of suspected claudication (89.3%), suspected rest pain (86.0%) and history of diabetes (85.3%). The most common barrier to performing vascular assessment was time constraints (52.4%). Doppler examination (72.3%) was the most frequently reported assessment type, with ankle-brachial index (31.9%) and toe brachial index (5.9%) less frequently performed. There were variable interpretations of vascular test results. The most common topic for education was smoking cessation (69.5%). Most participants (72.2%) were confident in determining ongoing management, with the majority referring to the patient’s general practitioner (67.6%). Practitioner characteristics did not predict the types of vascular tests performed. Conclusion The majority of vascular assessments currently performed by podiatrists in the UK are inconsistent with UK or international vascular guidelines and recommendations. Despite this, most podiatrists felt confident in diagnosing, referring and managing patients with peripheral arterial disease (PAD), however many felt they needed more education to feel confident to assist patients with PAD to manage their cardiovascular risk factors. Electronic supplementary material The online version of this article (10.1186/s13047-019-0341-2) contains supplementary material, which is available to authorized users.

INTRODUCTION: The ankle-brachial index (ABI) is the most common test to diagnose peripheral artery disease (PAD). In dialysis patients, the ABI may under-diagnose PAD, due to a high prevalence of concomitant medial arterial calcification (MAC). The toe-brachial index (TBI) is not as susceptible to misclassification by MAC. Taking the ABI and TBI together in the form of their difference, the ABI-TBI, may provide a single measure for assessing both atherosclerosis and calcification. The relationship of these variables in dialysis patients has not been well studied. METHODS: We identified 37 dialysis patients referred for vascular studies between 2009 and 2017 in the San Diego Veterans Administration Medical Center (SDVAMC). The ABI and TBI were performed systematically for each patient, and TBI was performed regardless of ABI or waveform. We examined associations between ABI, TBI, and the difference between them (ABI-TBI) with all-cause mortality and major adverse limb events (MALE), which includes revascularizations and amputations. FINDINGS: The mean age was 65 years and 30% were African American. All patients were men, reflecting the Veterans Administration population. There were 26 deaths during follow-up and mortality was highest in patients who had low ABI and low TBI and least in those with high ABI and high TBI. Persons with TBI < 0.7 had an increased risk of all-cause mortality. The ABI-TBI, and the ABI itself, were not significantly associated with all-cause mortality although the patterns were similar. DISCUSSION: Although ABI may be an important initial risk stratification tool, the TBI may be a more informative predictor of mortality in dialysis patients. Strengths of this study include a high rate of MALE and deaths. The TBI, and the difference between ABI and TBI, should be studied further in a larger cohort of persons with advanced kidney disease.

Based on our previous reports, ipsilateral systolic toe pressure (STP) and toe-brachial index (TBI) have a strong association with midterm cardiovascular and overall mortality as well as with amputation-free survival in patients with symptomatic lower extremity peripheral artery disease (PAD). The effect of the often overlooked contralateral lower limb on patient outcome remains unknown. This study aimed to resolve the significance of contralateral STP (CL_STP) and contralateral TBI for long-term overall and cardiovascular mortality.This is a retrospective cohort study of 727 consecutive patients with symptomatic lower extremity PAD. All patients admitted to the Department of Vascular Surgery at Turku University Hospital for digital subtraction angiography between January 2009 and August 2011 and for whom STP measurements were available were recruited and observed for up to 7 years. Dates and causes of death were collected from the national cause of death registry of Statistics Finland.In the study cohort, STP was 30 mm Hg in 67 contralateral limbs and 227 ipsilateral limbs. CL_STP 30 mm Hg resulted in a 60-month estimated freedom from cardiovascular death and overall survival of 39% (standard deviation [SD], 0.57) and 25% (SD, 0.41), respectively, and contralateral TBI 0.25, of 45% (SD, 0.54) and 36% (SD, 0.54), respectively. Cumulative freedom from cardiovascular death and overall survival at 60 months for patients with ipsilateral STP 30 mm Hg varied by CL_STP as follows: CL_STP 30 mm Hg: 41% (SD, 0.58) and 25% (SD, 0.43); CL_STP of 30 to 49 mm Hg: 56% (SD, 0.49) and 44% (SD, 0.49); STP ≥50 mm Hg: 62% (SD, 0.52) and 47% (SD, 0.52), respectively. In Cox regression analysis, low STP or TBI of either extremity was associated with significant (P .001) risk of death for cardiovascular or any reason.Low STP and TBI of both contralateral and ipsilateral lower extremities are associated with high cardiovascular and overall mortality in symptomatic PAD patients. Bilaterally low STP and TBI are associated with a particularly poor prognosis.

Background Asymptomatic peripheral artery disease (PAD) increases the risk of mortality in non-hemodialysis patients. However, the association between asymptomatic PAD and mortality rate remains unclear in patients on hemodialysis. Methods This retrospective cohort study aimed to assess the prognostic significance of asymptomatic PAD in a population of 310 hemodialysis patients. Patients with an ankle–brachial index of 1.40 with a toe–brachial index of

ObjectiveToe systolic pressure is a component of the standard vascular and diabetic foot assessment. Until now, clinicians have measured only first toe pressure given a lack of evidence for measurements of the other toes. In diabetic patients, first toe measurements are often not possible because of ulceration or amputation. It was hypothesized that the adjacent second toe systolic pressure measurements would be interchangeable with those of the first toe.MethodsA prospective study was performed on 100 participants with diabetes mellitus. Duplicate systolic toe pressures were measured in the first toe and adjacent second toe using the Systoe Automated Toe Pressure System, Systoe Photophlethysmograph Sensor Cuff, and occlusion cuffs measuring 120 × 25 mm for the first toe and 90 × 15 mm for the second toe. Correlation analysis was followed by Ordinary Least Products regression to detect and distinguish fixed and proportional bias between the two toe measurements. The acceptable limits of interchangeable results were defined as 5–10 mmHg.ResultsCorrelation coefficient r = 0.908; p

Aims: It is unclear how well non-invasive lower-limb vascular assessments can identify those at risk of foot complications in people with diabetes. We aimed to investigate the relationship between a history of foot complication (ulceration or amputation) and non-invasive vascular assessments in people with diabetes. Methods: Bilateral ankle–brachial index (ABI), toe brachial index (TBI) and continuous wave Doppler (CWD) were performed in 127 adults with diabetes (97% type 2; age 66.08 ± 11.4 years; 55% men; diabetes duration 8.8 ± 7.6 years; 28% on insulin therapy; 31% with foot complication history. Correlations were performed between known risk factors for, and documented history of, foot complication. Regression analysis was used to determine the effect of TBI on the likelihood of a prior foot complication. Results: By logistic regression, the likelihood of foot complication history was highest in those with TBI < 0.6 (OR = 7.74, p = 0.001); then longer diabetes duration (OR = 1.06, p = 0.05). HbA1c did not independently predict history of foot complications (OR = 1.10, p = 0.356). Conclusions: Likelihood of previous foot complication in this population was ~ 8 times higher when TBI was < 0.6. Such clinical risk profiling was not shown by other non-invasive measures. Prioritizing TBI as a measure of lower-limb vascular disease may be useful to prospectively identify those at risk of diabetic foot complications.

Both diabetic peripheral neuropathy and peripheral arterial disease (PAD) cause foot ulcers and often result in non-traumatic amputations in patients with type 2 diabetes. This study aimed to evaluate the association between clinical variables, PAD, and subclinical diabetic small fiber peripheral neuropathy detected by abnormal thermal thresholds of the lower extremities in patients with type 2 diabetes. We investigated 725 consecutive patients with type 2 diabetes (male/female: 372/353; mean age, 67 ± 11 years) who did not have apparent cardiovascular disease (including coronary artery disease, arrhythmia, and stroke) and who underwent the quantitative sensory test for thermal (warm and cold) thresholds of the lower limbs and ankle-brachial index (ABI)/toe-brachial index (TBI) examinations in 2015. The analyses included glycated hemoglobin, estimated glomerular filtration rate, and other characteristics. In total, 539 (74.3%) patients showed an abnormality of at least 1 thermal threshold in their feet. All patients with an abnormal ABI (