Prevalence of Tibial Artery and Pedal Arch Patency by Angiography in Patients With Critical Limb Ischemia and Noncompressible Ankle Brachial Index

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Approximately 20% of patients undergoing ankle brachial index testing for critical limb ischemia have noncompressible vessels because of tibial artery calcification. This represents a clinical challenge in determining tibial artery patency. We sought to identify the prevalence of tibial artery and pedal arch patency by angiography in these patients.

Methods and Results—

One hundred twenty-five limbs (of 89 patients) with critical limb ischemia and ankle brachial index ≥1.4 who underwent lower extremity angiograms within 1 year were included. Reviewers of angiography were blinded to results of physiological testing. Tibial artery vessels were classified as completely occluded, significantly stenosed (≥50%), or patent (<50% stenosis). The sensitivity of toe brachial index and pulse volume recording to predict tibial artery disease was also determined. Of 125 limbs with noncompressible ankle brachial index, 72 (57.6%) anterior tibial and 80 (64%) posterior tibial arteries were occluded. Another 23 (18.4%) anterior tibial and 13 (10.4%) posterior tibial arteries had ≥50% stenosis. Pulse volume recording was moderate to severely dampened in 54 of 119 (45.4%) limbs. Toe brachial index <0.7 was found in 75 of 83 (90.4%) limbs. Moderate to severe pulse volume recording dampening was 43.6% sensitive, whereas toe brachial index <0.7 was 89.7% sensitive in diagnosing occluded or significantly stenotic tibial artery disease. The pedal arch was absent or incomplete in 86 of 103 (83.5%) limbs.


Among patients with critical limb ischemia and noncompressible ankle brachial index results, the prevalence of occlusive tibial and pedal arch disease is very high. Toe brachial index <0.7 is more sensitive in diagnosing occluded and significantly stenotic tibial artery disease in these patients compared with ankle pulse volume recording.

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