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On leg ischaemia: aspects of epidemiology and diagnostics
Linköping University, Department of Medicine and Care, Vascular surgery. Linköping University, Faculty of Health Sciences.
2005 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The first part of this thesis consists of a population-based epidemiological study on symptomatic leg arterial disease in a Swedish community, based on a postal questionnaire and systolic ankle pressure measurements, with calculation of the ankle-brachial pressure index (ABPI; usually ≥ 1.0 in healthy subjects). The second part investigates alternative methods for ankle systolic pressure measurements, with the potential of automation.

(Papers I-III) A postal questionnaire on leg symptoms and concomitant diseases was distributed to all the inhabitants of Vadstena 50-89 years old (n=7,524). The response rate was 92% and of those reporting any leg pain, 80% (353/441) attended an examination with ABPI determination. Symptomatic leg ischaemia (SLI) was defined as leg pain on walking + ABPI ≤ 0.8. The prevalence was 4.1 %, increasing with age, with no major difference between men and women. Other manifestations of arteriosclerotic disease (previous angina pectoris, myocardial infarction or cerebrovascular incident), hypertension and diabetes mellitus were more prevalent among SLI cases than in healthy subjects. At a four-year follow-up, the age and sex adjusted mortality ratio was almost doubled in SLI subjects. Their relative risk of a myocardial infarction, cardiac death and death due to any cardiovascular event was 2.7, 2.0 and 1.9, respectively, compared to an age and sex matched control group. In SLI subjects without a previous history of ischaemic heart disease, the relative risk of a myocardial infarction was 3.1. Cardiovascular disease alone was mainly responsible for the increased risk of death. At a ten-year follow-up, a baseline ABPI up to 0.8 was inversely correlated with mortality. In a Cox regression model, a low ABPI was significantly and independently associated with an increased risk of death. An ABPI of 0.81-0.99 was not associated with an increased mortality risk. Over ten years, 1/7 of the SLI cases had a leg vascular reconstructive procedure, the majority within the first two years, and 1/14 underwent a major amputation. In conclusion, in spite of the good prognosis of the local disease, SLI can be looked upon as a marker for generalised arteriosclerotic disease and as a risk predictor for severe arteriosclerotic events and premature death.

(Papers IV-VI) Oscillometric technique, commonly used for automatic arm blood pressure measurements, was validated against the CW Doppler in systolic ankle pressure determination in healthy subjects and in patients with leg arterial disease. While performing adequately in healthy subjects, it was found to be invalid in leg arterial disease. The oscillometric technique was deemed as not suitable for use as an automatic ankle pressure recorder in the diagnosis ofleg arteriosclerotic disease.

A new technique, based on a two-channel photoplethysmographic (PPG) probe (880nm) placed underneath the pneumatic cuff, together with electronics, was developed and compared with both CW Doppler and intra-arterial recordings in subjects without vascular disease, and with the CW Doppler in leg arterial disease. On visual analysis of the PPG curves, the agreement was good. An automatic algorithm for analysis of PPG-data gave comparable results. The PPG method is a promising technique for future automation of systolic ankle pressure measurements, and for inclusion in a complete ABPI recorder.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2005. , 81 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 884
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-30837Local ID: 16490ISBN: 91-7373-862-X (print)OAI: oai:DiVA.org:liu-30837DiVA: diva2:251660
Public defence
2005-03-04, Berzeliussalen, Universitetssjukhuset, Campus US, Linköpings Universitet, Linköping, 13:00 (Swedish)
Opponent
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2012-10-03Bibliographically approved
List of papers
1. Prevalence of symptomatic leg ischaemia in a swedish community: an epidemiological study
Open this publication in new window or tab >>Prevalence of symptomatic leg ischaemia in a swedish community: an epidemiological study
1993 (English)In: European Journal of Vascular Surgery (United Kingdom), ISSN 0950-821X, Vol. 7, no 4, 432-437 p.Article in journal (Refereed) Published
Abstract [en]

The prevalence of symptomatic leg ischaemia (SLI) was studied using a standardised postal questionnaire and by measuring ankle systolic blood pressure among those with leg pain. All individuals, aged 50–89 years, of both sexes (n = 2748) in a community of 7524 inhabitants were included. The overall questionnaire response rate was 92%, of whom 441 (17%) reported any form of leg pain. Ankle systolic blood pressure (ASBP) was measured in 353 (80%) of those. Ankle/brachial index (ABI) ⩽0.8 was chosen as the criterion for verified SLI. One hundred and seven (30%) had a verified SLI (ABI ⩽0.8).Hospital records could be reviewed in 83% of the non-responders, and revealed corresponding distributions of risk factors among the non-responders and the questionnaire-responders. Risk factor frequencies among ASBP-examined and not examined individuals were also comparable. The overall prevalence of SLI in the age 50–89 years was 4.1%, ranging from 1.5% in the age decade of 50–59 years, to maximum 7.1% in the decade 70–79 years. A slight but not significant male predominance was recorded, except for the age decade 70–79 years. The prevalence of SLI in the whole community population was approximately 2000/100 000 of which 5% were possible candidates for vascular intervention.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-84282 (URN)10.1016/S0950-821X(05)80262-2 (DOI)
Available from: 2012-10-03 Created: 2012-10-03 Last updated: 2012-10-03Bibliographically approved
2. Outcome of symptomatic leg ischaemia: four year morbidity and mortality in vadstena, Sweden
Open this publication in new window or tab >>Outcome of symptomatic leg ischaemia: four year morbidity and mortality in vadstena, Sweden
1996 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 11, no 3, 315-232 p.Article in journal (Refereed) Published
Abstract [en]

Objective:

To quantify cardiovascular morbidity and mortality including the incidence of vascular surgery and amputations, among individuals with symptomatic leg ischaemia.

Design:

Prospective cohort study.

Material:

Inhabitants 50–89 years of age (n = 2784) of Vadstena community, Östergötland, Sweden, with 4 years of follow-up. 107 subjects with symptomatic leg ischaemia (SLI), selected by a postal questionnaire and ankle pressure measurements, and an age and sex matched control group of 214 individuals.

Chief outcome measures:

Cardiovascular morbidity and mortality, all cause mortality, surgical procedures for leg ischaemia, major amputations, ankle brachial pressure index.

Main results:

Age and sex adjusted all-cause mortality risk in the SLI-group was increased by 1.9. This was most prominent among men in their sixties and women in their seventies. Cardiovascular mortality was increased by 1.9 (95% confidence interval 1.1–3.3). Relative risks for acute myocardial infarction and cerebrovascular events were 2.4 (1.1–5.1) and 1.7 (0.9–3.2), respectively. The increase in age and sex adjusted incidence of primary reconstructive surgery during the first year after initial examination was 67-fold compared to the total population of Vadstena 50–89 years old, and 18-fold for the whole observation period, while the increase in risk for major amputation during the observation period was 12-fold. Median ankle brachial index improved significantly during follow-up among the individuals alive and not subjected to vascular surgery.

Conclusions:

Among the SLI-subjects identified in a general population, the overall risk for cardiovascular morbidity and mortality over 4 years was significantly increased compared to normals.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-84284 (URN)10.1016/S1078-5884(96)80078-5 (DOI)
Available from: 2012-10-03 Created: 2012-10-03 Last updated: 2017-12-07Bibliographically approved
3. Ankle-brachial index and mortality in a cohort of questionnaire recorded leg pain on walking
Open this publication in new window or tab >>Ankle-brachial index and mortality in a cohort of questionnaire recorded leg pain on walking
2002 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 24, no 5, 405-410 p.Article in journal (Refereed) Published
Abstract [en]

Objective: to study the association between the ankle–brachial pressure index (ABPI), premature death and the need for surgical treatment for lower limb ischaemia.

Design: population based cohort study.

Subjects: three hundred and fifty-three men and women, 50–89 years old, underwent a leg pain questionnaire and measurement of ABPI and was then followed for 10 years.

Outcome Measures: all cause mortality, vascular procedures and major amputations.

Results: a low ABPI was independently associated with premature all cause mortality in the multiple regression analysis, carrying a relative risk of 3.4 (95% confidence interval 2.0–5.9) and 2.1 (1.3–3.3) for ABPIs ≤0.50 and 0.51–0.80, respectively, compared to those with ABPI ≥1.0. Individuals with an ABPI in the interval 0.81–0.99 suffered only a slight, not statistically significant risk increase compared to normals. A low ABPI at baseline implied a continuous constant increased risk of death throughout the study period. The same risk was observed among elderly (70–89, median 77 years), and in the middle aged (50–69, median 63 years) individuals. The vast majority of those subjected to vascular intervention or major amputation during follow-up had an ABPI≤0.8 at baseline (83 and 89%, respectively). However, within that group, the individual ABPI was not predictive for surgical intervention.

Conclusion: the association found between an ABPI ≤0.8 and premature mortality in this cohort of symptomatic subjects implies that the ABPI is a powerful, independent predictor for premature death. The prognostic information carried by an ABPI in the interval 0.81–0.99 remains uncertain. Septuagenarians and octogenarians carry the same risk increase associated with a low ABPI as those in the middle ages.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-26965 (URN)10.1053/ejvs.2002.1747 (DOI)11598 (Local ID)11598 (Archive number)11598 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
4. Is oscillometric ankle pressure reliable in leg vascular disease?
Open this publication in new window or tab >>Is oscillometric ankle pressure reliable in leg vascular disease?
2001 (English)In: Clinical Physiology and Functional Imaging, ISSN 1475-0961, E-ISSN 1475-097X, Vol. 21, no 2, 155-163 p.Article in journal (Refereed) Published
Abstract [en]

The objective of the study was to evaluate the validity of oscillometric systolic ankle pressure in symptomatic leg arterial occlusive disease. Ankle pressure measurements using oscillometric curves obtained using a standard 12-cm cuff with a specially designed device for signal processing were validated against the continuous wave (CW) Doppler technique. Thirty-four subjects without signs or symptoms of peripheral vascular disease (68 legs) and 47 patients with leg ischaemia (85 legs) varying from moderate claudication to critical ischaemia were examined. The oscillometric curves were analysed using several algorithms reported in the literature, based on the assumption that maximum oscillations are recorded near mean arterial pressure. In normals, reasonable agreement between CW Doppler and oscillometric methods was seen. When an algorithm that determined the lowest cuff pressure at which maximum oscillations occurred, and a characteristic ratio for systolic pressure of 0·52 was used, the mean difference between CW Doppler and oscillometry was 1·7 mmHg [range −19 to +27, limits of agreement (2 SD) 21·1 mmHg]. In ischaemic legs, oscillometry overestimated systolic ankle pressure by a mean of 28·8 mmHg [range –126 to +65, limits of agreement 82·8 mmHg]. The difference was more pronounced among patients with critical ischaemia compared with claudicants, and also more evident among diabetics. The error of oscillometric pressure determination in subjects with leg arterial disease inversely increased with CW Doppler ankle pressure. In 39% of the recordings in legs with a CW Doppler systolic pressure below 100 mmHg, the oscillometric mean arterial pressure was higher than the recorded CW Doppler systolic pressure. In conclusion, the oscillometric method to determine systolic ankle pressure, based on the concept of maximum cuff oscillations occurring near mean arterial pressure, is not reliable in leg arterial disease, usually overestimating ankle pressure.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-26714 (URN)10.1046/j.1365-2281.2001.00314.x (DOI)11308 (Local ID)11308 (Archive number)11308 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
5. A new probe for ankle systolic pressure measurement using Photoplethysmography (PPG)
Open this publication in new window or tab >>A new probe for ankle systolic pressure measurement using Photoplethysmography (PPG)
2005 (English)In: Annals of Biomedical Engineering, ISSN 0090-6964, E-ISSN 1573-9686, Vol. 33, no 2, 232-239 p.Article in journal (Refereed) Published
Abstract [en]

An automated method for ankle systolic pressure measurement, less operator dependent than the standard continuous wave (CW) Doppler technique, would imply an advantage both in patient measurements and in epidemiological studies. We present a new photoplethysmographic (PPG) probe that uses near-infrared light (880 nm) to detect pulsatory blood flow underneath the distal end of a standard pneumatic cuff. The probe is adapted to the anatomical conditions at the ankle, permitting recording of pressures in both ankle arteries separately. The validity of the equipment was tested with CW Doppler-derived systolic pressures and invasive blood pressure measurements for reference. In 20 healthy subjects, visual analysis of the PPG curves revealed a mean difference between CW Doppler and PPG measurements of –0.5 mmHg (SD 6.9). Corresponding results for the anterior and posterior tibial arteries separately were –1.8 mmHg (SD 6.2) and 0.9 mmHg (SD 7.3), respectively. A correct probe position was essential for the results. In direct recordings from the dorsalis pedis artery in 10 intensive care patients, PPG underestimated systolic pressure in the anterior tibial artery by 4.5 mmHg (SD 12.1). With further development, the PPG probe, integrated in the pneumatic cuff, may simplify measurements of ankle systolic pressures.

Keyword
near-infrared light, CW Doppler, leg, anterior tibial artery, posterior tibial artery, blood pressure determination
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-28919 (URN)10.1007/s10439-005-8982-7 (DOI)14122 (Local ID)14122 (Archive number)14122 (OAI)
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2017-12-13Bibliographically approved
6. Automatic ankle pressure measurements using PPG in ankle-brachial pressure index determination
Open this publication in new window or tab >>Automatic ankle pressure measurements using PPG in ankle-brachial pressure index determination
Show others...
2005 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 30, no 4, 395-401 p.Article in journal (Refereed) Published
Abstract [en]

Objective

To evaluate a new technique using a photoplethysmographic (PPG) probe for automatic ankle pressure measurements.

Design

Comparative study on two techniques for ankle pressure measurement.

Setting

University hospital.

Material

Thirty-five patients with leg arterial disease and eight healthy volunteers. Ankle-brachial indices (ABPI) were measured using conventional CW Doppler technique and PPG-based prototype equipment for the ankle pressure recordings.

Chief outcome measures

ABPIs calculated from CW Doppler and PPG ankle pressure measurements. The PPG signals were analysed both by visual judgement and by a software based, automatic algorithm.

Main results

The mean difference between ABPIs calculated from CW Doppler recordings and PPG (visual analysis) was −0.01 (limits of agreement (±two standard deviations) +0.16 to −0.19). The correlation coefficient was 0.93. When the algorithm was used, the mean difference (CW Doppler−PPG) was 0.05 (limits of agreement 0.28 to −0.18, r=0.89).

Conclusions

The PPG method is a promising technique with an inherent potential for automatisation of the ankle pressure measurements, thereby reducing the observer-dependency in ABPI recordings.

Keyword
photoplethysmography, ankle, blood pressure determination, ultrasonography, Doppler
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-30084 (URN)10.1016/j.ejvs.2005.05.012 (DOI)15964772 (PubMedID)15552 (Local ID)15552 (Archive number)15552 (OAI)
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2017-12-13Bibliographically approved

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