ABI Measurement Protocol
Ankle Brachial Index & Toe Brachial Index Measurement Guide
Standardized academic protocol based on the 2024 ACC/AHA/Multisociety Guidelines for Lower Extremity PAD.
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Clinical Insight (Fast Science):
- Legs in slight flexion: In cases of severe arterial obstruction, full contact of the calves with the examination bed can apply external pressure, further stopping flow and causing false low readings on the Posterior Tibial artery.
- Foot in relaxed, semi-extended position: The foot must be completely relaxed anatomically to prevent the Anterior Tibial / Dorsalis Pedis artery from being mechanically obstructed by the rigid circular retinaculum of the flexor/extensor tendons.
⚠ Contraindications
Avoid cuff compression in cases of suspected Deep Vein Thrombosis (DVT), severe leg pain, or directly over bypass grafts and open ulcers.
Here's how John P. Cooke MD PhD at Stanford University simply solves this aspect
Using a simple, affordable, and accessible device.
🩺 Measurement Technique
1. Brachial Pressures
Measure systolic pressure on both right and left arms using your preferred clinical method.
- Record the systolic pressure for each arm.
- Note: If pressure difference between arms >10 mmHg, repeat measurement. Use the highest value of both arms for the final ABI calculation denominator.
2. Ankle Pressures
Measure systolic pressures for two arteries on each leg.
- Anterior Tibial / DP Artery: Measured just proximal to the bifurcation on the anterior tibial artery.
- PT Artery: Located just behind the medial malleolus.
- Record the systolic pressure when the pulse signal returns during cuff deflation.
- Note: The highest ankle pressure per leg (whether Anterior/DP or PT) is used as the numerator for that leg's ABI.
▶ Ankle Brachial Index Praxis
John P. Cooke MD PhD at Stanford University
ABI executing demonstration
Ann-Marie McLaren MD Toronto
ABI executing demonstration
▶ Toe Brachial Index Praxis
Peta Tehan MD Lecturer Monash University
TBI executing demonstration
✔ Academic Sources & Clinical Practice
- • Fast Science - Open Research: Independent clinical practice observations regarding severe obstruction flow loss due to calf pressure against examination bed, and the mechanical obstruction of Anterior Tibial/Dorsalis Pedis arteries by the rigid retinaculum during extreme flexion/extension.
- • 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease.
- • American Heart Association Scientific Statement on Measurement and Interpretation of the Ankle-Brachial Index (Circulation).
- • Stanford Medicine 25: Ankle Brachial Index Protocol.
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