The diagnostic pitfall of ankle-brachial index in Buerger's disease: can we trust pressure measurements in the presence of corkscrew collaterals?

Abstract

Purpose: To evaluate the diagnostic performance of the ankle-brachial index (ABI) in patients with Buerger disease and to assess the impact of collateral circulation on ankle pressure measurements in the presence of angiographically confirmed infrapopliteal arterial occlusions. Materials and Methods: This retrospective study included 66 lower limbs from 45 male patients (mean age, 45.4 years [SD ± 9.7]) diagnosed with Buerger disease. All patients underwent digital subtraction angiography (DSA) and ABI measurement prior to endovascular intervention. Limbs were categorized according to the angiographic patency of the anterior and posterior tibial arteries. ABI diagnostic performance was evaluated using DSA as the reference standard, with emphasis on the prevalence of normal ABI values (≥0.90) in limbs with complete tibial artery occlusion. Results: Angiography demonstrated complete occlusion of both tibial arteries in 50 of 66 limbs (75.7%). Despite severe infrapopliteal disease, 21 of these 50 limbs (42.0%) exhibited normal ABI values, indicating a high false-negative rate. The mean ABI in limbs with complete tibial occlusion was 0.82 (SD ± 0.20). Doppler-derived ankle pressure measurements were obtainable in 94%–98% of occluded tibial arteries due to extensive collateral circulation. ABI values did not differ significantly between limbs with isolated tibial occlusion and those with combined popliteal and tibial artery involvement (P > .05). Conclusions: ABI frequently underestimates disease severity in Buerger disease because collateral networks preserve ankle pressures despite critical infrapopliteal occlusions. ABI should not be used as a standalone screening tool, and adjunct physiologic testing or imaging is required for accurate vascular assessment