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Hadeco Systolic Pressure Measuring Devices
Alternative to the ankle brachial index (ABI) the toe brachial index (TBI) is available as a non invasive assessment of peripheral vascular disease.
A) How to Perform a PPG Toe Pressure and Toe Brachial Index (TBI)
Hands-free Vascular testing for potential sub-surface e.g. vascular abnormalities, blood flow interruptions and wounds manifestation.
The PPG (photoplethysmography) Toe Pressure and related Toe Brachial Index (TBI) are performed to assess the vascular condition of the foot by obtaining systolic pressures at the toe. PPG toe pressure studies are considered reimbursable when performed using a bidirectional Doppler with hard-copy output. PPG probes are available for the Bidop® 3, Smartdop® 45, Smartdop® 30EX, and Smartdop® 50EXF Vascular Dopplers.
How to Perform an Ankle Brachial Index Stydy (ABI)
The Ankle Brachial Index (ABI) exam is the most simple and common test currently used to diagnose Peripheral Arterial Disease (PAD). An Ankle Brachial Index (ABI) uses an ultrasound Doppler to assess the ratio of the highest systolic pressure at the arm to the systolic pressure of the ankle.
B) Take a blood pressure reading at the arm
1. Place a blood pressure cuff around the patient's arm. Place ultrasound gel on the tip of the probe and apply the probe at a 45 to 60 degree angle over the brachial or radial artery.
2. Wait for Doppler sounds to become stable. If your Doppler has an LCD display, watch the waveform on the display until it becomes rhythmic and stable.
3. Inflate the cuff to 20 mmHg over pressure cessation. Then, slowly deflate the cuff until the first Doppler sound is heard.
4. Record the systolic pressure when the first sound is heard and repeat the test on the other arm. Use the highest arm pressure to calculate the ABI to rule out subclavean steal syndrome.
C) Take a systolic pressure at the toe
Prior to taking the systolic pressure(s) at the toe, take a printout of the PPG waveform for documentation.
1. Make sure the patient's foot is warm and placed at heart level. A warm foot is necessary to minimize vasoconstriction.
2. Place a digit cuff comfortably snug around the base of the patient's toe and affix the PPG probe to the pad of the big toe using double-sided clear tape.
3. Turn the Doppler on and wait for steady cyclic waveform motion to appear on the LCD display. Then, inflate the cuff to 20 mmHg above the anticipated systolic pressure. Waveform motion will cease. Deflate the cuff slowly until cyclic waveform motion returns.
4. Record the systolic pressure and repeat the test on the other foot.
Interpreting the Results
To calculate the TBI, divide the toe pressure by the highest arm pressure
Interpretation ¹
A toe pressure of greater than 30 mmHg may be an indicator of healing potential in foot ulcers²
A PPG waveform that does not have swift recovery may indicate poor perfusion
Watch the PV waveform on the LCD. When it becomes stable, freeze and print the waveform. Deflate the cuff and repeat at the other cuff sites.
D) Take a systolic pressure at the ankle
1. Place a blood pressure cuff snugly above the patient's ankle. Place ultrasound gel on the probe tip and apply the probe at a 45 to 60 degree angle over the posterior tibial or dorsalis pedis artery.
2. Wait for Doppler sounds to become stable. If your Doppler has an LCD display, watch the waveform on the display until it becomes rhythmic and stable.
3. Print the waveform for documentation
4. Inflate the cuff to 20 mmHg over pressure cessation. Then, slowly deflate the cuff until the first Doppler sound is heard.
5. Record the systolic pressure when the first sound is heard and repeat the test on the other leg.
Interpreting the Results
To calculate the ABI, divide the ankle pressure by the highest arm pressure
Interpretation ¹
Greater than 1.30 = Noncompressible
0.91 - 1.30 = Normal
0.41 - 0.90 = Mild to Moderate PAD
0.00 - 0.40 = Severe PAD
¹ Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WRC, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM Jr., White CJ, White J, White RA.ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery / Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). Circulation 2006;113:e463–e654. DOI:10.1161/CIRCULATIONAHA.106.174526.
² Zierler RE, Sumner DS. Physiologic Assessment of Peripheral Arterial Occlusive Disease. Vasc Surg 4th Edition 1:65-117 WB Saunders Co., PA, USA, 1995
The instructions provided above are intended as general guidelines. For specific instructions on performing a PPG Toe Pressure and Toe Brachial Index using your Doppler, please refer to the operation manual and/or inservice video provided.
D) How to Perform a Pulse Volume Arterial Study (PVR)
Pulse Volume Arterial studies (PVR) identify changes in leg blood volume. Waveform pattern recognition is used to detect the presence and/or severity of arterial disease. Pulse Volume Recordings (PVR's) are considered reimbursable when performed using a bidirectional Doppler with hard-copy output. Koven Technology Vascular Doppler models Smartdop® 45, Smartdop® 30EX, and Smartdop® 50EXF can be used to perform reimbursable Pulse Volume Recordings (PVR's).
Examination Procedure
1. Place the patient in a supine position with the leg and hip rotated outward. Wrap cuffs of appropriate width around both legs at the desired locations. Sites can include the high thigh at the groin, above and below the knee, the ankle and the toe.
2. Connect the PV module to the Doppler and turn the unit on. Connect a 3-way stopcock to the inlet of the PV module. Connect extender tubing to one of the two remaining sides of the stopcock and attach the tubing to one of the cuffs. Attach a sphyg to the other side of the stopcock.
3. Turn the stopcock so that air is routed from the sphyg to the cuff. The green arms on the stopcock will be at the 12, 3, and 6 o'clock positions.
4. Inflate the cuff to 60 to 80 mmHg.
Interpreting the Results
The general method of interpreting PV arterial waveforms is by pattern recognition.
A normal PV arterial waveform will display:
1. A rapid rise in the upstroke during systole
2. A sharp peak at maximum amplitude
3. A gradual downstroke following peak amplitude
4. Usually the presence of a dichrotic notch.
The first sign of possible abnormality is the absence of the dichrotic notch. More significant occlusions will show a decreased slope of the ascending and descending segments and a rounding of the systolic peak. More serious obstructions will show flattened waveforms.
It is important to note that arteries located lower on the leg will produce sharper waveform peaks, while those located higher on the leg will produce more rounded waveforms.
E) How to Perform a Segmental Pressure Study
A Segmental Pressure is performed using the same method as an Ankle Brachial Index, but incorporates additional cuffs wrapped at the high thigh and above and below the knee, in addition to the ankle. Segmental Pressure studies are considered reimbursable when performed using a bidirectional Doppler with hard-copy output. Koven Technology non-invasive Doppler models Smartdop® 45, Smartdop® 30EX, Smartdop® 50EXF, and Bidop® 3 (when used with Smart-V-Link® Vascular Software) can be used to perform a reimbursable Segmental Pressure study.
Take a blood pressure reading at the arm
1. Place a blood pressure cuff around the patient's arm. Place ultrasound gel on the tip of the probe and apply the probe at a 45 to 60 degree angle over the brachial or radial artery.
2. Wait for Doppler sounds to become stable. If your Doppler has an LCD display, watch the waveform on the display until it becomes rhythmic and stable.
3. Inflate the cuff to 20 mmHg over pressure cessation. Then, slowly deflate the cuff until the first Doppler sound is heard.
4. Record the systolic pressure when the first sound is heard and repeat the test on the other arm. Use the highest arm pressure to calculate the ABI to rule out subclavean steal syndrome.
Take the systolic pressures at the leg
Prior to taking the systolic pressures at the leg, take printouts of the Doppler waveforms at all cuff sites for documentation.
1. Wrap appropriately sized blood pressure cuffs around each leg at the ankle, above and below the knee, and at the high thigh. Place ultrasound gel on the tip of the probe and apply the probe at a 45 to 60 degree ankle over the posterior tibial or dorsalis pedis artery.
2. Wait for Doppler sounds to become stable. If your Doppler has an LCD display, watch the waveform on the display until it becomes rhythmic and stable.
3. Inflate the ankle cuff to 20 mmHg over pressure cessation. Then, slowly deflate the cuff until the first Doppler sound is heard. Record the systolic pressure and repeat for the ankle cuff on the other leg.
4. Repeat at the posterior tibial artery for the cuffs below the knee, the popliteal artery for the cuffs above the knee and at the femoral artery for the cuffs at the high thigh.
Interpreting the Results
* Observe pressure differences between adjacent cuff sites on the same leg. Pressure differences between cuff sites are used to localize the disease.
* Pressure differences between two adjacent levels of less than 20 mmHg is considered normal within limits ¹
* Segmental pressure tests should be combined with treadmill or reactive hyperemia studies to determine pressure recovery times.
¹ Weiss RA. Vascular Studies of the Legs for Venous or Arterial Disease. Dermatologic Clinics, Volume 12, Number 1, January 1994.
The instructions provided above are intended as general guidelines. For specific instructions on performing a Segmental Pressure study using your Doppler, please refer to the operation manual provided.
F) How to Perform a Venous Reflux Study
What is a Venous Reflux Study?
A Venous Reflux study uses a PPG probe affixed adjacent to the posterior tibial artery, at or above the ankle. Dorsiflexing the foot acts as a pump for venous augmentation. Recovery time is the time required for venous refilling to occur. Venous Reflux is used to assess valvular competence. PPG probes are available for the Bidop® 3, Smartdop® 45, Smartdop® 30EX, and Smartdop® 50EXF Vascular Dopplers.
Examination Procedure
1. Connect the PPG probe and make sure the Doppler is in DC or Venous mode.
2. Have the patient sit on an examination table so that the feet are not touching the floor. Use double-sided clear tape to affix the PPG sensor to the skin surface at the medial malleolus over the posterior tibial vein.
3. Ask the patient to dorsiflex the foot the specified number of time. The exercise should be performed forcefully, especially when lifting the foot upward.
4. After dorsiflexing, have the patient relax the foot. The waveform on the LCD will return to baseline and display the results.
Interpreting the Results
- Normal refill time will exceed 21 seconds
- Refill time between 18 and 21 seconds is questionable. Repeat the test.
- If refill time is less than 18 seconds, a venous condition may exist.
Proper technique and patient cooperation are important factors when performing a venous reflux study.
The instructions provided above are intended as general guidelines. For specific instructions on performing a Venous Reflux study using your specific Doppler, please refer to the operation manual and/or inservice video provided.
G) How to Perform a Venous Compression Study
What is a Venous Compression Study?
Venous compressions are auditory tests involving compression of the metatarsal arch to verify augmentation, followed by compression of the calf muscle to verify valvular competence. Venous compressions are performed to detect enlarge veins due to the presence of malfunctioning valves.
Examination Procedure
1. Make sure the Doppler is set on separate or venous mode and that the time is set on slow.
2. Place the patient in a supine position.
3. Locate the posterior tibial artery. Then, move the probe adjacent to the artery to achieve diminished sounds. The probe will now be in the area of the posterior tibial vein.
4. Hold the probe steady and firmly compress then release the metatarsal arch. An augmentation sound will be heard in the form of a "whoosh" and will show below the baseline on the visual display (if available).
5. Then, continue to hold the probe in place and squeeze the calf muscle in a downward direction without moving the hand.
Interpreting the Results
Following compression of the metatarsal arch, a loud sound is expected. A diminished sound may indicate some valvular incompetence.
Following compression of the calf, no sounds or augmentation should exist because the valves should block any downward venous flow. Augmentation or diminished sounds heard at this time may indicate valvular incompetence.
The instructions provided above are intended as general guidelines. For specific instructions on performing a Venous Compression study using your specific Doppler, please refer to the operation manual provided.
H) How to Perform a Maximum Venous Outflow Study (MVO)
Why perform an MVO study?
Because deep vein thrombosis cannot be reliably diagnosed solely on the basis of external signs and symptoms, objective screening tests are valuable for confirming or ruling out suspected venous objections in the lower extremities. Undiagnosed Deep Vein Thrombosis (DVT) can lead to a pulmonary embolism. The MVO test uses PV (pneumoplethysmography). It is performed by inducing temporary venous pooling by means of a constricting thigh cuff, then measuring the rate at which emptying occurs when the constricting cuff is suddenly vented. Maximum Venous Outflow can be used in addition to venous compression or venous reflux studies. Koven Technology Vascular Doppler models Smartdop® 45, Smartdop® 30EX, and Smartdop® 50EXF can be used to perform an MVO study.
Examination Procedure
1. Connect the PV module to the Doppler and make sure the Doppler is set on separate or venous mode.
2. Place the patient in a supine position with the leg and hip rotated outward. Wrap cuffs of appropriate width comfortably snug around the patient's mid thigh and mid calf.
4. Connect a 3-way stopcock to the inlet of the PV module. Connect extender tubing to one of the two remaining sides of the stopcock and attach the tubing to the cuff at the mid calf. Attach a sphyg to the other side of the stopcock.
5. Turn the stopcock so that air is routed from the sphyg to the cuff. The green arms on the stopcock will be at the 12, 3, and 6 o'clock positions.
6. Inflate the cuff to 40 mmHg. Wait 10 seconds to allow time for settling, then deflate the cuff to 15 mmHg.
7. Disconnect the sphyg from the stopcock, attach it to the thigh cuff and begin the measurement.
8. Inflate the thigh cuff to 60 mmHg or more. After 90 seconds, disconnect the sphyg from the cuff.
9. When performing an MVO study using a Koven Smartdop Doppler system, the results will be automatically plotted on the LCD.
Interpreting the Results
Normal results will show a return of venous flow to the original baseline within 3 seconds.
A return of venous flow to baseline taking longer than 3 seconds is considered abnormal.
Another method of interpretation is by applying the following formula:
MVO / VC x 100% =
> 70% = Normal
< 70% = Abnormal
VC = Venous Capacitance, 90 sec. sphyg disconnection point
MVO = Maximum Venous Outflow, 3 sec. after VC point.
The instructions provided above are intended as general guidelines. For specific instructions on performing a MVO study using your specific Doppler, please refer to the operation manual provided.
Other useful references concerning the clinical implications of Toe blood pressure:
Pe´rez-Martin A, et al., Validation of a Fully Automatic Photoplethysmographic Device for Toe Blood Pressure Measurement, Eur J Vasc Endovasc Surg (2010), doi:10.1016/j.ejvs.2010.06.008
J.C. de Graaff et al., The usefulness of a laser Doppler in the measurement of toe blood pressures, J. Vasc Surgery (2000); 32; 1172-9
D.T. Ubbink, Toe blood pressure measurements in patients suspected of leg ischaemia: a new Doppler device compared with photoplethysmography, Eur. J Vasc Endovasc Surg (2004); 27; 629-34
Koven Hadeco vascular Dopplers are ideal for monitoring, diagnosis, ans wound care and are widely used for clinical applications such as Ankel Brachial Index studies and Peripheral Vascular Procedures.
The collection features three Dopplers to suit a wide range of applications: The Bidop3 Visual Pocket Doppler, Smartdop 45 Vascular Ultrasound Doppler and the Smartdop 30EX Vascular Ultrasound Doppler.
The BIDOP*3 is a unique, handheld pocket Doppler that offers diagnostic capabilities previously seen only in large systems. The BIDOP*3 has a large viewing panel with real-time Doppler waveform display. The built-in microprocessor calculates ratios automatically without the need for manual adjustments. Store up to 30 waveforms for later reference or download to optional Smart-V-Link* vascular software for documentation (and reimbursement). An optional PPG (Photoplethysmography) probe for toe pressures is also available.
The Smartdop* 45 by Koven Technology is a lightweight, hand-held bidirectional Doppler for assessment of the vascular condition. It has a large visual LCD screen for viewing real-time waveforms and an integrated printer for documentation. Optional PPG and pulse volume is available for toe pressures and PVR studies.
The built-in microprocessor calculates ratios automatically without the need for manual adjustments. Save up yo 30 waveforms for later reference, print-out, or download to the optional Smart-V-Link* Software. Smart-V-Link* is a complete vascular software system for performing ABI's, TBI's, Segmental Pressures, Pulse Volume Recordings (PVR) and Venous studies.
The Smartdop* 30EX is Koven Technology's newest bidirectional portable Doppler for documentation and assessment of the vascular conditions. The Smartdop* 30EX is leightweight and portable with an integrated printer, large visual LCD display, and automatic cuff inflator to facilitate quick, simple, accurate ABI, TBI and PVR studies. Optional PPG and pulse volume modules are available for toe pressure and MVO studies. The built-in microprocessor calculates ratios automatically without the need for manual adjustments. Save up to 30 waveforms for later reference, print-out, or download to the optional Smart-V-Link* Software. Smart-V-Link* is a complete vascular software system for performing ABI's, TBI's, Segmental Pressures, Pulse Volume Recordings (PVR) and Venous studies.
These Koven Dopplers are cost effective due to the studies these can carry out. All units can do pulse volumes and arterial and venous studies. They show the pulse waveform as well as being able to hear the audible signal. Also these units can easily be connected to the computer to give printable reports for referring to vascular consultant. These products contribute to the timly understanding of diseses associated with podiatry care.
(1) Hadeco Bidop 3 ES-100V3
(2) Hadeco Smartdop 45
The ultimate in bidirectional dopplers. Has the flexibility and features to do everything the general practitioner could want.
Features
- Bi-directional Doppler with LCD display
- Built-in high resolution 58mm printer
- All standard numerical and patient data available
- Simplified three-key (Shuttle, Back key and Probe button) operation
- 30 waveform memory
- Easy mode settings with LCD menu and scroll button
- Multiple probe selection (2, 5, 8, 10 MHz) for user/patient flexibility - one standard probe supplied, please change probe below - 8Mhz supplied by default
- USB computer interface
- Optional PPG & Pneumo probes for arterial and venous testing.
Others
- Power: DC 12v
- Speaker output: 200 mW or more
- LCD Display: 128 x 64 dots
- Paper: 58 x 25mm rolls
- Print Speed: 25mm/sec
- Weight: 500g
- External outputs: Headset, USB port & PC keyboard.
- Automatic shut off: No signal: 2mins, Freeze: 5 mins and Othera: 15mins.
- Accessories (optional): PPG probe, PPG/PV Module, Smart-V-Link software.
(3) Hadeco Smartdop 30EX
Smart-V-Link Doppler Software
Works withthe following dopplers - Hadeco ES-100-V3, Hadeco Smartdop 30 and Hadeco Smartdop 45
Easy to connect to your PC via RS232 cable to obtain a print out to satisfy Medicare rebate requirements. The software is compatible with Windows operating systems only. Once connected the operations of doppler are remote controlled by computer. The software shows real-time vascular waveform display, data storage for future reference and data can be stored in the internal hard disk drive as well as any storage devices on network computers. Standardized testing modules for easy operation and documentation - ABI, TBI and arterial blood flow velocity, PPG toe pressure and venous reflux, PV arterial, venous compression, lower and upper extremities and individual test.
