Duplex ultrasound and pedal acceleration time as tools to evaluate foot perfusion: a literature review

Souza, Drako de Amorim; Medrado, Pedro Victor Freitas; Santos, Vinícius Alves; Aguiar, Carolline Xavier de; Silva, Guilherme Souza; Sousa, Lucas Pereira Pintos de; Amando, Yasmin Bione Diniz; Saad, Paulo Fernandes

doi:10.1590/1677-5449.202300172

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REVIEW ARTICLES • J. Vasc. Bras. 23 • 2024 • https://doi.org/10.1590/1677-5449.202300172 linkcopy

Duplex ultrasound and pedal acceleration time as tools to evaluate foot perfusion: a literature review

Ultrassonografia dúplex e tempo de aceleração plantar como ferramentas para avaliar a perfusão do pé: uma revisão da literatura

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Currently, the standard non-invasive test for diagnosing Peripheral Arterial Disease is the Ankle-Brachial Index. However, this test becomes unfeasible in a certain population. New evidence proposes the pedal acceleration time, an ultrasound index, as an alternative test. An integrative bibliographic review was carried out between June 3, 2022 and January 8, 2023, to investigate this new index as a tool to assess foot perfusion. Papers published in English, Portuguese, or Spanish between 2012 and 2022 were searched on PubMed, Google Scholar, and Scielo, using the keywords “Peripheral Arterial Disease” AND “Acceleration Time” AND (Pedal OR Plantar). Research that didn’t assess foot perfusion using the methods of interest or did not present human data and also case series or reports were excluded. Seven out of the sixty-six articles identified in the searches were selected for the review, all of which had notable methodological limitations. Pedal acceleration time seems to be able to diagnose and stratify and may reflect prognosis.

Keywords:
ultrasonography; duplex; peripheral arterial disease; foot

Author	Study type (duration)	Sample (limbs)	Results	LE
Trihan et al.⁸	Cross-sectional study with consecutive patients (12 months)	77 (88)	● Significant linear correlation (R = -0.46, P < 0.01) between ATmax and ABI;	II
			● Significant linear (R = -0.78, P < 0.0001) and multivariate correlation between ATmax and TBI;
			● ATmax ≥ 215ms diagnoses critical ischemia according to toe pressure (TP <= 30) with S = 85.7 (57.2-98.2), E = 81.1 (70.3-89.3), AUC = 0.89 (0.81-0.98), and 95%CI.
Sommerset et al.⁶	Cross-sectional study (12 months)	250 (499)	● Significant linear correlation (p<0.001) between lateral plantar artery PAT and ABI;	III
Sommerset et al.⁶	Cross-sectional study (12 months)	250 (499)	● Class 1 (no symptoms, ABI 0.90-1.30) correlated with PAT 89.9 ± 15.5 ms, Class 2 (moderate claudication, ABI 0.69-0.89) correlated with PAT 152.3 ± 28.4 ms, Class 3 (severe claudication, ABI 0.40 -0.68) correlated with PAT 209.8 ± 28.4 ms and Class 4 (critical ischemia, ABI 0.39-0.00) correlated with PAT 270.2 ± 35.3 ms;	III
Teso et al.⁴	Retrospective cohort (12 months)	72 (73)	● Post-revascularization PAT in the range of 213 ± 47 ms and difference between pre- and post-revascularization PAT in the range of 30 ± 30 ms correlated with significant amputation (p < 0.00001);	III
			● Post-revascularization PAT in the range of 122 ± 30 ms and difference between pre- and post-revascularization PAT in the range of 117 ± 34 ms correlated with limb salvage (p < 0.00001);
			● There was no significant difference between the amputation and limb salvage groups with respect to pre-revascularization PAT (p = 0.54);
Santos⁹	Cross-sectional study (10 months)	141 (198)	● Significant Spearman correlation (ρ) between PAT and ABI in diabetics: ρ = -0.8016 (-0.8627 to -0.7174 95%CI; p<0.001); non-diabetics: ρ = -0.8071 (-0.8693 to -0.7198 95%CI; p<0.001); men: ρ = -0.8133 (-0.8693 to -0.7368 95%CI; p<0.001) and women: ρ = -0.7611 (-0.8397 to -0.6511 95%CI; p<0.01);	III
			● PAT values to estimate the degree of ischemia were calculated, notably a PAT > 196 ms indicates grade 3 ischemia (ABI < 0.4) in diabetics with S = 0.88, E = 0.87 and Ac = 0.88 and in non-diabetics with S = 0.83, E = 0.98 and Ac = 0.87;
			● PAT was associated with moderate to high risk of amputation by the SVS-WIfI system, with a value > 145 ms in diabetics having S = 0.77, E = 0.77 and Ac = 0.77 and a value > 165 ms in non-diabetics having S = 0.78, E = 0.79 and Ac = 0.79;
Geskin et al.¹⁰	Cross-sectional study (5 months)	30 (38)	● There was a significant reduction in mean PAT after revascularization (193 ± 118.41 ms to 160.38 ± 92.19 ms, p = 0.009);	III
Geskin et al.¹⁰	Cross-sectional study (5 months)	30 (38)	● Negative Pearson correlation between PAT and ABI before revascularization (r2 = 0.41, p = 0.002, n = 21);	III
Ochoa-Ayón et al.¹¹	Prospective cohort (1 year)	31 (31)	● After angioplasty, all patients (n = 31) had a significant reduction in PAT (mean of 213.00 ± 83.26 ms before and 118.35 ± 16.40 ms after angioplasty, p = 0.000);	III
			● After 1 year, the mean time to wound healing was 4.35 ± 2.42. Only 1 patient did not achieve wound healing;
			● There were no significant amputations (at or above the ankle). 51.6% of patients (n = 16) had a minor amputation;
Arévalo Zamora and Cifuentes González¹²	Cross-sectional study (12 months)	68 (130)	● Pearson correlation of -0.67 between ABI and PAT in the arcuate artery of the foot and -0.65 in the lateral plantar artery;	III
			● Association between ABI < 0.5 and PAT > 160 ms (S = 92.3% and E = 83.7%, AUC = 0.89 (95%CI (0.839-0.959);
			● PAT < 120 ms correlated with normal ABI, PAT 120-160 ms correlated with ABI between 0.5-0.9.

	Level	Intervention	Diagnosis	Prognosis	Etiology
Least biased	I	Systematic review of Level II studies	Systematic review of Level II studies	Systematic review of Level II studies	Systematic review of Level II studies
	II	Randomized Controlled Trial	Cross-sectional study among consecutive patients	Inception cohort study	Prospective cohort study
	III	One of the Following:	One of the following:	One of the following:	One of the following:
		- Non randomized experimental study (e.g. controlled pre- and post-test intervention study)	- Cross-sectional study among non-consecutive patients	- Untreated control patients in a randomized controlled trial	- Retrospective cohort study
		- Comparative (observational) study with a concurrent control group (e.g. cohort study, case-control study)	- Diagnostic case-control study	- Retrospectively assembled cohort study	- Case-control study
Most biased	IV	Case series	Case Series	Case series, or a cohort study of patients at different stages of disease	A cross-sectional study

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[1] Source: Clinical Information Access Portal (CIAP).¹³