Copyright © 2012 The Korean Society of Plastic and Reconstructive Surgeons
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
The ankle brachial index (ABI), which is the ratio of ankle to
brachial systolic blood pressure, is a simple useful method for
the diagnosis of peripheral arterial disease (PAD) and is a highly
specific method for assessment of vascular risk in otherwise as-
ymptomatic patients . Although ABI is an objective diagnostic
method, this method is less reliable in cases where the arteries
may be calcified and, therefore, resistant to compression. There-
fore, the application of this index to diabetic patients is consid-
ered questionable, given the prevalence of medial arterial calcifi-
cation that results in falsely elevated ABI values . The presence
of media sclerosis produces falsely elevated pressure values, as the
arterial wall becomes stiffer and resists compression.
A low ABI indicates PAD. There are many cases of peripheral
artery stenosis even when the ABI is normal or elevated . In
such cases, great toe artery pressure is commonly advocated for
calculation of the toe brachial index (TBI), as the vessels of the
Utility of Toe-brachial Index for Diagnosis of
Peripheral Artery Disease
Seong Chul Park, Chang Yong Choi, Young In Ha, Hyung Eun Yang
Department of Plastic and Reconstructive Surgery, Soonchunhyang University Gumi Hospital, Soonchunhyang University College of Medicine,
Correspondence: Chang Yong Choi
Department of Plastic and
Soonchunhyang University Gumi
Hospital, Soonchunhyang University
College of Medicine, 179
1gongdan-ro, Gumi 730-706, Korea
Background The ankle brachial pressure index (ABI) is a simple, useful method for diagnosing
peripheral artery disease (PAD). Although the ABI is an objective diagnostic method, it has
limited reliability in certain scenarios. The aim of the present study was to determine the
accuracy and reliability of the toe brachial index (TBI) as a diagnostic tool for detecting
stenosis in PAD, associated with normal or low ABI values.
Methods ABI and TBI values were measured in 15 patients with diabetic gangrene who
were suspected of having lower extremity arterial insufficiency. The ABI and TBI values
were measured using a device that allowed the simultaneous measurement of systolic
blood pressure in the upper and lower extremities. In addition, the ABI and TBI values were
compared pre- and post-angiography.
Results Patients with an ABI of 0.9–1.3 showed almost no difference between the 2
measurements. The patients with TBI >0.6 had no arterial insufficiency. The patients with TBI
<0.6 required vascular intervention with ballooning. After the angiography, the gangrenous
wounds decreased in size more rapidly than they did prior to the intervention.
Conclusions Our findings suggest that TBI is the method of choice for evaluating lower limb
perfusion disorders. This result requires further studies of TBI in a larger number of patients.
Future long-term studies should therefore evaluate the utility of TBI as a means of screening
for PAD and the present findings should be regarded as preliminary outcomes.
Keywords Toe brachial index / Ankle brachial index / Peripheral arterial disease
Received: 27 Nov 2011 • Revised: 22 Feb 2012 • Accepted: 9 Mar 2012
pISSN: 2234-6163 • eISSN: 2234-6171 • http://dx.doi.org/10.5999/aps.2012.39.3.227 • Arch Plast Surg 2012;39:227-231
This article was presented at the 69th
congress of the Korean Society of
Plastic and Reconstructive Surgeons on
November 11, 2011 in Seoul, Korea.
No potential conflict of interest relevant
to this article was reported.
Park SC et al. Utility of toe-brachial index
Table 1. Data of patients undergoing infrapopliteal angiography
2 joint amputation
O Skin graft
O 1 joint amputation
2 joint amputation
1 joint amputation
O Local flap
2 joint amputation
1 joint amputation
ABI, ankle brachial index; TBI, toe brachial index; ATA, anterior tibial artery; PA, peroneal artery; PTA, posterior tibial artery; O, performing ballooning.
toes are generally unaffected by media sclerosis . The use of
the ABI has been reported in many studies, but its calculation
has been inconsistent among studies. The aim of the present
study was to determine the accuracy and reliability of the TBI
as an alternative diagnostic tool for the detection of stenosis in
PAD when the patient may have a normal or higher ABI value.
A total of 30 limbs, representing 15 patients (12 men and 3
women) were studied (Table 1). Patients with either diabetic
gangrene or symptoms of intermittent claudication were includ-
ed in the study. However, patients previously diagnosed with
cardiovascular disease or cerebrovascular incidents and already
undergoing treatment were excluded.
In patients with suspected lower extremity arterial insufficien-
cy, the ABI and TBI were measured using a device (Non-invasive
vascular screening device VP-2000, Omron, Kyoto, Japan) that
allows simultaneous systolic blood pressure measurements from
both the upper and lower extremities (Fig. 1). The measure-
ments were carried out by trained vascular nurses under optimal
conditions. In order to obtain the most accurate results, the
patients fasted for at least 2 hours prior to having measurements
taken and were not permitted to consume any form of caffeine
Fig. 1. Case 12
A 60-year-old female with diabetic gangrene. (A) Initial wound finding.
Diabetic gangrene on left foot, lateral side. (B) Left foot wound 3 months
later. The wound size was reduced.
Vol. 39 / No. 3 / May 2012
for 3 hours prior to the evaluations. In addition, physical activity
was limited during the 3-hour period before the evaluations and
the patients were taken to the testing laboratory in a wheelchair.
The ABI and TBI measurements were taken after the patients
had lain still on a table for about 15 minutes. The laboratory tem-
perature was also maintained at 22oC .
The ABI was measured by determining the systolic pressure
in the brachial artery and in both the dorsalis pedis and posteri-
or tibial arteries. The systolic pressures of each legs were divided
by the brachial pressure . Similarly, the TBI was calculated by
dividing the systolic pressure of the great toe by that of the bra-
chial artery . Probes were attached to the tips of both great
toes, and cuffs were placed on the arms and legs, above the ankle
or at the base of the great toes. The higher of the two simultane-
ously measured brachial systolic blood pressure values was used
in the analysis.
In patients diagnosed with arterial insufficiency, vessel dila-
tion using a balloon catheter was performed. Patients with high
TBI values were deemed to be candidates for this procedure.
The balloon catheter was inserted through an incision in the
Patient wounds were treated by debriding the wound, minor
amputations, or with skin grafts.
The patients in this study presented with either diabetic gangrene
(14 patients) or intermittent claudication (1 patient). Patients
with an ABI <0.9 and/or a TBI <0.6 in either leg were regarded
as presenting with PAD and were considered for angiography.
Some patients were clinically suspected of having PAD, but had
ABIs within the normal range of 0.9 to 1.3. These patients dem-
onstrated almost no difference between the ABI values calcu-
lated using the systolic pressure from the dorsalis pedis and that
calculated using the values from the posterior tibial artery. These
patients also presented with diabetic gangrene or ulcers.
After calculating the ABI and TBI, interventions were per-
formed in 15 patients. Among the 30 legs evaluated, 17 were
normal and 13 required intervention using an expandable bal-
loon catheter. Low ABIs were detected in 2 legs of 12 patients.
Normal ABIs and low TBIs were detected in 8 legs. A low ABI
and low TBI were detected in 3 legs of 12 patients. Two legs
from the 30 patients demonstrated an ABI <0.9 but had a nor-
mal TBI, and the angiography was also normal.
No patient with a TBI >0.6 demonstrated arterial insuffi-
ciency, nor did they have findings consistent with medial sclero-
sis. The patients with the TBI <0.6 required vascular interven-
tion with a balloon catheter. Four of these patients had lower
extremity swelling, and 6 presented with pain after the vascular
intervention. All 13 legs requiring vascular intervention had
elevated temperatures in their extremities, and the patients were
able to detect differences between the temperatures of their legs.
Pinpoint bleeding was observed in the wound margin after de-
bridement. Debridement was performed at least 2 to 3 times; 1
or 2 joint amputations were performed for 6 patients. The mean
hospital stay was 55 days.
A 60-year-old female patient was referred to the vascular clinic
with diabetic gangrene in her left foot. The patient had a left foot
ABI of 0.91 and a TBI of 0.58. Her gangrenous wound included
dirty necrotic tissue and bone. The distal portion of her fifth
toe had evidence of osteomyelitis. Debridement was repeated 3
times, and 1 joint amputation was performed. The mean values
of both the ABI and TBI increased following angiography, with
a concomitant reduction in the wound size (Fig. 1).
Cases 5, 6
A 69-year-old man was admitted with diabetic gangrene in his
right foot. The patient had a measured right foot ABI of 0.99, and
a left foot ABI of 1.01; the right and left TBI values were 0.31
and 0.63, respectively. This patient, with PAD, was a candidate
for angiography. An angiogram demonstrated complete occlu-
sion of the distal peroneal artery and distal posterior tibial artery.
Near total occlusion of the anterior tibial artery was also dem-
onstrated by the angiogram. Intervention was performed using
a balloon-expandable device. The post-angioplasty ABI and TBI
were measured approximately 3 months later. The TBI value on
Fig. 2. Cases 5, 6
(A) Initial toe brachial index (TBI) values. The right and left TBI were
0.31 and 0.63. (B) TBI values 3 months later. The values were elevated
to 0.45 on the right and 0.66 on the left.
Park SC et al. Utility of toe-brachial index
his right limb had increased to 0.45 from 0.41 (Figs. 2, 3).
PAD is a clinical manifestation of the atherosclerotic process.
The prevalence of PAD has been evaluated in several epidemio-
logical studies, and has been demonstrated to be as high as 20%
in persons over 75 years of age . PAD has been associated
with increased cardiovascular morbidity and mortality, but only
approximately one-third of PAD patients exhibit typical symp-
toms; the majority are asymptomatic . It is vital, therefore,
that general practitioners are able to accurately diagnose asymp-
tomatic cases. Although vascular insufficiency can be diagnosed
by either angiography or computed tomography angiograms,
these invasive and expensive tests are not generally available to
general practitioners. Therefore, a simple, non-invasive test, such
as taking the ABI or TBI, would be beneficial.
An ABI value <0.9, an independent risk factor for cardiovas-
cular disease, is caused by hemodynamically significant arterial
stenosis and is most often used in epidemiological studies as a
threshold value for the presence of PAD. However, in the pres-
ence of media sclerosis, the ABI is not a useful diagnostic tool.
This is because the ABI increases due to arterial wall resistance
to compression , tending to result in ABI values of 1.3 or
above. In addition, patients with chronic renal disease, a history
of smoking, congestive heart disease, or other severe, lower
extremity symptoms may have ABIs that are normal or above
1.3 . In patients with PAD, media sclerosis does not typically
affect the toe vessels. Therefore, TBI values are generally more
accurate than ABI in patients with media sclerosis.
In addition, many studies have indicated the utility of TBI
values. Martin et al. evaluated the utility of TBI in diabetic pa-
tients and concluded that TBI was the method of choice for
evaluating lower limb perfusion in the presence of overt arterial
wall calcification . Harrison et al.  also demonstrated that
TBI is warranted in the assessment of PAD. The present findings
also indicated that TBI was the preferred method for evaluating
lower limb perfusion disorders, especially in patients with dia-
Thus, a treatment algorithm was devised for patients with
diabetic gangrene. According to the algorithm, if the ABI was
less than 0.9 or if the TBI was lower than 0.6 after angiography,
we performed wound management. In addition, in patients with
normal ABI values, if the TBI was lower than 0.6, angiography
preceded wound treatment. Following this treatment algorithm,
more rapid detection of PAD in patients with diabetic gangrene
will be possible, allowing for improved wound management and
reduced hospital stays (Fig. 4).
The American Diabetic Society recommends the evaluation
of patients with diabetes mellitus for the presence of PAD at
least every 5 years, even those patients with a normal ABI. As
mentioned previously, media sclerosis in patients indicates the
need for both ABI and TBI evaluations in order to detect PAD.
Clinicians should also evaluate patients with diabetic gangrene
using both the ABI and TBI, and we recommend our algorithm
for the initial evaluation of these patients.
Verification of these results will require additional studies of
the utility of TBI measurements in a larger number of patients.
Fig. 4. Clinical course of diabetic gangrene
DM, diabetes mellitus; ABI, ankle brachial index; TBI, toe brachial index.
0.9 ≤ ABI ≤ 1.3
1.3 < ABI
DM patients with gangrene
ABI < 0.9
0.6 ≤ TBITBI < 0.6
Fig. 3. Case 5
(A, B) Preintervention angiogram demonstrating complete occlusion of
the distal peroneal artery and distal posterior tibial artery. Nearly total
occlusion of the anterior tibial artery appeared on the angiogram. (C, D)
Postintervention angiogram after vascular intervention by a balloon-
Vol. 39 / No. 3 / May 2012
Future long-term studies should evaluate the utility of the TBI
as a means of screening for PAD. In addition, larger clinical trials
are also required to determine the utility of our recommended
1. Harrison ML, Lin HF, Blakely DW, et al. Preliminary assess-
ment of an automatic screening device for peripheral arterial
disease using ankle-brachial and toe-brachial indices. Blood
Press Monit 2011;16:138-41.
2. Suominen V, Rantanen T, Venermo M, et al. Prevalence and
risk factors of PAD among patients with elevated ABI. Eur J
Vasc Endovasc Surg 2008;35:709-14.
3. Diehm C, Schuster A, Allenberg JR, et al. High prevalence
of peripheral arterial disease and co-morbidity in 6880 pri-
mary care patients: cross-sectional study. Atherosclerosis
4. Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral
arterial disease detection, awareness, and treatment in pri-
mary care. JAMA 2001;286:1317-24.
5. Martin Borge V, Herranz de la Morena L, Castro Dufourny
I, et al. Peripheral arterial disease in diabetic patients: utility
of the toe-brachial index. Med Clin (Barc) 2008;130:611-2.