General Review

Measurement, Calculation, and Normal

Range of the Ankle-Arm Index: A
Bibliometric Analysis and Recommendation
for Standardization

Steven Hein, MD, and J. Joris Haye, MD, PhD, Amsterdam, The Netherlands

Since its introduction in 1950, a variety of methods of measurement and calculation have been
used to establish the ankle-arm index (AAI). This has resulted in variations of its normal range
and difficulty in comparing study results. Hence, the objective of our study was to analyze the
disparate methods used to assess AAI and its normal range and to recommend a standardized
method to assess AAI based on that analysis. We made an inventory of the disparate AAI
methods and its normal range reported in 100 randomly selected publications and recommend
the means of such standardization. We recommend that an experienced observer assess AAI
with the patient at rest in the supine position. The width of the sphygmometer cuffs should be 1.5
times that of the extremity to be measured, and brachial and crural pulses should be detected
using a Doppler device. Systolic pressures should be measured at both arms and over the
anterior and posterior arteries of both legs, with the cuff placed just proximally to the malleoli.
The left arm pressure ought to be used as denominator and the mean of pressures of both crural
arteries of each leg ought to be used for the numerator of the AAI for that leg. We advocate 0.90
as the cut-off value to distinguish patients who need further arterial assessment.

INTRODUCTION et al. in 1969,” a wide variety of methods of AAI

The ankle-am index (AAI) is the ratio of systolic
blood pressure at the level of the ankle to that at
the level of the arm.’ Because this noninvasive
method is simple, reproducible,’-‘ and accurate at
detecting the decreased blood pressure distal to an
arterial s t e n ~ s i s , ~it. ~is often used to assess
peripheral arterial occlusive disease (PAOD). Since
the introduction of the concept of the AAI by
Winsor, in 195O1’ and its popularization by Yao
Section of Surgical Disciplines, Antmi van Leeuwenhoek Hospiral,
Amsterdam, The Netherlands.
Correspondence to: J . Joris Hage, M D , PhD, Section of Surgical
Disciplines, Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, NL-
1066 CX, Amsterdam, The Netherlands, E-mail: j.jorishage@inter.nl
net
Ann Vasc Surg 2006; 20: 282-292
DOI: 10.1 OO7lsi 00 16-006-9019-x
0 Annals of Vascular Surgery Inc.
Published online: March 23. 2006
measurement and calculation have been used in
studies on its diagnostic and epidemiological value.
Use of these nonuniform and nonstandardized
methods has resulted in variations of reportedly
“normal” versus “abnormal” distribution of AAI.
This results in confusion and hampers adequate
comparison of results from one study to another.
Moreover, it prohibits the development of an evi-
dence-based diagnostic approach. Therefore, the
objective of our study was to make an analysis of
the disparate methods used to assess AAI and its
normal range and LO recommend a standardized
method to assess AAI based on that analysis.
MATERIALS AND METHODS
Selection of 100 Publications on AAI
Our method of bibliornetric analysis has been pre-
viously tried and described.12 Briefly, it seeks to

282
Vol. 20, No. 2, 2006
reproducibly trace and analyze publications on a
certain topic, in this case the methodology of AAI
assessment. To do so, we considered all original
studies and reviews indexed in Pubmed or the
medical library of the University of Amsterdam,
The Netherlands, that featured the term ankle-arm
index or ankle-brachial index in the abstract for
inclusion in our analysis. Using the Pubmed search
engine (http://www.ncbi.nlm.nih.gov/ accessed
November 18, 2004) and the search engine of the
medical library, 812 medical journal articles and 32
book chapters were traced. As our purpose was to
review the variation of techniques of AAI assess-
ment rather than to calculate quantitative esti-
mates of the outcome of these assessments, we
used simple random sampling to select 100 publi-
cations that mentioned use of AAI as the method to
distinguish PAOD.13 Doing so, we came across 13
publications that neither mentioned what methods
had been used to assess and calculate the AAI nor
referred to any other report to provide any indi-
cation as to what method was used. Hence, these
13 publications were excluded, and instead, 13
other publications were randomly selected.
Assessment of Data from the Publications
The 100 publications were systematically analyzed
for indications as to what method of AAI assessment
had been used by the author(s).As such, we scored
on 11 key points of measurement and calculation.
Apart from data provided in each publication on (1)
the position of the patient during measurement, we
noted information on (2)the width of the cuff of the
sphygmometer used for the arm, (3) the width of
the cuff of the sphygmometer used for the lower leg,
(4) the level of placement of this cuff on the lower
leg, ( 5 ) the method of detection of the pulse in the
arm, (6) the method of detection of crural pulses,
(7) whether or not the brachial pressure was mea-
sured bilaterally, (8) whether or not crural pres-
sures were measured bilaterally, (9) which of the
crural pulses were assessed to calculate the AAI
(anterior tibial, posterior tibial, or peroneal), (10)
which of the brachial and crural pressures were
used for the AAI denominator and numerator, and
(11) the cut-off value for the normal AAI. To not
further complicate the grouping of various ranges of
distribution of normal AAI,no difference was made
between ”lower than ()” and “equal to or lower
than ( 5 )” or between ”higher than (>)” and
“equal to or higher than (2).”Likewise, no atten-
tion was paid to the mean and range indicated for
the different stages of PAOD because we did not
intend to describe these stages.
Ankle-arm index revisited 283
Whenever the methodology of any of the 11
scored items was not indicated in the text of the
publication, the references provided by the au-
thor(s) were searched for such an indication. Still,
when authors described the methods they had used
and referred to other studies to motivate their
choice of method, we did not check whether the
described method corresponded with the reported
source method.
RESULTS
Information on Patient Position during
Assessment of AAI
In 60 of the 100 analyzed reports, the supine po-
sition was mentioned as the position used to rnea-
sure the brachial and crural blood pressures. Only a
reference to other studies indicated the position in
nine of the other 40 reports. Still, two of these nine
references failed to mention this position. The
remaining 3 1 reports offered neither information
on the position of the patient nor a reference to
indicate this position.
Information on Sphygmometer Cuff Width
Used to Assess Brachial Blood Pressure
While describing the method of AAI measurement,
a single largest group of 56 (groups of) authors did
not provide any information as to the size of the cuff
that was used to assess the brachial blood pressure.
Twenty-one (groups of) authors stipulated what
size of cuff was used, and of these, nine used a cuff
of 12 cm,3,4,14-20 two a cuff of 13 cm,21,22two a cuff
of 14 cm,23r24and three a cuff of 15 cm.25-27One
author measured the circumference of the arm to
determine the proper cuff width,28 and a cuff of 1.5
times the diameter of the arm was used in two
One group of authors used either a 14
or a 17 cm cuff, depending on the size of the pa-
tient’s arm. The one remaining of these 21 (groups
of) authors reported using a pediatric cuff (8 cm) to
assess AAI in ~hildren.~’
In 10 studies, the cuff size was reported to have
been “appropriate” or ”carefully ~ e l e c t e d ” , ~ ~ - ~ ’
whereas a “standard” cuff was reportedly used in
five.41-45Eight (groups of) a ~ t h o r s ~ referred
, ~ ~ , ~ ~ - ~ ~
to other studies for their method of AAI assess-
ment, but in seven of these references, no infor-
mation on cuff size was provided either.
Information on Sphygmometer Cuff Width
Used to Assess Crural Blood Pressure
A majority of 52 (groups of) authors did not pro-
vide any information as to the size of the cuff used
284 Klcin and Hagc
to take the crural blood pressure while describing
the method of A A I measurement.
Twenty-six (groups of) authors stipulated what
size of cuff was used. Of these, one used a cuff of 10
cm,53 1 1 a cuff of 12 20,38,54 two a cuff of
12.5 c ~ n ,two , ~of~13 cm,21,22one a cuff of
~ a~ cuff
13.5 cm, two a cuff of 14 cm,23,24and three a cuff
of 15 cm.25-27Three (groups of) authors used a cuff
of 1.2 or 1.5 times the diameter of the 1eg,7,29,57 and
again, the one remaining of these 26 (groups of)
authors reported using a pediatric cuff of 8 cm
width to assess AAI in children.30
In nine studies, a n “appropriate” or “carefully
selected” sized cuff was used, 1-37,39.40 whereas use
of a “standard“ cuff was reported in three.41,43*44
An arm-cuff size was probably used at the ankle in
two of the s t ~ d i e s . ~ ~ , ~ ~
Finally, eight (groups of) authors referred to
other studies for their method of AAI assess-
ment,9,21,46-52 but again, no information on cuff
size was provided in seven of these references.
Information on Sphygmometer Cuff Position
on the Lower Leg
In 54 studies, the cuff position on the lower leg was
indicated by either “ankle (or malleolus)” ( n = 24).
”proximal to malleoli (or ankle)” ( n = 27), “as
distal as possible on the calf” ( n = 1), “lower 1/ 3 of
lower leg” ( n = I ) , or the “posterotibial level”
( n = 1).
Eight (groups of) author5 referred wlely to other
studies for their method of AAI assessment, but in
two of these, no information on the position of the
crural cuff was provided in the reference either.
Thirty-eight studies provided no indication as to
the position of the crural cuff, while other aspects
of the AAI assessment were described.
Information on the Method of Detection of
the Pulse in the Arm
In 58 of the 100 studies, the brachial pulse was
detected with a pencil-Doppler device, whereas
auscultation was used for this in six.11,15,18,55,57,5swhich arm was used, and seven (groups of) authors
Other techniques used were the Dynamap
( n = 7 )15.25.26.32.53.59.60 and p hotoplethy smography ~ s e d . ~ ~ - ~ ~
( n = 2).10*35The technique of assessment of the
arm systolic pressure was not mentioned in 23 re-
ports. In seven report^,^^-'^ reference was made to
other studies to indicate the method of assessment,
but these references were not always clear on the
method used either.
The number of techniques totaled 103 rather
than 100 because Jeelani et al.15 used Dynamap
and auscultatory methods in addition to the pencil-
Annals of Vascular Surgery
Doppler to compare these three methods of pulse
detection and Yao et al.” used both the ausculta-
tory method and the pencil-Doppler.
Information on the Method of Detection of
the Pulse in the Leg
A vast majority of 77 (groups of) authors reported
using a pencil-Doppler to detect the crural pulses.
Of these, Strandness and Sumner7 used capacitance
pulse pick-ups and plethysmography in addition to
the pencil-Doppler, whereas Carter55 also used
capacitance pulse pick-ups, visual flush technique,
and spectroscopy. They did so to compare the
influence of these methods on AAI measurements.
One author used solely capacitance pulse pick-
ups for pulse detection, 56 whereas three authors
used solely plethysmography. 10,’8*61 Other meth-
ods used to detect the crural pulses were the Dy-
namap ( n = 5 ) 25.26.32.59,62 and the strain-gauge
technique ( n = 4).21,57,63r64
Seven (groups of) authors (7%) referred to other
studies to indicate their method of assessment of
crural p ~ l s e s . However,
~ ~ - ~ ~ three of those seven
(groups of) authors referred to more than one other
study and, because different techniques were used
in these references, it remained unclear which
technique they had actually used. Finally, three of
the 100 studies did not report at all what kind of
device was used for crural pulse d e t e c t i ~ n . ~ ~ . ~ ~
Information on Whether or Not Brachial
Pressure Was Measured Bilaterally
A single largest group of 47 (groups of) authors
measured the brachial blood pressure at both
arms to determine the denominator of the AAI
formula. Fourteen other reports stipulated the
blood pressure to be measured at the right
arm,2.6.23. 38.42.54.58.60.6I .68-72
whereas one other
indicated the left arm to be used.” According to
five reports, the blood pressure may be taken on
either arm.9.10.29.32.73
Twenty-six (groups of) authors did not specify
only provided a reference for the method they had
Information on Whether or Not Crural
Pressures Were Measured Bilaterally
A vast majority of 96 (groups of) authors measured
the crural blood pressure at both legs to separately
distinguish the presence of PAOD in each leg. Of
these, eight (groups of) a ~ t h o r s ~ ~ , ~ ~ , ~
reported measuring both legs and using the lowest
Vol. 20, No. 2, 2006
Table I. The 100 publications that were studied divided according to the information provided on the
crural pulses used to assess AAI numerator
Description
PT and DPIAT
PT, DP/AT, and PA
EYT or DPlAT
PT only
"Ankle"
No information
References for method
of the bilateral blood pressures to determine the
presence of PAOD in their patients. Shinozaki et
al.23and Zheng et al.32reported diagnosing PAOD
by measuring the AAI of just one leg. Two authors
did not provide any information about whether
one or two legs were measured.75r76
Information on Which Crural Pulses Were
Assessed for AAI
In 33 studies, both the pressures over the posterior
tibial artery (PT) and the dorsal pedal or anterior
tibial artery (DP/AT) were measured before calcu-
lating AAI (Table I). The peroneal artery (PA) pulse
was assessed in addition to that of the PT and DP/
AT in three studies. Twenty-three studies recom-
mended using the pressures over the PT or DP/AT
for the numerator of the AM. Three of these 2 3
advocated use of the best audible flow
In 13 studies, the crural pulse was detected only at
the PT.
No specification of the crural artery other than
"ankle" was provided to indicate which of the
crural or pedal pulses were detected in 18 reports.
In 10 of these 18 reports, this remained unclear
because of the method used for crural pulse
detection (strain-gauge, plethysmography, capaci-
tance pulse pick-up, spectroscopy, visual flush
technique, or D ~.10,18.21.25,26,56.57.61.63,6,64
~ ~
Three reports did not clarify which pedal artery
was used to detect the crural pressure, whereas
seven (groups of) authors referred to other studies
for their method of AAI assessment. Two of these
seven references merely mentioned "ankle" as the
location of pulse detection.
Information on Which of the Brachial and
Crural Pressures (Highest, Mean, Median, or
Lowest) Were Used for Denominator and
Numerator of AAI
No fewer than 39 different ways to calculate AAI
were reported in 77 of the 100 studies. Among
these, the formulas provided most often were as
Ankle-arm index revisited 28 5
Number of reports
= ~~2,4,14,16,17,20,28,31,33-35,37,39,4O,46,53-55,62,65,74-76,78,82,93-lOO
= 327.101.102
= 2 ~3,7,19,24.29.30,36.41,43.56,66,67,69.73,77,79,81.90.103- 107
= 13 1,6,22,23,32,38,58-60.71.72.85.108
= 1g5.10.1 1,18,21,25,26,42,44,45,57,61,63,64,68,70,80,109
= 315.84.110
= 79.47-52
follows: AAI = highest of PT and DPlAT pressures/
highest arm pressure (n = IS), AAI = ankle pres-
surelarm pressure ( n = 9 ) , and AAI = PT or DPIAT
pressure/arm pressure ( n = 8). Seven times we
found the same (group of) author(s) to have used
two different formulas in two different stud-
ies~19,25,26,28,37,55,56,60,72,77-81 Confusing matters
even further, some authors used more than one
formula in a single s t ~ d y . ~ ~ , ~ ~ ~ ~ ~
The remaining 23 (groups of) authors did not
report the formula they had used to calculate the
AAI. Eight of these 23 provided a reference for the
formula, whereas 15 did not.
Of the 47 (groups of) authors who measured
systolic pressure at both arms, the highest pressure
found was used for the denominator of the AAI in
38 studies, whereas the mean of both arm pressures
was used in 11 studies. This totals 49 rarher than 47
studies because Hiatt et al. twice compared two
different ways of calculating the denominator.28r78
The lowest pressure of both arms was never re-
ported to have been used as denominator.
Seven (groups of) authors used both the PT and
the DPlAT for the numerator of separate
*,qs.2, 14,20,33,34,78,82
Twenty-nine more (groups of) authors used
more than one detected pressure for the definite
~ calculation
~ of the
~ numerator.
) In 2 3 of these 29
studies, the highest of the two or three crural blood
pressures was used for the numerator, whereas the
lower was used in the five and the mean of those
pressures in four. Again, this totals 32 rather than
29 studies because Hiatt et a1.28 compared two
methods (average and lower) while McGrae
McDermott et aL31 compared three methods
(average, higher, and lower) to calculate the
numerator of the AAI.
Cut-off Value of the Normal AAI
Some (groups of) authors defined a lower limit of
AAI for the absence of PAOD, whereas others
provided an upper limit felt to be indicative of the
286 Klein and Hage Annals of Vascular Surgery

Table 11. Reports categorized according to information provided on the lower limits of the range of AAI in
subjects without PAOD
Cut-off value Number of reports

AAI = 0.85 n = 174

= 1720,31,32,34,36,40.45,46.53.60.67-9.71.77.97.98
AAI = 0.90
AAI = 0.92 n = 1"'
II = 61,81,82,84,103.104
AAI = 0.95
AAI = 0.97 = 34.9.55

AAI = 1.00 n = 287,10,11,16.18,19.21-23,29.38,39,41,42,54.56,66.70.72,7~,75,80,99-101.1O5.1O6.108

AAI = 1.10 = 259.80

presence of PAOD. Still others considered these two
cut-off values to be the same, thus defining one
AAI below which PAOD was accepted to be present
and above which it was not.
The lower cut-off value of a normal AAI as of-
fered in 58 of the 100 studies varied from 0.85 to
1.10, but most often, 1.00 was cited for this (Ta-
ble 11).
Eight different upper AAI limits indicative of
PAOD were cited in 60 of the 100 studies. Although
these varied from 0.80 to 1.00 (Table HI), 0.90 was
most often used as this cut-off value.
Rather than one cut-off value, Lennihan and
MacKereth& cited median AAI values for subjects
with and without claudication. Eighteen reports
mentioned the method of assessment but lacked
any information on its normal or abnormal limits.
Three additional (groups of) authors provided ref-
erences for information on these
Neither a description nor a reference was found in
one s t ~ d y . ' ~
The supine position seems to be the position of
COMMENTS AND RECOMMENDATIONS
Although AAI assessment currently is the most
common diagnostic instrument for the detection
and quantification of PAOD, 33,7734 the repeatabil-
ity of assessment continues to be subject to con-
troversy. 2,33377,83~'5,86 The variability of AAI
assessment attributable to observers, timing of
measurement, and repeated measures is consider-
ably less than that attributable to biological factors.
Estimates of intraobserver variability range from
7.3% for experienced observers to 12% for less-
experienced observer^,^,^, 19r'7 and repeated
measurements may decrease this ~ a r i a b i l i t y . ~ , ' ~
Standardized, repeated measurement of AAI by
experienced observers is sufficiently accurate to
guide clinical decision m a k i r ~ g . When
~ ~ , ~ the
~ art
and science of AAI measurement and calculation
are being taught or discussed, moreover, it is
important that all involved are speaking of the
same standard. Even when limited to 100 publi-
cations, however, our bibliometric analysis yielded
a great variety of methodology. This indicates that
there is still need for a consensus on the method of
AAI measurement.
Before we present our recommendations to
come to such consensus, some potential limitations
of our study need to be addressed. As such, we
stress that ours are not evidence-based suggestions.
Because of the variety of methodology, any and all
of such suggestions would lack an adequate level of
evidence. Furthermore, we did not score for po-
tential key points such as minimum resting time
prior to measurement, room temperature, or fre-
quency of Doppler probe since these were rarely
mentioned in the 100 reviewed publications.
Hence, ours are merely recommendations provided
in an attempt at the standardization that is urgently
needed to allow comparison and meta-analysis of
future study results.
Position of the Patient during Measurement
choice to assess AAI because the influence of height
of the subject and his or her blood column pressure
on AAI may be prevented only in this position. Less
agreement exists on the routine use of premea-
surement exercise. Such exercise may be needed
since the ankle pressure may be normal at rest in
patients with mild PAOD and there may be ade-
quate collateral flow around the arterial occlu-
sions.' Even though such PAOD may only be
detectable after exercise, exercise influences the
heart rate during measurement, which in turn
influences AAI.25 Hence, in studies where AAI is
measured during exercise, this should be men-
tioned in the Melhods section.
Width and Level of the Sphygmometer
Cuff@)
If the width of the sphygmometer cuff is too nar-
row in comparison to the extremity ("undercuff-
Vol. 20, No. 2, 2006 Ankle-arm index revisited 287

Table In. Reports categorized according to information provided on the upper limits of the range of AAI in
subjects with PAOD
Description Number of reports

AAI = 0.80
AAI = 0.85
AAI = 0.90
AAI = 0.92
AAI = 0.94
AAI = 0.95
AAI = 0.97
AAI = 1.00

ing”), the blood pressure reading will be errone-
ously high, whereas the reading may be too low if
the cuff is too wide (“overcuffing”).88Ideally, the
cuff width should be at least 1.5 times the diameter
of that part of the extremity where the pressure is
being r n e a s ~ r e dand
, ~ the size of the cuff should be
adjusted in obese patients or in patients with odd-
shaped arms or ankles.88 Still, calcification in the
arterial wall can result in spuriously high readings
of the systolic pressure,7t29and this may not be
corrected by the use of a wider cuff.
As to the position of the cuffs at the extremities,
general agreement exists on placement just proxi-
mal to the elbow on the upper arm and just prox-
imal to the malleoli at the lower leg.
Method of Detection of the Pulse in the Arm
and Leg
From their comparison of three methods of mea-
surement of brachial systolic blood pressure, Jee-
lani et aL15 concluded that the technique of
measurement significantly affects the calculation of
AAI. As they found a 20% margin of error, these
authors advocated the use of just one technique to
limit inter- and intraobserver errors. For this, use of
a pencil-Doppler should be considered the method
of choice to detect the brachial pulse as this was
already done in half of the reviewed studies.
Measurements by Doppler device were proven at
high, medium, and low blood pressures to correlate
with systolic pressure measurement obtained by
conventional methods. lo,’
observed good agreement between the
values of systolic blood pressure obtained by four
different methods of monitoring the crural pulses
(pulse pick-ups, pencil-Doppler flow detection,
spectroscopy, and visual flush), and capacitance
pulse pick-up even allows for detection of nonpal-
pable pulse^.^ Still, allegedly normal crural blood
pressures can be recorded with pulse pick-up, spec-
troscopic, and visual flush methods as long as only
one crural artery is patent, whereas the pencil-
Doppler may provide information on individual
tibia1 Pencil-Doppler readings are highly
correlated to intra-arterial pressure reading^.^,'^
Moreover, ultrasonography is less cumbersome than
plethysmography and more reliable than the aus-
cultation method, which has a 10% failure rate in
obtaining ankle pressures in normal individ~als.~’
Although the accuracy of measurement with the
Dynamap may be higher than that with pencil-
Doppler, the Dynamap is not available everywhere.
For this reason, we recommend the pencil-Doppler
device as the standard instrument to measure both
the brachial and crural blood pressures.
Whether or Not to Bilaterally Measure the
Brachial Pressure and Which One to Use for
Denominator
A majority of authors measured the systolic pres-
sures of both arms to assess the denominator of the
AAI. A minority measured only one arm, and of
these, only one indicated using the left arm.’’ This
is remarkable as the blood pressure used for the
denominator of the AAI should be measured at the
left arm in cases where aortic coarctation results in
a difference of blood pressure in the right and left
arms.28.31.36 In these cases, a difference of 5-10 mm
Hg warrants further examination, while a differ-
ence of 20 mm Hg between the arms indicates se-
vere stenosis.” In general, AAI calculated on the
basis of systolic pressure at the left arm was 0.02
lower than that at the right arm.78 For these rea-
sons, we advise taking the blood pressure at both
arms to rule out serious differences and using that
of the left arm to calculate the AAI denominator.
Whether or not to Bilaterally Measure Crural
Pressures and Which of These to Use as
Numerator
In the healthy population, the differences between
the systolic pressures of the DP/AT and PT do not
288 Klein and Hage
exceed 10 mm Hg.55In general, the AAI at the DPI
AT was found to be 0.04 lower than that at the
PT.7s PAOD may, however, separately affect each
of the main arteries, and a difference of over 1 5
mm Hg between the DPfAT and the PT may pro-
vide a useful clue about the involvement of the
individual crural arteries by the occlusive pro-
ces~.”~~
Difference in pressure readings between the DP/
AT and PT in the same limb, as well as an abnormal
AAI of both the DP/AT and PT in the same leg,
should be considered indicative of PAOD.8*55Be-
cause PAOD may also affect both legs separately,
moreover, we advise bilaterally measuring the
blood pressure of both the DPIAT and the PT.
How to Calculate the AAI Numerator and
Denominator
Numerator. McGrae McDermott et a1.3’ per-
formed a multiple linear analysis to identify which
one out of three commonly used formulas to cal-
culate the AAI was most closely associated with
objective measures of leg functioning in PAOD:
AAI = highest of DPIAT and PT/mean of both arms,
AAI = mean of DP/AT and PT/mean of both arms,
and AAI = lowest of DP/AT and PT/mean of both
arms.
The prevalence of PAOD, defined as an AAI 0.9,
ranged from a minimum of 47% when the first
formula was used to a maximum of 59% when the
third was used.3’ In cases where the right and left
legs showed a difference of AAI, the lowest of these
correlated best with leg functioning. Moreover, the
lower AAI determined by “mean of DP/AT and FT/
mean both radial artery” was most predictive of
walking endurance and walking velocity in cases of
PAOD. The authors offered two potential explana-
tions for the finding that using the mean of the DP/
AT and PT systolic pressures is the optimal way to
calculate AAI when assessing lower extremity
functioning.
First, the mean of DP/AT and PT may best reflect
total perfusion of the more diseased lower
extremity and, second, when the two pressures are
averaged, the random variation and measurement
error intrinsic to measures of arterial pressure are
minimized, the result being a closer association of
the mean AAI with f ~ n c t i o n i n g .Hiatt
~ ~ et
used two ways to calculate the numerator of the
M I . Since the difference in systolic blood pressure
between the DP/AT and PT was found to have a
95% range of -21 to + I 0 mm Hg, the “mean of PT
and DP/AT” was used if PT and DPIAT differed no
more than -21 to +10 mm Hg. Alternatively, the
Annals of Vascular Surgery
“lower of PT and DPIAT” was used if PT and DP/AT
differed more than -21 to +10 mm Hg.
Since AAI may indicate the presence and, more
vaguely, the severity of PAOD without a high
sensitivity or specificity, only one standardized
formula should be used to calculate it. This may
keep its use simple and reproducible in varying
hospital and general practice settings. We strongly
advise against calculating AAI separately for each
lower leg artery since the sensitivity and specificity
of the AAI for detecting PAOD per artery is even
lower.92Still, a large difference in pressure readings
between the DPIAT and PT in the same limb should
be considered indicative of PAOD.s,55Hence, we
advise calculating AAI for each leg by measuring
the systolic pressures over both DP/AT and PT and
using their mean for the numerator as this reduces
the measurement bias and gives a good impression
of the total lower leg perfusion. Bias can further be
reduced by measuring the AAl twice per leg and
using the mean of both measurements for the
numerator.
Denominator. Furthermore, Hiatt et al.28878
advised using the “mean of both arms” for the
denominator in cases where the difference in sys-
tolic blood pressure between the right and left arms
did not exceed the 95% range of -9 to +8 mm Hg.
Alternatively, they advised using the “higher of
both arms” for this if the brachial pressure of both
arms differed more than -9 to +8 mm Hg because
they assumed that there might be an arterial
occlusion on one side causing the
For reasons of simplicity, we advise measuring
the systolic pressures of both arms to detect possible
pressure differences indicating aortic coarctation or
brachial arterial stenosis. Because the systolic
pressure perfusing the body distal of the run-off of
the left subclavian artery is equal to that in the left
arm, the left brachial systolic pressure should be
used for the denominator, provided no brachial
arterial stenosis is found. Isolated stenosis of the left
subclavian artery, however, is very rare; and the
chance of having a left subclavian stenosis without
lower extremity involvement can be considered
naught.
In short, we advice calculating AAI separately
for each leg and using the formula AAI = mean of
DPIAT and PT/left brachial artery.
Cut-off Value of the Normal AAI
The lower cut-off point of the normal AAI indica-
tive of the absence of PAOD may importantly differ
from the upper cut-off point of an aberrant AAI
indicating the presence of PAOD (Tables TI and 111).
Vol. 20, No. 2, 2006
Typically, the AAI cut-off value for presence of
disease has been defined between 0.90 and
0.80,60,74 but it is obvious that there is - not in the
least due to differences in methods of AAI mea-
surement - no one fixed cut-off point indicating
the absence or presence of PAOD.
Varying the cut-off AAI may triple the sensitivity
of the test4,25and double the estimates of PAOD
p r e v a ~ e n c e . ~ ~Hiatt
, ~ ' , et
~ ~aL7' included an exten-
sive table of lower limits of the normal range sub-
divided for the left and right legs, the PT and DP,
and the two sexes; and some (groups of) authors
even included estimations on the probability of
PAOD for a given AAI.54r63Still, such differentia-
tion is hardly applicable in daily clinical practice.
The sensitivity and specificity of AAI cut-off
values to detect PAOD are 96% or higher when
using arteriography as the gold standard,24 and
subjects with a resting M I of 0.94 or higher have
no arteriographic evidence of PAOD.4r24r55
found 95% of patients without PAOD to have AAI
of 0.97 or higher, whereas all of his patients with
arteriographically proven PAOD had AAI lower
than that.
We recommend that 0.9 be accepted as the up-
per limit of an aberrant AAI and 1.0 as the lower
limit of a normal AAI. An AAI between 0.9 and 1.0
seems to be not conclusive and should lead to
further assessment. Future investigators should
state what AAI value was used as a cut-off point
since the sensitivity of the AAI for the presence of
PAOD depends on this.
To summarize, we feel that AAI reported in sci-
entific work should be assessed by experienced
observers. Assessment of AAI at rest in the supine
position is acceptable as the standard procedure.
Different sphygmometer cuffs ought to be used for
the arms and legs, both of which should have a
width of 1.5 that of the extremity at the level of
measurement. The cuff should be placed just
proximal to the malleoli to assess crural blood
pressures. A handheld pencil-Doppler device ought
to be used for measurement of both the brachial
and crural blood pressures. Measurements should
be performed at both arms and over the DPlAT and
PT of both legs, but the left arm pressure is pre-
ferred for use as the denominator. The mean of the
systolic pressures of the DP/AT and the PT ought to
be used for the numerator of the AAI for that leg.
However, difference in pressure readings between
the DP/AT and PT in the same limb should be
considered indicative of PAOD. Measurement bias
is further reduced by measuring AAI twice per leg
and using the mean of the two measurements. We
recommend accepting 0.9 as the upper limit of an
Ankle-arm index revisited 289
aberrant AAI and further assessing the arterial
status of all patients with an AAI between 0.9 and
1.o.
To allow for comparison of results from one
investigator to another without tremendous varia-
tions due to the different methods of assessment,
we urge future investigators to adhere to these
recommendations or to mention the circumstances
or methods of assessment and calculation of AAI in
the Method section of their report in cases where
these differ from those recommended. In these
cases, information on why the authors felt it better
to use an alternative method may further enhance
the possibilities of comparison with reports from
other research groups.
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