Koven Technology Canada Vascular Ultrasound Dopplers for Toe Pressure Studies

How to Perform a PPG Toe Pressure and Toe Brachial Index (TBI)

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. A PPG probe is used instead of a Doppler probe. PPG probes are available for the Bidop® 3, Smartdop™ 45, and Smartdop™ 50EXF Vascular Dopplers.

Take a blood pressure reading at the arm

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.
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.
Inflate the cuff to 20 mmHg over pressure cessation. Then, slowly deflate the cuff until the first Doppler sound is heard.
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 a systolic pressure at the toe

Make sure the patient's foot is warm and placed at heart level. A warm foot is necessary to minimize vasoconstriction.
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.
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.
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
	Greater than or equal to 0.70 = Normal
	Less than 0.70 = Abnormal

	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

	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.

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