The Relationship between Abnormal Ankle-brachial Index and Micro-vascular Complications of Diabetes Type II

Document Type : Original Article


1 Associate Professor, Endocrinologist, Endocrinology and Metabolism Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran

2 General Practitioner, Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran

3 General Practitioner, Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

4 Associate Professor, Radiologist, Physiology Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran


Background:The prevalence of diabetes mellitus is increasing worldwide and the relationship between peripheral vascular involvement and the complications of diabetes disease, such as retinopathy, has been reported in some studies but has not yet been fully proven. The aim of this study was to investigate the relationship between diabetes complications and peripheral and central vascular involvement.
Method:A number of 150 patients with diabetes type II aged 30 to 70 years old were entered into this cross- sectional study. Ankle-brachial index (ABI), carotid intima media thickness and diabetes complications were investigated in them.
Results:Abnormal ABI was more prevalent (79%) in Female patients. Furthermore, diabetes disease duration (P=0.005), systolic blood pressure (P=0.005) and retinopathy (P=0.003) were higher in females. Based on regression model, the highest relation of abnormal ABI incidence was observed with female gender (OR=2.4). Moreover, only blood pressure was among the abnormal ABI effective risk factors.
Conclusion:Female gender, duration of diabetes disease, systolic blood pressure and retinopathy incidence were among the effective factors in the incidence of abnormal ABI and abnormal ABI had a direct and reverse relationship with causing vascular diseases in diabetic type II patients.


  1. Dabelea D, Mayer-Davis EJ, Saydah S, Imperatore G, Linder B, Divers J, et al. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA 2014; 311(17):1778-86.
  2. Sharma M, Nazareth I, Petersen I. Trends in incidence, prevalence and prescribing in type 2 diabetes mellitus between 2000 and 2013 in primary care: a retrospective cohort study. BMJ Open 2016; 6(1):e010210.
  3. Hunt D. Diabetes: foot ulcers and amputations. BMJ Clin Evid 2009; 2009:0602.
  4. Zoungas S, Woodward M, Li Q, Cooper ME, Hamet P, Harrap S, et al. Impact of age, age at diagnosis and duration of diabetes on the risk of macrovascular and microvascular complications and death in type 2 diabetes. Diabetologia 2014; 57(12):2465-74.
  5. Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract 2014; 103(2):137-49.
  6. Brownlee M, Hirsch IB. Glycemic variability: a hemoglobin A1c–independent risk factor for diabetic complications. JAMA 2006; 295(14):1707-8.
  7. Cohen RM, Haggerty S, Herman WH. HbA1c for the diagnosis of diabetes and prediabetes: is it time for a mid-course correction? J Clin Endocrinol Metab 2010; 95(12):5203-6.
  8. Azimi-Nezhad M, Ghayour-Mobarhan M, Parizadeh MR, Safarian M, Esmaeili H, Parizadeh S, et al. Prevalence of type 2 diabetes mellitus in Iran and its relationship with gender, urbanisation, education, marital status and occupation. Singapore Med J 2008; 49(7):571-6.
  9. Esteghamati A, Etemad K, Koohpayehzadeh J, Abbasi M, Meysamie A, Noshad S, et al. Trends in the prevalence of diabetes and impaired fasting glucose in association with obesity in Iran: 2005–2011. Diabetes Research and Clinical Practice 2014; 103(2):319-27.
  10. Fowler MJ. Microvascular and macrovascular complications of diabetes. Clinical Diabetes 2008; 26(2):77-82.
  11. Mostaza JM, Suarez C, Manzano L, Cairols M, López-Fernández F, Aguilar I, et al. Sub-clinical vascular disease in type 2 diabetic subjects: relationship with chronic complications of diabetes and the presence of cardiovascular disease risk factors. European Journal of Internal Medicine 2008; 19(4):255-60.
  12. Khammash MR, Obeidat KA, El-Qarqas EA. Screening of hospitalised diabetic patients for lower limb ischaemia: is it necessary? Singapore Medical Journal 2008; 49(2):110.
  13. Newman AB, Sutton-Tyrrell K, Vogt MT, Kuller LH. Morbidity and mortality in hypertensive adults with a low ankle/arm blood pressure index. JAMA 1993; 270(4):487-9.
  14. Khawaja N, Abu-Shennar J, Saleh M, Dahbour SS, Khader YS, Ajlouni KM. The prevalence and risk factors of peripheral neuropathy among patients with type 2 diabetes mellitus; the case of Jordan. Diabetol Metab Syndr 2018; 10:8.
  15. Göksan B, Erkol G, Bozluolcay M, Ince B. Diabetes as a determinant of high-grade carotid artery stenosis: evaluation of 1,058 cases by Doppler sonography. J Stroke Cerebrovasc Dis 2001; 10(6):252-6.
  16. Cheng KS, Mikhailidis DP, Hamilton G, Seifalian AM. A review of the carotid and femoral intima-media thickness as an indicator of the presence of peripheral vascular disease and cardiovascular risk factors. Cardiovasc Res 2002; 54(3):528-38.
  17. Abramson B, Mannik J, Figol A, Aw J. [PP. 21.39] carotid intima-media thickness screening adds value in a Canadian cohort: implications for patient management. Journal of Hypertension 2017; 35:e277.
  18. Baldassarre D, De Jong A, Amato M, Werba PJ, Castelnuovo S, Frigerio B, et al. Carotid intima‐media thickness and markers of inflammation, endothelial damage and hemostasis. Ann Med 2008; 40(1):21-44.
  19. American Diabetes Association. Classification and diagnosis of diabetes. Diabetes care 2017; 40(Supplement 1):S11-24.
  20. Mahaling DU, Basavaraj MM, Bika AJ. Comparison of lipid profile in different grades of non-alcoholic fatty liver disease diagnosed on ultrasound. Asian Pac J Trop Biomed 2013; 3(11):907-12.
  21. Beckman JA, Creager MA, Libby P. Diabetes and atherosclerosis: epidemiology, pathophysiology, and management. JAMA 2002; 287(19):2570-81.
  22. Santaguida PL, Balion C, Hunt D, Morrison K, Gerstein H, Raina P, et al. Diagnosis, prognosis, and treatment of impaired glucose tolerance and impaired fasting glucose. Evid Rep Technol Assess (Summ) 2005; 128(1).
  23. Williams R, Van Gaal L, Lucioni C, CODE-2 Advisory Board. Assessing the impact of complications on the costs of Type II diabetes. Diabetologia 2002; 45(1):S13-S7.
  24. Lee MY, Hsiao PJ, Huang JC, Hsu WH, Chen SC, Chang JM, et al. Abnormally low or high ankle-brachial index is associated with the development of diabetic retinopathy in type 2 diabetes mellitus. Sci Rep 2018; 8(1):441.
  25. Chen SC, Hsiao PJ, Huang JC, Lin KD, Hsu WH, Lee YL, et al. Abnormally low or high ankle-brachial index is associated with proliferative diabetic retinopathy in type 2 diabetic mellitus patients. PloS One 2015; 10(7):e0134718.
  26. Newman AB, Tyrrell KS, Kuller LH. Mortality over four years in SHEP participants with a low ankle‐arm index. J Am Geriatr Soc 1997; 45(12):1472-8.
  27. Orchard TJ, Strandness Jr DE. Assessment of peripheral vascular disease in diabetes. Report and recommendations of an international workshop sponsored by the American Diabetes Association and the American Heart Association September 18-20, 1992 New Orleans, Louisiana. Circulation 1993; 88(2):819-28.
  28. Abbott JD, Lombardero MS, Barsness GW, Pena-Sing I, Buitrón LV, Singh P, et al. Ankle-brachial index and cardiovascular outcomes in the bypass angioplasty revascularization investigation 2 diabetes trial. Am Heart J 2012; 164(4):585-90.
  29. Hayashi C, Ogawa O, Kubo S, Mitsuhashi N, Onuma T, Kawamori R. Ankle brachial pressure index and carotid intima-media thickness as atherosclerosis markers in Japanese diabetics. Diabetes Res Clin Pract 2004; 66(3):269-75.
  30. Li J, Luo Y, Xu Y, Yang J, Zheng L, Hasimu B, et al. Risk factors of peripheral arterial disease and relationship between low ankle-brachial index and mortality from all-cause and cardiovascular disease in Chinese patients with type 2 diabetes. Circ J 2007; 71(3):377-81.
  31. Tseng CH, Chong CK, Tseng CP, Tai TY. The association between urinary albumin excretion and ankle-brachial index in elderly Taiwanese patients with type 2 diabetes mellitus. Age and Ageing 2008; 37(1):77-82.
  32. Pignone M, Phillips C, Mulrow C. Use of lipid lowering drugs for primary prevention of coronary heart disease: meta-analysis of randomised trials. BMJ 2000; 321(7267):983-6.
  33. Makhdoomi K, Mohammadi A, Yekta Z, Aghasi MR, Zamani N, Vossoghian S. Correlation between ankle-brachial index and microalbuminuria in type 2 diabetes mellitus. Iran J Kidney Dis 2013; 7(3):204-9.
  34. Lahoz C, Mostaza JM. Ankle-brachial index: a useful tool for stratifying cardiovascular risk. Rev Esp Cardiol 2006; 59(07):647-9. [In Spanish].
  35. Lv WS, Sun RX, Gao YY, Wen JP, Pan RF, Li L, et al. Nonalcoholic fatty liver disease and microvascular complications in type 2 diabetes. World J Gastroenterol 2013; 19(20):3134-42.
  36. Kim BY, Jung CH, Mok JO, Kang SK, Kim CH. Prevalences of diabetic retinopathy and nephropathy are lower in K orean type 2 diabetic patients with non‐alcoholic fatty liver disease. J Diabetes Investig 2014; 5(2):170-5.
  37. Vanjiappan S, Hamide A, Ananthakrishnan R, Periyasamy SG, Mehalingam V. Nonalcoholic fatty liver disease in patients with type 2 diabetes mellitus and its association with cardiovascular disease. Diabetes Metab Syndr 2018; 12(4):479-82.
  38. Wu CK, Yang CY, Tsai CT, Chiu FC, Huang YT, Lee JK, et al. Association of low glomerular filtration rate and albuminuria with peripheral arterial disease: the National Health and Nutrition Examination Survey, 1999–2004. Atherosclerosis 2010; 209(1):230-4.
  39. Bosevski M, Stojanovska L. Progression of carotid-artery disease in type 2 diabetic patients: a cohort prospective study. Vasc Health Risk Manag 2015; 11:549-53.
  40. Soares DV, Spina LD, Brasil RR, da Silva EM, Lobo PM, Salles E, et al. Carotid artery intima-media thickness and lipid profile in adults with growth hormone deficiency after long-term growth hormone replacement. Metabolism 2005; 54(3):321-9.
  41. Erzen B, Sabovic M, Sebestjen M, Poredos P. Endothelial dysfunction, intima-media thickness, ankle-brachial pressure index, and pulse pressure in young post-myocardial infarction patients with various expressions of classical risk factors. Heart Vessels 2007; 22(4):215-22.