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ARTERIAL DOPPLER
Peripheral arterial disease is a common and serious disorder, with a prevalence of approximately 4.5% to 9%. Compromise of arterial flow due to stenoses and occlusionscan result in limb ischemia, which may manifest as claudication, rest pain, local tissueloss (ulceration), and, potentially, amputation. Treatment options include medicaltherapy, bypass surgery, and various percutaneous interventions such as angioplasty,atherectomy, stent placement, and thrombolysis. Techniques available for the diagnosisof peripheral arterial disease include angiography, which is considered the standard of reference but is invasive, and various noninvasive methods. The noninvasive tests thathave traditionally been performed include segmental pressures, pressure volume tests(plethysmography), and color-assisted duplex sonography. In recent years, magneticresonance (MR) imaging and computed tomographic (CT) angiography have been usedin the evaluation of PAD, with promising results that should only improve withrefinements in technology. Since the type (ie, stenosis vs occlusion), length, location,and number of lesions play an important role in the determination of choice of therapy,obtaining this information before an invasive procedure may be advantageous for treatment planning. Noninvasive imaging is also useful for follow-up of treated lesionsand for graft survellience.The noninvasive examination for peripheral arterial disease in our laboratory consistsof ultrasonography (US) and pressure measurements, the latter including ankle:brachialindex and segmental pressures. Although less sensitive than US, this is a relativelysimple and rapid test that provides a global, quantitative, and objective indication of disease and complements the information obtained from the US examination. Thepurpose of this presentation is to review the techniques of arterial US and pressuremeasurments for the diagnosis of lower-extremity arterial disease.
HEMODYNAMICS OF STENOSIS
The basis for the Doppler diagnosis of vascular stenosis is the principle of volumecontinuity, which states that the velocity of blood flow through a narrowed portion of avessel will increase if the volume of flow per unit time in the segment is constant. Thevolume of flow
Q
is equal to the product of the vessel cross-sectional area
 A
and theaverage flow velocity
v 
. Assuming the volume of blood remains constant throughout theregion of narrowing (Fig.1).
 
Fig.1 Assuming flow is constant, as the cross-sectional area (
 A
) decreases, the velocity (
v 
)increases.
Q = v1A1 = v2A2;
therefore,
v2/v1 = A1/A2,
and as
 A
decreases,
v 
increases.As the residual diameter of a stenosis decreases, there is an increase in resistance and,eventually, a decrease in overall flow and a drop in pressure. From a clinicalperspective, a lesion is hemodynamically significant if it causes a perfusion deficit duringrest or exercise. The greater the degree of stenosis and the longer its length, thegreater the associated pressure decrement. The degree of stenosis beyond which asmall increase in severity results in a significant reduction of flow is referred to as a"critical" or "hemodynamically significant" narrowing. This value is generallyacknowledged to be 50% of the luminal diameter in the peripheral arterial system, whichcorresponds to a 75% decrease in cross-sectional area. This number is somewhatarbitrary in that it is strongly affected by peripheral vascular resistance and the status of the pre- and poststenotic vasculature.The major criterion for the Doppler diagnosis of arterial stenosis is a focal increase invelocity (peak systolic velocity [PSV]), but there are several other hemodynamic issuesthat affect the pulsed Doppler waveform and are therefore useful in waveforminterpretation. These are laminar versus turbulent flow, and pulsatile flow.
LAMINAR AND TURBULENT FLOW
The flow velocity profile in a straight vessel with a uniform diameter is known as alaminar profile; it is characterized by a smooth, predictable velocity gradient across thecross-sectional area (Fig 2), 
Fig. 2 Parabolic flow. Flow occurs in orderly, aligned laminae, with the fastest velocity in thecenter, and a progressive decrease in velocity toward the vessel wall.
 
with the highest-velocity flow at the center and a gradual decrease toward the vesselwall, with an infinitesimally thin layer in contact with the wall having a velocity of zero.The geometry of this flow pattern approximates a parabola and can be conceptualizedas a concentrically arranged stack of cylinders moving along a smooth path at differingvelocities relative to each other. True parabolic flow exists in the smaller vessels of theabdomen but not usually in the major arteries, where instead there is some flattening inthe middle of the velocity profile, which is known as "plug flow." The pulsed Doppler feature of laminar flow is the presence of a clear "window" beneath the spectrum,indicating that the red blood cells are moving in an orderly manner, with similar velocityand direction (Fig 3).Fig.3 Pulsed Doppler spectrum, clear window. The width of the white tracing indicatesthe range of cell velocities at a given time, and the thinness of this line and the absenceof markings below the line are known as a clear spectral "window." Filling in of thisspace, known as "spectral broadening," occurs when there is a larger range of velocities,such as in turbulent flow. Note that a tracing above the baseline indicates flow towardthe transducer and a tracing below the baseline indicates flow away from the transducer.Multiple factors in "real" arteries can focally alter laminar flow, such as vessel tapering,curvature, and bifurcations. Disruption of laminar flow can result in a spectrum of flowabnormalities, ranging from "disturbed" to "turbulent" flow, with the precise distinctionbetween the two being somewhat arbitrary. Flow disturbance comprises a continuum of flow abnormalities ranging from minor irregularities of flow streamlines to completelydisorganized, multidirectional flow vectors (Fig 4).
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Mohamed A.Azeem Hussein

Thanks for precious illustrations

reply05 / 07 / 2012
kimo0127106615

hi more details in explenations of how to analyse the waves dr. abdelhakim G&O.spec.& sonographer

reply12 / 02 / 2009
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