Lower Extremity Arterial Protocol

Scan through each vessel prior to taking any images.


1. Students should document all images identified below
2. Ankle-Brachial Indices (ABIs) should be performed after all images have been stored
 Utilizing an arterial machine
 Apply blood pressure cuffs to both ankles and both upper arms
 Record pressures at rest
3. If resting ABIs are normal and the patient’s symptoms include claudication (leg pain when walking
and relieved with rest) you must exercise the patient if they are able.
 Perform exercise with patient standing beside bed and holding onto bed, have patient
raise up then down on their toes until pain occurs, or 3-5 minutes if pain does not occur.
 Repeat ABI pressures immediately and every 2-3 minutes until pressures return to normal
(or up to 10 minutes)

Structure Scan Plane Label Images Stored
Identify RT
or LT
External Iliac Sagittal EIA Color Doppler
Artery Color & Spectral Doppler - measure PSV
Common Sagittal CFA Color Doppler
Femoral Artery Color & Spectral Doppler - measure PSV
Deep Femoral Sagittal DFA Color Doppler
Artery Color & Spectral Doppler - measure PSV
Superficial Sagittal SFA PROX Color Doppler
Femoral Artery Color & Spectral Doppler - measure PSV
Superficial Sagittal SFA MID Color Doppler
Femoral Artery Color & Spectral Doppler - measure PSV
Superficial Sagittal SFA DIST Color Doppler
Femoral Artery Color & Spectral Doppler - measure PSV
Sagittal POP ART Color Doppler
Popliteal Artery
Color & Spectral Doppler - measure PSV
Posterior Tibial Sagittal PTA Color Doppler
Artery Color & Spectral Doppler - measure PSV
Dorsalis Pedis Sagittal DPA Color Doppler
Artery Color & Spectral Doppler - measure PSV

 Follow the vessels in their entirety in color, taking the appropriate images at the described locations
 If abnormalities are seen with color Doppler in any segment of vessel, include a gray scale image of
that segment of vessel to document pathology in gray scale.
 With diabetic patients, you may experience trouble getting accurate blood pressures for ABIs due to
calcification of the vessel walls.

Color Doppler
 Will vary with the presence/absence of pathology & curvature of the vessel
 Color images should relay the same information as your spectral images
 Color box should be steered (angled) with the vessel direction
AK\backup\Vascular II\protocols
Lower Extremity Arterial Protocol
 Color in a normal vessel should be free of aliasing and extend to vessel walls

 Utilize preset color PRF (scale) and gain, and adjust according to the type of blood flow (velocities) being
 If flow is normal and the color is outside the vessel wall or aliasing in center of vessel, slowly
increase PRF and/or decrease color gain until color is no longer outside the vessel wall or
 If flow is normal and the color in the vessel is not filled in, slowly decrease PRF and/or
increase color gain until the color fills the vessel without aliasing or bleeding.

Spectral Doppler
 Must use angle correct – Angle correct must be less than 60 degrees
 Gate (SV length) must be in center of vessel & small width.
 Use color Doppler appearance to aid in placement of gate for spectral interrogation. Your goal is to
document the highest velocities present.
 Set the PRF (scale) appropriately for the velocities imaged.
 Adjust the PRF (scale) to display a large waveform.
 Adjust the spectral gain so that there is no background noise on the spectral trace.
 Normal waveforms in the extremities are high-resistive and triphasic, with a sharp systolic upstroke
followed by a brief period of diastolic flow reversal, ending with minimal forward flow in diastole
 Elevated velocities with spectral broadening indicate a stenosis
 Record velocities in the stenotic area as well as approximately 2 cm prior to (prestenotic) and after
(poststenotic) the area of stenosis
 Stenosis is considered significant if the flow in stenotic area is twice the velocity of an area just
previous (prestenotic) to it
 Waveforms distal to a significant stenosis will become monophasic

Pathology Seen
Atherosclerosis (plaque)
o Walls will appear thick
o Calcified plaque will produce acoustic shadowing
o Use color Doppler to evaluate for flow disturbances (aliasing)
o Vessel diameter will be 1.5 times larger than adjacent more proximal segment
o Measure in sagittal (AP) and transverse (width) from outer wall to outer wall
o Document intramural thrombus in sagittal and transverse with gray scale and color Doppler
Document any soft tissue abnormalities seen in proximity to the arteries.
Document any venous thrombosis seen.
Document any pseudoaneurysms seen (size, residual lumen, and width of communicating channel/

Ankle-Brachial Indices (ABI)
A ratio of systolic pressures at the ankle to systolic pressures at brachial level
Indicate the overall severity of peripheral artery disease
Calculated by dividing the highest pressure at ankle level (obtained from either PTA or DPA) by the
higher of the two brachial pressures.
ABI Severity of PAD
> 1.30 Incompressible
0.90-1.30 Normal
0.75-0.89 Mild
0.50-0.74 Moderate
< 0.50 Severe
< 0.35 Tissue threatening

Source: Diagnostic Medical Sonography: The Vascular