Doppler Ultrasonography of Lower Extremity Artery: Anatomy and

Basic Approach

Ji Young Hwang, MD,

Department of Radiology

Ewha Womans University School of Medicine

1071, Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, Korea

Tel. 82-2-2650-2687

Fax. 82-2-2650-5302

E-mail: mshjy@ewha.ac.kr

Type of manuscript: Review article

No potential conflict of interest relevant to this article was reported.

Doppler Ultrasonography of Lower Extremity Artery: Anatomy

and Basic Approach

Abstract

Doppler ultrasonography of the lower extremity artery is a valuable method

although it is less frequently indicated for peripheral arterial disease than for deep

vein thrombosis and varicose vein. Ultrasonography can diagnose stenosis by direct

visualization of plaques and by analysis of Doppler waveform at stenotic and post-

stenotic artery. To perform the lower extremity Doppler ultrasonography, the

operator should be familiar with arterial anatomy of the lower extremities as well as

basic scan techniques and some parameters of color and pulsed wave Doppler

ultrasonography.

Keywords: Arteries; Lower Extremity; Ultrasonography, Doppler, Color;

Ultrasonography, Doppler, Pulsed; Peripheral Arterial Disease

 Introduction

Imaging modalities for evaluating peripheral arterial disease in the lower

extremities includes computed tomography (CT) angiography, conventional

angiography, and Doppler ultrasonography (US). Three-dimensional CT angiography

provides information about atherosclerotic calcification, extent of stenosis or

occlusion of arteries. CT angiography has some advantages such as shorter

examination time, the ability of iliac artery evaluation, and less effect of operator’s

experiences. Conventional angiography is used for vascular intervention such as

angioplasty or stent application as well as the diagnosis of peripheral arterial

disease. Doppler US is the only noninvasive technique without a contrast

enhancement, any preparation before study, nor a radiation (1, 2). Doppler US is

good method for screening and follow-up as well as definite diagnosis for

peripheral arterial disease (3-7). Color Doppler US can easily identify artery by

finding round objects with regular pulsation and detect the stenotic or occluded

segments (4, 8). Pulsed wave Doppler US can show the exact flow velocity of each

arterial segment and determine the degree of severity based on analysis of pulsed

wave Doppler spectral waveform (9).

 The knowledge of ultrasonographic anatomy of the lower extremity artery with

anatomical landmark is essential to perform Doppler US. The basic scan techniques

of color and pulsed wave Doppler US for the lower extremity artery and spectral

analysis of normal and stenotic artery on pulsed wave Doppler US will be reviewed

in this article.

Anatomy of Lower Extremity Artery on CT Angiography

Each lower extremity artery is visible with an accompanying vein from the iliac

artery to the popliteal artery. The anterior tibial artery, the posterior tibial artery,

and the peroneal artery are seen with two homonymous veins. The overall anatomy

of the arteries in the lower extremities are shown on a CT angiography (Fig.1).

The common iliac artery divides into the internal iliac artery and the external iliac

artery in the pelvic cavity. The external iliac artery is continuous with the common

femoral artery (Fig.1A). The inguinal ligament is a landmark for the junction of

external iliac artery and common femoral artery. The inguinal ligament is located

more proximal than the inguinal crease. The common femoral artery is a short

segment, generally about 4cm long, and bifurcates into the superficial femoral

artery medially and the deep femoral artery laterally (10). The superficial femoral
artery descends without prominent branch between the quadratrus and adductor

muscle groups in the anteromedial thigh. In the distal thigh, the superficial femoral

artery enters the adductor canal. On leaving the adductor hiatus, the name of artery

becomes the popliteal artery in the popliteal fossa and ends by bifurcating the

anterior tibial artery and the tibioperoneal trunk in the posterior aspect of proximal

calf (11).

Below the knee, the anterior tibial artery passes from posterior to anterior, and

then descends along the interosseous membrane behind the anterior tibialis muscle

and the extensor muscles in the anterolateral leg. The tibioperoneal trunk divides

into the posterior tibial artery medially and the peroneal artery laterally (Fig.1B). The

posterior tibial artery runs along the intermuscular space between the posterior

tibialis muscle and the soleus muscles. The peroneal artery extends down between

the posterior tibialis muscle and the flexor hallucis longus muscle.

In the ankle and foot region, the anterior tibial artery continues onto the dorsalis

pedis artery distal to the extensor retinaculum (11). The dorsalis pedis artery forms

arcuate artery at metatarsal base and gives rise to the dorsal metatarsal artery. The

posterior tibial artery passes behind the medial malleolus of tibia and bifurcates

forming the medial plantar and the lateral plantar arteries. The deep plantar arch
from medial and lateral plantar arteries gives rise to the plantar metatarsal and

digital arteries of foot (11).

US Anatomy of Lower Extremity Artery

An artery can be differentiated from a vein on US by several characteristics. First,

an artery is round while a vein is somewhat oval on transverse image. Second, an

artery is smaller than a vein. Third, an artery has visible walls and sometimes the

calcified plaque on the wall. Fourth, when the vessels are compressed by the

transducer, an artery is partially compressed; while a vein is completely collapsed

(12).

Doppler US of the lower extremity begins at the inguinal crease by putting a

transducer on the common femoral artery in the transverse plane with a supine

position (Fig. 2). The common femoral artery is seen lateral to the femoral vein

which is drained from the greater saphenous vein anteromedially at inguinal area

(Fig. 3A). Just below inguinal crease, there are the superficial femoral artery and the

deep femoral artery besides the femoral vein, showing Mickey mouse’s face on

transverse scan (Fig. 3B). The common femoral artery and the bifurcated superficial

artery and deep femoral artery are seen as fallen Y configuration on the
longitudinal scan (Fig.2). From proximal to distal thigh, scanning is performed with

moving a transducer distally along the superficial femoral artery deep to the

sartorius muscle. The superficial femoral artery goes together with femoral vein

(Fig.2).

The popliteal artery is evaluated from the knee crease level in the transverse

plane and then traced proximally up to adductor canal at supracondylar level of the

femur (Fig.2). The popliteal artery is seen in the central portion of popliteal fossa

between medial head and lateral head of the gastrocnemius muscles. The

evaluation of posterior tibial artery can be started from its origins at the

tibioperoneal trunk with scanning distally or started from the ankle behind medial

malleolus with scanning proximally (Fig. 4). The peroneal artery is scanned along the

lateral side of posterior calf and is depicted besides the fibular bone (Fig. 4).

The evaluation of anterior tibial artery can be started from the ankle anterior to

the talus neck and continued proximally or started from proximal anterolateral leg

between the tibia and the fibula with scanning distally (Fig. 4). The transducer is

traced from the anterior ankle to dorsal foot for evaluating dorsalis pedis artery and

continued to the first dorsal metatarsal artery between first and second metatarsal

bones (Fig. 4).

 US Technique

Transducer and Patient Position

The linear transducer with a variable ultrasound frequency of 9-15MHz is used,

but the convex transducer with lower frequency can be selected for the iliac artery

evaluation in the pelvic cavity (13). A transducer is placed over an artery on

transverse scan, and then is rotated to 90 degrees for longitudinal scanning. You

should scan the artery on a longitudinal plane as longer as you can show by

rotating head side or foot side of a transducer with a bit of angle. Pulsed wave

Doppler US is performed with the longitudinal plane.

The examination is usually performed with the patient placed in the supine

position. The patient’s hip is generally abducted and externally rotated and the knee

is flexed like frog legs in order to easily approach to the popliteal artery in the

popliteal fossa and the posterior tibial artery in the medial calf (Fig. 2). Another

position for the popliteal artery, the posterior tibial artery, and the peroneal artery

are a left lateral decubitus position or a prone position (Fig. 4). The anterior tibial

artery and dorsalis pedis artery are scanned in the supine position (Fig. 4).

Parameters and Optimization of Doppler US

 The operator should be aware both color and pulsed wave Doppler parameters

and how to adjust these parameters to get an optimal Doppler images.

Among these parameters, the color box, the color gain, the color velocity scale,

and the inversion are frequently used during color Doppler US scanning. The color

box is a square shaped area within the gray scale US image in which all color

Doppler information is displayed (Fig. 3). The size and location of the box are

adjustable and image resolution and quality are affected by the box size and depth

(14). The box should be placed as small and superficial as possible, thereby

maximizing the frame rate. The color box should be tilted using a ‘steer’ button

according to the arterial axis during the longitudinal scanning (Fig. 5). The color

gain refers to amplification of flow data to improve the depiction of flow (14). The

color gains (‘gain’ button in the US machine) should be set as high as possible

without displaying background color noise. The color velocity is the range of flow

velocities that are depicted with the color Doppler US (14). In case of the velocity

scale (‘scale’ button in the US machine) setting is lower than the flow velocity of the

artery, then there will be aliasing artifacts. An operator can detect the color flow

within an arterial lumen by increasing the ‘gain’ or decreasing the ‘scale’. The color

flow artifact outside an artery should be removed by decreasing ‘gain’. The

homogeneous color of an arterial flow can be obtained by increasing the ‘scale’.

Flow toward the transducer typically appears red on color Doppler US image when

a red color appears above the baseline on the color bar. Inversion can electronically

invert the direction of flow, which may complicate interpretation of flow direction.

Therefore, the flow direction should be interpreted with the setting of color bar.

It is important to understand the meaning and how to adjust the parameters of

pulsed wave Doppler US. The sample volume (SV) curser is parallel lines on both

sides of arterial axis line. The sample volume should be placed within an arterial

lumen and the range of sample volume size is generally from 1/3 to 1/2 of luminal

diameter (15). The Doppler angle (θ) is formed by the Doppler line and axis of

arterial flow and should be between 45 and 60 degrees for accuracy (9). On

Doppler US, the line in the center of the artery indicates of the axis of arterial flow.

The nearly vertical line is the Doppler line of sight (Fig. 5). Doppler spectrum is a

graph showing the mixture of frequencies over a short period of time (9). Doppler

frequency is defined as the difference between the received and transmitted

frequencies when blood cells is moving. The key elements of the Doppler spectrum

are time and velocity scale (9). On the Doppler spectrum, the time (sec) is

represented on the X axis, the velocity scale (cm/sec) is shown on the y-axis (Fig.5).
Flow direction relative to the transducer is shown in relation to the spectrum

baseline. Flow toward the transducer is represented by positive velocity above the

baseline (Fig. 5). The ‘High-Q’ or peak velocity envelope is the blue outlining the

Doppler spectrum. Based on this envelope, peak systolic velocity (PSV), minimum

diastolic velocity (MDV), resistivity index (RI), and the pulsatility index (PI) are

provided with numeric results (Fig. 5). If there is an aliasing artifact on Doppler

spectrum, you may lower baseline or increase scale for widening of velocity range

(Fig. 6). It can be automatically optimized by pressing ‘i-scan’ button.

Doppler Spectrum of the Normal Lower Extremity Artery

The Doppler waveform of lower extremity artery at rest is classified into the high

pulsatility waveform and is characterized by the triphasic flow pattern (9). According

to each cardiac activity, a tall, narrow, sharp systolic peak at first phase is followed

by early diastolic flow reversal at second phase, and then by late diastolic forward

flow at third phase (Fig. 5). The diastolic flow reversal is resulted from the high

peripheral resistance of normal extremity artery (9). In normal extremity artery, flow

acceleration in systole is rapid that means the peak velocity is reached within a few

hundreds of a second after ventricular contraction begins. Blood in the center of the
artery move faster than the blood at periphery, which is described as laminar flow

(9). When flow is laminar, the blood cells are moving at similar speed. This features

of normal artery produce a clear space called the spectral window under the

Doppler spectrum. The peak systolic velocities of lower extremity arteries are shown

in Table 1 (16).

Abnormal US Findings

Doppler US of lower extremity can be started with obtaining the gray scale

images before the color Doppler study, however, gray scale evaluation are

sometimes optional and second step when the stenosis or occlusion is suspicious

by color Doppler study. On gray scale image, you should describe the presence and

the size of the plaque, whether the plaque is calcified or not. The plaque size can

be measured based on a height and length on transverse and longitudinal scans

(17). Three-dimensional US has been recently used for measuring plaque volume

with good intra- and inter-observer reproducibility (18).

On color Doppler US, a pulsating color flow is present in the arterial lumen (Fig.3).

If there is occlusion in the artery, the color flow is absent within the lumen (Fig.7).

Doppler spectrum at severe stenotic arterial segment and post-stenotic or post-

obstructive distal arterial segment will be briefly reviewed. The peak systolic velocity

at stenotic segments increases until the diameter reduced by 70%, which equals the

area reduced by 90% (16). The flow disturbance showing spectral broadening occurs

within 2cm beyond stenosis due to loss of laminar flow pattern (Fig. 6). The spectral

broadening is prominent with 20-50% of diameter reduction. The lower extremity

artery waveform may convert to a low-resistance with low pulsatility after exercise

or resulting from occlusion of more proximal arteries (16). The waveform is

monophasic that means entire waveform is either above or below the Doppler

spectrum baseline depending on the orientation of the US transducer (9). In is

characterized by the ‘damped’ pattern, which means systolic flow acceleration is

slowed, peak systolic velocity is reduced, and diastolic flow is increased (19). This

monophasic waveform is seen at stenotic site and at distal artery in case of severe

stenosis with more than 50% of diameter reduction.

Conclusion

The Doppler US distinguished between stenosis of greater or less than 50% of

diameter reduction equals to 70% of area reduction with a sensitivity of 77~82%

and a specificity of 92~98% (16, 20-24). The A complete scanning of both lower
extremities may require up to 2 hour depending on the level of operator’s

experiences (16). However, the operator who is familiar with the US anatomy of

lower extremity arteries and understands parameters and Doppler waveforms of

Doppler US can produce accurate diagnostic results and reduce scanning time.

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Table 1. Mean Arterial Diameter and Peak Systolic Flow Velocity

Artery Diameter (cm) * Peak systolic velocity
(cm/sec) *
External iliac 0.79 ± 0.13 119.3 ± 21.7
Common femoral 0.82 ± 0.14 114.1 ± 24.9
Superficial femoral (proximal) 0.60 ± 0.12 90.8 ± 13.6
Superficial femoral (distal) 0.54 ± 0.11 93.6 ± 14.1
Popliteal 0.52 ± 0.11 68.8 ± 13.5
* mean ± SD

Figure legends
Figure 1. The anatomy of the lower extremity arteries on the CT angiography.

A. above the knee. B. below the knee. CIA common iliac artery, EIA external iliac

artery, IIA internal iliac artery, CFA common femoral artery, SFA superficial femoral

artery, DFA deep femoral artery. POPA popliteal artery, ATA anterior tibial artery, PTA

posterior tibial artery, PA peroneal artery.

Figure 2. The steps of color Doppler US for the lower extremities above the knee

with patient’s position.

The red rectangular boxes are essential scanning sites and plane for the femoral

arteries and the popliteal artery. The number within the box represents the general

steps of scanning. The schema in the box demonstrates typical US features of

arteries and veins on each scanning sites. GSV greater saphenous vein, FV femoral

vein, CFA common femoral artery, SFA superficial femoral artery, DFA deep femoral

artery, POPA popliteal artery, POPV popliteal vein, SSV small saphenous vein.

Figure 3. Normal color Doppler US of the femoral arteries at inguinal area.

A. The common femoral artery (CFA) is lateral to the femoral vein (FV) on a

transverse scan at inguinal crease. Note the size of color box is as small as
 possible. B. The superficial femoral artery (SFA) and the deep femoral artery (DFA)

make Mickey mouse’s ears and the femoral vein (FV) forms Mickey mouse face.

CFA common femoral artery, SFA superficial femoral artery, DFA deep femoral

artery, FV femoral vein

Figure 4. The steps of color Doppler US for the lower extremities below the knee

with patient’s position.

The posterior tibial artery (PTA) is seen along the tibia (Ti) at medial side of

posterior calf (box 1) and behind the medial malleolus (MM) of ankle (box 2). The

peroneal artery (PA) is depicted along the fibula (F) at lateral side of posterior calf

with the prone position (box 3). The anterior tibial artery (ATA) is detected between

the tibia (Ti) and the fibula (F) at anterolateral side of calf (box 4). At ankle level, the

ATA is seen anterior to the tibia plafond (Ti) and the talus (T) (box 5), which

continues to the dorsalis pedis artery (DOA) distal to the ankle and metatarsal

artery (MA) between the metatarsal bones (box 6).

Figure 5. Color and pulsed wave Doppler US images of normal lower extremity

artery with parameters

Top: On color image of pulsed wave (PW) Doppler US longitudinal scan, the color
box is tilted in parallel to the arterial axis using steer key. The Doppler angle (θ) is

60 degrees in this case, which is formed by the Doppler line of sight (s) and axis of

arterial flow (a). a, the axis of arterial flow; s, the Doppler line of sight; SV, sample

volume. Bottom: On the Doppler spectrum, the time (sec) is represented on the X

axis. The blood flow velocity (cm/sec) is shown on the y-axis (dashed line). Flow

direction relative to the transducer is shown in relation to the spectrum baseline

(arrow). The ‘High-Q’ is the blue outlining the Doppler spectrum (open arrow).

Figure 6. Adjustment of pulsed wave Doppler US in the stenotic arterial segment.

The aliasing artifact on Doppler spectrum can be adjusted by lowering the baseline

and increasing the scale. Note the spectral broadening (arrow) in Doppler spectrum

due to stenosis of the artery.

Figure 7. A 56-year-old man with arterial occlusion.

The color flow is absent in the superficial femoral artery (arrow) on color Doppler

US, representing complete occlusion. Red one is deep femoral artery and blue one

is collapsed femoral vein at inguinal level.

Table 1. Mean Arterial Diameter and Peak Systolic Flow Velocity

Artery Diameter (cm) * Peak systolic velocity

(cm/sec) *

External iliac 0.79 ± 0.13 119.3 ± 21.7

Common femoral 0.82 ± 0.14 114.1 ± 24.9

Superficial femoral (proximal) 0.60 ± 0.12 90.8 ± 13.6

Superficial femoral (distal) 0.54 ± 0.11 93.6 ± 14.1

Popliteal 0.52 ± 0.11 68.8 ± 13.5

* mean ± SD
fig 1A

The anatomy of the lower extremity arteries on the CT angiography. A. above the knee. B. below the knee. CIA common 
iliac artery, EIA external iliac artery, IIA internal iliac artery, CFA common femoral artery, SFA superficial femoral artery, DFA 
deep femoral artery. POPA popliteal artery, ATA anterior tibial artery, PTA posterior tibial artery, PA peroneal artery. 
fig 1B

The anatomy of the lower extremity arteries on the CT angiography. A. above the knee. B. below the knee. CIA common 
iliac artery, EIA external iliac artery, IIA internal iliac artery, CFA common femoral artery, SFA superficial femoral artery, DFA 
deep femoral artery. POPA popliteal artery, ATA anterior tibial artery, PTA posterior tibial artery, PA peroneal artery. 
fig 2

The steps of color Doppler US for the lower extremities above the knee with patient’s position. The red rectangular boxes 
are essential scanning sites and plane for the femoral arteries and the popliteal artery. The number within the box 
represents the general steps of scanning. The schema in the box demonstrates typical US features of arteries and veins on 
each scanning sites. GSV greater saphenous vein, FV femoral vein, CFA common femoral artery, SFA superficial femoral 
artery, DFA deep femoral artery, POPA popliteal artery, POPV popliteal vein, SSV small saphenous vein. 
fig 3A

Normal color Doppler US of the femoral arteries at inguinal area. A. The common femoral artery (CFA) is lateral to the 
femoral vein (FV) on a transverse scan at inguinal crease. Note the size of color box is as small as possible. B. The superficial 
femoral artery (SFA) and the deep femoral artery (DFA) make Mickey mouse’s ears and the femoral vein (FV) forms Mickey 
mouse face. CFA common femoral artery, SFA superficial femoral artery, DFA deep femoral artery, FV femoral vein 
fig 3B

Normal color Doppler US of the femoral arteries at inguinal area. A. The common femoral artery (CFA) is lateral to the 
femoral vein (FV) on a transverse scan at inguinal crease. Note the size of color box is as small as possible. B. The superficial 
femoral artery (SFA) and the deep femoral artery (DFA) make Mickey mouse’s ears and the femoral vein (FV) forms Mickey 
mouse face. CFA common femoral artery, SFA superficial femoral artery, DFA deep femoral artery, FV femoral vein 
fig 4

The steps of color Doppler US for the lower extremities below the knee with patient’s position. The posterior tibial artery 
(PTA) is seen along the tibia (Ti) at medial side of posterior calf (box 1) and behind the medial malleolus (MM) of ankle (box 
2). The peroneal artery (PA) is depicted along the fibula (F) at lateral side of posterior calf with the prone position (box 3). 
The anterior tibial artery (ATA) is detected between the tibia (Ti) and the fibula (F) at anterolateral side of calf (box 4). At 
ankle level, the ATA is seen anterior to the tibia plafond (Ti) and the talus (T) (box 5), which continues to the dorsalis 
pedis artery (DOA) distal to the ankle and metatarsal artery (MA) between the metatarsal bones (box 6). 
fig 5

Color and pulsed wave Doppler US images of normal lower extremity artery with parameters Top: On color image of pulsed 
wave (PW) Doppler US longitudinal scan, the color box is tilted in parallel to the arterial axis using steer key. The Doppler 
angle (θ) is 60 degrees in this case, which is formed by the Doppler line of sight (s) and axis of arterial flow (a). a, the axis 
of arterial flow; s, the Doppler line of sight; SV, sample volume. Bottom: On the Doppler spectrum, the time (sec) is 
represented on the X axis. The blood flow velocity (cm/sec) is shown on the y­axis (dashed line). Flow direction relative to 
the transducer is shown in relation to the spectrum baseline (arrow). The ‘High­Q’ is the blue outlining the Doppler 
spectrum (open arrow). 
fig 6

Adjustment of pulsed wave Doppler US in the stenotic arterial segment. The aliasing artifact on Doppler spectrum can be 
adjusted by lowering the baseline and increasing the scale. Note the spectral broadening (arrow) in Doppler spectrum due 
to stenosis of the artery. 
fig 7

A 56­year­old man with arterial occlusion. The color flow is absent in the superficial femoral artery (arrow) on color Doppler 
US, representing complete occlusion. Red one is deep femoral artery and blue one is collapsed femoral vein at inguinal level.