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 occlusions can result in limb ischemia, which may manifest as claudication, rest pain, local tissue loss (ulceration), and, potentially, amputation. Treatment options include medical therapy, bypass surgery, and various percutaneous interventions such as angioplasty, atherectomy, stent placement, and thrombolysis. Techniques available for the diagnosis of peripheral arterial disease include angiography, which is considered the standard of reference but is invasive, and various noninvasive methods. The noninvasive tests that have traditionally been performed include segmental pressures, pressure volume tests (plethysmography), and color-assisted duplex sonography. In recent years, magnetic resonance (MR) imaging and computed tomographic (CT) angiography have been used in the evaluation of PAD, with promising results that should only improve with refinements 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 lesions and for graft survellience. The noninvasive examination for peripheral arterial disease in our laboratory consists of ultrasonography (US) and pressure measurements, the latter including ankle:brachial index and segmental pressures. Although less sensitive than US, this is a relatively simple and rapid test that provides a global, quantitative, and objective indication of disease and complements the information obtained from the US examination. The purpose of this presentation is to review the techniques of arterial US and pressure measurments for the diagnosis of lower-extremity arterial disease. HEMODYNAMICS OF STENOSIS The basis for the Doppler diagnosis of vascular stenosis is the principle of volume continuity, which states that the velocity of blood flow through a narrowed portion of a vessel will increase if the volume of flow per unit time in the segment is constant. The volume of flow Q is equal to the product of the vessel cross-sectional area A and the average flow velocity v. Assuming the volume of blood remains constant throughout the region 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 clinical perspective, a lesion is hemodynamically significant if it causes a perfusion deficit during rest or exercise. The greater the degree of stenosis and the longer its length, the greater the associated pressure decrement. The degree of stenosis beyond which a small increase in severity results in a significant reduction of flow is referred to as a "critical" or "hemodynamically significant" narrowing. This value is generally acknowledged to be 50% of the luminal diameter in the peripheral arterial system, which corresponds to a 75% decrease in cross-sectional area. This number is somewhat arbitrary 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 in velocity (peak systolic velocity [PSV]), but there are several other hemodynamic issues that affect the pulsed Doppler waveform and are therefore useful in waveform interpretation. 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 a laminar profile; it is characterized by a smooth, predictable velocity gradient across the

cross-sectional area (Fig 2),
Fig. 2 Parabolic flow. Flow occurs in orderly, aligned laminae, with the fastest velocity in the center, and a progressive decrease in velocity toward the vessel wall.

with the precise distinction between the two being somewhat arbitrary. Note that a tracing above the baseline indicates flow toward the transducer and a tracing below the baseline indicates flow away from the transducer. The width of the white tracing indicates the range of cell velocities at a given time. The geometry of this flow pattern approximates a parabola and can be conceptualized as a concentrically arranged stack of cylinders moving along a smooth path at differing velocities relative to each other. Flow disturbance comprises a continuum of flow abnormalities ranging from minor irregularities of flow streamlines to completely disorganized. Multiple factors in "real" arteries can focally alter laminar flow. known as "spectral broadening. indicating that the red blood cells are moving in an orderly manner. which is known as "plug flow. where instead there is some flattening in the middle of the velocity profile. . such as in turbulent flow. True parabolic flow exists in the smaller vessels of the abdomen but not usually in the major arteries. ranging from "disturbed" to "turbulent" flow." The pulsed Doppler feature of laminar flow is the presence of a clear "window" beneath the spectrum. multidirectional flow vectors (Fig 4). such as vessel tapering. with an infinitesimally thin layer in contact with the wall having a velocity of zero. Disruption of laminar flow can result in a spectrum of flow abnormalities.3 Pulsed Doppler spectrum.with the highest-velocity flow at the center and a gradual decrease toward the vessel wall. clear window. and the thinness of this line and the absence of markings below the line are known as a clear spectral "window." occurs when there is a larger range of velocities. curvature. with similar velocity and direction (Fig 3)." Filling in of this space. and bifurcations. Fig.

The far right of the image. 4 Disturbed flow.000 is generally defined as the critical value for the transition from laminar to turbulent flow. a value exceeding approximately 2. With these variables. There is disruption of the orderly laminae within the region of narrowing (mild flow disturbance).5 Turbulent flow. Fig. color Doppler US. The color Doppler appearance of turbulent flow is a heterogeneous distribution of different shades of color across the vessel lumen (Fig 5). indicates flow in the same direction. multidirectional flow vectors distal to the stenosis (turbulent flow). of moderate frequency shift and therefore moderate . the density p of the fluid.Fig. the Reynolds number (Re) can be calculated by using the equation Re = v2rp/h). the average flow velocity v across the lumen. The distinction between the two is somewhat arbitrary. and the viscosity h of the fluid. turbulence is usually present within and distal to a stenosis. Since a stenosis is associated with elevated velocity. and disorganized. showing homogeneous red color. The variables that influence the existence of turbulent flow include vessel radius r.

Arteries that supply muscles and skin at rest (extremities.velocity. These conditions result in two basic forms of the Doppler waveform: high and low resistance. The heterogeneity of the colors elsewhere on the image indicates the multidirectional flow of turbulence and a larger frequency shift (see discussion of "aliasing" in the Doppler artifact section). Lower-extremity arteries are an example of this. . and the large vessels. a brief reversal of flow in early diastole. since the Doppler angles related to individual cells are no longer identical. pulsed Doppler. Sometimes turbulent flow may be bidirectional and the waveform contour ill-defined. and allow more continuous flow. and mesenteric when fasting) have a high-resistance Doppler waveform. and a brief component of antegrade flow in mid-diastole ( "triphasic waveform ") (Fig 7). These vessels are sufficiently compliant to store some of the pulsatile energy of the heart. 6 Turbulent flow. The large pressure amplitude produced by the left ventricle is reduced by the receiving arterial bed. The degree of the continuous flow component is predominantly a function of peripheral vascular resistance. particularly at the arteriolar level. and typically have a rapid acceleration to and deceleration from peak systole. The peak systolic velocity is elevated (>300 cm/sec) because of a stenosis. disorganized simultaneous forward and reverse flow. PULSATILE FLOW PATTERN Because of the pulsatile pumping activity of the heart. flow in the arterial system is characterized by alternating phases of acceleration and decelerration. known as "spectral broadening" and indicative of the wide range of velocities present in turbulent flow. penile. The pulsed Doppler appearance of turbulence includes spectral broadening (filling in of the window of the spectrum). There is filling in of the "window" beneath the spectrum. Reflections of the pressure waves within the arterial tree also influences the flow velocity waveform. the aorta. external carotid. and fluctuations in flow velocity with time (Fig 6) Fig.

and no reversed flow component (Fig 8). followed by a brief component of antegrade flow in mid-diastole. Parenchymal organs such as the liver. a brief reversal of flow in early diastole. The characteristic waveform in a vessel supplying these organs has a signficant degree of antegrade flow throughout diastole. and have a more continuous. . low-resistance flow pattern. spleen. 7 Triphasic waveform. kidney. in contrast to demand-oriented tissue such as muscle. There is rapid systolic acceleration and deceleration.Fig. pulsed Doppler US. and brain require constant perfusion.

lowering of peripheral resistance due to a hemodynamically significant lesion or exercise can result in a lowresistance waveform in the femoral artery (Fig 9).10). distal to a high-grade stenosis. with no reversed flow component. which may provide important diagnostic information (4.Fig.7. Fig. pulsed Doppler US. There is holodiastolic antegrade flow in diastole. such as acute rejection or renal vein thrombosis.8. These alterations of waveform can be used to detect changes in peripheral vascular resistance. the usual low-resistance waveform in a renal transplant may convert to a highresistance pattern due to processes that raise intrarenal resistance. .8 Low-resistance waveform.9 Low-resistance waveform in the distal superficial femoral artery. Similarly. For instance. Physiologic or pathologic conditions that alter peripheral resistance can affect the pulsatility and contour of Doppler waveforms.

Fig. and this is the value calculated by the Doppler US machine: V = Df c . 2 f cos q The angle of insonation qis estimated by the sonographer by aligning an indicator on the duplex image along the longitudinal axis of the vessel. and the major reflector is the red blood cell. The line (arrow) within the sample gate is used to estimate the Doppler angle between the ultrasound beam and the blood flow direction. c is the speed of sound. 11 Angle correction. . duplex Doppler US. In medicine. The Doppler shift is dependent on the insonating frequency. c where Df is the Doppler shift frequency (the difference between transmitted and received frequencies). and q is the angle between the sound beam and the direction of moving blood. or in the case of a reflected wave.10 Doppler angle. and the angle between the sound beam and direction of moving blood. motion of the reflector. DOPPLER ULTRASOUND Principle The Doppler effect is a change in the frequency of a wave. resulting from motion of the wave source or receiver. as expressed in the Doppler equation: Df = 2 f v cos q . Doppler US is used to detect and measure blood flow. v is the blood velocity. the velocity of moving blood. f is the transmitted frequency.Fig. The equation can be rearranged to solve for blood velocity. a process known as angle correction (Fig 11). The angle of incidence between the ultrasound beam and the estimated flow direction (parallel to the long axis of the vessel) is the Doppler angle.

The mean frequency shift of blood flow is depicted in color. First. or graph. The angle of insonation should also be less than 60° at all times. is essential for the accurate determination of Doppler shift and blood flow velocity. The deeper. . of the full range (as opposed to the mean velocity. it is evident that appropriate estimation of the angle of insonation. and power Doppler. Blue-coded flow is toward the transducer. if the ultrasound beam is perpendicular to the direction of blood flow. and red-coded flow is away from the transducer. pulsed Doppler. indicating flow toward or away from the transducer.Observing the Doppler equation yields several points that are relevant to the performance of a Doppler examination. respectively. Color Doppler US provides an estimate of the mean velocity of flow within a vessel by color coding the information and displaying it superimposed on the gray-scale image (Fig 12). Pulsed Doppler allows a sampling volume (or gate) to be positioned in a vessel visualized on the gray-scale image. since the cosine function has a steeper curve above this angle. indicated by the blue and red vertical bar at the right of the image. and displays a spectrum. since the cosine of 90° is zero. as in color Doppler US) of blood velocities within the gate plotted as a function of time. or angle correction. There are several forms of depiction of blood flow in medical Doppler imaging: color Doppler. and flow direction is arbitrarily assigned. and errors in angle correction are therefore magnified. The flow direction is arbitrarily assigned the color red or blue. Second. more saturated colors have a lower mean frequency shift. Fig. there will be no Doppler shift and a potentially incorrect impression of no flow in the vessel. The amplitude of the signal is approximately proportional to the number of red blood cells and is indicated as a shade of gray (Fig 13).12 Normal color Doppler US.

which is not routinely used in arterial Doppler evaluation of the lower extremity. Artifacts A detailed overview of Doppler artifacts is beyond the scope of this article. Aliasing is an artifact due to an insufficient sampling rate and occurs when the frequency shift to be measured is more than twice the pulse repetition frequency (Nyquist frequency) (Fig 14). Velocities are indicated on the scale to the right of the image. depicts the amplitude.Fig. . Deflections above the baseline indicate flow toward the transducer. but several artifacts are particularly important for the performance and interpretation of an arterial Doppler examination. and deflections below the baseline indicate flow away from the transducer. Color Doppler provides a global depiction of blood flow in a region and may be used as a guide for the subsequent placement of the pulsed Doppler gate for detailed analysis at a site of potential flow abnormality. Power Doppler. or power. but at the expense of directional and velocity information.13 Pulsed Doppler US. This allows detection of a larger range of Doppler shifts and thus better visualization of small vessels. of Doppler signals rather than the frequency shift.

There is heterogeneity of colors within the vessel lumen. Aliasing at pulsed Doppler appears as a "folding over" of forward flow in systole in the reverse direction.and is therefore a useful artifact for detection of stenosis. if a region of aliasing is encountered. During mapping of the arteries with color Doppler US. Aliasing at color Doppler US may manifest as a mixture of colors or as a focus of color in the vessel corresponding to a continuum of colors folded over from the normal flow in the opposite direction within the vessel (Fig 15) Fig. it may be a marker for sites of high-velocity flow. below the baseline. 15 Aliasing. which is one of the color Doppler appearances of aliasing. color Doppler US.Fig. pulsed Doppler. Since aliasing is due to a high-frequency shift or inadequate sampling rate or both.14 Aliasing. The artifact results in a wraparound of the Doppler spectrum in pulsed or color Doppler US. There is folding over of forward flow in systole in the reverse direction. it should prompt a more detailed analysis with pulsed Doppler .

It is important to emphasize the importance of the Doppler angle in interpreting the examination. This artifact is due to an inappropriately high setting of the color gain. thus decreasing the Doppler shift (Fig 16). potentially masking the presence of thrombus or vessel narrowing. while the image on the right. pulsed Doppler US. effect of pulse repetition frequency (PRF).500 Hz) has no aliasing. . 16 Aliasing. shows aliasing.515 see if an elevated peak systolic velocity ratio is present. Fig. Aliasing can be reduced by increasing the pulse repetition frequency or using a lower-frequency transducer. or the flow direction may appear to be bidirectional. Both images were obtained in the same vessel. If the ultrasound beam is perpendicular to the vessel. The image on the left (PRF = 2. like a mirror image (Fig 17). there may be a spurious impression of no flow (occlusion). Another artifact is "bleeding" of color signal from a vessel into an adjacent area without flow. with a lower PRF of 1.

Fig. Finally. 18 Angle correction.17 Spectral mirror image artifact. This latter artifact is known as the spectral mirror image artifact and is due to the divergence of the Doppler beam in two directions along the long axis of the vessel. . as inappropriate estimates can result in spurious velocity determinations and potential misdiagnoses (Fig 18) Fig. pulsed Doppler US. This artifact may occur with a Doppler angle of 90° and manifests as bidirectional flow. Note the differing velocity readings from the same location in the same vessel but with different Doppler angles. it is important to emphasize that the accuracy of angle correction is essential. with identical spectra in both directions ("mirror image").

normal PSV. The principal Doppler criterion for the diagnosis of a lower-extremity arterial stenosis is therefore based on detection of a focal increase in . 19 Calculation of peak systolic velocity (PSV) ratio. the blood flow velocity increases within the stenosis . The PSVs in the narrowed (or aliasing) portion of the vessel (right) and in an immediately proximal.Doppler Diagnosis of Arterial Stenoses and Occlusions If the lumen of an artery is narrowed. as described by the principle of continuity of flow(see the Hemodynamics section) (Fig 19). normal portion (left) are obtained. Fig. The ratio consists of the elevated PSV divided by the proximal.

20 Stenosis. The examination of the lower-extremity arterial system is performed by using color Doppler US to map the vessels and identify sites of possible stenosis. manifest as aliasing or narrowing of the vessel diameter. nonstenosed portion of the artery. Fig. prestenotic velocity (left). Detection of a hemodynamically significant focal increase in PSV involves the ratio of the PSV within the suspected narrowed segment to the PSV in the immediately proximal. the use of absolute velocity is less accurate than the PSV ratio. compared with the normal. The intrastenotic velocity is elevated (right). A ratio of greater than 2 is the criterion for a hemodynamically significant (50% or greater) stenosis.22) . which provides a spectrum within and proximal to the possible lesion. Because of the large variation in velocities within the lower-extremity arteries. allowing computation of a PSV ratio (Fig 21.peak systolic velocity (PSV) with pulsed Doppler (Fig 20). and a ratio of 3. pulsed Doppler US. although the latter feature is often unreliable. Any site of suspected stenosis at color Doppler US is then interrogated with pulsed Doppler. which normalizes for this variability. depending on location.7-4 indicates a 75% or greater stenosis.

generally allowing both legs to be imaged in 30-45 minutes. . markedly reduces the examination time. Figure 22. and the PSV ratio is 5.Fig 21 and 22 Figure 21. indicative of a region of high-frequency shift and possibly a stenosis. the contour of the pulsed Doppler waveform is affected by their presence. resting lower-extremity arterial waveform demonstrates high resistance. A normal. or color-assisted duplex US. color Doppler US. The use of color Doppler US in conjunction with pulsed Doppler. The prestenotic velocity is 80 cm/sec (not shown). In addition to the change in velocity due to hemodynamically significant lesions. There is elevated PSV (>400 cm/sec) with spectral broadening. Stenosis with aliasing. Note aliasing in the common iliac artery. and a small antegrade flow component in mid-diastole (Fig 23 ). consistent with a greater than 75% stenosis. having a triphasic form with a rapid acceleration to and deceleration from peak systole. a brief reversal of flow in early diastole. Pulsed Doppler US of the color Doppler abnormality shown in Figure 21.

and. turbulent flow. it indicates disturbance of laminar flow and a decrease in pulsatility and loss of the reversed flow component. Fig. in severe stenoses. in addition to increased PSV. certain generalizations can be made.23 Triphasic waveform. followed by a brief component of antegrade flow in mid-diastole. turbulence. simultaneous forward and reverse flow and indistinctness of the spectral margin (Fig 24). Although the precise relationship between waveform contour alteration and lesion type and location is not well established. There is rapid systolic acceleration and deceleration. pulsed Doppler US. a brief reversal of flow in early diastole. There is severe spectral broadening. . 24 Stenosis. This disturbance of laminar flow may manifest as spectral broadening. pulsed Doppler US.Fig. The spectral waveform changes within and immediately distal to a stenosis.

ineffectual pulsations may be transmitted to the occlusion.25 Pulsed Doppler waveform. .The appearance of the waveform proximal to a lesion is variable and depends on the degree of collateral circulation formation. With an acute occlusion. with loss of flow reversal in diastole and abundant antegrade flow in diastole (Fig 26). Fig. reduced. The waveform may be normal or the systolic velocity may be low but the upstroke (systolic acceleration time and slope) unaffected and pulsatility increased. with absent. low-velocity Doppler signals that do not represent true flow (Fig 25). There is loss of flow in diastole and low velocities. or reversed flow in diastole. proximal to high-grade lesion. producing narrow. The waveform shape distal to an obstructing lesion often shows a low-resistance pattern.

Fig. resulting in less wave reflection and amplification. and (d ) dampening of the pressure wave with consequent reduction of pulse pressure. The development of an abnormal waveform contour does indicate the presence of a lesion. and the waveform demonstrates low resistance. low resistance distal to high-grade lesion. . which normally contribute to the reversed flow component in diastole. The waveform distal to a lesion may also have a delayed systolic upstroke and decreased peak systolic velocity and is sometimes referred to as a " tardus and parvus" waveform (Fig 27). but it does not accurately indicate the location of the lesion. the waveform often remains low resistance throughout the remainder of the extremity (Fig 28). Turbulence is always present within and distal to a stenosis and generally extends a few centimeters downstream. low resistance with "tardus and parvus" contour.27 Pulsed Doppler waveform. (c) high level of forward flow throughout the cardiac cycle due to the pressure gradient across the stenosis. There is delayed systolic acceleration. The decrease in pulsatility is probably due to a combination of factors including (a) decreased peripheral resistance due to ischemia.26 Pulsed Doppler waveform. These waveform contour changes are not the primary diagnostic criteria for arterial lesions but are adjunctive and complementary to the PSV changes.Fig. (b) resistance to the reversed flow component related to the stenosis. Distal to a hemodynamically signficant lesion.

Waveform abnormalities can probably also be detected at varying distances proximal to a lesion. It is important to ensure that the lack of detectable flow is not due to technical factors.28 Pulsed Doppler waveform.Fig. color and pulsed Doppler US. Fig. The Doppler gain should be set at a high level. The settings for low-flow detection can be normalized in a given patient by confirming detection of venous flow. but short of causing artifacts. and the pulse repetition frequency should be set low enough to allow detection of low-velocity signal from a subtotal occlusion.29 Occlusion. Doppler diagnosis of an occlusion is fairly straightforward and consists of the absence of color Doppler and pulsed Doppler detectable flow in an arterial segment (Fig 29). The conversion from a normal to an abnormal waveform when imaging down an artery either means that an intervening lesion was not detected with velocity criteria or that there is a lesion distal to the point of waveform conversion. Other potential sources of . compatible with an occlusion. There is absence of flow. low resistance distal to high-grade lesion.

we do not require any special patient preparation. The velocity scale is typically set at 30-40 cm/sec. The iliac. the gray-scale image is optimized. and popliteal arteries are imaged along their longitudinal axis with color Doppler. and (d) severe stenosis with very slow flow. Patient Preparation In our laboratory.7.13. Fig. such as in the adductor canal region. or areas without flow. First. wall filter. which would indicate an occlusion. common and superficial femoral. (c) external compression of the vessel. Once a suspicious site is identified. detailed analysis with pulsed Doppler is performed. (b) densely shadowing calcified plaque preventing detection of Doppler signal. A pulsed Doppler spectrum and . This preparation is problematic because of scheduling and logistic issues. below the threshold of detection with the Doppler instrument. Some laboratories require that the patient fast prior to the test to reduce bowel gas to allow better visualization of the iliac vessels. and sensitivity to eliminate aliasing in healthy vascular segments and to fill in the entire vessel lumen without extension of color signal outside the artery.9.10.5 MHz (Fig 30). in typical imaging positions to visualize the popliteal (left) and dorsalis pedis arteries (right).false-positive examinations include (a) inability to detect Doppler signals deep in the thigh. and then the color Doppler image is optimized by adjusting the pulse repetition frequency (velocity scale). stenosed artery (4. operating from 5 to 7.14). These vessels are mapped with color Doppler to detect any regions of aliasing that may indicate a stenosis. Another possible preparation technique is to have the patient rest on the examination table prior to the test to allow resolution of any exerciseinduced hyperemia. US Imaging US imaging is performed with a linear array transducer. A false-negative diagnosis can be due to mistaking high-velocity small arterial collateral vessels parallel to the occluded segment for a patent. which could affect the Doppler spectral and segmental pressure interpretation. 30 Linear array transducer.

Fig.PSV are obtained within the region of aliasing and several centimeters proximal to that region. Turbulent flow.33). color Doppler (Fig 32) and pulsed Doppler (Fig 33) US.frequency shift and possibly a . a 50% stenosis is diagnosed (Fig 31). indicative of a region of high. manifesting as spectral broadening and an ill-defined waveform contour. It is essential to ensure that the angle correction is accurate and that the Doppler angle is less than 60°. If a vascular segment contains no flow on color Doppler. and preferably as low as possible. where the color Doppler appearance is normal. The PSV within the region of aliasing is then divided by the PSV in the proximal region. Fig. 31 Stenosis. and a diagnosis of occlusion can made (Figs 32. this should be confirmed with pulsed Doppler. There is a focal velocity increase resulting in a PSV ratio of 2. 33 Stenosis with aliasing. 32. pulsed Doppler US. Note aliasing in the common iliac artery. and if the ratio is greater than 2. is often present within and just distal to the stenosis. compatible with a 50% stenosis.

if the popliteal artery waveform is normal and there is an abnormal waveform in the dorsal pedal artery (a branch of the anterior tibial artery) and a segmental pressue drop in this region. For instance. and popliteal arteries. and the PSV ratio is 5. the presence of a lesion in the anterior tibial artery can be suggested. and distal superficial femoral.6. Pulsed Doppler of the same region reveals elevated PSV (>400 cm/sec) with spectral broadening. The results in our laboratory have been closer to the lower end of these results. The sensitivity and specificity for detection of occlusions by the criterion of absence of Doppler detectable flow are both more than 90%. allows one to suggest the possiblity of a lesion that was not directly visualized.14). particularly in conjunction with a segmental pressure abnormality. In addition to insonation of abnormal regions with color Doppler. The prestenotic velocity is 80 cm/sec (not shown). . This type of information. proximal.9. Controversy exists regarding the issue of whether the presence of multiple lesions affects the sensitivity of stenosis detection. with specificities ranging from 80% to 99%. Normal Doppler Studies A normal color Doppler study is characterized by the absence of any hemodynamically significant focal velocity increases and a triphasic or biphasic waveform shape throughout all arterial segments (Fig 34). consistent with a greater than 75% stenosis. and in the posterior tibial and dorsal pedal arteries in the ankle (we do not routinely insonate the entire course of the calf vessels). common femoral. In the absence of a lesion demonstrated by the principal Doppler criteria (PSV ratio or absence of detectable flow). and results in our laboratory have been similar to these (4.13.stenosis. such as a low-resistance waveform. a conversion from a normal to abnormal waveform when proceeding distally suggests the presence of a lesion in the intervening segment or vessel distal to the area of insonation. representative pulsed Doppler spectra are obtained in the iliac. middle. Sensitivity and Specificity of Doppler Diagnosis of Arterial Lesions The sensitivity for detection of hemodynamically significant stenoses in the femoral and popliteal arteries with use of the PSV ratio ranges from 76% to more than 90%. These are examined for presence of abnormal waveforms.

Lower-Extremity Arterial Pressure Measurements Measurement of systolic blood pressures in the lower extremities is a fairly simple. and the pressure decrements can assist in lesion localization. and objective index of arterial obstructive disease. it is of value because of its ease of performance and potential for comparison to prior studies. however. and because it provides a simple global depiction of the disease process. Compared with US. and it cannot characterize lesions as stenoses versus occlusions. The examination consists of measuring the systolic blood pressure in the arm and at four levels in the leg and interpreting this information as an ankle/brachial pressure ratio and as pressure decrements in the extremity (segmental pressure). The degree of reduction in the ankle/brachial ratio is proportional to the severity of disease. it is less sensitive in the detection of lesions and less effective in disease localization. easily performed. and there are no focal velocity increases to suggest stenosis.Fig. quantitative. and repeatable test that provides a global. 34 Normal results from lower-extremity Doppler examination. . All waveforms are triphasic.

The cuff is inflated to a level above systolic pressure. Resumption of flow is assessed by using a continuous-wave Doppler probe. insonation of ankle vessels. such that arterial signal disappears. Reduction of the luminal diameter to a critical value by a stenosis results in diminished pressure and flow distal to the lesion. Systolic pressure normally increases as the pressure wave travels distally. . The systolic pressure is the most sensitive indicator of disease. 35 Continuous wave Doppler US probe.Principle Blood flow to an organ is determined by the difference in pressure and fluid energy between the large arteries and veins. promoting blood flow. generally at the posterior tibial (PT) or dorsal pedal (DP) artery. Fig. indicating the presence of an obstructive arterial lesion. as it is reduced earlier than the diastolic pressure. The pressure at which this occurs is recorded as the systolic pressure. Technique The systolic pressure at any level in the leg can be measured by placing a pneumatic cuff at the site of interest. The basis of lower-extremity pressure measurements is the detection of a reduction in systolic blood pressure along the course of the leg. The mean and diastolic pressures normally gradually decrease distally. the systolic pressure measured at the ankle is normally slightly higher than in the arm. and then the cuff is gradually deflated until flow reappears (Fig 35 ). The site of pressure measurement is determined by the cuff position and not the site of flow detection. a process known as systolic amplification. and by the resistance within a given vascular bed. although any vessel distal to the cuff can be used. Therefore. due to reflection of waves and high peripheral resistance.

36 Pneumatic cuffs on legs. below knee (BK). which is an index of the degree of disease in the lower limb. above knee (AK). The procedure is performed separately for each leg.The procedure is performed by placing four pneumatic cuffs at four different positions on the leg: high thigh (HT). as cold-induced vasospasm may make arterial signals difficult to detect. and ankle (Fig 36). . with measurement for flow performed at either the PT or DP artery. both brachial artery systolic pressures are obtained. the pressure is recorded at both the PT and DP arteries. the higher of the two is used to calculate the ratio for each leg. Fig. To calculate an ankle/brachial pressure ratio. If the brachial pressures differ. The results of the four leg and one arm pressures are recorded in a table form. The temperature in the room should be warm. and the ankle/brachial index is calculated by taking the higher of the two ankle pressures (PT or DP) and dividing it by the higher of the two brachial pressures (Fig 37). the brachial pressure is equal to the aortic pressure. When the ankle cuff is inflated. The examination is performed with the patient in the supine position. Systolic pressure is determined at each level with the technique described above. In the absence of subclavian or axillary artery disease. and therefore the ratio is reflective of obstructive lesions between the aorta and ankle.

generally at least 15 cm. with an HT/brachial ratio of 1. . the pressure may not be transmitted effectively to the vessels at the center of the limb and the pressure reading may be artifactually high. AK = above knee. such that the cuff-measured thigh pressure in persons without disease (variable depending on thigh size) is considerably greater than arm pressure. Two aspects of the response are evaluated: the degree of immediate decrease in ankle pressure and the time for recovery to resting pressure. Fig.1 (plus or minus 0. the true intraarterial pressure in the thigh vessels is slightly higher than in the arm.1) (Fig 39). normal study. The patient is usually exercised on a treadmill at 2 miles per hour on a 12% grade for 5 minutes or until symptoms occur. because of the phemonenon of systolic amplification. This problem is commonly encountered at the level of the thigh. In persons without disease. Exercise Testing The degree of narrowing at which a stenosis is "critical" is dependent on flow.2. DP = dorsal pedal AAI = ankle arm [brachial] index. The girth of the thigh results in an exaggeration of this fact. Therefore. 37 Format for recording lower-extremity pressures (in millimeters of mercury). 38 Segmental pressure chart. Note that the HT/brachial ratio is approximately 1. If a limb is very large in girth or the cuff inadequate in relative size. the normal ankle/brachial index is greater than 1. BK = below knee. as by exercise or reactive hyperemia. This artifact can be minimized by using adequate cuff diameters. PT = posterior tibial.Fig.0. with a mean value of 1. Our laboratory does not use exercise testing. the systolic pressure in the ankle is slightly higher than that in the brachial artery in persons without disease. Interpretation of Ankle/Brachial Index Because of the phenomenon of systolic amplification. There are two factors that may result in spuriously high pressure readings and consequent interpretative difficulties: limb girth and arterial wall rigidity.2 or more (Fig 38). and pressure gradients that are minimal at rest may be accentuated when flow rates are increased.

rigidity or calcification of the arterial walls can result in the vessel being "incompressible. The degree in reduction of the ankle/brachial index also correlates with the degree of clinical arterial insufficiency and severity of symptoms (Table).Fig.3 or considerable increases in pressures distally. . Ankle/Brachial Index and Patient Status In some persons. Rofsky NM.3 1.0 0. sometimes greater than 300 mm Hg.9-1.0. The ankle/brachial index is 1.5 <0. This occurs most frequently in patients with diabetes but has also been seen in the settings of long-term corticosteroid therapy.5-0." resulting in extremely high pressures. and renal transplantation. such as with an HT/brachial ratio exceeding 1. Patient Status Normal Minimal ischemic disease (minimal symptoms) Mild-to-moderate disease (claudication) Moderate-to-severe disease (ischemic rest pain) Severe disease (gangrene) References Ankle/Brachial Index >1. renal dialysis. normal values. Both of these artifacts can be recognized by the presence of inappropriately high pressures. 2:371-384 [Abstract]. Magn Reson Clin N Am 1998.0 0. MR angiography of the aortoiliac and femoropopliteal vessels. 39 Segmental pressure chart. and there are no pressure drops (>20 mm Hg) either down or across the extremities.3-0.9 0.

Clinical applications of Doppler ultrasound. 55-98. 99-107. J Vasc Surg 1993. ed. 1992. Karmel MI. Carter SA. Moneta GL. ed. Fobbe F. Wells PNT. Clinical applications of Doppler ultrasound. Wells PNT. . New York. eds. Polak JF. eds. 3. In: Zwiebel WJ. Burns PN. Wells PNT. 13. eds. New York. Strandness DE. Burns PN. Burns PN. 8. Extremity arteries. Owen RS. 12. New York. 1-17. 1995. O'Leary DH. Introduction to vascular ultrasonography. Doppler artifacts. Role of pressure measurements. Extremity arteries. Color flow and duplex sonography in lower-extremity ischemia. New York. Burns PN. New York. In: Bernstein EF. 14. 15. Magn Reson Clin N Am 1998. St Louis. Clinical applications of Doppler ultrasound. In: Taylor KJW. In: Taylor KJW. NY: Thieme. Schmiedt W. Prospective comparison of CT angiography of the legs with intraarterial digital subtraction angiography. Clinical applications of Doppler ultrasound. 1995. Wells PNT.2. Color duplex sonography. NY: Raven. 35-54. NY: Raven. 11. Orlando. Burns PN. 6. Hemodynamics. Limitations of ultrasonic duplex scanning for diagnosing lower limb arterial stenosis in the presence of adjacent segment disease. eds. 1995. Clinical applications of Doppler ultrasound. NY: Raven. NY: Raven. Duber C. NY: Raven. Zierler RE. In: Wolf KJ. 17:578-582 [Abstract]. 20-36. Nonimaging physiologic tests for assessment of extremity arterial disease. 4. Allard L. Burns PN. New York. 1993. et al. 337-354. 486-507. 7. Burns PN. Interpreting and analyzing the Doppler examination. 155:1085-1089 [Abstract]. Wells PNT. eds. Wells PNT. Donaldson MC. NY: Thieme. Polak JF. In: Wolf KJ. 19:650-657. Burns PN. MR angiography of the peripheral vessels. 10. 2:385395 [Abstrast]. 166:269-276 [Abstract]. In: Taylor KJW. In: Taylor KJW. Basic principles and Doppler physics. 1995. Mannick JA. 1995. eds. New York. Vascular diagnosis. J Vasc Surg 1994. Whittemore AD. 1995. AJR 1996. AJR 1990. 9. In: Taylor KJW. 68-90. Color duplex sonography. Noninvasive localization of arterial occlusive disease: a comparison of segmental Doppler pressures and arterial duplex mapping. Landwehr P. 5. 1995. Determination of the extent of lower extremity peripheral arterial disease with color-assisted duplex sonography: comparison with angiography. Landwehr P. Mo: Mosby. Rieker O. Fobbe F eds. Fla: Saunders.

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