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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.


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)

Q = v1A1 = v2A2;


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.


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 highest-velocity flow at the center and a gradual decrease toward the vessel
wall, 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 conceptualized
as a concentrically arranged stack of cylinders moving along a smooth path at differing
velocities relative to each other. True parabolic flow exists in the smaller vessels of the
abdomen but not usually in the major arteries, where instead there is some flattening in
the 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 velocity
and direction (Fig 3).

Fig.3 Pulsed Doppler spectrum, clear window. The width of the white tracing indicates
the range of cell velocities at a given time, and the thinness of this line and the absence
of markings below the line are known as a clear spectral "window." Filling in of this
space, 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 toward
the 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 flow
abnormalities, ranging from "disturbed" to "turbulent" flow, with the precise distinction
between the two being somewhat arbitrary. Flow disturbance comprises a continuum of
flow abnormalities ranging from minor irregularities of flow streamlines to completely
disorganized, multidirectional flow vectors (Fig 4).
Fig. 4 Disturbed flow. There is disruption of the orderly laminae within the region of narrowing
(mild flow disturbance), and disorganized, multidirectional flow vectors distal to the stenosis
(turbulent flow). The distinction between the two is somewhat arbitrary.

The variables that influence the existence of turbulent flow include vessel radius r, the
average flow velocity v across the lumen, the density p of the fluid, and the viscosity h of
the fluid. With these variables, the Reynolds number (Re) can be calculated by using the
equation Re = v2rp/h); a value exceeding approximately 2,000 is generally defined as
the critical value for the transition from laminar to turbulent flow. Since a stenosis is
associated with elevated velocity, turbulence is usually present within and distal to a
stenosis. The color Doppler appearance of turbulent flow is a heterogeneous distribution
of different shades of color across the vessel lumen (Fig 5),

Fig.5 Turbulent flow, color Doppler US. The far right of the image, showing homogeneous red
color, indicates flow in the same direction, of moderate frequency shift and therefore moderate
velocity. 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).

since the Doppler angles related to individual cells are no longer identical. The pulsed
Doppler appearance of turbulence includes spectral broadening (filling in of the window
of the spectrum), disorganized simultaneous forward and reverse flow, and fluctuations
in flow velocity with time (Fig 6)

Fig. 6 Turbulent flow, pulsed Doppler. There is filling in of the "window" beneath the spectrum,
known as "spectral broadening" and indicative of the wide range of velocities present in turbulent
flow. The peak systolic velocity is elevated (>300 cm/sec) because of a stenosis. Sometimes
turbulent flow may be bidirectional and the waveform contour ill-defined.


Because of the pulsatile pumping activity of the heart, flow in the arterial system is
characterized by alternating phases of acceleration and decelerration. The large
pressure amplitude produced by the left ventricle is reduced by the receiving arterial
bed, the aorta, and the large vessels. These vessels are sufficiently compliant to store
some of the pulsatile energy of the heart, and allow more continuous flow. The degree of
the continuous flow component is predominantly a function of peripheral vascular
resistance, particularly at the arteriolar level. Reflections of the pressure waves within
the arterial tree also influences the flow velocity waveform. These conditions result in
two basic forms of the Doppler waveform: high and low resistance. Arteries that supply
muscles and skin at rest (extremities, external carotid, penile, and mesenteric when
fasting) have a high-resistance Doppler waveform. Lower-extremity arteries are an
example of this, and typically have a rapid acceleration to and deceleration from peak
systole, a brief reversal of flow in early diastole, and a brief component of antegrade flow
in mid-diastole ( "triphasic waveform ") (Fig 7).
Fig. 7 Triphasic waveform, pulsed Doppler US. There is rapid systolic acceleration and
deceleration, a brief reversal of flow in early diastole, followed by a brief component of antegrade
flow in mid-diastole.

Parenchymal organs such as the liver, spleen, kidney, and brain require constant
perfusion, in contrast to demand-oriented tissue such as muscle, and have a more
continuous, low-resistance flow pattern. The characteristic waveform in a vessel
supplying these organs has a signficant degree of antegrade flow throughout diastole,
and no reversed flow component (Fig 8).
Fig.8 Low-resistance waveform, pulsed Doppler US. There is holodiastolic antegrade
flow in diastole, with no reversed flow component.

Physiologic or pathologic conditions that alter peripheral resistance can affect the
pulsatility and contour of Doppler waveforms. For instance, lowering of peripheral
resistance due to a hemodynamically significant lesion or exercise can result in a low-
resistance waveform in the femoral artery (Fig 9).

Fig.9 Low-resistance waveform in the distal superficial femoral artery, distal to a high-grade

Similarly, the usual low-resistance waveform in a renal transplant may convert to a high-
resistance pattern due to processes that raise intrarenal resistance, such as acute
rejection or renal vein thrombosis. These alterations of waveform can be used to detect
changes in peripheral vascular resistance, which may provide important diagnostic
information (4,7,8,10).
Fig.10 Doppler angle. 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 Doppler effect is a change in the frequency of a wave, resulting from motion of
the wave source or receiver, or in the case of a reflected wave, motion of the reflector.
In medicine, Doppler US is used to detect and measure blood flow, and the major
reflector is the red blood cell. The Doppler shift is dependent on the insonating
frequency, the velocity of moving blood, and the angle between the sound beam and
direction of moving blood, as expressed in the Doppler equation:

Df = 2 f v cos q ,

where Df is the Doppler shift frequency (the difference between transmitted and received
frequencies), f is the transmitted frequency, v is the blood velocity, c is the speed of
sound, and q is the angle between the sound beam and the direction of moving blood.
The equation can be rearranged to solve for blood velocity, 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, a process known as angle
correction (Fig 11).

Fig. 11 Angle correction, duplex Doppler US. The line (arrow) within the sample gate is used to
estimate the Doppler angle between the ultrasound beam and the blood flow direction.
Observing the Doppler equation yields several points that are relevant to the
performance of a Doppler examination. First, since the cosine of 90° is zero, if the
ultrasound beam is perpendicular to the direction of blood flow, there will be no Doppler
shift and a potentially incorrect impression of no flow in the vessel. Second, it is evident
that appropriate estimation of the angle of insonation, or angle correction, is essential for
the accurate determination of Doppler shift and blood flow velocity. The angle of
insonation should also be less than 60° at all times, since the cosine function has a
steeper curve above this angle, and errors in angle correction are therefore magnified.

There are several forms of depiction of blood flow in medical Doppler imaging: color
Doppler, pulsed Doppler, and power Doppler. 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).

Fig.12 Normal color Doppler US. The mean frequency shift of blood flow is depicted in color, and
flow direction is arbitrarily assigned, indicated by the blue and red vertical bar at the right of the
image. Blue-coded flow is toward the transducer, and red-coded flow is away from the
transducer. The deeper, more saturated colors have a lower mean frequency shift.

The flow direction is arbitrarily assigned the color red or blue, indicating flow toward or
away from the transducer, respectively. Pulsed Doppler allows a sampling volume (or
gate) to be positioned in a vessel visualized on the gray-scale image, and displays a
spectrum, or graph, of the full range (as opposed to the mean velocity, as in color
Doppler US) of blood velocities within the gate plotted as a function of time. 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).
Fig.13 Pulsed Doppler US. Velocities are indicated on the scale to the right of the image.
Deflections above the baseline indicate flow toward the transducer, 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, which is not routinely used in arterial
Doppler evaluation of the lower extremity, depicts the amplitude, or power, of Doppler
signals rather than the frequency shift. This allows detection of a larger range of Doppler
shifts and thus better visualization of small vessels, but at the expense of directional and
velocity information.


A detailed overview of Doppler artifacts is beyond the scope of this article, but several
artifacts are particularly important for the performance and interpretation of an arterial
Doppler examination. 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).
Fig.14 Aliasing, pulsed Doppler. There is folding over of forward flow in systole in the reverse
direction, below the baseline.

The artifact results in a wraparound of the Doppler spectrum in pulsed or color Doppler
US. Aliasing at pulsed Doppler appears as a "folding over" of forward flow in systole in
the reverse direction. 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. 15 Aliasing, color Doppler US. There is heterogeneity of colors within the vessel lumen,
which is one of the color Doppler appearances of aliasing.

Since aliasing is due to a high-frequency shift or inadequate sampling rate or both, it

may be a marker for sites of high-velocity flow,and is therefore a useful artifact for
detection of stenosis. During mapping of the arteries with color Doppler US, if a region
of aliasing is encountered, it should prompt a more detailed analysis with pulsed Doppler
to see if an elevated peak systolic velocity ratio is present. Aliasing can be reduced by
increasing the pulse repetition frequency or using a lower-frequency transducer, thus
decreasing the Doppler shift (Fig 16).

Fig. 16 Aliasing, pulsed Doppler US, effect of pulse repetition frequency (PRF). Both images were
obtained in the same vessel. The image on the left (PRF = 2,500 Hz) has no aliasing, while the
image on the right, with a lower PRF of 1,515 Hz, shows aliasing.

Another artifact is "bleeding" of color signal from a vessel into an adjacent area without
flow, potentially masking the presence of thrombus or vessel narrowing. This artifact is
due to an inappropriately high setting of the color gain. It is important to emphasize the
importance of the Doppler angle in interpreting the examination. If the ultrasound beam
is perpendicular to the vessel, there may be a spurious impression of no flow
(occlusion), or the flow direction may appear to be bidirectional, like a mirror image (Fig
Fig.17 Spectral mirror image artifact. This artifact may occur with a Doppler angle of 90° and
manifests as bidirectional flow, with identical spectra in both directions ("mirror image").

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.

Finally, it is important to emphasize that the accuracy of angle correction is essential, as

inappropriate estimates can result in spurious velocity determinations and potential
misdiagnoses (Fig 18)

Fig. 18 Angle correction, pulsed Doppler US. Note the differing velocity readings from the same
location in the same vessel but with different Doppler angles.
Doppler Diagnosis of Arterial Stenoses and Occlusions

If the lumen of an artery is narrowed, the blood flow velocity increases within the
stenosis , as described by the principle of continuity of flow(see the Hemodynamics
section) (Fig 19).

Fig. 19 Calculation of peak systolic velocity (PSV) ratio. The PSVs in the narrowed (or aliasing)
portion of the vessel (right) and in an immediately proximal, normal portion (left) are obtained.
The ratio consists of the elevated PSV divided by the proximal, 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
peak systolic velocity (PSV) with pulsed Doppler (Fig 20).

Fig. 20 Stenosis, pulsed Doppler US. The intrastenotic velocity is elevated (right), compared with
the normal, 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, nonstenosed portion of the artery. A ratio of greater than 2 is the criterion for a
hemodynamically significant (50% or greater) stenosis, and a ratio of 3.7-4 indicates a
75% or greater stenosis.

Because of the large variation in velocities within the lower-extremity arteries,

depending on location, the use of absolute velocity is less accurate than the PSV ratio,
which normalizes for this variability.

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, although the latter feature is often
unreliable. Any site of suspected stenosis at color Doppler US is then interrogated with
pulsed Doppler, which provides a spectrum within and proximal to the possible lesion,
allowing computation of a PSV ratio (Fig 21,22)
Fig 21 and 22 Figure 21. Stenosis with aliasing, color Doppler US. Note aliasing in the common
iliac artery, indicative of a region of high-frequency shift and possibly a stenosis.

Figure 22. Pulsed Doppler US of the color Doppler abnormality shown in Figure 21. There is
elevated PSV (>400 cm/sec) with spectral broadening. The prestenotic velocity is 80 cm/sec (not
shown), and the PSV ratio is 5, consistent with a greater than 75% stenosis.

The use of color Doppler US in conjunction with pulsed Doppler, or color-assisted

duplex US, markedly reduces the examination time, generally allowing both legs to be
imaged in 30-45 minutes. In addition to the change in velocity due to hemodynamically
significant lesions, the contour of the pulsed Doppler waveform is affected by their
presence. A normal, resting lower-extremity arterial waveform demonstrates high
resistance, having a triphasic form with a rapid acceleration to and deceleration from
peak systole, a brief reversal of flow in early diastole, and a small antegrade flow
component in mid-diastole (Fig 23 ).
Fig.23 Triphasic waveform, pulsed Doppler US. There is rapid systolic acceleration and
deceleration, a brief reversal of flow in early diastole, followed by a brief component of antegrade
flow in mid-diastole.

Although the precise relationship between waveform contour alteration and lesion type
and location is not well established, certain generalizations can be made. The spectral
waveform changes within and immediately distal to a stenosis; in addition to increased
PSV, it indicates disturbance of laminar flow and a decrease in pulsatility and loss of the
reversed flow component. This disturbance of laminar flow may manifest as spectral
broadening, turbulence, and, in severe stenoses, simultaneous forward and reverse flow
and indistinctness of the spectral margin (Fig 24).

Fig. 24 Stenosis, turbulent flow, pulsed Doppler US. There is severe spectral broadening.
The appearance of the waveform proximal to a lesion is variable and depends on the
degree of collateral circulation formation. 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, reduced, or reversed flow in diastole. With an
acute occlusion, ineffectual pulsations may be transmitted to the occlusion, producing
narrow, low-velocity Doppler signals that do not represent true flow (Fig 25).

Fig.25 Pulsed Doppler waveform, proximal to high-grade lesion. There is loss of flow in diastole
and low velocities.

The waveform shape distal to an obstructing lesion often shows a low-resistance

pattern, with loss of flow reversal in diastole and abundant antegrade flow in
diastole (Fig 26).
Fig.26 Pulsed Doppler waveform, low resistance distal to high-grade lesion.

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).

Fig.27 Pulsed Doppler waveform, low resistance with "tardus and parvus" contour. There is
delayed systolic acceleration, and the waveform demonstrates low resistance.

The decrease in pulsatility is probably due to a combination of factors including (a)

decreased peripheral resistance due to ischemia, (b) resistance to the reversed flow
component related to the stenosis, (c) high level of forward flow throughout the cardiac
cycle due to the pressure gradient across the stenosis, and (d ) dampening of the
pressure wave with consequent reduction of pulse pressure, resulting in less wave
reflection and amplification, which normally contribute to the reversed flow component in

These waveform contour changes are not the primary diagnostic criteria for arterial
lesions but are adjunctive and complementary to the PSV changes. Turbulence is
always present within and distal to a stenosis and generally extends a few centimeters
downstream. The development of an abnormal waveform contour does indicate the
presence of a lesion, but it does not accurately indicate the location of the lesion. Distal
to a hemodynamically signficant lesion, the waveform often remains low resistance
throughout the remainder of the extremity (Fig 28).
Fig.28 Pulsed Doppler waveform, low resistance distal to high-grade lesion.

Waveform abnormalities can probably also be detected at varying distances proximal to

a lesion. 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.

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).

Fig.29 Occlusion, color and pulsed Doppler US. There is absence of flow, compatible
with an occlusion.

It is important to ensure that the lack of detectable flow is not due to technical factors.
The Doppler gain should be set at a high level, 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. The settings for low-flow detection can be normalized
in a given patient by confirming detection of venous flow. Other potential sources of
false-positive examinations include (a) inability to detect Doppler signals deep in the
thigh, such as in the adductor canal region; (b) densely shadowing calcified plaque
preventing detection of Doppler signal; (c) external compression of the vessel; and (d)
severe stenosis with very slow flow, below the threshold of detection with the Doppler
instrument. A false-negative diagnosis can be due to mistaking high-velocity small
arterial collateral vessels parallel to the occluded segment for a patent, stenosed artery

Patient Preparation

In our laboratory, we do not require any special patient preparation. Some laboratories
require that the patient fast prior to the test to reduce bowel gas to allow better
visualization of the iliac vessels. Another possible preparation technique is to have the
patient rest on the examination table prior to the test to allow resolution of any exercise-
induced hyperemia, which could affect the Doppler spectral and segmental pressure
interpretation. This preparation is problematic because of scheduling and logistic issues.

US Imaging

US imaging is performed with a linear array transducer, operating from 5 to 7.5 MHz (Fig

Fig. 30 Linear array transducer, in typical imaging positions to visualize the popliteal
(left) and dorsalis pedis arteries (right).

First, the gray-scale image is optimized, and then the color Doppler image is optimized
by adjusting the pulse repetition frequency (velocity scale), wall filter, 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. The velocity scale is typically set at
30-40 cm/sec. The iliac, common and superficial femoral, and popliteal arteries are
imaged along their longitudinal axis with color Doppler. These vessels are mapped with
color Doppler to detect any regions of aliasing that may indicate a stenosis, or areas
without flow, which would indicate an occlusion. Once a suspicious site is identified,
detailed analysis with pulsed Doppler is performed. A pulsed Doppler spectrum and
PSV are obtained within the region of aliasing and several centimeters proximal to that
region, where the color Doppler appearance is normal. The PSV within the region of
aliasing is then divided by the PSV in the proximal region, and if the ratio is greater than
2, a 50% stenosis is diagnosed (Fig 31).

Fig. 31 Stenosis, pulsed Doppler US. There is a focal velocity increase resulting in a PSV ratio of
2, compatible with a 50% stenosis.

It is essential to ensure that the angle correction is accurate and that the Doppler angle
is less than 60°, and preferably as low as possible. Turbulent flow, manifesting as
spectral broadening and an ill-defined waveform contour, is often present within and just
distal to the stenosis. If a vascular segment contains no flow on color Doppler, this
should be confirmed with pulsed Doppler, and a diagnosis of occlusion can made (Figs

Fig. 32, 33 Stenosis with aliasing, color Doppler (Fig 32) and pulsed Doppler (Fig 33) US. Note
aliasing in the common iliac artery, indicative of a region of high- frequency shift and possibly a
stenosis. Pulsed Doppler of the same region reveals elevated PSV (>400 cm/sec) with spectral
broadening. The prestenotic velocity is 80 cm/sec (not shown), and the PSV ratio is 5, consistent
with a greater than 75% stenosis.

In addition to insonation of abnormal regions with color Doppler, representative pulsed

Doppler spectra are obtained in the iliac, common femoral, proximal, middle, and distal
superficial femoral, and popliteal arteries, and in the posterior tibial and dorsal pedal
arteries in the ankle (we do not routinely insonate the entire course of the calf vessels).
These are examined for presence of abnormal waveforms, such as a low-resistance
waveform. In the absence of a lesion demonstrated by the principal Doppler criteria
(PSV ratio or absence of detectable flow), 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.

This type of information, particularly in conjunction with a segmental pressure

abnormality, allows one to suggest the possiblity of a lesion that was not directly
visualized. For instance, 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, the presence of a lesion in the anterior tibial
artery can be suggested.

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%, with
specificities ranging from 80% to 99%. The results in our laboratory have been closer to
the lower end of these results. Controversy exists regarding the issue of whether the
presence of multiple lesions affects the sensitivity of stenosis detection. The sensitivity
and specificity for detection of occlusions by the criterion of absence of Doppler
detectable flow are both more than 90%, and results in our laboratory have been similar
to these (4,6,9,13,14).

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).
Fig. 34 Normal results from lower-extremity Doppler examination. All waveforms are triphasic,
and there are no focal velocity increases to suggest stenosis.

Lower-Extremity Arterial Pressure Measurements

Measurement of systolic blood pressures in the lower extremities is a fairly simple, easily
performed, and repeatable test that provides a global, quantitative, and objective index
of arterial obstructive disease. Compared with US, it is less sensitive in the detection of
lesions and less effective in disease localization, and it cannot characterize lesions as
stenoses versus occlusions; however, it is of value because of its ease of performance
and potential for comparison to prior studies, and because it provides a simple global
depiction of the disease process. 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, and the pressure decrements can assist in lesion localization.

Blood flow to an organ is determined by the difference in pressure and fluid energy
between the large arteries and veins, and by the resistance within a given vascular bed.
The mean and diastolic pressures normally gradually decrease distally, promoting blood
flow. Systolic pressure normally increases as the pressure wave travels distally, due to
reflection of waves and high peripheral resistance, a process known as systolic
amplification. Therefore, the systolic pressure measured at the ankle is normally slightly
higher than in the arm.

Reduction of the luminal diameter to a critical value by a stenosis results in diminished

pressure and flow distal to the lesion. The systolic pressure is the most sensitive
indicator of disease, as it is reduced earlier than the diastolic pressure. The basis of
lower-extremity pressure measurements is the detection of a reduction in systolic blood
pressure along the course of the leg, indicating the presence of an obstructive arterial


The systolic pressure at any level in the leg can be measured by placing a pneumatic
cuff at the site of interest.The cuff is inflated to a level above systolic pressure, such that
arterial signal disappears, and then the cuff is gradually deflated until flow reappears (Fig
35 ).

Fig. 35 Continuous wave Doppler US probe, insonation of ankle vessels.

The pressure at which this occurs is recorded as the systolic pressure. Resumption of
flow is assessed by using a continuous-wave Doppler probe, generally at the posterior
tibial (PT) or dorsal pedal (DP) artery, although any vessel distal to the cuff can be used.
The site of pressure measurement is determined by the cuff position and not the site of
flow detection.
The procedure is performed by placing four pneumatic cuffs at four different positions on
the leg: high thigh (HT), above knee (AK), below knee (BK), and ankle (Fig 36).

Fig. 36 Pneumatic cuffs on legs.

Systolic pressure is determined at each level with the technique described above, with
measurement for flow performed at either the PT or DP artery. The procedure is
performed separately for each leg. When the ankle cuff is inflated, the pressure is
recorded at both the PT and DP arteries. To calculate an ankle/brachial pressure ratio,
which is an index of the degree of disease in the lower limb, both brachial artery systolic
pressures are obtained. In the absence of subclavian or axillary artery disease, the
brachial pressure is equal to the aortic pressure, and therefore the ratio is reflective of
obstructive lesions between the aorta and ankle. If the brachial pressures differ, the
higher of the two is used to calculate the ratio for each leg. The examination is
performed with the patient in the supine position. The temperature in the room should be
warm, as cold-induced vasospasm may make arterial signals difficult to detect.

The results of the four leg and one arm pressures are recorded in a table form, 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).
Fig. 37 Format for recording lower-extremity pressures (in millimeters of mercury), normal study.
AK = above knee, BK = below knee, PT = posterior tibial, DP = dorsal pedal AAI = ankle arm
[brachial] index.

There are two factors that may result in spuriously high pressure readings and
consequent interpretative difficulties: limb girth and arterial wall rigidity. If a limb is very
large in girth or the cuff inadequate in relative size, the pressure may not be transmitted
effectively to the vessels at the center of the limb and the pressure reading may be
artifactually high. This problem is commonly encountered at the level of the thigh. This
artifact can be minimized by using adequate cuff diameters, generally at least 15 cm. In
persons without disease, the true intraarterial pressure in the thigh vessels is slightly
higher than in the arm, because of the phemonenon of systolic amplification. The girth
of the thigh results in an exaggeration of this fact, such that the cuff-measured thigh
pressure in persons without disease (variable depending on thigh size) is considerably
greater than arm pressure, with an HT/brachial ratio of 1.2 or more (Fig 38).

Fig. 38 Segmental pressure chart. Note that the HT/brachial ratio is approximately 1.2.

Exercise Testing

The degree of narrowing at which a stenosis is "critical" is dependent on flow, and

pressure gradients that are minimal at rest may be accentuated when flow rates are
increased, as by exercise or reactive hyperemia. The patient is usually exercised on a
treadmill at 2 miles per hour on a 12% grade for 5 minutes or until symptoms occur. Two
aspects of the response are evaluated: the degree of immediate decrease in ankle
pressure and the time for recovery to resting pressure. Our laboratory does not use
exercise testing.

Interpretation of Ankle/Brachial Index

Because of the phenomenon of systolic amplification, the systolic pressure in the ankle
is slightly higher than that in the brachial artery in persons without disease. Therefore,
the normal ankle/brachial index is greater than 1.0, with a mean value of 1.1 (plus or
minus 0.1) (Fig 39).
Fig. 39 Segmental pressure chart, normal values. The ankle/brachial index is 1.0, and there are
no pressure drops (>20 mm Hg) either down or across the extremities.

The degree in reduction of the ankle/brachial index also correlates with the degree of
clinical arterial insufficiency and severity of symptoms (Table).

Ankle/Brachial Index and Patient Status

In some persons, rigidity or calcification of the arterial walls can result in the vessel being
"incompressible," resulting in extremely high pressures, sometimes greater than 300 mm
Hg. This occurs most frequently in patients with diabetes but has also been seen in the
settings of long-term corticosteroid therapy, renal dialysis, and renal transplantation.
Both of these artifacts can be recognized by the presence of inappropriately high
pressures, such as with an HT/brachial ratio exceeding 1.3 or considerable increases in
pressures distally.

Patient Status Ankle/Brachial Index

Normal >1.0

Minimal ischemic disease (minimal


Mild-to-moderate disease

Moderate-to-severe disease
(ischemic rest pain)

Severe disease (gangrene) <0.3


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