Tungpalan, Jan Mar R.

BSN-4
Doppler ultrasonography is a non invasive test used to evaluate blood flow in the major
veins and arteries of the arms and legs and in the extra cranial cerebrovascular system. An
alternative to arteriography and venography, it’s safer, less costly, and faster than invasive tests.

In Doppler ultrasonography, a handheld transducer directs high-frequency sound waves to

the artery or vein being tested. The sound waves strike moving red blood cells and are reflected
back to the transducer, allowing direct listening and graphic recording of blood flow.

Measurement of systolic pressure during this test is used to detect the presence, location,
and extent of peripheral arterial occlusive disease. Changes in sound wave frequency during
respiration are observed to detect venous occlusive disease. Compression maneuvers detect
occlusion of the veins and occlusion or stenosis of carotid arteries. Pulse volume recorder testing
may be performed with Doppler ultrasonography to record changes in blood volume or flow in an
extremity or organ.

PURPOSE

• To aid in the diagnosis of venous insufficiency and superficial and deep vein thrombosis
(popliteal, femoral, iliac)
• To aid in the diagnosis of peripheral artery disease and arterial occlusion
• To monitor the patient who has had arterial reconstruction and bypass grafts
• To detect abnormalities of carotid artery blood flow associated with conditions such as
aortic stenosis
• To evaluate possible arterial trauma

PATIENT PREPARATION

• Explain to the patient that Doppler ultrasonography is used to evaluate blood flow in the
arms and legs or neck.
• Tell the patient who will perform the test.
• Reassure the patient that the test doesn’t involve risk or discomfort.
• Tell the patient that he’ll be asked to move his arms to different positions and to perform
breathing exercises as measurements are taken. A small ultrasonic probe resembling a
Tungpalan, Jan Mar R.
BSN-4
microphone is placed at various sites along veins or arteries, and blood pressure is checked
at several sites.
• Check with the vascular laboratory about special equipment or instructions.

PROCEDURE AND POSTTEST CARE

• Water-soluble conductive gel is applied to the tip of the transducer.

Peripheral Arterial Evaluation

• Peripheral arterial evaluation is always performed bilaterally. The usual test sites in each
leg are the common femoral, superficial femoral, popliteal, posterior tibial, and dor salis
pedis arteries; in each arm, the test sites are usually the subclavian, brachial, radial, ulnar
and, occasionally, the palmar arch and digital arteries.
• The patient is instructed to remove all clothing above or below the waist, depending on the
test site, and he’s placed in a supine position on the examining table or bed, with his arms
at his sides.
• Brachial blood pressure is measured, and The transducer is placed at various points along
the test arteries
• The signals are monitored and the wave forms recorded for later analysis.
• Segmental limb blood pressure is obtained to localize arterial occlusive disease.
• During lower extremity tests, a blood pressure cuff is wrapped around the calf, pressure
readings are obtained, and wave- forms are recorded from the dorsalis pedis and posterior
tibial arteries. Then the cuff is wrapped around the thigh, and waveforms are recorded at
the popliteal artery.
• In upper extremity tests, examination is performed on one arm, with the patient first placed
in a supine position and then sitting: it’s then repeated on the other arm. A blood pressure
cuff is wrapped around the forearm, pressure readings are taken, and waveforms are
recorded over the radial and ulnar arteries. Then the cuff is wrapped around the up- per
arm, pressure readings are taken, and waveforms are recorded with the transducer over the
brachial artery.
• Blood pressure readings and waveform recordings are repeated with the arm in extreme
hyperextension and hyperabduction to check for possible compression factors that may
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BSN-4
interfere with arterial blood flow. The upper extremity examination is performed on one
arm, with the patient first placed in a supine position and then sitting; it’s then repeated on
the other arm.

Peripheral Venous Evaluation

• Usual test sites for peripheral venous evaluation include the popliteal, superficial femoral,
and common femoral veins in the leg and the posterior tibial vein at the ankle; the brachial,
axillary, and subclavian veins in the arm; jugular veins; and, occasionally, the inferior and
superior vena cava.
• The patient is instructed to remove all nothing above or below the waist, depending on the
test site.
• He’s placed in a supine position and instructed to breathe normally.
• The transducer is placed over the appropriate vein, waveforms and compressibility are
recorded, and respiratory modulations are noted.
• Proximal limb compression maneuvers are performed and augmentation is noted after
release of compression, to evaluate venous valve competency.
• Changes in respiration are monitored.
• During lower extremity tests, the patient is asked to perform Valsalva’s maneuver, and
venous blood flow is recorded.
• The procedure is repeated for the other arm or leg

Extracranial Cerebrovascular Evaluation

• Usual test sites for extracranial cerebrovascular evaluation include the supraorbital.
Common carotid, external carotid, internal carotid, and vertebral arteries.
• The patient is placed in a supine position on the examining table or bed, with a pillow
beneath his head for support
• Brachial blood pressure is then recorded using the Doppler probe.
• The transducer is positioned over the test artery, and blood flow velocity is monitored and
recorded.
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BSN-4
• The influence of compression maneuvers on blood flow velocity is measured, and the
procedure is repeated on the opposite side.

All Procedures

• Remove the conductive gel from the patient’s skin.

PRECAUTIONS

• Don’t place the Doppler probe over an open or draining lesion.

NORMAL FINDINGS

Arterial waveforms of the arms and legs are triphasic, with a prominent systolic component
and one or more diastolic sounds. The ankle-arm pressure index – the ratio between ankle systolic
pressure and brachial systolic pressure is normally equal to or greater than 1. (The ankle-arm
pressure index is also known as the arterial ischemia index, the ankle-brachial index, or the pedal-
brachial index) Proximal thigh pressure is normally 20 to 30 mm Hg higher than arm pressure, but
pressure measurements at adjacent sites are similar. In the arms, pressure readings should remain
unchanged despite postural changes.

Venous blood flow velocity is normally phasic with respiration and is of a lower pitch than
arterial flow. Distal compression or release of proximal limb compression increases blood flow
velocity. In the legs, abdominal compression eliminates respiratory variations, but release
increases blood flow; Valsalva’s maneuver also interrupts venous flow velocity.

In cerebrovascular testing, a strong velocity signal is present. In the common carotid artery,
blood flow velocity increases during diastole due to low peripheral vascular resistance of the brain.
The direction of periorbital arterial flow is normally anterograde out of the orbit.

ABNORMAL FINDINGS

Arterial stenosis or occlusion diminishes the blood flow velocity signal, with no diastolic
sound and a less prominent systolic component distal to the lesion. At the lesion, the signal is high-
pitched and, occasionally, turbulent. If complete occlusion is present and collateral circulation
hasn’t taken over, the velocity signal may be absent.
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A pressure gradient exceeding 20 mm Hg at adjacent sites of measurement in the leg may
indicate occlusive disease. Specifically, low proximal thigh pressure signifies common femoral or
aortoiliac occlusive disease. An abnormal gradient between the proximal thigh and the above or
below-knee cuffs indicates superficial femoral or popliteal artery occlusive disease; an abnormal
gradient between the below-knee and ankle cuffs indicates tibiofibular disease. Abnormal
gradients of arm and forearm pressure readings may indicate brachial artery occlusion.

An abnormal ankle-arm pressure index is directly proportional to the degree of circulatory

impairment: mild ischemia, 1.0 to 0.75; claudication, 0.75 to 0.50; pain at rest, 0.50 to 0.25; and
pregangrene, 0.25 to 0.

If venous blood flow velocity is unchanged by respirations, doesn’t increase in response to

compression or Valsalva’s maneuver, or is absent, venous thrombosis is indicated. In chronic
venous insufficiency and varicose veins, the flow velocity signal may be reversed. Confirmation
of results may re- quire venography.

Inability to identify Doppler signals during cerebrovascular examination implies total

arterial occlusion. Reversed periorbital arterial flow indicates significant arterial occlusive disease
of the extracranial internal carotid artery. In addition, the audible signal may take on the acoustic
characteristics of a normal peripheral artery. Internal carotid artery stenosis causes turbulent
signals. Collateral circulation can be assessed by compression maneuvers.

Oculoplethysmography, carotid phonoangiography, or carotid imaging can further

evaluate cerebrovascular disease. Retrograde blood velocity in the vertebral artery can indicate
subclavian steal syndrome. A weak velocity signal on comparison of contralateral vertebral arteries
can indicate diffuse verte- bral artery disease.