VASCULAR SURGERY e I
Imaging in vascular
surgery
Tarryn Carlsson
Abstract
A modern vascular service cannot function without high quality, timely
and relevant diagnostic imaging. In this age of evidence-based medi-
cine, radiological findings and their expert interpretation are funda-
mental in aiding decisions with regard to patient management and
surgical intervention. In this chapter we present the basic principles,
clinical indications, advantages and limitations of the different imaging
modalities used to assess vascular patients including duplex ultra-
sound (DUS), computed tomography (CT), magnetic resonance imag-
ing (MR) and digital subtraction angiography (DSA).
Keywords CT angiography; digital subtraction angiography; duplex
ultrasound; MR angiography; vascular imaging
Ultrasonography (US)
Basic principles
Ultrasonography is the transmission, absorption and partial
reflection of high frequency sound waves that are inaudible to
the human ear. Ultrasound transducers contain crystalline ma-
terials that when subjected to an alternative electric current un-
dergo compression and expansion and thereby generate
ultrasonic waves ( piezoelectric effect). The transducers have the
ability to both transmit and receive ultrasonic waves. When a
sound wave hits a boundary between two surfaces, two things
happen: some energy is reflected e this is called the echo e and
the rest of the energy is transmitted. The unit of measurement of
sound is in Hertz (Hz). Audible sound is between 20 Hze20 kHz,
whereas medical US uses higher frequencies between 2 and 20
MHz.
B-mode
Grey scale (B-mode) ultrasound is used to demonstrate anatomic
structural detail. The amount of sound that is transmitted or re-
flected back to the receiver depends on the physical character-
istics of the tissue (e.g. the density of the tissue and the speed the
waves travel through that tissue). This is especially relevant
when imaging vascular structures that have overlying bowel (e.g.
the aorta or common/external iliac arteries) as gas in the large or
small bowel causes total sound reflection. In other words, gas-
filled organs cast a shadow and structures beneath them cannot
be visualized.
Doppler mode
By combining B-Mode and using the Doppler effect, we are not
only able to image anatomical detail of a blood vessel. but also
Tarryn Carlsson MBChB (Hons) FRCR is a Consultant Interventional
Radiologist at Southmead Hospital, North Bristol Trust, Bristol, UK.
Conflicts of Interest: none declared.
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calculate the velocity of blood flow through the vessel during
systole and diastole. As the sound waves hit the moving blood,
depending on the speed and direction of blood flow, the reflected
sound wave returns to the transducer at a different frequency.
The frequency shift (also known as ‘Doppler shift’) is mathe-
matically analysed and displayed as a spectral pattern or in
colour. Usually, the colour is superimposed on the grey scale
imaging e red is used to indicate blood flow towards and blue
indicates blood flow away from the probe. Accurate measure-
ment of velocities requires the ultrasound transducer to be
correctly aligned to the blood vessel, which is also known as the
angle of isonation and should be between 45 and 60 .
The normal arterial waveform
The normal arterial waveform is triphasic (Figure 1) and consists
of a sharp upstroke during cardiac systole as the flow is forward.
It reaches peak systolic velocity (PSV) and is followed by a short
reverse-flow component in early diastole. There is then another
short forward flow component in late diastole.
Duplex assessment is the workhorse in determining whether a
vascular stenosis is critical or not, i.e. will it benefit from inter-
vention? The shape of the waveform changes according to the
degree of stenosis. A mild stenosis (20e49%) changes the
waveform to biphasic, a moderate stenosis (50e75%) produces a
high acceleration monophasic waveform, and a critical stenosis
(>75%) is demonstrated as a dampened monophasic waveform
(Figure 2). Physics dictates that velocity will increase as the
cross-sectional area of a vessel reduces. For example, in the
lower limb the normal peak systolic velocity (PSV) varies from
45 to 180 cm/s, but flow rates within a severe stenosis can cause
the PSV to rise well above 200 cm/s.1 Figure 3 demonstrates the
waveform proximal, within and distal to a tight stenosis with the
superficial femoral artery. Only when a stenosis becomes critical
(>70%) will the luminal flow be reduced.2 With this in mind,
stenoses are graded according to the peak systolic velocity ratio
(PSVR), the ratio of the PSV across the stenosis to the PSV just
proximal to it (Table 1).
Clinical indications
Duplex ultrasound is the first-line investigation in assessing a
wide range of vascular pathologies: peripheral arterial disease
(PAD), carotid artery disease, deep vein thrombosis, lower limb
superficial venous disease and renal access. Additionally, US is
the workhorse when it comes to vascular surveillance and is
widely used in following up lower limb bypass grafts, arterial
stent patency, renal dialysis fistulas and post endovascular aortic
aneurysm repairs. It is the investigation of choice for most
abdominal aortic aneurysm (AAA) screening programmes
worldwide.
Advantages and limitations of ultrasound
Ultrasound is safe, non-invasive and does not involve ionizing
radiation. In addition, it is portable and can safely and relatively
easily be performed on less mobile patients without having to put
them in a defined ‘anatomical position.’ The diagnostic accuracy
of US is operator dependent and the quality of the imaging and
reporting can vary from centre to centre. When compared to
digital subtraction angiography (DSA), which is regarded as the
gold standard imaging, US has a median sensitivity of 88e90%
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 VASCULAR SURGERY e I

Triphasic waveform

a
(systole)
Peak systolic velocity 100%

Velocity
(late diastole)
End-diastolic velocity

0
Time
(cardiac cycle)

(early diastole)
(a) Normal arterial waveform. The first positive upstroke is forward systolic flow (1), the negative dip is reverse flow in early diastole (2) and
the final upstroke represents forward flow in late diastole (3). (b) Normal triphasic waveform in a common femoral artery with a peak systolic
velocity of 120 cm/s.

Figure 1

and specificity of 96e99% in detection of stenoses >50% or
occlusions. However, accuracy reduces below the knee.3 It is also
difficult to accurately interpret another operator’s images due to
the dynamic aspect of this modality. In addition, US cannot travel
through dense calcified vessels and abdominal vessels are prone
to being obscured by bowel gas.
Computed tomography
Basic principles
Computed tomography (CT) imaging is acquired by firing X-rays
in a fan-shaped beam through the patient, while the radiation
source spins helically around the patient (Figure 4). A panel of
solid-state detectors lies behind the patient and the amount of
radiation reaching the detectors is configured into a grey-scale
image (usually a 512  512 pixel matrix). The shade of grey of
each pixel is determined by the density of the tissues within the
body and is given a CT number (also known as a Hounsfield
unit). Water has a CT number of 0 and air, because of its low
density, has a CT number of 1000. Once acquired, CT images
can undergo multi-planar reconstruction (images are displayed in
the axial, sagittal and coronal planes but can be manipulated into
any plane). An example of this can been seen in Figure 5.
CT angiography (CTA) allows detailed analysis of the arterial
system by co-ordinating the timing of the scanning to coincide
with maximum opacification of the arteries following iodinated
contrast administration via a wide gauge cannula. For example, a
CT whole aorta is usually performed with the patient’s arms
above their head in inspiration. A scout image is obtained, which
in essence is a chest and abdominal plain film. The radiographer
then selects an axial slice in the chest at the level of the carina
and a single CT slice at this level is performed. A small region of
interest (ROI) is drawn, usually in the descending thoracic aorta
and a threshold CT number of 100 is programmed into the
scanner. The contrast is injected rapidly through a pump and the

Waveform changes in stenosis

b High acceleration c Low acceleration

a Biphasic monophasic monophasic

50–75% >75%
stenosis stenosis
20–49%
stenosis

Waveform morphology changes through mild (a), moderate (b) and severe arterial
stenoses (c).

Figure 2

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Figure 3 A triphasic waveform is seen in the proximal SFA with a normal PSV of 40 cm/s (a). The PSV velocities increase by nine-fold to 360 cm/s
within a severe stenosis (b). Note how the waveform complex has narrowed with a steep upstroke of the PSV. Distal to the stenosis the velocities
return to normal, but the waveform becomes monophasic (c). A schematic is often drawn (d) in order to visualize the disease in a more con-
ventional way rather than a difficult to read technical report.

CT will only start scanning once the descending aorta has
reached that particular threshold CT number, i.e. once the aorta
is optimally opacified.
Clinical indications
The National Institute of Health and Care Excellence (NICE) only
recommends CTA in patients with PAD where MRI is contra-
indicated or not tolerated.4 In the UK, access to MR angiography,
particularly out of normal working hours, means that this is not
often the case and CTA is performed relatively commonly as a
second-line imaging modality (after duplex US). UK practice is
therefore more reflective of the European and American guide-
lines, which give MRI and CTA equal recommendation as sec-
ond-line imaging.5,6 NICE do recommend that CTA is offered to
patients being evaluated for elective abdominal aortic aneurysm
(AAA) repair.7 CTA is often used as a second imaging modality
after duplex of the carotids following stroke to assess anatomy
prior to carotid endarterectomy.
CTA is an essential diagnostic tool for vascular emergencies
and is the mainstay investigation for suspected acute aortic
syndrome (including aortic dissection), acute limb ischaemia,
mesenteric ischaemia, vascular trauma, ruptured aneurysms and
other internal bleeding. CTA is also a crucial tool in the sur-
veillance of patients following endovascular repair of AAA both
with standard endovascular aortic stent grafts (often in
conjunction with ultrasound) and after complex endovascular
repair (thoracic, fenestrated and branched aortic stent grafts).
Figure 6 depicts both the US and follow up CT imaging findings
of an endoleak (aneurysm sac perfusion) following EVAR
placement.
Advantages of CT
CTA is readily available 24 hours a day in almost all emergency
departments and vascular centres across the UK. Modern scan-
ners are fast and can non-invasively image any or all of the
vascular tree in a matter of minutes. Images are displayed with
submillimetre spatial resolution and high temporal resolution. In
the past it was suggested that delay for CT imaging could be
harmful for a patient with ruptured AAA as it delayed surgery;
The degree of stenosis is calculated according to the
peak systolic velocity ratio
Peak systolic velocity ratio % Stenosis
2 50%
2.5 50e70%
3 >70% (critical)
Table 1

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Limitations of CT
Arrangement of detector panel in relation Imaging of the vascular tree from arch to toes exposes the patient
to patient to a relatively high dose of ionizing radiation. This is less of a
X-ray concern in the typical elderly vascular population but of impor-
source tance when used in children or young adults.
CT is particularly sensitive to motion, and even the slightest
patient movement can be detrimental to image quality. Streak
artefact from metallic implants (e.g. hip and knee re-
placements) degrade image quality as well, and the surround-
ing vasculature may require a second imaging modality for
accurate assessment. Similarly, vascular calcification can make
image interpretation more difficult, especially in the smaller
below knee arteries where intimal calcification is harder to
Patient distinguish from intraluminal contrast. It is useful to review
these images on bone windows to more accurately differentiate
vascular calcification from luminal contrast (Figure 7). Modern
CT scanners can negate this using dual energy scanning tech-
niques, which use two different peak voltage levels to better
differentiate the lower density contrast medium from the higher
density vascular calcification.9 When compared to DSA as the
Detector panel gold standard, CTA has median sensitivities of 91e97% and
The X-ray tube spins around the patient with a large number mediate specificities of 91e97% in detecting a >50% stenosis
of smaller detectors arranged in an arc to cover the complete or occlusion.3
cross-section of a patient. The use of iodinated contrast comes with its own risks,
including a range of allergic reactions. Moderate to severe idio-
Figure 4 syncratic reactions include bronchospasm, laryngeal oedema,
however, the recent IMPROVE trial, in which CT angiography hypotension, anaphylaxis and hypertensive crisis.10 Contrast-
was required to assess suitability for emergency endovascular induced nephropathy (CIN) is especially relevant to vascular
repair, does not support this view.8 CTA can also identify con- patients, who often have a degree of renal impairment at time of
current non-vascular pathology (i.e. a lung cancer in a patient imaging and a riskebenefit analysis should always precede pa-
being worked up for AAA repair). tient selection for CTA. To minimize risk of CIN, certain

Figure 5 Multiplanar reconstruction of a focal infrarenal aortic transection following lap belt injury during a road traffic accident. Axial (a), sagittal (b)
and coronal (c) reformats demonstrate a full thickness aortic injury consistent with an aortic transection (yellow arrow). There is a small surrounding
haematoma (green arrow) but no active bleeding or pseudoaneurysm. The patient remained stable and was treated with a covered aortic stent
placed percutaneously under local anaesthetic.

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Figure 6 (a) Transverse duplex image of an aorta 5 years following EVAR with sac expansion. Patent flow through the limbs of the graft (green
arrow) but there is a large endoleak anteriorly in the thrombus filled sac (yellow arrow). (b) and (c) Arterial and 2 minute delayed phase imaging
showing similar appearances with patent limbs of the EVAR graft (green arrow) and a large endoleak (yellow arrow) e only seen on the delayed
phase. This highlights the importance of performing delayed phase imaging in patients with ongoing sac expansion but no endoleak on the arterial
phase. This was proven to be a type II endoleak with inflow/outflow from the lumbar arteries.

Figure 7 Axial slices of a CTA through a patient’s lower limbs in soft tissue (a) and bone (b) windows. Note how on the soft tissue windows the right
posterior tibial artery (yellow arrow) appears patent but on the bone windows you can appreciate this vessel is occluded with no luminal opaci-
fication. The same is true for the other crural arteries.
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Figure 8

precautions should be taken. Diabetic patients should stop met-
formin on the day of the examination and withhold it for a
further 48 hours post CTA due to the small risk of developing
lactic acidosis if CIN occurs.11 Common practice advocates pa-
tients with underlying chronic kidney disease should be pre-
hydrated before the CTA; however, a recent prospective, ran-
domized control trial suggests there is no benefit in giving pa-
tients pre-hydration prophylaxis.12
Magnetic resonance imaging (MRI)
Basic principles
MRI involves placing a patient through a large magnet and
sending radiofrequency pulses through the body. These cause
the protons (i.e. hydrogen nuclei) within the patient’s cells to
spin (also known as precess), which in turn emit radio waves
that are received and reconstructed into a visual image.
Charged hydrogen atoms are either in a low energy state
(parallel to the magnetic field) or a high energy state (anti-
parallel to the magnetic field). As the radiofrequency pulse
wears off, the anti-parallel hydrogen atoms lose their energy
and flip back into alignment with the magnetic field, the rate of
these relaxation times are known as T1 (longitudinal relaxation
time e rate at which excited ‘spinning’ protons return to
equilibrium) and T2 (transverse relaxation time e rate at
which excited ‘spinning’ protons lose phase coherence among
the nuclei spinning perpendicular to the main magnetic field).
By varying the sequence of RF pulses applied and collected,
different types of images are created (e.g. T1 weighted, T2
weighted and diffusion weighted). MRI measures the hydrogen
content and represents it as shades of grey in the corresponding
pixels.
MR angiography (MRA)
Depending on how the MR images are acquired, blood can be
made to appear ‘dark’ or ‘bright.’ In spin echo sequences
(Figure 8), tissues are exposed to two radiofrequency (RF) pul-
ses: 90 and 180 . The blood in the slice is usually only exposed

Figure 9

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Figure 10 Three-phase MRA shows a right common iliac occlusion
and left superficial femoral artery occlusion. The images of the lower
limbs are distorted due to patient movement.
to the 90 RF pulse because by the time the 180 pulse comes in
the blood has left the slice. Therefore, it will emit no signal and
the blood vessel will be seen as ‘dark’ but the rest of the tissues
will appear as usual.
Time-of-flight (TOF) MR angiography is a good way to see
blood as ‘bright.’ In this technique, repetitive RF pulses are sent
through the slice, known as RF hammering. This in turn
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Figure 11 MRA of the lower limbs shows a diseased trifurcation but
patent right peroneal and posterior tibial arteries (PTA) distally with an
occluded anterior tibial artery (ATA). On the left, the PTA is patent from
origin but peroneal is occluded shortly beyond origin. The ATA is
diseased proximally but is patent in the lower calf but occludes at the
ankle.
bombards the cells in that slice with RF pulses and suppresses
their signal. The supressed blood will move on and fresh, new
blood will move into the slice (that has not had its signal
supressed) and appear bright. This imaging technique is espe-
cially good in fast flowing blood (arterial blood). In sluggish flow
or venous flow, which is much slower, the supressed blood may
stay in the slice while the image is acquired and may appear
darker (Figure 9).
Contrast-enhanced MR angiography uses gadolinium as a
contrast agent, which is injected into a peripheral vein. The
gadolinium significantly reduces the relaxation time of blood and
in a similar way to TOF angiography, the stationary background
tissues are supressed by multiple RF pulses. The contrast-
enhanced blood has such a short relaxation time that it can
recover despite the RF hammering and therefore gives a strong
signal and appears as ‘bright.’
Clinical indications
According to NICE, MRA should be offered to all patients with
PAD if duplex imaging is insufficient.4 In practice, this is not
usually feasible (see below for limitations of MRI) and is often
superseded by CT angiography. A three-phase lower limb MRA is
shown in Figure 10. MRI is very useful in arch and thoracic aortic
aneurysm surveillance in young patients (i.e. Marfan’s syn-
drome) and when imaging vascular malformations. Diffusion-
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 VASCULAR SURGERY e I

contra-indicated in patients with pacemakers or patients with

metallic fragments in their eyes. It can produce stark artefacts in
patients with metallic stents, thereby overestimating an in-stent
stenosis. Additionally, gadolinium-based contrast agents have
been associated with the development of nephrogenic systemic
fibrosis in patients with end stage renal failure.13
MRA has a tendency to over-estimate the severity of vascular
disease with overall median sensitivities of 94e95% and median
specificities of 97e99% to detect a >50% stenosis or occlusion
(compared to DSA).3

Digital subtraction angiography (DSA)

Figure 12 Interventional radiology (IR) suite showing the ceiling
mounted C-arm and imaging detector (yellow arrow), imaging display
screen (green arrow), patient table (black arrow), lead shielding (blue
arrow) and the radiographer control area (orange arrow).
weighted imaging is an extremely sensitive method for detecting
acute stroke and is often helpful in detecting embolic lesions in
the carotid territories.
Advantages and limitations of MRI
MR does not involve ionizing radiation and can produce images
that are recognizable to vascular surgeons as those produced by
digital subtraction angiography. It can provide more information
of the run-off vessels in patients with heavily calcified arteries
where the CTA is non-diagnostic (Figure 11). MRI acquisition can
be time consuming and in most centres around the UK has
limited availability, when compared to CT angiography. It is
Basic principles
DSA is still regarded as the ‘gold standard’ vascular imaging
technique. Historically, its role was purely diagnostic but due to
the advances of the different non-invasive imaging techniques
over the past few decades, fewer purely diagnostic angiograms
are now performed. DSA is performed in a purpose-built room
(e.g. interventional radiology suite or hybrid operating theatre)
that has met particular specifications in order to adhere to na-
tional radiation standards. The fluoroscopy unit is integrated into
a ceiling or floor-mounted C-arm that can be rotated axially and
sagittally around a floating table, on which the patient lies on
(Figure 12).
This technique involves the acquisition of high-quality fluo-
roscopic images (just like a fully exposed X-ray) before and
during contrast administration of intra-arterial iodinated
contrast. The pre-contrast image (mask) is digitally subtracted,
leaving only the intra-vascular contrast images that are then
displayed on a large screen in real time. If any of the later images
are different from the mask image, this will be shown as a

Figure 13 DSA of the pelvic arteries. An imaging catheter has been passed through a sheath placed into the right common femoral artery and up
into the distal abdominal aorta. A pumped angiogram shows a chronic occlusion of the left internal and external iliac arteries (a). The patient was
treated with left common and external iliac covered stents and a left common femoral endarterectomy (b).

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Summary of imaging the imaging modalities (DSA, digital subtraction angiography)

Duplex US CT Angiography MR Angiography Digital subtraction angiography

Sensitivitya 88e90% 91e97% 94e95% N/A

Specificityb 96e99% 91e99% 97e99% N/A
C Non-invasive C Universally available C No ionizing radiation C Gold standard
C Inexpensive C Imaging of whole vascular system C Non-contrast option (TOF) C Therapeutic intervention can be
done at same time as diagnosis

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Advantages C Dynamic information C High spatial resolution
C No radiation C Rapid acquisition
C 3D reconstruction
265

C Vessel wall calcification visible

C User dependent C High dose ionizing radiation C Not universally available C High dose ionzing radiation
C High level of training required (vascular C Difficult to interpret images of heavily C No information about vessel wall C Invasive
scientists) calcified vessels
Disadvantages C Static images difficult for non- specialists C Complications of contrast C Lengthy image acquisition Image quality C Complications of arterial puncture
to interpret degraded by movement
C Challenging in iliac and tibial arteries C Claustrophobia C Complications of iodinated contrast
C Prohibited at wound sites C Risk of nephrogenic systemic fibrosis
a
Sensitivity of detecting a >50% stenosis or occlusion as compared to DSA.
b
Specificity of detecting a >50% stenosis or occlusion as compared to DSA.

Table 2
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 VASCULAR SURGERY e I
density, which can sometimes be confused as contrast; this is
especially noticeable when imaging the abdomen and bowel
movement shows up as dense artefacts. With recent advances in
technology, some C-arms will be able to perform an on-table CT
scan, which can be especially useful during specific interventions
such as embolization or complex aortic aneurysm repair.
Clinical indications
DSA is performed most frequently when intervention is planned.
The diagnostic element confirms or adds to what has already
been imaged with either duplex, CT or MR (this is especially
important when there has been a delay between imaging and
intervention). Figure 13 shows the DSA of a patient with a
known occluded left iliac system and the subsequent treatment.
DSA is performed in a purely diagnostic capacity only when other
imaging techniques have been non-diagnostic. One example we
see not-infrequently in clinical practice is when heavily calcified
crural arteries are unable to be accurately imaged by CT or MR
and a target vessel for surgical bypass needs to be identified; a
diagnostic antegrade angiogram can accurately delineate the
anatomy of the run-off vessel and the pedal arch. Angiography
also remains the gold standard for imaging digital vessels,
important in diagnosis for vasculitis or very distal arterial
disease.
Advantages of DSA
As the gold standard imaging technique, as clinicians we can rely
on its sensitivity and specificity above all other imaging modal-
ities. It is the imaging technique with the highest spatial
resolution.
Limitations of DSA
By the very nature of this modality, it is invasive and requires
intra-arterial puncture to gain intraluminal access for contrast
injection. Unless being performed under general anaesthetic,
patients need to be compliant; they need to lie stationary during
the procedure and lie flat for up to 4 hours post procedure. This
often is difficult for elderly patients who have cardiac or respi-
ratory problems.
Because of its invasive nature there is more potential for
harm. Complications can occur at the puncture site (groin hae-
matoma, pseudo-aneurysm) or in the artery itself (flow-limiting
dissections, vessel occlusion, arterial rupture, distal emboliza-
tion). Major amputation following peripheral endovascular
intervention in patients with chronic limb-threatening ischaemia
(CLTI) is a very real risk at just over 2%.14
In addition, DSA carries the risks associated with adminis-
tration of iodinated contrast (see the section on CT). Carbon di-
oxide can be used as an alternative as a negative contrast agent,
but image quality is usually compromised, especially below the
knee. It is contraindicated in cerebral, thoracic and cardiac
angiography due to its potential neurotoxic and cardiotoxic
effects.15
Summary
Imaging is such a key part of diagnosis and management in the
vascular patient and to be a successful vascular department there
need to be well established and close working relationships
with radiographers, vascular scientists and interventional
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radiologists. Table 2 summarizes the merits of each imaging
modality.2 A
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266 Ó 2021 Published by Elsevier Ltd.
 VASCULAR SURGERY e I

Practice points

C Duplex is the first line diagnostic imaging for peripheral arterial

and venous disease.
C When reviewing CT angiograms, be sure to view them on the bone
windows to enhance contrast resolution and allow easy differ-
entiation between intimal calcification and luminal contrast
C Although recommended as a second line imaging modality, MRA
is more expensive, less readily available and more time
consuming than CTA
C Catheter angiography should be reserved for patient treatment
and intervention and should not be used as a diagnostic modality
on a routine basis
C Engage in clinical discussions with your diagnostic and inter-
ventional radiologists to optimize patient diagnosis and
management

SURGERY 39:5 267 Ó 2021 Published by Elsevier Ltd.

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