Ultrasound in Med. & Biol., Vol. 24, No. 2, pp.

169 –176, 1998

Copyright © 1998 World Federation for Ultrasound in Medicine & Biology
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● Historical Review

A BRIEF HISTORY OF DOPPLER ULTRASOUND IN THE DIAGNOSIS

OF PERIPHERAL VASCULAR DISEASE

BERNARD SIGEL
Department of Surgery, Allegheny University of the Health Sciences, MCP-Hahnemann School of Medicine,
3300 Henry Avenue, Philadelphia, PA 19129 USA

(Received 23 June 1997; in final form 6 October 1997)

Abstract—The history of Doppler ultrasound in peripheral vascular diagnosis is considered in terms of basic
developments, clinical applications and impact on medical practice. Many early developments occurred at Osaka
University in Japan and the University of Washington in the United States. Through progressive steps, Doppler
ultrasound technology has provided clinical applications in blood-flow sensing, waveform analysis, localizing blood
flow and two-dimensional (2-D) mapping of blood flow. An important advance was the development of duplex and
color Doppler scanning. Real time velocity measurements and flow mapping have led to many clinical applications.
Two important applications have been detection and grading of atherosclerotic plaques in the internal carotid artery
and the diagnosis of deep venous thrombosis. Doppler ultrasound is the preferred noninvasive imaging method for
each of these clinical problems. The recent reaffirmation of carotid endarterectomy as the appropriate management
for certain categories of carotid atherosclerotic occlusive disease has led to guidelines for selecting patients for carotid
endarterectomy. New Doppler ultrasound criteria are being developed to identify categories of stenosis that relate to
these guidelines. The establishment of Doppler ultrasound has led to training programs for technologists and
physicians, certification of technologists and establishment of standards and quality control measures for vascular
laboratories. © 1998 World Federation for Ultrasound in Medicine & Biology.

Key Words: Doppler ultrasound, History, Review.

INTRODUCTION instrument systems. I will only minimally retrace their

The rapid growth of medical ultrasound prompted the
World Federation of Ultrasound in Medicine and Biol-
ogy and the American Institute of Ultrasound in Medi-
cine to compile a history of medical ultrasound. This
review is part of that project, with the task of covering
developments in the history of Doppler ultrasound.
Doppler ultrasound today is established in medical
imaging. The number of Doppler ultrasound publications
cited by the National Library of Medicine MEDLINE
[database online] service in the United States starting in
1966 (10 y after the introduction of medical Doppler
ultrasound) to June 1997 is 5557. This constitutes 15% of
all medical ultrasound references. Of all Doppler ultra-
sound publications during this interval, 77% appeared
between 1987 and 1997 (June).
A history of Doppler ultrasound should cover basic
developments, clinical applications and impact of Doppler
ultrasound on medical practice. The basic developments in
Doppler ultrasound have been presented in excellent re-
views by Wells and Skidmore (1985) and White (1992),
who considered physical principles and development of
account to provide a basis for reviewing the clinical aspects
of Doppler ultrasound. I will emphasize clinical applica-
tions and the impact of Doppler ultrasound on medical
practice. Furthermore, I will deal primarily with peripheral
(including extracranial cerebral) vascular uses of Doppler
ultrasound, because cardiac and obstetrical applications are
better considered in context with other ultrasound technol-
ogies in these fields.
White’s review appeared at a time of controversy
regarding the effectiveness of carotid endarterectomy to
remove stenosis-producing plaques. The outcome of this
controversy would significantly effect Doppler ultra-
sound because Doppler carotid studies had become the
preferred means of screening for carotid occlusive dis-
ease. The controversy has now largely been resolved and
its effect upon Doppler ultrasound imaging will be ex-
amined.
EARLY DEVELOPMENTS
Doppler ultrasound in medical diagnosis began with
the work of Shigeo Satomura at Osaka University, Japan

169
170 Ultrasound in Medicine and Biology
(Satomura et al. 1956). Satomura and his associates, in
their initial paper, reported the Doppler ultrasound de-
tection of heart wall motion using 3-MHz ultrasound
signals. In a revealing background account, Kaneko
(1986) described how Satomura and his associates fur-
ther developed Doppler methodology by pursuing three
applications. These were to study heart movement (Yo-
shida et al. 1956; Satomura 1957; Satomura et al. 1960;
Yoshida et al. 1961), pulsatility of the eye ball (Suzuki
and Satomura 1958) and flow in peripheral vessels (Sato-
mura et al. 1958; Satomura 1959; Satomura and Kaneko
1960). The peripheral vascular work indicated that blood
flow in peripheral arteries and veins could be detected
transcutaneously and that the frequency of the reflected
waves was proportional to the velocity of the blood flow.
Doppler signal differences from carotid and extremity
arteries were noted and the potential for using the meth-
odology to study artherosclerotic arteries was suggested.
The initial reports attributed the reflection of waves from
flowing blood to turbulent flow. However, Kato et al.
(1962) showed that Doppler signals were from moving
red cells, with their frequency related to velocity and
their output voltage related to the number of red cells.
Kaneko et al. (1965) found that spectrum analysis pro-
vided the best means for analyzing Doppler signals. A
directional Doppler flowmeter was developed by Kato
and Izumi (1966). Much of the effort of the early Japa-
nese investigators was to study the extracranial cerebral
arteries (Kaneko 1986). This work led to a demonstration
that Doppler signals from the carotid arteries of patients
with atherosclerosis differed from signals obtained from
healthy subjects (Kaneko et al. 1961). Thus, in a short
period of time, Japanese investigators had applied the
Doppler principle to ultrasonic examination of the heart
and arteries, performed noninvasive monitoring, identi-
fied clinical applications, explained the mechanism of
blood flow detection, applied sound spectrum analysis
and developed directional flow detection.
In the United States, Dean Franklin, working in the
laboratory of R. F. Rushmer at the University of Washing-
ton, was employing ultrasound to study cardiovascular dy-
namics by developing a transit-time recorder (Franklin et al.
1959). In a letter to J. H. Holmes (August 26, 1980),
Rushmer credits Franklin with the idea of using the Doppler
shift principle. Franklin developed a system and described
the detection of blood flow with Doppler ultrasound (Frank-
lin et al. 1961), apparently unaware of the previous studies
done by Japanese investigators. Rushmer attracted a num-
ber of investigators in Doppler ultrasound. These included
D. W. Baker and D. E. Strandness, Jr. Baker, an engineer,
was highly productive in instrument development and the
transfer of information to industry. A timely and effective
transfer of research information facilitated the development
and production of instruments that enabled clinicians to use
Volume 24, Number 2, 1998
and discover new applications. Strandness, a surgeon, rec-
ognized the potential of Doppler ultrasound in the evolving
new field of vascular surgery. He became an early clinical
investigator and brought Doppler methodology to the atten-
tion of surgeons interested in vascular diseases. The avail-
ability of simple-to-operate continuous-wave devices drew
immediate interest for clinical applications. This led to the
use of these initial Doppler units to provide early detection
of fetal heart sounds (Bishop 1966; Bernstine and Callagan
1966). Doppler ultrasound measurement of blood flow in
peripheral vessels was described by Strandness et al. (1966,
1967), who demonstrated differences in the waveforms
between normal and atherosclerotic arteries and described
venous flow signals. The University of Washington group
was highly productive in instrument development and ap-
plication of Doppler as a noninvasive means of peripheral
vascular diagnosis. A directional Doppler system was de-
veloped by McLeod (1967) and employed by Strandness et
al. (1969). Most importantly, the work of the Washington
group with industry led to clinical instruments that could be
used in an office or at the bedside. Members of this group
became pioneers in the development of pulsed-wave and
duplex scanners (discussed below).
An important impetus for Doppler methodology
development was the rapid growth of reconstructive pe-
ripheral vascular surgery during the 1950s and early
1960s. Grafting procedures to replace or bypass diseased
artery segments and endarterectomy to remove luminal
structures were gaining wide acceptance in the treatment
of the complications of atherosclerosis. In the early days
of vascular surgery, the stethoscope, sphygmomanome-
ter and plethysmography were still the main noninvasive
tools for evaluating patients with peripheral vascular
disease. These instruments could neither effectively de-
tect and quantitate occlusive atherosclerotic disease nor
evaluate venous disease. Before reconstructive vascular
surgery, prompt and effective vascular testing was not a
pressing issue. The situation changed with the rapid
development of vascular surgery. Doppler flow detection
was quickly recognized as a potentially useful technique
for diagnostic evaluation, and became the subject of
active investigation.
Nondirectional continuous-wave Doppler was the
initial methodology in peripheral vascular diagnosis. Al-
though still very important today, further advances in
instrumentation occurred as a result of clinical need.
Clinicians wanted tools that not only could provide pre-
cise blood flow information, but also relate blood flow to
anatomic structures. The limitations of continuous-wave
Doppler systems soon became apparent and stimulated
development of pulsed-wave, duplex and color Doppler
instruments. How these developments related to clinical
interests are considered in terms of the progressive ap-
plications of Doppler ultrasound: blood-flow sensing,
 Doppler ultrasound in vascular disease ● B. SIGEL 171

waveform analysis, localizing blood flow, and 2-D map- ferent waveforms than normal arteries. Thus, two impor-
ping of blood flow. tant determinants of arterial waveforms were discovered
that related to the type of end-organ (skeletal muscle or
BLOOD-FLOW SENSING visceral tissue) and vessel wall disease.
The development of directional Doppler instru-
The earliest systematic clinical applications of
ments by Kato and Izumi (1966) and McLeod (1967)
Doppler ultrasound were by Satomura and Kaneko
permitted a clearer distinction of reverse flow in arteries
(1960) and Strandness et al. (1966, 1967), to sense the
and veins. Directional Doppler measurements enabled a
presence of blood flow in arteries and veins transcutane-
more precise evaluation of waveforms (Nimura et al.
ously.
1974). Analyses of waveform pulsatility have been used
In arteries, blood-flow detection by Doppler ultra-
in assessing distal resistance. Simple indices derived
sound permitted the measurement of systolic blood pres-
from the waveforms defined resistance (Pourcelot 1975)
sure. Yao et al. (1968) showed that ankle blood pressures
and pulsatility (Gosling and King 1974) in quantitative
were reduced and arterial waveforms abnormal in ath-
terms.
erosclerosis. The ratio of the ankle-to-brachial artery
The use of spectrum analysis to display Doppler
blood pressures was found by Carter (1969) to be an
frequency shift signals not only provided the best means
effective means of assessing and following the course of
of measuring blood-flow velocity and, also, information
arterial insufficiency.
about the presence of disturbed flow. Green (1964) pro-
In veins, blood-flow detection was more difficult
posed that turbulence could be a cause of spectral broad-
because the slower flow velocities produced lower fre-
ening. The ability of spectrum analysis to distinguish
quency shifts. Doppler signals from slow-flowing blood
laminar from turbulent flow was shown experimentally
were nearer to the noise level and, consequently, largely
(Sigel et al. 1970) and applied in patients with carotid
filtered out by most continuous-wave instruments. This
artery stenosis (Felix et al. 1976). Initially, spectrum
limitation was overcome by enhancing venous flow tran-
analysis required off-line analysis. The development and
siently by the use of augmentation maneuvers (Sigel et
application of real-time spectrum analyzers significantly
al. 1967; Sumner et al. 1968; Evans and Cockett 1969).
facilitated its use in clinical diagnosis (Barnes 1979;
Augmented venous-flow signals permitted the detection
Rittgers et al. 1980).
of obstruction due to deep venous thrombosis and the
recognition of venous valve incompetence.
Continuous-wave Doppler instruments have been LOCALIZING BLOOD FLOW
miniaturized to permit easy transportability and are used
A major limitation of the initial Doppler velocity
as peripheral vascular ‘‘stethoscopes.’’ They are applied
detectors was the inability to identify the exact location
extensively in pediatric and critical care medicine and in
of moving reflectors that produced Doppler signals. The
vascular laboratories to determine blood pressure. Dopp-
depth of a blood vessel could not be determined. Nor was
ler determination of segmental systolic blood pressure
it possible to distinguish varying flow velocities in large
continues to be an important means for evaluating the
vessels and to relate them to their location within the
circulation in the lower extremities. Doppler ultrasound
vessel lumen. Instruments were needed that could effec-
was found to be capable of detecting air emboli (Gillis et
tively measure velocities at specific ranges and display
al. 1968; Spencer et al. 1969a), and has proven to be
profiles across the lumen of a blood vessel. The result
useful in monitoring during open-heart surgery (Spencer
was the development of pulsed-wave Doppler instru-
et al. 1969b) and certain neurosurgical procedures (Ma-
ments. Many investigators were involved in this en-
roon et al. 1969).
deavor. Baker and Watkins (1967) gated a continuous
signal to produce pulses that permitted range detection of
WAVEFORM ANALYSIS
Doppler signals. Single-channel pulsed systems were
An early means of recording Doppler signals was developed by Peronneau and Leger (1969); Flaherty and
by the use of zero-crossing detectors and spectrum anal- Strouts (1969); Wells (1969); Baker (1970); and McLeod
ysis. This enabled the recording of waveforms and as- (1967).
sessment of relative blood flow velocities. Pulsed-wave Doppler enabled transcutaneous deter-
The earliest recordings of arterial Doppler signals mination of velocity profiles and the development of
demonstrated differences in the shape of waveforms. As transcranial Doppler studies (Aaslid et al. 1982). Trans-
mentioned above, internal carotid waveforms were dif- cranial Doppler methodology has the ability to measure
ferent from waveforms in arteries primarily supplying blood-flow velocity in basal intracranial arteries and is
skeletal muscle (Satomura and Kaneko 1960; Strandness being applied increasingly to detect stenosis, spasm and
et al. 1966, 1967). Atherosclerotic vessels showed dif- emboli (Newell and Aaslid 1992).
172 Ultrasound in Medicine and Biology
Pulsed-wave Doppler only partially overcame the
limitation to localize the source of Doppler shifted sig-
nals. Pulsed-wave Doppler only permitted localization of
blood flow in the range dimension. The next step in
localization would be to display Doppler information in
two dimensions and to relate this information to the
anatomy of vascular structures.
TWO-DIMENSIONAL MAPPING OF
BLOOD FLOW
Two-dimensional (2-D) mapping was a landmark
transition and established Doppler ultrasound as an im-
portant medical imaging technology. The development
of 2-D flow mapping by Doppler techniques occurred in
progressive steps. Pulsed-wave Doppler provided only
relative velocity information from a sampled volume at a
given range. To measure velocity in more absolute terms,
the angle of insonification in relation to the long axis of
the blood vessel must be known. This could be accom-
plished by referencing the Doppler sampling site to a 2-D
image of the blood vessel and identifying the long axis of
the blood vessel. Knowing absolute velocities could lead
to volume flow determination. However, there have been
many problems associated with this application (White
1992). Simultaneously acquiring velocity and anatomic
information could better demarcate the junction between
the vessel lumen and the vessel walls (Barber et al.
1974). B-mode can make this distinction in normal ves-
sels because of the marked echogenic differences be-
tween lumen and wall, although the presence of thrombi
or atherosclerotic plaques can make this distinction dif-
ficult. Doppler detection could determine whether junc-
tional tissue was flowing or stationary.
The issue, then, was to combine Doppler velocity
detection with B-mode imaging. There were problems in
achieving this objective. The effective combination of
Doppler and B-mode information had to await the de-
velopment of real-time B-mode instruments. The pulsed
signals usually used for B-mode are as brief as possible
and of relatively broad frequency bands. To use these
same signals for Doppler required that they be of longer
duration and narrower in frequency bandwidth. The in-
creased duration of the pulsed signal significantly re-
stricted the amount of depth resolution achievable for
flow detection.
Kelsey (1968) described an approach for using
Doppler with B-mode to help distinguish moving from
static structures. The first combination of Doppler and
real-time B-mode was described by Barber et al (1974),
who used real-time B-mode and referred to their instru-
ment as a ‘‘duplex’’ scanner.
Duplex scanning was widely applied in arterial and
venous diagnosis. In particular, duplex scanning had a
Volume 24, Number 2, 1998
significant impact on diagnostic screening for carotid
artery atherosclerosis and endarterectomy (the surgical
operation to remove stenosis-producing plaques from the
internal carotid artery). The reasons are related to an
awareness of the significance of carotid arteriosclerosis
and the effectiveness of surgery in stroke prevention.
Atherosclerotic occlusion of the carotid arteries was
recognized as a major cause of strokes and other isch-
emic cerebral problems by Fisher (1951). Endarterec-
tomy to remove high-risk plaques was introduced in the
1950s (Eastcott et al. 1954). The operation became
widely applied. The number of carotid endarterectomies
performed in the United States increased from 15,000 in
1977 to 107,000 in 1985 (Pokras and Dyken 1988).
Radiographic arteriography was the means by which
stenotic carotid plaques could be diagnosed and graded
in terms of their severity. Arteriography became the
means for selecting patients for surgical operations.
However, cerebrovascular arteriography was associated
with a small, but significant, occurrence of stroke and
death. Consequently, noninvasive approaches were
sought to select patients with potential carotid occlusive
disease for radiographic arteriography and possible sur-
gery. Direct examination of the carotid arteries by B-
mode ultrasound could detect plaques, but was not ef-
fective in determining the degree of stenosis with suffi-
cient accuracy (Ricotta et al. 1987). Innovative Doppler
techniques were developed to map blood flow by dis-
playing contiguous sites within a vessel lumen in 2-D
(Mozersky et al. 1971; Reid and Spencer 1972; Fish et al.
1972; Blackwell et al. 1977). These techniques, using
pulsed-wave and continuous-wave Doppler signals, were
limited by problems in extracting and displaying multi-
ple Doppler signal samples simultaneously in 2-D and in
grading stenosis accurately. An indirect Doppler exami-
nation was developed (Maroon et al. 1970) to screen
patients for internal carotid stenosis. However, this ap-
proach was insensitive to stenosis of less than 75%
(Barnes et al. 1982) and could not distinguish marked
stenosis from total occlusion or establish the location of
the stenotic site. The availability of duplex scanning
offered a new direct approach for grading internal artery
stenosis.
Although the initial rationale for performing duplex
scanning in atherosclerotic disease was to better demar-
cate the interface between the lumen and arterial wall
containing plaque deposits (Barber et al. 1974), the Uni-
versity of Washington group addressed the problem of
stenosis quantitation by means of absolute velocities
with Doppler measurements. Strandness et al. (1967)
demonstrated increased velocity signals from stenotic
segments of arteries. Brinker et al. (1968) showed that
Doppler ultrasound could noninvasively detect increased
velocity at a stenotic site in the internal carotid artery.
 Doppler ultrasound in vascular disease ● B. SIGEL
Duplex scanning made it possible to quantitate velocities
in the stenotic sites and to measure velocities up- and
down-stream to the stenosis. From the velocity informa-
tion, an accurate measure of stenosis was achieved that
correlated well with radiographic arteriography (Barnes
et al. 1976; Blackshear et al. 1979, 1980; Fell et al.
1981). The demonstration that carotid stenosis could be
more accurately measured by Doppler velocity rather
than by vessel diameter was an important advance. The
effectiveness of Doppler velocity measurements to grade
the degree of stenosis was quickly recognized and widely
adopted as the preferred means of screening for athero-
sclerotic occlusive disease in the carotid arteries. Greater
experience with carotid duplex scanning increased inter-
est in employing the examination, not only for screening,
but also as a means of making a definitive diagnosis.
Duplex scanning has been proposed as a definitive test to
replace contrast arteriography under certain conditions
(Chervu and Moore 1994).
The recognized usefulness of duplex scanning led to
further endeavors to improve 2-D Doppler imaging. Du-
plex scanning permitted the measurement of absolute
velocities in an anatomically defined, but relatively
small, sample volume. There was renewed interest in
obtaining 2-D flow mapping of larger regions and to
clearly display flow information in relation to blood
vessel walls and surrounding structures.
Duplex scanning showed vessel walls and surround-
ing structures in 2-D, but flow information was based on
selective sampling. Unless an operator knew where to
sample the B-mode image, important flow information
could be missed. To provide a full field scanning capa-
bility of both flow and structure, displaying Doppler
information simultaneously throughout the entire vessel
lumen would be needed. The interest in developing such
a capability led to color Doppler imaging.
A color Doppler imaging system using continuous
wave signals was described by Curry and White (1978),
in which regions with moderately and highly increased
flow velocity were distinguished by color coding from
normal flow-velocity regions. Color Doppler imaging
systems that could show the direction and velocity of
flow simultaneously through the vessel lumen in real-
time were developed (Brandestini 1978; Eyer et al.
1981). Such systems provided a full area view of Dopp-
ler flow and enabled the selection and measurement of
absolute velocities at specific sites.
IMPACT ON MEDICAL PRACTICE
The establishment of duplex and color scanning as
a means to detect and grade carotid stenosis occurred at
a time when the effectiveness of carotid enderterectomy
surgery became controversial. How this would be re-
173
solved would significantly influence Doppler imaging.
The controversy arose because of reported high stroke
and mortality rates after carotid endarterectomy at com-
munity hospitals in the United States during the 1970s
(Easton and Sherman 1977; Brott and Thalinger 1984;
Fode et al. 1986). Concern was expressed about the
appropriateness of carotid endarterectomy (Barnett et al.
1984; Chambers and Norris 1984). The number of ca-
rotid endarterectomies performed in the United States,
which had increased steadily to 107,000 in 1985,
dropped dramatically to 83,000 in 1986 (Pokras and
Dyken 1988). Matchar and Pauker (1987) examined data
from multiple published reports and concluded that the
appropriateness of surgery was related to surgical risk,
surgical efficacy and future stroke risk. Prospective clin-
ical trials were proposed to determine under what cir-
cumstances carotid endarterectomy would be beneficial
(Jonas 1986). Such trials were established in North
America and Europe. Their results, reported in 1991,
(ECSTCG 1991; NASCETC 1991) concluded that symp-
tomatic patients with 70 to 99% stenosis derived signif-
icant benefit from the operation.
These reports led to new proposed guidelines for
performing carotid endarterectomy (Moore et al. 1995).
The guidelines considered the degree of stenosis, as well
as other factors, such as documented low operative mor-
bidity and mortality rates of individual surgeons and the
type and extent of patient’s diseases and stroke risk.
The demonstrated benefits of carotid endarterec-
tomy appear to have increased the number of carotid
endarterectomies. The fall in rate of carotid endarterec-
tomies that started after 1985 showed a sharp upturn in
1992 (Gillum 1995).
With the reconfirmation of the utility of carotid
endarterectomy, Doppler ultrasound velocity criteria are
being established to meet the categories of stenosis rel-
evant to the North American and European trials (Mo-
neta et al. 1993; Neale et al. 1994; Faught et al. 1994).
Color Doppler imaging has been a clinically useful
tool for blood-flow mapping. Color Doppler is proving to
be more effective than gray-scale duplex scanning in
several respects. Small blood vessels and narrowed chan-
nels through partially occluded large blood vessels can
be identified more rapidly and with greater certainty.
Tortuous arteries can be tracked more readily. Filling
defects within the lumen of blood vessels can be recog-
nized more easily. The latter advantage has improved
accuracy in the diagnosis of deep venous thrombosis.
Acute deep venous thrombosis of the lower extrem-
ities is a common disorder with no or nonspecific symp-
toms. A review of the literature by Comerota et al.
(1993) found a high sensitivity for gray-scale duplex
scanning in proximal lower limb thrombosis, and lower
sensitivity in calf vein thrombosis, in symptomatic pa-
174 Ultrasound in Medicine and Biology
tients. The accuracy was much less in asymptomatic
patients. These results appeared to be improved with
color Doppler imaging. Laissy et al. (1996) compared
color Doppler and magnetic resonance venography to
radiographic contrast venography in a small series of
patients. They found no significant differences in accu-
racy between the two noninvasive techniques for proxi-
mal lower extremity, but magnetic imaging was more
accurate in detecting thrombus extension. Color Doppler
imaging currently is becoming the preferred noninvasive
test for deep venous thrombosis.
New techniques are being developed to study blood
flow in relation to structure. Power Doppler imaging is
generating considerable interest and has the potential for
many clinical applications (Rubin et al. 1994). Power
Doppler flow mapping is being investigated as a means
of evaluating carotid artery stenosis (Griewing et al.
1996; Steinke et al. 1996).
OVERVIEW
In just over 40 y, Doppler ultrasound has progressed
from the discovery of a methodology to its establishment
as a major clinical diagnostic tool. The rapid develop-
ment of Doppler ultrasound in peripheral vascular diag-
nosis was significantly related to the need for effective
noninvasive diagnostic tests to evaluate patients with
atherosclerosis. This need was accentuated with the ad-
vent of new vascular surgical procedures and the devel-
opment of reconstructive vascular surgery as a specialty.
Doppler-determined segmental pressures became a stan-
dard means for assessing lower extremity atherosclerotic
occlusive disease. A major objective of research was to
develop an ultrasound test that could find and grade
stenosis in the carotid artery. Work toward this objective
was largely responsible for the clinical development of
pulsed-wave, duplex and color Doppler imaging. Duplex
and color Doppler imaging were found to be highly
effective and are now widely accepted as the preferred
noninvasive tests for carotid screening. The perceived
utility of duplex and color Doppler imaging in carotid
studies created a demand for scanning instruments and
trained personnel. Instrument manufacturers provided an
extensive assortment of gray-scale and color duplex
scanners. Training programs for vascular surgeons began
to include experience in performing ultrasound examina-
tions. Formal training courses and certifying procedures
were established for technologists. There has been a
proliferation of vascular laboratories that use Doppler
ultrasound as the principal means of testing. Although
the exact figures are not known, it is estimated that, in the
United States, there are currently between 10,000 and
20,000 sites using imaging ultrasound instruments for the
diagnosis of vascular disease. To establish standards and
Volume 24, Number 2, 1998
maintain quality control, several societies representing
radiologists, neurological surgeons, cardiologists, vascu-
lar surgeons and technologists have organized the Inter-
societal Commission for Accreditation of Vascular Lab-
oratories. This organization provides inspection for ac-
creditation upon request. Although the process is
voluntary, insurance providers are now beginning to
require such accreditation.
The aggregation of instruments and trained person-
nel within vascular laboratories has led to new tech-
niques of vascular testing. Procedures for upper and
lower extremity arterial and venous examinations, graft
surveillance, abdominal studies, sapheneous vein map-
ping and retroperitoneal assessment have been developed
as physicians and technologists have gained increased
experience with Doppler ultrasound. Because of its
proven benefit, safety and cost-effectiveness, Doppler
ultrasound is likely to make more significant contribu-
tions to medical imaging.
Acknowledgements—Dr. Barry Goldberg made available material from
the Archives Committees of the American Institute of Ultrasound in
Medicine and the World Federation of Ultrasound in Medicine and
Biology. This included correspondence from R. F. Rushmer, D. W.
Baker and D. E. Strandness, Jr.
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