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Methods of imaging
Imaging of peripheral arteries depends upon pulsating arterial wall which is more
hyperechoic than venous wall. Arteries are usually displayed in longitudinal section.
Localising occlusions and stenosis is the aim.
Colour doppler
Normal arteries show good wall to wall colour flow. Colour flow aliasing is seen in areas
of stenosis. No colour flow is identified in cases of occlusion due to thrombosis.
Collaterals are searched for.
Pulsed doppler
Assessment of the spectral waveform, peak systolic velocities, phasicity and difference in
the spectra of adjacent segments are all informative about the status of blood flow.
PATHOLOGY
ATHEROSCLEROSIS
More common in lower limb arteries than in upper limb.
Prevalence increases as age increases.
PAD due to atherosclerosis is at least as common as CAD.
More common and severe in patients with diabetes.
Calf arteries are more severely affected in diabetics.
EMBOLIC OCCLUSIONS
ANEURYSMS/PSEUDOANEURYSMS
TRAUMA
VASCULITIS
ARTERIAL DISSECTIONS
ARTERIOVENOUS FISTULAS
Importance of duplex:
1] Confirm atherosclerotic changes
2] Differentiate significant stenotic lesions from hemodynamically nonsignificant ones
3] Assessment of perivascular masses (hematoma Vs pseudoaneurysm)
Power Doppler:
It is the summation of Doppler signals caused by moving blood.
Advantages—
1] No aliasing
2}Less angle dependent
3}Slowly moving blood more easily picked up.
Disadvantages:
1}No directional information
EXTREMITY FLOW PATTERN:
Table:
Summary of measurements and indexes for assessment of lower extremity
arterial disease.
Parameter Interpretation
Ankle systolic pressure Normally exceeds brachial systolic pressure by
about 10%.
Ankle-brachial index Normally >1.0 (values >0.90 typically interpreted
as normal.
High-thigh systolic Normally 30-40mm Hg > brachial systolic
pressure pressure.
Thigh-brachial index Normally > 1.2.
Segmental pressure Normally <20mm Hg between adjacent levels on
gradients the same leg or the same levels on the two legs.
Toe systolic pressure Normally 80-90% of brachial systolic pressure.
Treadmill exercise test Normal walking time 5.0min without symptoms or
drop in ankle systolic pressure ( 2mph, 12%
grade).
NORMAL—0.91-1.30
MILD OBSTRUCTION—0.70-0.90
MODERATE OBSTRUCTION—0.40-0.90
SEVERE OBSTRUCTION-- <0.40
DUPLEX STUDIES:
Post stenotic turbulence and presence of bruit at the site of stenosis suggest >50%
narrowing.
Peak systolic velocity ratio = PSV at stenotic site/PSV 2-4 cm proximal to it.
RATIO STENOSIS
2 or more 50%
3 or more 75%
4 or more > 75% (critical stenosis)
LOWER EXTREMITY ARTERIES:
TABLE :
Probes used:
Sector probe for iliacs.
Linear probe for thigh and calf arteries.
D) Aneurysms
TABLE :
Probes used:
Arm arteries 8-12 mhz
Area near clavicle 3-8 mhz
Digital arteries 10-15 mhz
A) Thoracic outlet syndrome:
Subclavian artery, vein and brachial plexus has to pass through three naturally narrow
points—anterior scalene muscle, clavicle and cervical rib. This can lead to functional
stenosis.
Disappearance of pulse on abducting the arm is seen as Doppler signal going flat in the
subclavian artery.