PERIPHERAL ARTERIAL DOPPLER

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

BASIC PRINCIPLES OF PERIPHERAL ARTERIAL DOPPLER

Peripheral arteries lie at depths of 6 cm or less. Hence use of >5mhz transducers is ideal.
Duplex studies combine both grey scale and colour Doppler.

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:

High resistance muscular bed allows less diastolic flow.

Triphasic waveform: strong forward flow during systole, short reversal during diastolic,
low amplitude forward flow during late diastole. This is the normal pattern.

At the stenotic site—very high peak systolic velocities.

Proximal to it—low velocity, high resistance, biphasic flow

Distal to it—low velocity, low resistance, monophasic pattern

A-V fistula—low resistance, high velocity, monophasic flow.

Pseudoaneurysms—biphasic, “ying-yang” pattern.

Noninvasive assesment of peripheral arteries

Diagnostic Tools:
1) Pulse volume recordings and segmental pressures
2) Continuous wave doppler
3) Plethysmographic sensors to detect digital flow
4) Duplex studies.

Table:
Summary of measurements and indexes for assessment of lower extremity
arterial disease.

Parameter
Ankle systolic pressure
Ankle-brachial index
High-thigh systolic
pressure
Thigh-brachial index
Segmental pressure
gradients
Toe systolic pressure
Treadmill exercise test
Interpretation
Normally exceeds brachial systolic pressure by
about 10%.
Normally >1.0 (values >0.90 typically interpreted
as normal.
Normally 30-40mm Hg > brachial systolic
pressure.
Normally > 1.2.
Normally <20mm Hg between adjacent levels on
the same leg or the same levels on the two legs.
Normally 80-90% of brachial systolic pressure.
Normal walking time 5.0min without symptoms or
drop in ankle systolic pressure ( 2mph, 12%
 grade).

ANKLE BRACHIAL INDEX:

Ratio of systolic B.P. at the ankle/ systolic B.P. in the arm.

The method is reasonably accurate and reproducible. It requires a 5 to 10 mhz doppler
probe and a blood pressure cuff.

Diagnostic criteria for PAD based on ABI:

NORMAL—0.91-1.30
MILD OBSTRUCTION—0.70-0.90
MODERATE OBSTRUCTION—0.40-0.90
SEVERE OBSTRUCTION-- <0.40

POORLY COMPRESSIBLE IF >1.30.this renders ABI alone insufficient for assessing

stenotic lesions.

DUPLEX STUDIES:

Qualitative grading of stenotic lesions:

1-19% (minimal wall lesions)—spectral broadening alone

20-49%-- increased PSV >30% but <100% + preserved diastolic reversal
50-99% (critical stenosis)—increased PSV >100%
Total occlusion—no flow

Post stenotic turbulence and presence of bruit at the site of stenosis suggest >50%
narrowing.

Quantitative grading of stenotic lesions:

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 :

Peak systolic velocities ( Lower extremity)

100 + 20 Abdominal Aorta
119 + 22 Common / external iliac
114 + 25 Common femoral artery
91 + 14 Proximal superficial femoral artery
94 + 14 Distal superficial femoral artery
69 + 14 Popliteal artery

Probes used:
Sector probe for iliacs.
Linear probe for thigh and calf arteries.

Vascular/Perivascular masses and complications:

A) Synthetic bypass grafts:

B) Masses (Pseudoaneurysm Vs hematoma):

C) Graft occlusion and stenosis:

D) Aneurysms

UPPER EXTREMITY ARTERIES:

TABLE :

PSV ( Upper Extremity)

SCA / Axillary artery 70 – 120cm/sec.
Brachial artery 50 – 100cm/sec.
Radial / Ulnar artery 40 – 90cm/sec.

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.

B) Vertebral to subclavian steal:

Tight stenosis in SCA proximal to ipsilateral VA.
Insufficient blood flow through the stenosis causes subclavian to steal blood from
contralateral VA.
Retrograde and undulating flow in the affected VA.
Significant pressure difference in the two arms ( 20 mm hg or more lower in affected
arm).

C) Dialysis access grafts and fistulas:

Sources of error in doppler studies:

Pelvic gas shadows
Inappropriate incident angle
Improper identification of arteries
Hematoma and obesity
Plaque echogenecity
Multiple stenotic segments
Collaterals mimicking original artery

Precision of colour doppler:

Comparable to DSA
Exact localisation and length measurement in 95% cases.
The sensitivity of detecting occlusions is 98%.
Excellent non invasive method in symptomatic patients to decide on further management.