1. Doppler ultrasound of lower limb arteries
Samir Haffar M.D.
Assistant Professor of internal medicine

2. Doppler US of lower limb arteries
 Anatomy of lower limb arteries
 Normal Doppler US of lower limbs arteries
 Duplex US criteria for arterial evaluation
 Causes of lower limb arterial diseases
 Doppler US of bypass graft

3. Anatomy of abdominal aorta & its branches
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
• Lies to left of midline
• Inferior vena cava to its right
• Extends from L1 to L4
• Gives visceral branches
• Gives phrenic & lumbar branches

4. Anatomy of iliac artery
CIA (4 – 5 cm long)
From L4 to sacroiliac joint
Divides into IIA & EIA
Left to corresponding CIV
EIA (twice long of CIA)
Superficial to corresponding vein
Gives inferior epigastric artery
Becomes CFA at inguinal ligament
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.

5. Anatomy of femoral & popliteal arteries
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
Common femoral artery (4-6 cm long)
Lies superficially in the groin
Divides to SFA & PFA
Superficial femoral artery
Extends down medial thigh
Passes deep through adductor hiatus
Popliteal artery
Commences below adductor hiatus
Passes vertically through popliteal fossa
Divides to tibio-peroneal trunk & ATA

6. Anatomy of crural arteries
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
There are several interconnection
So that each artery can supply all regions

7. Normal diameter of lower limb artery
• Sub-diaphragmatic aorta 21 – 24 mm
• Infra-diaphragmatic aorta 17 – 20 mm
• Common iliac artery 10 – 12 mm
• External iliac artery 8 – 10 mm
• Common femoral artery 7 – 9 mm
• Superficial femoral artery 6 – 8 mm
• Popliteal artery 4 – 6 mm
Stiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.

8. Anatomical variations of lower limb arteries
May be occasionally encountered
Artery Variation
Aorta Duplication (very rare – duplication image artifact)
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
ATA High origin across knee joint
May be small or hypoplastic (2%)
Peroneal artery Origin from ATA rather than tibio-peroneal trunk
CFA bifurcation Bifurcation can sometimes be very high
EIA Aplasia with blood supply to leg via strong IIA

9. Duplicated aorta or duplication artifact
Meuwly JY et al. Ultraschall Med 2011 ; 32 : 233 – 236.
Duplication image artifact frequent in lower abdomen:
False cases of twin pregnancies
Double intra-uterine devices
Gray-scale US
Duplicated aorta
Color Doppler US
2 aortic lumen filled
with color
Tiny sliding probe to right
Only one lumen filled
with color

10. Doppler US of lower limbs arteries
 Anatomy of lower limb arteries
 Normal Doppler US of lower limbs arteries
 Duplex US criteria for arterial evaluation
 Causes of lower limb arterial diseases
 Doppler US of bypass graft

11. Arteries scanned in Doppler US of lower limbs
• Tibio-peroneal trunk
• Posterior tibial artery
• Anterior tibial artery
• Peroneal artery
• Dorsalis pedis artery
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
Aorta & the following arteries on both sides
• Common iliac artery
• External iliac artery
• Common femoral artery
• Profunda femoris artery
• Superficial femoral artery
• Popliteal artery

12. Normal wall of the artery
3 layers

13. Transducer positions for scanning AA
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
Sagittal or
longitudinal
Transverse
Coronal

14. Normal aortic bifurcation

15. Normal external iliac vessels
Transverse scan

16. Region of the groin

17. Normal SFA & PFA
Transverse view Longitudinal view

18. Region of adductor canal & popliteal fossa
Region of adductor canal is difficult to evaluate

19. Region of adductor canal & popliteal fossa
Distal superficial femoral vessels Normal popliteal vessels

20. Insonation of leg arteries
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
Posterior tibial artery
Peroneal artery
Medial approach
Anterior tibial artery
Anterolateral approach

21. Proximal
Normal anterior tibial artery

22. Normal posterior tibial vessels
Proximal Distal

23. Normal peroneal vessels
Longitudinal view Transverse view

24. Normal triphasic waveform of peripheral arteries
Arterial high resistance flow
Narrow frequency band
Steep systolic increase
Quick drop
Early diastolic reverse flow
(⅕ of systolic flow amplitude)
Late diastolic short forward flow
ABPI: Ankle Brachial Pressure Index
Stiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.

25. Normal PSV of lower limb arteries

26. Pulsatility index
Most commonly used of all indices
S: Systolic
D: Minimum diastolic
M: Mean
PI: S – D / M
Normal PI: 4 – 13 (average 6.7)
Depending on location of peripheral arteries

27. Factors influencing pulsed Doppler waveform
Complicate evaluation
• Cardiac pump function Cardiac insufficiency
• Aortic valve function Aortic stenosis/insufficiency
• Course of vessel Tortuosity
• Vessel branching
• Peripheral vascular resistance Peripheral inflammation
Polyneuropathy
Warm or cold extremity
Vaso-spastic disorders
Stiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.

28. Arterial monophasic flow
• Hyperemic (normal PSV& normal RT*)
Exercise
Fever
Downstream infection
Temporary arterial occlusion by blood pressure cuff
• Tardus-Parvus waveform (low PSV & longer RT)
Distal to severe stenosis or occlusion
* Rise time: Time between beginning of systole & peak systole

29. Hyperemic monophasic flow
Following exercise
Normal triphasic waveform
Normal DPA at rest
Monophasic hyperemic flow
Following exercise

30. Hyperemic flow
Phlegmon of foot
Monophasic waveform
Normal PSV
Normal rise time

31. Doppler US of lower limbs arteries
 Anatomy of lower limb arteries
 Normal Doppler US of lower limbs arteries
 Duplex US criteria for arterial evaluation
 Causes of lower limb arterial diseases
 Doppler US of bypass graft

32. Duplex US criteria for arterial evaluation
Anatomy (course, variants)
Vessel contour (aneurysm, stenosis)
Wall structures (calcification, plaque, cyst)
Pulsation (axial, longitudinal)
Perivascular structures (hematoma, abscess, tumor, muscle)
B-mode
Demonstration of flow
Flow direction
Flow pattern (laminar, turbulent)
Flow profile (monophasic, triphasic)
Flow velocity
Doppler
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.

33. Doppler US of lower limbs arteries
 Anatomy of lower limb arteries
 Normal Doppler US of lower limbs arteries
 Duplex US criteria for arterial evaluation
 Causes of lower limb arterial diseases
 Doppler US of bypass graft

34. Causes of arterial diseases
Atherosclerosis
Thrombosis or embolism
Aneurysm
Intimal dissection
Pseudo-aneurysm
Arterio-venous fistula
Arteritis
Entrapment syndrome
Cystic adventitial disease
Most common cause

35. Peripheral arterial disease
Fontaine & Leriche classification
Stage Complains
I Asymptomatic
II a
II b
Mild claudication
Moderate to severe claudication
III Ishemic rest pain
IV Ulcer or gangrene
Underdiagnosed & therefore undertreated disease

36. Ankle Brachial Pressure Index (ABPI)
Continuous wave Doppler (takes 10 - 15 min)
 Posterior
tibial artery
 Dorsalis
pedis artery
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
 Peroneal artery
Highest ankle pressure / highest brachial pressure

37. Grading arterial disease using ABPI
ABPI Comment
> 1.3 Falsely high value (suspicion of medial sclerosis)
0.9 – 1.3 Normal finding
0.75 – 0.9 Mild PAD
0.4 – 0.75 Moderate PAD
< 0.4 Severe PAD
ABPI: Ankle Brachial Pressure Index
Stiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.

38. ABPI in diabetics
Calcification of vessel walls
Beaded appearance of color flow
Ankle pressure 280 mmHg
Brachial pressure 120 mmHg
ABPI 2.3
Falsely elevated recordings in diabetic patients
Calcified & rigid arterial walls

39. Direct & indirect signs of stenosis
Proximal to stenosis
At site of stenosis
Distal to stenosis

40. Grading of lower limb artery stenosis
Flow pattern proximal to lesion
High resistance, low volume waveform
Characteristic shoulder on systolic downstroke
Due to pulse wave reflection from distal disease
Shoulder

41. Grading of lower limb artery stenosis
PSV at site of stenosis

42. Grading of lower limb artery stenosis
PSV ratio
Robbin ML et al. Ultrasound Clin 2006 ; 1 : 111 – 131.
Proximal: 2 cm proximal to stenosis
At stenosis : Same Doppler angle if possible

43. Grading of lower limb artery stenosis
PSV ratio

44. Grading of lower limb artery stenosis
Ranke scale
Left vertical line: Pre-stenotic PSV
Right vertical line: Intra-stenotic PSV
Middle vertical line: Degree of stenosis in %
Ranke C et al. Ultrasound Med & Biol 1992 ; 18 : 433 – 440.

45. Grading of lower limb artery stenosis
Effect of collaterals
Excellent collaterals
Poor collaterals
Absence of collaterals

46. Grading of lower limb artery stenosis
Flow pattern distal to lesion
Tardus: Longer rise time
Parvus: Low PSV
Severe stenosis or occlusion
Tardus-Parvus waveformDamping waveform
Increased systolic rise time
Loss of pulsatility

47. Lower limb arterial stenoses
Most common sites
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
 
Aorto-iliac: 25 %

Femoro-popliteal: 65%
Infra-popliteal: 10%

48. Stenosis of PFA / Aliasing

49. Grading of arterial stenosis
SFA:
PSV of A 69 cm/sec
PSV of B 349 cm/sec
B / A 349 / 69 = 5
> 80% diameter stenosis
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.

50. Two severe stenosis of SFA
2 severe stenoses demonstrated in SFA
Areas of color flow disturbance & aliasing (arrows)
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.

51. Calcified atheroma in SFA
Drop-out of color flow signal in parts of lumen
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.

52. Occlusion of the CIA
Occlusion in CIA
Reversed flow in IIA (blue) to supply flow to EIA (red)
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.

53. Arterial occlusion & collaterals
Short occlusion of mid-SFA (large arrow)
Large collateral at both ends of occlusion (small arrows)
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.

54. Diagnostic reliability of peripheral arterial disease
Systematic review – DSA as gold standard
Collins R et al. BMJ 2007 ; 334 : 1257 – 1266.
MRA CTA CDUS
No of studies 6 5 7
Sensibility
Median (range)
94%
(85 – 100)
97%
(89 – 100)
90%
(74 – 94)
Specificity
Median (range)
99.2%
(97 – 99.8)
99.6%
(99 – 100)
99%
(96 – 100)

55. Causes of arterial diseases
Atherosclerosis (most common cause)
Thrombosis or embolism
Aneurysm
Intimal dissection
Pseudo-aneurysm
Arterio-venous fistula
Arteritis
Entrapment syndrome
Cystic adventitial disease

56. FA lumen filled with hypoechoic thrombus or embolus
Good delineation of vessel wall without signs of plaque
Normal flow in adjacent FV
Hamper UM et al. Radiol Clin N Am 2007 ; 45 : 525 – 547.
Thrombosis or embolism / Femoral artery

57. Causes of arterial diseases
Atherosclerosis (most common cause)
Thrombosis or embolism
Aneurysm
Intimal dissection
Pseudo-aneurysm
Arterio-venous fistula
Arteritis
Compression syndrome (entrapment syndrome)
Cystic adventitial disease

58. Definition of aneurysm & ectasia
Aneurysm
Diameter increase > 50% of normal expected diameter
Ectasia
Diameter increase < 50% of normal expected diameter
Considerable variability in normal diameter of arteries
Depends on physical size, sex, & age
Johnston K W et al. J Vasc Surg 1991; 13:452 – 458.

59. Types of aneurysm
True aneurysm
False aneurysm
Dissecting aneurysm

60. Common sites for lower limbs aneurysms
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.

61. Abdominal Aortic Aneurysm (AAA)
• Normal size of abdominal aorta 1.5 – 2.5 cm
• Ectatic aorta 2.5 – 3 cm
• Aortic aneurysm > 3 cm
• Annual growth rate of aneurysms 0.33 cm/year
measuring between 4 & 5.5 cm
* Bhatt S et al. Ultrasound Clin 2008 ; 3 : 83 – 91.

62. Classification of abdominal aortic aneurysms
Classification Categories
By location Suprarenal: Above origin of renal areteries (very rare)
Juxtarenal: Where renal arteries originate
Infrarenal: Below origin of RA (most common)
Bhatt S et al. Ultrasound Clin 2007 ; 2 : 437 – 453.
By morphology Fusiform (most common)
Hourglass
Saccular
By etiology Atherosclerotic (most common)
Inflammatory (5% – 10%)
Mycotic (1%): saccular, salmonella & SA, high mortality

63. Measurement of widest part
Measurement technique of aneurysm
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.

64. Measuring diameter of AAA
Incorrect measurement Correct measurement
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin, 2nd edition, 2011.
Correct diameter measured by rotating transducer clockwise
until round image of aorta comes into view

65. Shapes of aneurysm
Fusiform Saccular
Most frequent
Double aneurysm
Hourglass aorta

66. Abdominal aortic aneurysm / Fusiform
Transverse image
Anteroposterior diameter
from outer wall to outer wall
Sagittal image
Diameter measured in transverse
image larger due to obliquity
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.

67. Abdominal aortic aneurysm / Hourglass
Bhatt S et al. Ultrasound Clin 2007 ; 2 : 437 – 453.
Two discontinuous focal segments of aneurysmal dilatation
Aortic diameter in between is normal in caliber

68. Abdominal aortic aneurysm / Saccular
Saccular or mycotic aneurysm
Thrombus seen as low-level echoes within aneurysm
Sagittal image of abdominal aorta
Abraham D et al. Emergency medicine sonography: Pocket guide.
Jones & Bartlett Publishers, Boston, MA, USA, 1st edition, 2010.

69. Battaglia S et al. J Ultrasound 2010 : 13 : 107 – 117.
Abdominal aortic aneurysm / Swirling flow
Pseudo „„yin-yang sign‟‟
Similarity in appearance to pseudo-aneurysm finding

70. Suprarenal aortic aneurysm
Schuster H et al. Ultraschall Med 2009 ; 30 : 528 – 543.
Cross section viewLongitudinal section view
Inclusion of visceral & renal
arteries
Perfused lumen
& narrow circular thrombus

71. Infrarenal aortic aneurysm
Distance between RA & upper limit of aneurysm
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
SMA
LRV

72. Abdominal aortic aneurysm / Rupture
High mortality rate (90%)
AAA with peripheral thrombus
Small hypoechoic area (wall rupture)
Hypoechoic structure at upper end
Presence of active bleeding
No further imaging confirmation
Taken directly to OR
Bhatt S et al. Ultrasound Clin 2007 ; 2 : 437 – 453.

73. Abdominal aortic aneurysm / Dissection
B-mode image Color flow imaging
Dissection into thrombus & vessel wall has occurred
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.

74. Abdominal aortic aneurysm / Thrombus liquefaction
Area of thrombus liquefaction may be confused with dissection
Large thrombus separate area of liquefaction from lumen
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.

75. Diameter of aneurysm (indication for surgery)
Shape of aneurysm (Fusiform, hourglass, sacular)
Partial thrombosis
Infra-renal or supra-renal
Involvement of iliac arteries: common, internal
Additional criteria if endovascular treatment
Distance of proximal end of aneurysm to renal artery
Degree of angulation in case of elongation of infra-renal aorta
Conic neck of aneurysm
Lumen of CFA (large enough for stent insertion)
Relevant color duplex findings in AAA
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin, 2nd edition, 2011.

76. Stent-graft expands to make firm
circumferential contact with
 ‘neck’ of relatively normal aorta
between RA & upper end of AAA
 each CIA below aneurysm
Endovascular aortic aneurysm repair (EVAR)
First performed by Parodi from Argentina in 1990 1
1 Parodi JC et al. Ann Vasc Surg 1991 ; 5 : 491 – 499.
2 Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
Stent-graft

77. Endoleak after EVAR
Persistence flow in aneurysm lumen after procedure
• Increase in aneurysmal diameter with risk of rupture
• 20 – 40% at any time after graft placement1
• Lifelong surveillance 1st month, 6th month, yearly2
• Modalities CTA: gold standard
CDUS/CEUS: acceptable alternative
MRA – DSA
1 Demirpolat G et al. J Clin Ultrasound 2011; 39 : 263–269.
2 Stavropoulos SW et al. Radiology 2007;243:641.
Determination of endoleak & aneurysmal size

78. Type IV
Porosity of graft material (resolved in 1 month)
Type III
Perforation & tear in graft material (rare)
Type I
Failure of proximal or distal attachment sites
Type II
Flow through aortic or iliac branches (common)
Endoleak following EVAR
White GH et al. J Endovasc Surg 1996 ; 3 : 124 – 5.
Carrafiello G et al. Cardiovasc Intervent Radiol 2006 ; 29 : 969 – 974.
Type V
Source not identified (controversial)

79. EVAR / Mirror artifact
Demirpolat G et al. J Clin Ultrasound 2011 ; 39 : 263 – 269.
Synchronous pulsatility with flow in patent graft
Changing position while examining from different aspects
Spectral analysis aids in reducing false positive
Mirror image behind patent limbs of stent graft

80. EVAR / Poorly organized thrombus
Aneurysmal sac contains mix of echoes
Large anechoic area (A) which could represent an endoleak
No flow detected (region of poorly organized thrombus)
Hartshorne T. Ultrasound 2006 ; 14 : 34 – 42.

81. Types of endoleak
Type I: Distal attachment site
Type II: Patent lumbar artery
Thrush A et al. Peripheral vascular ultrasound. Elsevier, London, 2nd edition, 2005.
Hartshorne T. Ultrasound 2006 ; 14 : 34 – 42.
Type II: Inferior mesenteric artery
Type I: Proximal attachment site

82. Selective screening for AAA
• Selective screening
3 important risk factors Males
Age > 65 years
History of smoking
• Effectiveness of screening
4 RCTs including more than 125,000 men
Reported results for up to 5 – 10 years of follow-up
Reduction in mortality from 68% to 21%
Lederle FA. Ann Intern Med 2003 ; 139 : 516 – 22.

83. Popliteal artery aneurysm / Partial thrombosis
Transverse CDUS Sagittal pulsed & CDUS
Hamper UM et al. Radiol Clin N Am 2007 ; 45 : 525 – 547.
Most common peripheral aneurysm
70% of peripheral aneurysms

84. Popliteal artery aneurysm / Complete thrombosis
Useche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
Thrombosed popliteal aneurysm occluding PA
Patency of popliteal vein clearly demonstrated

85. Differential diagnosis of pain in popliteal fossa
• Arterial aneurysm or pseudoaneurysm
• Arterial dissection
• Venous aneurysm
• Adventitial cystic disease
• Baker’s cyst
• Enlarged lymph nodes
• Hematoma, seroma, abscess
• Muscle tears
• Muscle tumors

86. Popliteal vein aneurysm / Rare
1 MacDevitt DT et al. Ann Vasc Surg 1993 ; 7 : 282 – 286.
2 Graham RN et al. Am J Surg 2010 ; 199 : e5 – e6.
Dilatation twice or 3 times of normal vein diameter 1
PE (70-80% ) – Post-thrombotic syndrome – Swelling in popliteal fossa
Longitudinal US Transverse US Color Doppler US

87. Causes of arterial diseases
Atherosclerosis (most common cause)
Thrombosis or embolism
Aneurysm
Intimal dissection
Pseudo-aneurysm
Arterio-venous fistula
Arteritis
Entrapment syndrome
Cystic adventitial disease

88. Intimal dissection of abdominal aorta
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
Change in color coding due to
position of re-entry site
Color Doppler US
Longitudinal & transverse scan
Gray-scale US
Longitudinal & transverse scan
Intimal flap seen if sound beam
strikes at perpendicular angle
Search for involvement of visceral & iliac arteries

89. Causes of arterial diseases
Atherosclerosis (most common cause)
Thrombosis or embolism
Aneurysm
Intimal dissection
Pseudo-aneurysm
Arterio-venous fistula
Arteritis
Entrapment syndrome
Cystic adventitial disease

90. Pseudo-aneurysm
Middleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.
To-and-fro flow
Typical triphasic flow

91. Pseudo-aneurysm / “to-and-fro” flow
Middleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.
During systole
“to”
Flow enters PA via the neck
Pseudo-aneurysm lumen enlarges
During diastole
“fro”
Flow exits PA via the neck
Pseudo-aneurysm lumen contracts

92. Pseudo-aneurysm / CFA
2 – 4% of cases after catheter intervention
Large perivascular
fluid collection
Color Doppler: swirling pattern
“yin-yang” pattern
Pulsed Doppler: “to-and-fro” flow
classic pattern

93. Pseudoaneurysm / Variations in ‘‘to-and-fro’’ flow
Middleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.
Limited systolic flow
More pronounced diastolic flow
Diastolic flow decreases progressively
Diastolic flow increases progressively
Diastolic flow relatively limited
Two distinct phases of diastolic flow
Variations in duration & velocities of
systolic & diastolic flow due to arrhythmia

94. Pseudo-aneurysm / Multiloculated type
Not uncommon
Middleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.
Mistake made by inexperienced examiners:
Recognize most superficial lobe correctly
Confuse deeper lobe with femoral artery

95. Pseudo-aneurysm / Differential diagnosis
Middleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.
Arborizing flow in enlarged inguinal LN mistaken for PS
Low-resistance arterial flow with continuous diastolic flow
Venous flow below baseline

96. Middleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.
Inguinal LN from melanoma
Vessels at base of LN different from pattern seen in PA
“to and fro’’ pattern near base of LN
Pseudo-aneurysm / Differential diagnosis

97. Pseudo-aneurysm / US-guided compression
3 steps
Franklin JA et al. J Am Coll Surg 2003 ; 197 : 293 – 301.
Preparation Compression Following repair
Duration of compression: 10 – 15 minutes
Success rate: 75 – 85%
Complications: PA rupture, distal embolization, & venous thrombosis

98. Pseudo-aneurysm / US-guided compression
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
Marked perivascular tissue
vibration associated with arterial jet
US guided
compression
Pseudoaneurysm
successfully thrombosed
ThrombosisPA of CFA

99. Pseudo-aneurysm / US-guided thrombin injection
Replaced compression as technique of choice
Needle advanced into superficial aspect of PA to avoid neck
100 – 300 units of human thrombin
Avoid fast injection
Success rate 97% according to several studies
Franklin JA et al. J Am Coll Surg 2003 ; 197 : 293 – 301.

100. Pseudo-aneurysm / US-guided thrombin injection
Second injection
Complete thrombosis
CFA pseudoaneurysm
Surrounded by hematoma
Thrombin injection
under US guidance
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
Success rate 97% according to several studies

101. Causes of arterial diseases
Atherosclerosis (most common cause)
Thrombosis or embolism
Aneurysm
Intimal dissection
Pseudo-aneurysm
Arterio-venous fistula
Arteritis
Entrapment syndrome
Cystic adventitial disease

102. Arterio-venous fistula
Left external iliac artery
Right external iliac artery
Low resistance arterial flow
Right external iliac vein
Arterialized venous flow
Left external iliac vein

103. Causes of arterial diseases
Atherosclerosis (most common cause)
Thrombosis or embolism
Aneurysm
Intimal dissection
Pseudo-aneurysm
Arterio-venous fistula
Arteritis
Entrapment syndrome
Cystic adventitial disease

104. Arteritis / “macaroni or halo sign”
Higher-level echo
Lumen intima interface
Surrounded by
Concentric homogeneous hypoechoic structure
Intima media complex
Schäberle W. Ultrasonography in vascular diagnosis. Springer, Berlin, 2nd edition, 2011.

105. Transverse scanLongitudinal scan
Giant cell arteritis / Abdominal aorta
“Macaroni sign”
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
Aortic wall thickening (typical finding)
IMA at its origin pierces thickened wall directly
without first coursing close to aortic wall as in fibrosis

106. Moussavian B & Horrow MM. Ultrasound Quarterly 2009 ; 25 : 89 – 91.
Retroperitoneal fibrosis / Ormond’s disease
Hypoechoic cap-like structure anterior to aorta & IVC
Involvement of IVC important for differential diagnosis
Infra-renal abdominal aorta
Sagittal view
Infra-renal abdominal aorta & IVC
Transverse view

107. Retroperitoneal fibrosis / Ormond’s disease
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
IMA arising from left lateral aspect of aorta
Pushed against aortic wall before piercing hypoechoic layer
Aorta at origin of IMA

108. Inflammatory aortic aneurysm
Typical appearance
Schäberle W. Ultrasonography in vascular diagnosis. Springer, Berlin, 2nd edition, 2011.
Atherosclerotic wall change
Circumferential hypoechoic layer around aneurysm confirms
the inflammatory origin of aneurysm
Transverse scan Longitudinal scan

109. Thrombangiitis obliterans / Buerger disease
Male – Smoker – Young (34 years)
• Location Distal lower leg & foot
• Occlusion material Hypoechoic
• Vascular wall Hypoechoic without calcification
• Occlusion length alternating normal/abnormal seg
• Collaterals “corkscrew vessels”
• Vein Phlebitis migrans
Stiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.

110. Thrombangiitis obliterans / Buerger disease
Stiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.
37-year-old smoker – Rest pain in forefoot for 14 days
PTA
Occlusion without IMT Inflamed venous wall thickening
Superficial vein
35-year-old smoker – 3-year history of Buerger – Necrosis of toes
Typical corkscrew arteries

111. Buerger’s Disease / Corkscrew Collaterals
Fujii et Y. J Am Col Cardiol 2011 ; 57 : 2539.
Type I: Large snake sign
> 5 mm
Type II: Small snake sign
3 – 5 mm
Type IV: Small dot sign
< 1 mm
Type III: Dot sign
1 – 3 mm

112. Causes of arterial diseases
Atherosclerosis (most common cause)
Thrombosis or embolism
Aneurysm
Intimal dissection
Pseudo-aneurysm
Arterio-venous fistula
Arteritis
Entrapment syndrome
Cystic adventitial disease

113. Vascular complications of entrapment syndrome
 Post-stenotic aneurysm
 Mural thrombi
 Thrombotic occlusion
Method of choice for diagnosis & evaluation:
Duplex US with provocation tests
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.

114. Popliteal entrapment syndrome / Provocation tests
Examaging PA just below knee joint space
 Plantar flexion of foot
against hand of examiner
 Standing on tip toe
 Stretching of knee
while patient lies prone
Stiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.

115. Popliteal artery entrapment syndrome (PAES)
Plantar flexion test
Progressive compression of popliteal artery by GCM
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
Asymptomatic compression of PA by provocation tests in > 50%

116. Popliteal aretery entrapment syndrome (PAES)
Isolated popliteal artery occlusion
Transverse section
AS Soleus artery
VS Soleus vein
Longitudinal section
AS Soleus artery
VS Soleus vein
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.

117. Causes of arterial diseases
Atherosclerosis (most common cause)
Thrombosis or embolism
Aneurysm
Intimal dissection
Pseudo-aneurysm
Arterio-venous fistula
Arteritis
Entrapment syndrome
Cystic adventitial disease

118. Cystic adventitial disease of PA
Cyst involving long popliteal segment
Transverse view Longitudinal view
Difficult to differentiate from dissection with thrombosis of false lumen
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.

119. Cystic adventitial disease of PA
Transverse view Longitudinal view Pulsed Doppler
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.

120. Doppler US of lower limb arteries
 Anatomy of lower limb arteries
 Normal Doppler US of lower limbs arteries
 Duplex US criteria for arterial evaluation
 Causes of lower limb arterial diseases
 Doppler US of bypass graft

121. Bypass graft
Sonography is the recommended non-invasive
technique for the postoperative monitoring
of bypass graft patency

122. Types of graft
• Synthetic graft
PTFE* Above knee
• Autologous vein
Reversed vein Removal – reversal – anastomosis
In situ vein Leaves vein in its bed – anastomosis
In all cases Removal of valves in vein graft
Perforating veins tied off
* PTFE: Polytetrafluoroethylene

123. Aorto-bi-femoral graft Femoral-to-femoral artery bypass graft
Peripheral arterial bypass graft – 1

124. Peripheral arterial bypass graft – 2
Femoro-Popliteal
Above Knee
Femoro-Popliteal
Below Knee
Femoro-Tibial
Below Knee

125. Bypass graft / Normal US
Composite PTFE & vein graft
Slightly dilated area
corresponding to valve site
In situ vein graft

126. Bypass graft / Normal flow pattern
Hyperemic flow often seen
in early postoperative period
Hyperemic monopahasic flow Pulsatile flow
Over time, flow normally
assumes a pulsatile flow

127. Bypass graft / Normal PSV
Average PSV
from 3 – 4 sites
without stenosis
Graft flow velocity
Normal PSV: 45 – 180 cm/s
AbuRahma AF et al. Noninvasive peripheral arterial diagnosis.
Springer-Verlag, London Limited, 1st edition, 2010.

128. Bypass graft / Causes of graft failure
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
 Atherosclerosis
 Graft degeneration
 Neointimal
hyperplasia
 Technical faults

129. Bypass graft / Sampling velocities in stenosis
Ratio 2.0 = 50% stenosis
Ratio 4.0 = 75% stenosis
Proximal anastomotic stenosis
Graft conduit stenosis
Distal anastomotic stenosis

130. Bypass graft / Severe stenosis
Stenosis
PSV of A 16.4 cm/sec
PSV of B 319 cm/sec
Spectral broadening
B / A 19 times
A
Proximal to stenosis
A
B
At stenosis
B
Critical stenosis

131. Hemodynamic criteria & management of graft stenosis
Category Risk PSV
cm/sec
PSV
ratio
Graft
velocity
Management
I Maximum > 300 > 3.5 < 45 Anticoagulation
Immediate intervention
Wixon CL et al. J Vasc Surg 2000 ; 32 : 1 – 12.
II High > 300 > 3.5 > 45 Elective intervention
in 15 days
III Moderate < 300 > 2 > 45 Observation
Correction if progression
IV Low < 180 < 2 > 45 Observation

132. Bypass graft / Entrapment
Graft running between two
muscles causing moderate stenosis
Vein graft in lower tight
Graft compressed between two
muscles causing virtual occlusion
Leg flexion

133. Bypass graft / Occlusion
Extremely low volume flow recorded from in situ
vein graft indicates imminent graft occlusion

134. Bypass graft / Fibro-intimal hyperplasia
Large area of intimal hyperplasia in a vein graft

135. Bypass graft / Aneurysmal area in vein graft
Aneurysmal area in vein graft corresponding to valve site
Area of hyperplasia or thrombus in area of dilation

136. Bypass graft / False aneurysm
GFA
False aneurysm at distal end of femorofemoral graft
due to failure of anastomosis
Note corrugated appearance of Dacron material

137. Bypass graft / Seroma
Fluid-filled seroma
adjacent to vein graft
Differential diagnosis:
– Seroma
– Hematoma
– Lymphocele
– Abscess

138. Bypass graft / Infection
G
Echo region tracking from PTFE graft to skin surface
Pus discharging from skin surface at this point
I
G
I
PTFE (transverse view) PTFE (longitudinal view)

139. References
Arnold – 2004 Elsevier – 2005 Springer-Verlag – 2011

140. Thank You