c t i o n

w S e x Gail P. Size

r e v i e te r i a l Duple BS, RPhS, RVS, RVT, FSVU

Power Ext y A r Laurie Lozanski

r e m it BS, RVT
Troy Russo
L RDCS, RDMS, RCS, RVT

EDITED BY:
E ileen French-Sherry
proved MA, RVT, FSVU

is ap C ME
Book rs of SVU
Christopher L. Skelly
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W !
MD, FACS

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for
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The complete guide tovascular disease,
non-invasive testing and interpretation
 PL M
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Anterior Tibial ANTERIOR

Artery and Veins Peroneal Artery
and Veins
This book is dedicated to the
memory of two very special people:

To our dear friend,

Andrea Michelle Griffin, RDMS, RVT
We loved your mix of innocence, energy and frank honesty. You were a gifted sonographer and
passionate teacher. Although your time with us was short, your lessons will live on for years to
come. We loved you dearly, Missy.

To Gails beloved sister,

Sharon Schoen
Thank you for years of inspiration and always telling me how proud you were of me;
those words helped me become the person I am today, you are missed everyday.

QR codes can be found throughout this book, which will allow

you to view video clips of various pathology or duplex findings
using your smartphone or tablet. To access
these files, use the camera on your device
and a QR code reader. Your device must
have internet to use this feature.
There are many free QR code readers
available for download, please check
your app store for more information.

Gail P. Size, BS, RPhS, RVS, RVT, FSVU
Inside Ultrasounds Vascular Reference Guide
Copyright 2013 by Inside Ultrasound, Inc., First Edition, Updated
Inside Ultrasound, Inc
13303 S. Desert Dawn Drive
Pearce, AZ, 85625
Phone 520-642-1303
Fax 520-642-1304
www.insideultrasound.com
ISBN: 978-0-9747694-3-1
All rights reserved. This book is protected by copyright. Unauthorized
reprint or use of this material is prohibited. No part of this book may be
reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or by any information
storage and retrieval system without express written permission from
the publisher.
Printed in the United States of America
Notice: All authors, editors and contributors have taken care to
provide accurate up-to-date clinical information, best practices, and
information on generally accepted practices and protocols in the
standard vascular laboratory. The authors, editors and contributors
are not responsible or liability for errors or omission of material or for
any consequences from the application of the information.
 TABLE
OF
THROMBUS
CONTENTS

CME Information
Go to www.insideultrasound.com, from the bookstore, pick Successful candidates will earn 20 hours of CME awarded from
product IU400CME and make your purchase. Upon receiving the Society of Vascular Ultrasound (SVU). This program meets
ATHEROSCLEROTIC
your receipt, in the upper right corner click on download, this the criteria for SVU-CMEs which are accepted by the American
will give you further instructions. Your exam will be available Registry of Diagnostic Medical Sonographers (ARDMS), the
within two business days. Watch your email; you will be receiving American Registry of Radiologic Technologists (ARRT), for
a message from admin@exambuilder.com with instructions Category A credit, Cardiovascular Credentialing International
and a link to access the exam. You should add this address (CCI) and the Intersocietal Accreditation Commission
to your contacts so that it does not go into your spam. The (IAC - Vascular) for laboratory accreditation.
exam contains 100 multiple choice questions. The passing
grade is 70%. Each candidate will be allowed three attempts
to successfully complete the exam. Upon successful completion
you will be able to download your certificate.

List of Tables............................................................... vii 3 Vascular Diseases 44

Authors....................................................................... xii Adventitial Cystic Disease................................... 44
Contributors................................................................ xii Aneurysm............................................................ 44
Book Introduction....................................................... xiv Aortic Coarctation................................................ 47
Arterial Dissection............................................... 48
Atherosclerosis.................................................... 49
1 Anatomy 1 Cerebrovascular Events
(Transient Ischemic Attack, Stroke)...........................51
Extracranial and Intracranial........................................ 1
Carotid Body Tumor............................................ 55
Abdominal Vasculature.............................................. 10 Fibromuscular Dysplasia (FMD).......................... 57
Upper Extremity Venous............................................ 13 Lymphedema....................................................... 58
Raynauds Phenomenon MayThurner Syndrome...................................... 59
Upper Extremity Arterial............................................. 16
Lower Extremity Venous............................................ 18 Mesenteric Ischemia........................................... 60
Neointimal and Intimal Hyperplasia .................... 61
Lower Extremity Arterial............................................. 23
Phlegmasia Alba Dolens..................................... 62
2 Vascular Physiology and Hemodynamics 25 Phlegmasia Cerulea Dolens................................ 63
Normal Pallor
Hand (digits turn white) Portal Hypertension............................................. 63
Pseudoaneurysm................................................ 64
Popliteal Artery Entrapment Syndrome............... 66
Pulmonary Embolism.......................................... 66
Raynauds Syndrome: Raynauds Disease
and Raynauds Phenomenon.............................. 67
Renovascular Hypertension................................ 68
Subclavian Steal Syndrome................................ 69
Cyanosis Erythema Superior Vena Cava (SVC) Syndrome................ 70
(digits turn blue) (digits turn red)
Thoracic Outlet Compression Syndrome............ 71
Varicose Veins..................................................... 72
Vasculitis............................................................. 73
Venous Insufficiency (Postphlebitic Syndrome)
Venous Thrombosis............................................. 76
iv

4 Cerebrovascular Testing 81 7 Additional Arterial Testing 183

Carotid Artery Duplex Ultrasound.............................. 81 Pseudoaneurysm Duplex Ultrasound...................... 183

Carotid-Intima Media Thickness................................ 95 Duplex of Arteriovenous Fistulas
and Grafts for Hemodialysis Access........................ 189
Intracranial Cerebrovascular Testing......................... 99

8 Penile Testing 202

5 Arterial Testing (Lower Extremity) 115

ABI and Analog Pedal Artery Waveforms.................115 9 Venous Testing 208

Lower Extremity Segmental Pressures
and Doppler Waveforms.......................................... 120 Lower Extremity Venous Duplex Ultrasound........... 208
Volume Pulse Recording......................................... 125 Lower Extremity Venous Insufficiency Duplex......... 219
Lower Extremity Digital Evaluations: Toe Pressures Venous Ablation Duplex Ultrasound........................ 225
(TBI) and Photoplethysmography (PPG)................. 130 Upper Extremity Venous Duplex Ultrasound........... 230
Exercise and Stress Testing of the Extremities........ 134 IVC and Iliac Venous Duplex Ultrasound................. 240
SAMPLE Lower Extremity Arterial Duplex Ultrasound....... 138
SECTION Upper and Lower Extremity
Arterial Bypass and Stent Surveillance Venous Duplex Mapping.......................................... 248
Duplex Ultrasound................................................... 147
10 Non-Imaging Venous Testing 254
6 Arterial Testing (Upper Extremity) 158
Venous Photoplethysmography (PPG).................... 254
Upper Extremity Segmental Pressures Air Plethysmography (APG)..................................... 259
and Doppler Waveforms.......................................... 158
Upper Extremity Digital Evaluations: 11 Abdominal Arterial Testing 264
Pressure and Photoplethysmography
(DBI) and (PPG)...................................................... 162 Abdominal Aorto-Iliac Duplex Ultrasound................ 264
Upper Extremity Arterial Duplex Ultrasound............ 166 Abdominal Aortic Stent Graft
Thoracic Outlet Testing............................................ 174 (Endograft) Duplex Ultrasound................................ 276

Cold Immersion Testing for Renal Duplex Ultrasound......................................... 284

Raynauds Phenomenon.......................................... 179 Celiac and Mesenteric Artery Duplex Ultrasound.... 293
Hepatoportal Duplex Ultrasound.............................. 302
Renal Transplant Duplex..........................................311

Absent ACA (A1) - 6% Absent ACoA - 1%

Anterior
Communicating
Left Anterior (ACoA)
Cerebral (ACA)

Absent PCoA
Left Middle one side
Cerebral
9%
Left Posterior Right Anterior
Communicating Cerebral (ACA)
(PCoA)
Right Middle
Cerebral
Left Posterior
Cerebral (PCA) Right Posterior
Communicating (PCoA)
Right Posterior
Cerebral (PCA)
Basilar

Absent PCoAs
both sides
Complete 9%
Circle of Willis
20%

Absent PCoA
and contralateral PCA (P1)
9%
Absent PCA (P1) fetal origin - 9%

12 Vascular Screening 321
ABI and Analog Pedal Artery Waveforms.......... 322
Screening Carotid Duplex Ultrasound............... 322
Carotid Intima-Medical Thickness (CIMT)......... 323
Screening AAA Duplex Ultrasound.................... 323
13 Correlative Testing Modalities 326
Computed Tomography (CT) Scan.................... 326
Magnetic Resonance Imaging (MRI)................. 327
Angiography...................................................... 328
Venography....................................................... 328
Ddimer Blood Test ........................................... 329
Ventilation/Perfusion (VQ) Scan........................ 330
Scoring for Risk of DVT..................................... 331
14 Testing Optimization 332
15 Cardiac Effects on Spectral Doppler 336
High Cardiac Output.......................................... 337
Low Cardiac Output........................................... 337
Aortic Regurgitation (AR) ................................. 338
Aortic Stenosis (AS).......................................... 338
Mitral Stenosis (MS).......................................... 339
Mitral Regurgitation (MR).................................. 339
Tricuspid Regurgitation (TR)............................. 339
Pulmonary Regurgitation................................... 339
Pulmonic Stenosis ............................................ 339
Tricuspid Stenosis............................................. 340
Cardiac Tamponade.......................................... 340
Constrictive Pericarditis..................................... 340
Cardiac Arrhythmias.......................................... 340
Atrial Fibrillation................................................. 341
TYPICAL TORTUOUS KINKED COILED
v
TABLE
OF
CONTENTS
16 Vascular Pharmacology 345
Aneurysm.......................................................... 345
Aortic Coarctation.............................................. 345
Arterial Dissection............................................. 345
Arteritis see vasculitis
Atherosclerosis.................................................. 345
Carotid Body Tumor.......................................... 345
Cerebrovascular Events (TIA/Stroke)................ 345
Fibromuscular Dysplasia................................... 345
Lymphedema..................................................... 345
May-Thurner Syndrome.................................... 346
Mesenteric Ischemia......................................... 346
Neointimal Hyperplasia..................................... 346
Phlegmasia Alba Dolens see venous thromboembolism
Phlegmasia Cerulea Dolens see venous thromboembolism
Popliteal Artery Entrapment Syndrome............. 346
Popliteal Cystic Disease.................................... 346
Portal Hypertension........................................... 346
Postphlebitic Syndrome/
Venous Insufficiency.......................................... 346
Pseudoaneurysm.............................................. 346
Raynauds Phenomenon................................... 346
Renovascular Hypertension.............................. 346
Subclavian Steal Syndrome.............................. 346
Superior Vena Cava Syndrome......................... 346
Thoracic Outlet Compression Syndrome.......... 347
Varicose Veins................................................... 347
Vasculitis........................................................... 347
Venous Thromboembolism/
Pulmonary Embolism........................................ 347
E D
NT
LA Y
E
KI SP
DN
AN
Iliac Vein
TR
Iliac
Artery
ER
URET
Arterial
Anastomosis
Venous
Anastamosis
 138
vi

17 Math Review 348
Math Symbols.................................................... 348
Order of Operations........................................... 349
Variables............................................................ 349
Integers ............................................................. 349
Fractions............................................................ 350
Conversions...................................................... 350
Exponents......................................................... 352
Formulas........................................................... 352
Gain: 55%
18 Statistics 356
Formulas........................................................... 356
R) Dors. Pedis
Protocol for Gathering
Statistical Correlation........................................ 356
Statistical Correlation........................................ 357
19 Measurements 361
Arterial (Lower Extremity).................................. 361
Arterial (Upper Extremity).................................. 364

Gain: 100%
Penile................................................................ 365
Velocity Ratio..................................................... 366
Diameter Reduction........................................... 366
PT 155
Pulsatility Index................................................. 366
R) Digit PPG DP 367
Brachial
Peripheral Venous............................................. 152
Right Left Renal................................................................. 367
st Tibial L) Post Tibial Extracranial Cerebrovascular............................ 369
138 140
Hemodialysis AVF/Prosthetic Graft................... 369
Identifying and Analyzing
131 TB
Atypical Spectral Doppler Waveforms............... 370 0.94
: 55% Gain: 100% 20 References 373
Gain: 100% 1.11 ABI
Glossary of Terms.................................................... 373

rs. Pedis L) Dors. Pedis Prefixes and Suffixes............................................... 391

Acronyms................................................................. 391
Index........................................................................ 393

100% Gain: 68%

PT 155 154
git PPG DP 152 L) Digit PPG
141

131 TBI 116

0.94 0.83

100% 1.11 ABI 1.10 Gain: 100%

 /vii

L I S T O F TA B L E S
Vascular Physiology and Hemodynamics
27 TABLE 1: Average Distribution And Blood Volumes
29 TABLE 2: Flow, Pressure and Resistance Relationships
38 TABLE 3: Pressure and Flow Relationships of Inspiration and Expiration
38 TABLE 4: Inspiration/Expiration Changes
39 TABLE 5: Calf Muscle Pump Dynamics

Cerebrovascular Testing

Carotid Artery Ultrasound Examination

84 TABLE 6: Identification of ICA vs ECA Vessels
84 TABLE 7: Normal Values for Extracranial Vessels
86 TABLE 8: V
 elocity Criteria Defining Stenoses in the Stented Carotid Artery
Compared to Criteria for the Native Carotid Artery
88 TABLE 9: Grayscale and Plaque Morphology
89 TABLE 10: University of Washington Diagnostic Criteria for Classification of Internal Carotid Artery Disease
89 TABLE 11: New Consensus Diagnostic Criteria for Classification of Internal Carotid Artery Disease
89 TABLE 12: University of Chicago Diagnostic Criteria for Classification of Internal Carotid Artery Disease
89 TABLE 13: Bluth Diagnostic Criteria for Classification of Internal Carotid Artery Disease
90 TABLE 14: Carotid Artery Examination Protocol Summary

Carotid-Intima Media Thickness

97 TABLE 15: Carotid Intima Media Thickness Protocol at a Glance
97 TABLE 16: Risk for CVD Based on CIMT Values

Intracranial Cerebrovascular Testing

103 TABLE 17: Windows for visualization of the intracranial arteries
104 TABLE 18: Collateral Pathways of Intracranial Flow
106 TABLE 19: Intracranial Artery Diameter and Length
112 TABLE 20: Quantification of RLS Shunts
112 TABLE 21: PFO Grading System
112 TABLE 22: Protocol and Diagnostic Criteria Summary for Intracranial Cerebrovascular Techniques

Arterial Testing (Lower Extremity)

ABI and Analog Pedal Artery Waveforms

117 TABLE 23: ABI Protocol Summary
118 TABLE 24: Diagnostic Criteria for ABI
118 TABLE 25: University of Chicago Diagnostic ABI Criteria
118 TABLE 26: ABI Symptoms

Lower Extremity Segmental Pressures and Doppler Waveforms

122 TABLE 27: Lower Extremity Segmental Pressures Protocol Summary
123 TABLE 28: Findings of the Lower Extremities and Level of Disease
123 TABLE 29: University of Chicago Diagnostic Criteria for ABI
123 TABLE 30: Diagnostic Criteria for ABI Severity
124 TABLE 31: Diagnostic Criteria for Occlusive Disease by Segmental Arterial Pressures Indices
124 TABLE 32: ABI Symptoms
viii \ Inside Ultrasound Vascular Reference Guide

Volume Pulse Recording

126 TABLE 33: VPR Settings for Upper Extremities
126 TABLE 34: VPR Settings for Lower Extremities
127 TABLE 35: Volume Pulse Recording Protocol Summary
127 TABLE 36: Normal Amplitudes for Lower Extremity VPR
127 TABLE 37: Lower Extremity VPR Changes Based on Location of Disease

Lower Extremity Digital Evaluations: Toe Pressures (TBI) and Photoplethysmography (PPG)
131 TABLE 38: Lower Extremity Digital Protocol Summary
132 TABLE 39: Lower Extremity TBI Symptoms
132 TABLE 40: Diagnostic Criteria for Lower Extremity Digital Testing
132 TABLE 41: University of Chicago Lower Extremity TBI Diagnostic Criteria

Exercise and Stress Testing of the Extremities

135 TABLE 42: Treadmill Testing Protocol Summary
136 TABLE 43: PostOcclusive Reactive Hyperemia Protocol Summary
136 TABLE 44: Diagnostic Criteria for PostReactive Hyperemia AnkleBrachial Index
136 TABLE 45: Diagnostic Criteria for PostTreadmill Exercise AnkleBrachial Indices and Recovery Times
137 TABLE 46: Lower Arterial Exam with Exercise Report

Lower Extremity Arterial Duplex

140 TABLE 47: Lower Extremity Arterial Duplex Summary
141 TABLE 48: Normal PSV of Lower Extremity Arteries
145 TABLE 49: University of Washington Arterial Duplex Diagnostic Criteria
145 TABLE 50: University of Chicago Arterial Duplex Diagnostic Criteria
145 TABLE 51: Alternative Arterial Duplex Imaging Diagnostic Criteria

Arterial Bypass and Stent Surveillance

151 TABLE 52: Arterial Bypass Graft or Stent Surveillance Protocol Summary
159 TABLE 53: Duplex Diagnostic Criteria for InStent Restenosis of the Superficial Femoral Artery
156 TABLE 54: Diagnostic Criteria for Prosthetic Graft Surveillance
156 TABLE 55: Diagnostic Criteria for Vein Graft Surveillance
156 TABLE 56: Diagnostic Criteria for Femoropopliteal Arterial Duplex After Endovascular Intervention

Arterial Testing (Upper Extremity)

Upper Extremity Segmental Pressures and Doppler Waveforms

160 TABLE 57: Upper Extremity Segmental Pressures and Doppler Waveforms Protocol Summary

Upper Extremity Digital Evaluations: Pressure and Photoplethysmography (DBI) and (PPG)
164 TABLE 58: Upper Extremity Digital Protocol Summary
164 TABLE 59: PPG Digital Waveforms
165 TABLE 60: Diagnostic Criteria for Upper Extremity Digital Testing

Upper Extremity Arterial Duplex

169 TABLE 61: Upper Extremity Arterial Protocol Summary
169 TABLE 62: Normal PSV of Upper Extremity Arteries
170 TABLE 63: Diagnostic Criteria for Arterial Stenosis

Thoracic Outlet Testing

177 TABLE 64: Thoracic Outlet Examination Protocol Summary
178 TABLE 65: Diagnostic Criteria for TOS Disease

Cold Immersion Testing for Raynauds Phenomenon

181 TABLE 66: Cold Immersion Protocol Summary
181 TABLE 67: Cold Immersion Thermometry Worksheet
 List of Tables / ix

Additional Arterial Testing

Pseudoaneurysm Duplex
187 TABLE 68: Pseudoaneurysm Duplex Protocol Summary
187 TABLE 69: UltrasoundGuided Pseudoaneurysm Injection Protocol Summary

Duplex of Arteriovenous Fistulas and Grafts for Hemodialysis Access

195 TABLE 70: Dialysis Arteriovenous Fistula Protocol Summary
195 TABLE 71: University of Chicago Diagnostic Criteria for 50% Stenosis in a Hemodialysis AVF
196 TABLE 72: Prosthetic DialysisLoop Graft Protocol Summary
196 TABLE 73: Prosthetic DialysisStraight Graft Protocol Summary
197 TABLE 74: Diagnostic Criteria for Prosthetic Hemodialysis Grafts

Penile Testing
205 TABLE 75: Penile Pressures Protocol Summary
205 TABLE 76: Penile VPR Protocol Summary
206 TABLE 77: Diagnostic Criteria for Penile Brachial Index

Venous Testing

Lower Extremity Venous Duplex Ultrasound Examination

212 TABLE 78: Lower Extremity Venous Protocol Summary
214 TABLE 79: Thrombosis Descriptions and Characteristics
217 TABLE 80: Risk Factors for Acute Deep Venous Thrombosis (Caprini DVT Risk Score)
218 TABLE 81: Diagnostic Criteria for Venous Duplex

Lower Extremity Venous Insufficiency Duplex Examination

223 TABLE 82: Lower Extremity Venous Insufficiency Examination Protocol Summary
223 TABLE 83: Diagnostic Criteria for Venous Reflux

Duplex Imaging for Venous Ablation

228 TABLE 84: Duplex Imaging for Venous Ablation Protocol Summary
228 TABLE 85: Diagnostic Criteria for Post-Venous Ablation Venous Duplex

Upper Extremity Venous Duplex Ultrasound Examination

233 TABLE 86: Upper Extremity Venous Protocol Summary
235 TABLE 87: Thrombosis Descriptions and Characteristics
237 TABLE 88: Diagnostic Criteria for Venous Duplex

IVC and Iliac Venous Scanning

243 TABLE 89: IVC and Iliac Venous Duplex Protocol Summary
243 TABLE 90: Thrombosis Descriptions and Characteristics

Upper and Lower Extremity Venous Duplex Mapping

251 TABLE 91: Upper and Lower Extremity Venous Duplex Mapping Protocol Summary
252 TABLE 92: Thrombosis Descriptions and Characteristics
253 TABLE 93: Diagnostic Criteria for Venous Duplex
x \ Inside Ultrasound Vascular Reference Guide

Non-Imaging Venous Testing

Venous Photoplethysmography (PPG)

257 TABLE 94: Photoplethysmography Protocol Summary
258 TABLE 95: Diagnostic Criteria for PPG

Air Plethysmography (APG)

261 TABLE 96: APG Protocol SUMMARY
262 TABLE 97: Air Plethysmography Normal Values
262 TABLE 98: Diagnostic Criteria for Venous Filling Index
262 TABLE 99: Diagnostic Criteria for Ejection Fraction (EF)
262 TABLE 100: Diagnostic Criteria for Residual Volume Fraction (RVF)

Abdominal Arterial Testing

Abdominal Aorto-Iliac Duplex

270 TABLE 101: Abdominal AortoIliac Duplex Protocol Summary
273 TABLE 102: Normal Peak Systolic Velocities
273 TABLE 103: Normal Arterial Dimensions and Peak Systolic Velocities

Abdominal Aortic Stent Graft (Endograft) Duplex

280 TABLE 104: Abdominal Aortic Stent Graft Protocol Summary
282 TABLE 105: Endoleak Classification

Abdominal Arterial Testing

Renal Duplex
289 TABLE 106: Renal Duplex Protocol Summary
291 TABLE 107: Normal RenalAortic Peak Systolic Velocities
291 TABLE 108: Diagnostic Criteria for Significant Renovascular Resistance Within the Kidney
291 TABLE 109: Diagnostic Criteria of Renal Artery Stenosis

Celiac and Mesenteric Artery Duplex

298 TABLE 110: Celiac and Mesenteric Artery Duplex Protocol Summary
300 TABLE 111: Normal Celiac and Mesenteric Peak Systolic Velocities (PSV)
300 TABLE 112: Normal Celiac and Mesenteric Waveforms
300 TABLE 113: Diagnostic Criteria of Celiac for Mesenteric Artery Stenosis

Hepatoportal Duplex Scan

306 TABLE 114: Hepatoportal Duplex Protocol Summary
306 TABLE 115: Normal Hepatoportal Doppler Waveform Analysis
308 TABLE 116: Normal Hepatoportal Interpretation Summary
309 TABLE 117: Normal Hepatoportal Velocity Ranges Reported in the Literature
309 TABLE 118: Diagnostic Criteria for Abnormal Hepatoportal Disease

Renal Transplant Duplex

314 TABLE 119: Renal Transplant Duplex Protocol Summary
315 TABLE 120: Resistive Index (RI) Severity for Renal Transplant

Vascular Screening
323 TABLE 121: ABI Screening Protocol Summary
324 TABLE 122: CIMT Screening Protocol Summary
324 TABLE 123: Carotid Duplex Ultrasound Screening Protocol Summary
324 TABLE 124: AAA Duplex Ultrasound Screening Protocol Summary
324 TABLE 125: Screening ABI Diagnostic Criteria
324 TABLE 126: CIMT Diagnostic Criteria
324 TABLE 127: Screening Carotid Duplex Diagnostic Criteria
324 TABLE 128: Screening AAA Diagnostic Criteria
 List of Tables / xi

Correlative Testing Modalities

329 TABLE 129: Ddimer Criteria
331 TABLE 130: Clinical Prediction Criteria for Deep Venous Thrombosis (Wells Criteria)
331 TABLE 131: Clinical Prediction Criteria for Pulmonary Embolism
331 TABLE 132: Pioped Criteria (Prospective Investigation of Pulmonary Embolism Diagnosis)

Cardiac Effects on Spectral Doppler

336 TABLE 133: Summary of Cardiac Effect on Spectral Doppler Vascular Waveforms
342 TABLE 134: Effects of Cardiac Diseases on the Spectral Waveform
343 TABLE 135: Cardiac Diseases and Symptoms

Vascular Pharmacology
346 TABLE 136: Anticoagulants and Thrombolytics
346 TABLE 137: Pharmacology
347 TABLE 138: Anti-inflmmatory
347 TABLE 139: Recommendations for Treatment of DVT and PE

Math Review
350 TABLE 140: Fraction to Decimal Conversion/Equivalent
351 TABLE 141: Prefix Definitions
351 TABLE 142: American-Metric Conversion
353 TABLE 143: Decibel Chart
353 TABLE 144: Commonly Used Cosines
354 TABLE 145: Additional Formulas
355 TABLE 146: Circular Formulas

Measurements
361 TABLE 147: Disease Categorization for ABI/TBI
363 TABLE 148: Treadmill Testing Protocol Summary
363 TABLE 149: ABI Response to Exercise
364 TABLE 150: Diagnostic Criteria for PostTreadmill Exercise AnkleBrachial Indices and Recovery Times
364 TABLE 151: Diagnostic Criteria for WBI/DBI
365 TABLE 152: Diagnostic Criteria for Penial Bracial Index (PBI)
366 TABLE 153: Velocity Ratio Vs Diameter Reduction
366 TABLE 154: Calculating Stenosis by Diameter Vs Area
366 TABLE 155: Pulsatility Index and Resistance Relationship
367 TABLE 156: Diagnostic Criteria for Venous Reflux by Duplex
367 TABLE 157: Venous Refill Time (VRT)
368 TABLE 158: Diagnostic Criteria for Disease According to Renal-to-Aortic-Ratio (RAR)
368 TABLE 159: Resistive Index (RI)
368 TABLE 160: Interpretation of End-Diastolic Ratio (EDR)
369 TABLE 161: Ratio Correlation to Diameter Reduction
369 TABLE 162: Diagnostic Criteria for Hemodialysis AVF
369 TABLE 163: Diagnostic Criteria for Prosthetic Hemodialysis Graft (AVG)
138

Arterial Testing (Lower Extremity)

Lower Extremity Arterial Duplex

Definition Mechanism of disease

The combination of real time Bmode imaging with pulsed Atherosclerosis is the most common arterial disease.
wave and color flow Doppler (duplex scan) to evaluate the lower Atherosclerotic plaque forms in the artery blocking flow
extremity arteries. by either narrowing it (arterial stenosis) or totally blocking
the artery (arterial occlusion). The term hemodynamically
Etiology significant obstruction refers to either a stenosis or an
occlusion that results in a decrease in blood pressure or flow
Atherosclerosis Extrinsic compression distal to the obstruction. Typically, a stenosis must narrow the
Embolization External radiation diameter of the artery by at least 50% to decrease pressure and
Thrombus AV fistula (abnormal flow distally. 1 An arterial occlusion is typically seen from one
Pseudoaneurysm connection between an artery major branch to the next.
Aneurysm and a vein) Emboli may occur as contents of a plaque or fragments of an
Intimal hyperplasia Popliteal entrapment organized thrombus from the heart or aneurysm loosen and
(extrinsic compression flow downstream. Emboli become lodged in a distant blood
Trauma of the popliteal artery) vessel, causing arterial occlusion and reduction of flow. 1
Traumatic occlusion
Vasospasm is a temporary constriction of the arteries (typically
Risk Factors digital arteries) that may cause significant discomfort to the
Age (increased risk with age) Sedentary lifestyle patient or be a sign of a more serious underlying disease. 2
Coronary artery disease Previous history of Extrinsic compression from tumors, musculoskeletal
Diabetes CVA or MI configuration, hematoma, etc. can result in stenosis or
Elevated levels of occlusion by placing enough pressure on arterial walls to
Family history compromise blood flow. 1
Hyperlipidemia homocysteine
Excessive levels of Entrapment syndrome occurs in certain leg positions, when
Hypertension
Creactive protein the gastrocnemius muscle compresses the popliteal artery
Obesity resulting in loss of distal pulses. 3
Postop cardiac
Smoking catheterization Aneurysmal disease results from weakening of the structural
proteins (elastin and collagen) within the medial layer of the
Indications for Exam arterial wall. 4
Claudication (exerciserelated Abnormal ABI A pseudoaneurysm (PA) or false aneurysm forms due
leg pain) Aneurysmal disease to trauma to all three layers of the arterial wall. The false
Limb pain at rest Dependent rubor aneurysm is actually a hematoma, receiving its blood supply
Extremity ulcer Evaluation prior to via communication with an artery through a patent neck. 5
Gangrene dialysis access An arteriovenous fistula or abnormal connection between
Absent peripheral pulses A decrease in ankle brachial artery and vein can result from trauma or complications
Digital cyanosis index (ABI) >0.15 compared during invasive procedures (e.g., cardiac catheterization). In
to the previous exam such cases, blood flows directly from the artery into the venous
Arterial trauma
system without passing through the tissues and capillary bed. 6
Contraindications/Limitations Arterial dissections are caused by tears in the intimal layer
Patients with extensive bandages or casts. of the arterial wall and allow blood flow to access the media.
Poor visualization due to vessel depth secondary to obesity/ Dissection between the medial and adventitial layers
severe leg edema. may result in true and false lumens. The false lumen can
progressively dilate into a pseudoaneurysm. 7
Diffuse arterial wall calcification (such as in diabetics and
endstage renal failure patients) may interfere with acquisition Location of Disease
of duplex information.
Patients who cannot be adequately positioned. Location of disease can be focal or diffuse and affect any level
or multiple levels.
The most common location of atherosclerotic obstruction in
the lower extremities is the distal superficial femoral artery.
Arterial bifurcations
Popliteal artery (entrapment syndrome)
 Lower Extremity Arterial Duplex / 139

The patient is examined in the supine position with the leg

Bifurcation of the common femoral artery into the
superficial femoral and deep femoral arteries
externally rotated.
Some patients may require the use of a range of transducers,
including highfrequency (57 MHz) (815 MHz) transducers
and a lower frequency (14 MHz) transducer to assist in the
Hunters canal.
Locate the common femoral artery and vein at the groin in
the transverse (short axis) plane. Rotate your probe onto the
common femoral artery in the longitudinal (sagittal) plane. As
you move the probe distally down the leg, obtain and record
grayscale images in longitudinal view of the following:
Common femoral artery (CFA)
Deep femoral artery (DFA)
Superficial femoral artery (SFA)
Popliteal artery (POPA)

Position the probe in the abdomen to record additional

grayscale images from the abdominal aorta, common iliac
(CIA) and external iliac (EIA) arteries when indicated.
Color flow Doppler will be a useful guide to help identify
these arteries. Locate the artery and vein in the transverse
plane and rotate the probe longitudinally onto the artery
for documentation.
Position the probe behind the knee and scan distally (or begin
from the ankle and scan proximally) to record additional
grayscale images from the tibial arteries when indicated.
Color flow Doppler will be a useful guide to help identify
Bifurcation of the popliteal artery into the
these arteries. Locate the artery and veins in the transverse
anterior tibial artery and tibioperoneal trunk
plane and rotate the probe longitudinally onto the artery

Lower Extremity Arterial Duplex

Patient History
Claudication
(exerciserelated limb pain)
Limb pain at rest
Paralysis (weakness)
Paresthesia (pins
and needles)
Physical Examination
Pulselessness
Cyanosis
Pallor
Dependent rubor
Poikilothermia (icecold limb)
Previous ulceration/gangrene
of feet/toes
Previous therapeutic vascular
procedure (e.g., bypass, stent)
Marked temperature
difference between
extremities
Gangrene/necrosis (tissue
death)
for documentation.
Measure and record the peak systolic velocity (PSV) in
longitudinal view of the following using pulsed wave Doppler
(60 Doppler angle or less, with the angle cursor parallel to the
vessel walls in the center of the flow stream):
Common femoral artery (CFA)
Proximal deep femoral artery (DFA)
Proximal, mid and distal superficial femoral artery (SFA)
Popliteal artery (POPA)
Dorsalis pedis (DPA) and posterior tibial (PTA) arteries
Highest obtainable velocity through any area(s) of stenosis
Proximal and distal to any stenosis

(Lower Extremity)
Bruit (abnormal sound heard Abdominal aorta, common iliac (CIA), external iliac (EIA),

through auscultation caused Palpable thrill (vibration
by turbulent flow) caused by turbulent blood
flow as seen in an AV fistula)
Pulsatile mass
Lower Extremity Arterial Duplex Protocol
Obtain a patient history to include symptoms, risk factors,
past vascular interventions and general dates.
Obtain bilateral anklebrachial indices (ABIs) using
posterior tibial and dorsalis pedis artery waveforms with
continuouswave (CW) or pulsedwave (PW)Doppler (Refer
to section on ABI).
Arterial Testing
anterior tibial and peroneal arteries (when indicated)
Document grayscale and color images in areas of suspected
stenosis. Measure lumenal reduction, especially caused by
a hemodynamically significant lesion to provide backup
information for the velocity data.
Color flow can obscure the true lumenal reduction
if the color gain is set too high. Measure lumenal
reduction in grayscale whenever possible.
 140 \ Inside Ultrasound Vascular Reference Guide

Instruct the patient to hyperextend the knee and point the foot
downward (plantarflexion).
Remeasure AP and transverse diameter measurements
on images of the popliteal artery taken while the foot was
pointed downward.
Repeat the PW Doppler measurements while the patient
hyperextends the knee and points their toes upward
(dorsiflexion).

Plaque and Lesion Descriptions/Characteristics

Diffuse plaque: long segment of the artery lined with plaque,
but <50% diameter reduction at any point.
Stenotic: lumen is narrowed and velocity increases.
Hemodynamically significant stenosis typically occurs when
Normal, clear arterial lumen narrowing results in a >50% diameter reduction (75% area
Image courtesy of Philips Healthcare reduction). A stenosis can be focal or involve a long segment.
Calcific: highly reflective plaque(s) with acoustic shadowing
Occluded: complete occlusion of the vessel
Moving/Mobile: debris within the lumen is poorly
adhered to the vessel wall, e.g., moving thrombus.
Lower Extremity Arterial Duplex

Abnormal artery: lumenal reduction and calcific plaque

Determine classification of stenosis according to laboratory

diagnostic criteria (see criteria tables).
Document any additional abnormal findings with grayscale
and color imaging (e.g., aneurysmal formation, plaque, Abnormal, stenotic arterial waveform
thrombus, wall irregularity, aneurysm, AV fistula, etc.).
Retrograde arterial flow direction is another possible abnormal
finding that requires additional documentation. TABLE 47: Lower Extremity
Arterial Duplex Summary
Decrease color and velocity scales to detect
low velocity flow and confirm occlusion. Scan longitudinal (sagittal) view
with grayscale, color and PW Doppler
When arterial occlusion is suspected, document the lack of
flow with PW Doppler and any visualized collateral branches 1. CFA Measure and record the peak
by color and PW Doppler. Also note the anatomic level of flow systolic velocity (PSV) for
(Lower Extremity)

2. Proximal DFA
Arterial Testing

reconstitution when visualized. all segments.

Repeat protocol for the contralateral extremity. 3. Proximal SFA When an area of stenosis
4. Mid SFA is identified, walk the
Duplex Evaluation for sample gate through the
Popliteal Entrapment Syndrome 5. Distal SFA area of stenosis and obtain
Ask the patient to lie on his/her side for best access to the 6. POPA representative waveforms at the
popliteal during the positional maneuvers required for narrowest point of stenosis, as
this exam. 7. PTA * well as proximal and distal to
the stenosis.
Measure and record the PSV in longitudinal view of the distal 8. DPA *
popliteal artery at the level of the gastrocnemius muscle heads Determine classification of
using pulsed wave Doppler (60 Doppler angle or less, with 9. EIA (optional) stenosis according to laboratory
the angle cursor parallel to the vessel walls in the center of the 10. ATA (optional) diagnostic criteria.
flow stream). * Waveforms may be taken with either
11. Per A (optional) CW or PW Doppler.
Document grayscale images of the popliteal artery at
rest and measure anteriorposterior (AP) and transverse
diameter measurements.
 Lower Extremity Arterial Duplex / 141

Interpretation Doppler waveforms and flow velocities:

Determine: Biphasic
arterial signals are characterized by strong forward
flow in arterial systole (sharp upstroke) with a loss of
Plaque
location and plaque characteristics
flow reversal in early diastole (no flow below the baseline)
Peak
systolic velocity (PSV) and flow direction and either forward flow or no flow in the late diastolic
component. 14
V
2/V1 peak systolic velocity ratio (Vr); where V2 represents
the maximum PSV of a stenosis and V1 is the PSV of the Monophasic
arterial signals are characterized by reduced
proximal normal segment pulsatility or forward flow in late systole (blunted upstroke).
A diastolic flow component may or may not be apparent.
Any
change in spectral waveform analysis (e.g., triphasic to Parvus tardus is an alternative term for monophasic
biphasic to monophasic) used by some laboratories to describe a waveform with
Normal (absence of a hemodynamically continuous forward flow and a slow, blunted systolic
significant stenosis, <50%) component. 15 Monophasic waveforms are common distal to
a hemodynamically significant stenosis or occlusion. 911,14
Doppler waveforms and flow velocities:
Normal
lower extremity arterial waveforms are triphasic. A
triphasic signal is demonstrated by strong forward flow in
arterial systole (sharp upstroke), followed by flow reversal
in late systole or early diastole (below the baseline),
plus a late diastolic forward component. 814
PSV
and Vr are relatively uniform throughout the
sampled arterial segment. 8
General grayscale and color characteristics: The
artery is free of intralumenal echoes. When utilized, color
Doppler fills the entire arterial lumen. 9

TABLE 48: Normal PSV of Lower

Extremity Arteries

Lower Extremity Arterial Duplex

Artery PSV cm/s (anglecorrected)
Monophasic popliteal arterial waveform
EIA 119 22
CFA 114 25 A
hemodynamically significant lesion (>50%) will result in
SFA (proximal) 91 14 a focal velocity increase (at least double the velocity in the
SFA (distal) 94 14 proximal arterial segment), change in spectral waveform
(from triphasic to biphasic or biphasic to monophasic),
PopA 69 14 poststenotic turbulence and a possible color bruit. 8,10,11,13,16
Source: Modified from Jager KA, Ricketts HJ, Strandess DE Jr. (1985). Duplex scanning for the
evaluation of lower limb arterial disease. In Bernstein EF (Ed.), Noninvasive diagnostic techniques in
A
hemodynamically significant lesion (>70%) will result
vascular disease. St. Louis: Mosby in a focal velocity increase at least triple the velocity in the
proximal arterial segment. 13

Abnormal

(Lower Extremity)
Arterial Testing

Hemodynamically significant stenosis

Biphasic arterial waveform of the deep femoral artery
Note: Triphasic, biphasic, and monophasic waveforms have multiple definitions throughout the vascular
ultrasound community. Some laboratories reserve the term biphasic only for waveforms with a reversed
flow component but no third phase. Other labs describe a biphasic waveform as one with a sharp peak but
continuous forward flow throughout the waveform. Some labs describe any waveform without a reversed
flow component as monophasic whether or not it has a sharp peak.
 142 \ Inside Ultrasound Vascular Reference Guide

General grayscale and color characteristics: Intralumenal

echoes are visualized within the artery resulting in a
measurable lumenal reduction. When utilized, color Doppler
does not fill the entire arterial lumen.
A color jet can be visualized through the narrowed lumen. 12
A mosaic color pattern can be observed due to turbulent flow
in the poststenotic region. 9,10

Lumenal reduction of the superficial femoral artery

Use indirect signs to evaluate hemodynamically significant
lesions in regions where a proximal velocity is technically
difficult to obtain or a ratio cannot be calculated (e.g., distal to
calcified plaque), such as:
Increased
velocities (with lumenal reduction) followed by a
waveform change
Change
in spectral waveform from one segment to the next Color changes through a stenotic area
Comparison
of arterial waveform in the contralateral
extremity at the same site
Lower Extremity Arterial Duplex

Staccato arterial waveform (preocclusive)

Occlusion:
PW Dopplerpreshadowing A
staccato waveform often indicates that there is
downstream occlusion. 8,12

Use flow in the adjacent vein as a guide to identify

an occluded artery. Always confirm flow by placing
(Lower Extremity)
Arterial Testing

the Doppler sample volume in the vessel lumen.

An
occlusion of the artery is present when no flow is
detected by color or spectral Doppler. Determine the extent
of the occlusion. 8,9,12

Often
a large collateral can be identified at the proximal and
distal ends of the occlusion. These collaterals often exit and
enter the artery at 90 angles.

PW Doppler postshadowing

The criterion for abnormal lower extremity

arterial duplex varies across institutions.
 Lower Extremity Arterial Duplex / 143

Absent waveform from arterial occlusion Doppler waveforms documenting forward flow direction
in the SFA and reversed flow direction of the DFA

Other Pathology
Arteriovenous fistula (AVF): An arteriovenous fistula between
any artery and an adjacent vein is characterized by color bruit
on duplex image along with high velocity, lowresistance
spectral waveforms at the same site by pulsedwave Doppler. 7

The arterial segment proximal to the AVF typically

demonstrates a low resistance configuration as the arterial
flow feeds the low resistance vein. The venous segment
immediately proximal to the AVF will demonstrate a pulsatile,
turbulent waveform.

Lower Extremity Arterial Duplex

Collaterals at the distal end of an occlusion

Blood
flow may reverse in arteries supplying collateral flow,
especially near arterial bifurcations when the proximal artery
is occluded (e.g., retrograde arterial flow from the DFA will
supply the SFA in cases of CFA occlusion). 17

(Lower Extremity)
Arterial Testing
Arteriovenous fistula by color duplex

Pseudoaneurysm (PA): A pulsatile mass observed

Retrograde deep femoral arterial flow by color
Doppler feeding the SFA in cases of CFA occlusion
communicating with a native artery is indicative of a
pseudoaneurysm. A toandfro Doppler flow pattern will
be apparent within the neck of the PA. The size of a
pseudoaneurysm varies in diameter, but is typically between
15 cm. 18
 144 \ Inside Ultrasound Vascular Reference Guide
Doppler waveforms at the site of
an arteriovenous fistula
Lower Extremity Arterial Duplex
Superficial femoral artery pseudoaneurysm
(Lower Extremity)
Arterial Testing
Pseudoaneurysm: characteristic toandfro waveform
Aneurysm: An aneurysm is defined as a focal enlargement of
an artery at least twice the diameter of the proximal segment.
Intralumenal thrombus may be observed and is a possible
source of distal emboli. 12 PSV are typically reduced with
abnormal flow patterns within an aneurysm. 10
Arteriomegaly:
The term used to describe a uniform arterial
dilation throughout an artery. 19
An
artery can also be described as ectatic (dilatation of a
circular tube) when diameters are somewhat larger through a
segment, though not yet aneurysmal. The dilated areas of the
artery may or may not be uniform.
Common femoral artery aneurysm: transverse plane
Superficial femoral artery aneurysm: longitudinal plane
Arterial dissection: A dissection of the arterial lumen is
recognized by two distinct flow channels by Bmode and/or
color Doppler separated by the dissected intima seen as a
white line within the lumen. One lumen is known as the true
lumen while the other is referred to as the false lumen. Each
lumen has a distinctly different flow pattern or one lumen may
be occluded. 7
Popliteal entrapment syndrome: A reduction in arterial
diameter while the patient points their foot downward with
resulting stenosis or loss of arterial pulse may indicate popliteal
entrapment syndrome. 10,20
The use of duplex testing to diagnose popliteal
entrapment syndrome is controversial. Some
believe the reduction in arterial diameter is a normal
response when pointing the foot downward.
Adventitial cystic disease (ACD): Duplex findings of
ACD include focal stenosis or occlusion of the popliteal
artery and observance of compression on the arterial lumen
by the cyst. 20,21
 Lower Extremity Arterial Duplex / 145

TABLE 49: University of Washington Arterial Duplex Diagnostic Criteria

% Spectral Velocity/ Distal

Stenosis Waveform Broadening Ratio Waveform
Normal Triphasic None None Normal
119% Triphasic Minimal <30% increase in PSV from Waveforms remain normal
spectral broadening proximal segment proximally and distally

2049% Tri/biphasic Prominent spectral 30-100% increase Waveforms remain normal

broadening in PSV from proximal proximally and distally
segment

5099% Monophasic Extensive spectral >100% increase in PSV Waveform becomes

broadening from proximal segment monophasic distally

Occlusion No flow (preocclusive None None Collateral waveforms

thump may be are monophasic with
heard proximal to reduced PSV
occluded segment)

Source: Moneta GL, Zacardi MJ, Olmsted KA. (2010). Lower extremity arterial occlusive disease. In Zierler RE (Ed.), Strandesss duplex scanning disorders in Vascular Diagnosis 4th ed. (133147).Philadelphia:Wolters Kluwer
Lippincott Williams & Wilkins.

Differential Diagnosis
TABLE 50: University of Chicago Arterial Duplex Spinal stenosis Neuropathy
Diagnostic Criteria Venous thrombosis Muscle/tendon strains
Velocity Spectral

Lower Extremity Arterial Duplex

Restless leg syndrome Arthritis
% Stenosis Waveform Ratio Broadening Distal Waveform Compartment Cystic disease
Normal Triphasic 0-2.0 None Normal, triphasic syndrome (such as popliteal)
Nocturnal leg cramps
1-49% Triphasic 0-2.0 Minimal Normal, triphasic
Correlation
50-99% Bi/ >2.1 Pronounced, Bi/monophasic Spiral CT scan
monophasic significant
spectral MRA
broadening Arteriography

Occluded Absent None None Collateral flow Medical Treatment

(monophasic) Modify risk factors (e.g., reduce cholesterol/HTN,
or absent flow manage DM, smoking cessation)
Source: Modified from Vandenberghe,NJ. (1994). Duplex scan assessment of arterial occlusive disease. Journal of Vascular Exercise regimen
Technology. 18:287293.
Antiplatelet medication (e.g., aspirin)

(Lower Extremity)
Arterial Testing
Anticoagulation (warfarin)
TABLE 51: Duplex Imaging Diagnostic Criteria Surgical Treatment
% Stenosis Peak Velocity Velocity Ratio Bypass grafting
Endarterectomy
Normal <150 cm/s <1.5: 1
Direct focal repair
30-49% 150-200 cm/s 1.5:1-2:1 Amputation

50-74% 200-400 cm/s 2:1-4:1 Endovascular Treatment

Angioplasty
>75-99% >400 cm/s >4:1
Stent
Occlusion No color saturation NA Atherectomy
Intraarterial directed thrombolysis
Source: Cossman DV, Ellison JE, et al (1989). Comparison of contrast arteriography to arterial mapping with color flow
duplex imaging in the lower extremity The Journal of Vascular Surgery, Nov; 10(5):5228; discussion 5289.
 146 \ Inside Ultrasound Vascular Reference Guide
Points to Remember
Arterial duplex ultrasound can identify the presence, exact
location, extent and severity of disease. The course of the
arteries, collaterals and disease can be visualized using Bmode
and color while the measurement of Doppler velocity and
waveform changes can estimate the severity of obstructions
and flow direction.
Color Doppler can underestimate plaque and diameter
reductions due to bleeding of the color flow over the plaque
seen in Bmode. For increased accuracy when assessing disease,
measure in Bmode whenever possible and consider reductions
together with Doppler velocity ratios.
Besides atherosclerosis, narrowing of an arterial lumen can
result from intimal hyperplasia or cellular damage after
radiation therapy. 23,24
Surgical repair is suggested for peripheral aneurysms measuring
2.53 cm or more in diameter. 25
Monophasic CFA waveforms combined with a PSV <45 cm/s
is highly indicative of ipsilateral iliac artery occlusion. 26
An acceleration time >144 cm/s in the EIA suggests iliac
disease. 27
Calcific shadowing can prohibit Doppler and color flow
analysis of a specific arterial segment. Comparing the Doppler
waveform proximal and distal to the calcified segment can
point to a hemodynamically significant obstruction under the
calcific shadowing (e.g., if severe poststenotic turbulence is
present distal to the shadowing, there could be a stenosis in
Lower Extremity Arterial Duplex
the calcified segment, or conversely, if there is essentially no
change in the waveform pattern, it is unlikely that a significant
obstruction exists under the calcific area).
An important complication of popliteal artery aneurysms is
emboli from intramural thrombus, not rupture. 25
Popliteal aneurysms usually occur bilaterally. 25
The most common peripheral artery aneurysm is in the
popliteal artery. Approximately 64% of male patients
with a popliteal artery aneurysm will have an abdominal
aortic aneurysm. 19
3% of patients with a femoral artery aneurysm also have a
popliteal artery aneurysm. 25
Arteriovenous fistulas can be congenital or result from
penetrating, blunt or iatrogenic trauma. 28
(Lower Extremity)
Arterial Testing
References
1. Sumner DS, Zierler RE. (2005). Vascular physiology: essential hemodynamic principles. In Rutherford
Vascular Surgery 6th edition. (75123). Philadelphia. Elsevier Saunders.
2. Shepard RFJ. (2005). Raynauds syndrome: vasospastic and occlusive arterial disease involving the distal
upper extremity. In Rutherford Vascular Surgery 6th edition. (13191346). Philadelphia. Elsevier Saunders
3. Levien LJ. (2005). Nonatheromatous causes of popliteal artery disease. In Rutherford Vascular Surgery
6th edition. (12361255). Philadelphia. Elsevier Saunders.
4. Schermerhorn ML, Cronenwett JL. (2005). Abdominal aortic and iliac aneurysms. In Rutherford
Vascular Surgery 6th edition. (14081452). Philadelphia. Elsevier Saunders.
5. Casey, PJ, LaMuraglia GM. (2005). Anastomotic aneurysms. In Rutherford Vascular Surgery 6th edition.
(894902). Philadelphia. Elsevier Saunders
6. Rutherford RB. (2005). Diagnostic evaluation of arteriovenous fistulas and vascular anomalies. In
Rutherford Vascular Surgery 6th edition. (16021612). Philadelphia. Elsevier Saunders.
7. Baker JD. (2005). The role of noninvasive procedures in the management of extremity arterial disease.
In Zwiebel WJ. Pellerito JS (Eds.), Introduction to Vascular Ultrasonography 5th ed. (254260).
Philadelphia: Elsevier Saunders.
8. Moneta GL, Zacardi MJ, Olmsted KA. (2010). Lower extremity arterial occlusive disease. In Zierler RE
(Ed.), Strandesss duplex scanning disorders in Vascular Diagnosis 4th ed. (133147).Philadelphia Wolters
Kluwer Lippincott Williams & Wilkins.
9. Zierler RE. (2005 ). Ultrasound assessment of lower extremity arteries. In Zwiebel WJ, Pellerito JS
(Eds.), Introduction to Vascular Ultrasonography 5th ed, (341356 ). Philadelphia: Elsevier Saunders.
10. Thrush A, Hartshorne, T. (2005). Duplex assessment of lower limb arterial disease In
Peripheral Vascular Ultrasound, How Why and When, 2nd ed. (111131). Edinburgh: Elsevier
Churchill Livingstone.
11. Kohler TR. (1993). Duplex scanning for the evaluation of lower limb arterial disease. In Bernstein EF
(Ed.). Vascular Diagnosis 4th ed. (520526). St. Louis: Mosby.
12. Kerr TM, Bandyk DF. (1993). Color duplex imaging of peripheral arterial disease before angioplasty or
surgical intervention. In Bernstein EF (Ed.). Vascular Diagnosis 4th ed. (527533). St. Louis: Mosby.
13. Ascher E, SallesCunha SX, Hingorani A, Markevich N. (2005). Duplex ultrasound and arterial
mapping before infrainguinal revascularization. In Mansour MA, Labropoulos N. (Eds.), Vascular
Diagnosis. (237246). Philadelphia: Elsevier Saunders.
14. 14 Zierler RE, Sumner DS. (2005). Physiologic assessment of peripheral arterial occlusive disease. In
Rutherford Vascular Surgery 6th edition. (197222). Philadelphia. Elsevier Saunders
15. Armstrong PA, Bandyk DF. (2010). Vascular laboratory: arterial duplex scanning . In Rutherford Vascular
Surgery 7th edition. (Chapter 15). Philadelphia. Elsevier Saunders.
16. Rzucidlo EM, Zwolak RM. (2005). Arterial duplex scanning. In Rutherford Vascular Surgery 6th edition.
(233253). Philadelphia: Elsevier Saunders.
17. Kalman PG. (2005). Profundaplasty: isolated and adjunctive applications. In Rutherford Vascular Surgery
6th edition. (11741180). Philadelphia: Elsevier Saunders.
18. Burke BJ, Friedman SG. (2005). Ultrasound in the diagnosis and management of arterial emergencies.
In Zwiebel WJ. Pellerito JS (Eds.), Introduction to Vascular Ultrasonography 5th ed. (254260).
Philadelphia: Elsevier Saunders.
19. Cronenwett JL. (2005). Abdominal aortic and iliac aneurysms. In Rutherford Vascular Surgery 6th
edition. (14081452). Philadelphia. El Sevier Saunders.
20. Levien LJ. (2005). Nonatheromatous causes of popliteal artery disease. In Rutherford Vascular Surgery
6th edition. (12361255). Philadelphia. Elsevier Saunders.
21. Flanigan DP, Burnham SJ, Goodreau JJ, Bergan JJ. Summary of cases of adventitial cystic disease of the
popliteal artery. Ann Surgery 1979 Feb: 189 (2): 16575.
22. Cossman DV, Ellison JE, et al (1989). Comparison of contrast arteriography to arterial mapping
with color flow duplex imaging in the lower extremity The Journal of Vascular Surgery, Nov;
10(5):5228; discussion 5289.
23. Davies MG. (2005). Intimal hyperplasia: basic response to arterial and vein graft injury and
reconstruction. In Rutherford Vascular Surgery 6th edition. (149172). Philadelphia. El Sevier Saunders
24. Shepard RJ, Rooke T. (2005). Uncommon arteriopathies. In Rutherford Vascular Surgery 6th edition.
(453474). Philadelphia. Elsevier Saunders.
25. Van Bockel JH, Hamming JF. (2005). Lower extremity aneurysms. In Rutherford Vascular Surgery 6th
edition. (15341551). Philadelphia. El Sevier Saunders
26. Shaalan WE; FrenchSherry, E; Castilla MS; Lozanski L; Bassiouny Hisham S. (2003 ). Reliability of
common femoral artery hemodynamics in assessing the severity of aortoiliac inflow disease The Journal
of Vascular Surgery, May; 37(5):9609.
27. Burnham SJ, Jaques P, Burnham CB. (1992). Noninvasive detection of iliac artery stenosis in the
presence of superficial femoral artery obstruction. J Vasc Surg. Sep;16(3):44551; discussion 452.
28. Brawley JG, Modrall JG. (2005). Traumatic arteriovenous fistulas. In Rutherford Vascular Surgery 6th
edition. (16191626). Philadelphia. El Sevier Saunders.
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INSIDE ULTRASOUND

N o ideu
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Bwuww. Reference Guide
A must have for all students, educators,
technologists, sonographers and physicians.
Over 950 images, 160 tables, and full detailed information on:
Anatomy Vascular Pharmacology
Vascular Physiology and Math Review
Hemodynamics Statistics
Vascular Diseases Measurements
Vascular Testing and Interpretation Glossary of Terms
Vascular Screening And more
Correlative Testing Modalities
Testing Optimization
Right Frontal Branch

Cardiac Effects on HE
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SPH
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O F B R A I N ( MEDIA
LV
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of Superficial Temporal

Spectral Doppler
Right Parietal Branch FT Right Anterior Cerebral
LE
of Superfical Temporal P U S C A L L OS
COR UM
Right Middle Cerebral

for
Right Posterior Right Ophthalmic

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Communicating

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Right Supraorbital

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Appr urs of
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Right Lacrimal

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Left Vertebral

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Right Posterior Auricular

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Great Book! Invaluable, practical clinical information THROMBUS

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ATHEROSCLEROTIC

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