The Role of Color Doppler Ultrasound Arterial Mapping for Decision Making in the Treatment of Patients with Lower Extremity Peripheral Arterial Disease

doi:10.4236/ss.2013.410081

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Surgical Science, 2013, 4, 415-420

http://dx.doi.org/10.4236/ss.2013.410081 Published Online October 2013 (http://www.scirp.org/journal/ss)

The Role of Color Doppler Ultrasound Arterial Mapping

for Decision Making in the Treatment of Patients with

Lower Extremity Peripheral Arterial Disease

Ali Babaei Jandaghi1, Zahra Mardanshahi1, Ahmad Alizadeh1, Iraj Baghi2, Hossein Hemmati3,

Narges Tabarzan Baboli4, Shabnam Alizadeh Arasi4, Amin Keshavarzzirak1*

1Department of Radiology, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran

2Department of Vascular Surgery, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran

3Department of Vascular Surgery, Razi Hospital, Guilan University of Medical Sciences, Rasht, Iran

4Department of Cardiology, Heshmat Hospital, Guilan University of Medical Sciences, Rasht, Iran

Email: *[email protected]

Received August 9, 2013; revised August 31, 2013; accepted September 7, 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Purpose: To assess the efficacy of color Doppler imaging for decision making in the treatment of patients with lower

extremity peripheral arterial disease (PAD) compared to digital subtraction angiography (DSA). Materials and Meth-

ods: Color Doppler scan was done on patients suspected for lower limb PAD, a day prior to the DSA which was done

by a vascular surgeon. Also, for the patients who were candidates for endovascular intervention based on the color

Doppler arterial mapping results, endovascular interventions were performed at the same time if the DSA findings are

correlated with the color Doppler map. The grading for evaluated segments was normal, insignificant stenosis (<50%),

hemodynamically significant stenosis (≥50%) and occlusion. We yielded the diagnostic efficacy indices of Doppler for

detecting arterial stenosis in each 18 different arterial segments below the renal arteries including, infrarenal aorta,

common and external iliac, common femoral, superficial femoral (proximal, middle and distal segments), deep femoral,

popliteal artery, tibioperoneal trunk, anterior and posterior tibial arteries (proximal, middle and distal segments) and

peroneal artery (proximal and distal segments). Then, we yielded the kappa agreement between Doppler and DSA find-

ings considering the grade of stenosis in 18 arterial segments separately. Results: Totally 115 lower extremities (2045

arterial segments) were evaluated in 90 patients [mean age: 60.8 ± 8.9 (range: 47 - 84 years old)] of which 68 (75.6%)

were men. The sensitivity of color Doppler for all arterial segments was 90% or higher except for common iliac artery,

distal segment of superficial femoral artery and proximal segments of anterior and posterior tibialis and peroneal arter-

ies. However, the specificity was 89% or higher, in all arterial segments. Kappa agreement was 0.72 or higher in all

segments (All P-Values < 0.001). Conclusion: This study suggests that considering excellent capability of color Dop-

pler sonography in the evaluation of lower extremity arterial disease, color Doppler arterial mapping is sufficient for

decision making in the treatment of these patients and can reduce the rate of diagnostic angiography.

Keywords: Lower Extremity; Peripheral Arterial Disease; Color Doppler Sonography; Arterial Mapping; Digital

Subtraction Angiography

1. Introduction

Peripheral arterial disease (PAD) is a common problem

in the elderly, especially among diabetic patients. When

PAD limits the patients’ lifestyle, diagnostic imaging is

performed to characterize the number, length, level and

severity of the lesions. Although Doppler ultrasonogra-

phy is safe, relatively inexpensive, reproducible, a non-

ionizing method, non-invasive and widely available as an

outpatient service, it is yet time consuming and operator

dependent. On the other hand, digital subtraction an-

giography (DSA) provides easily visualized images of

arterial tree. It can be used for endovascular interventions.

However, it’s of high cost, ionizing radiation, need for

contrast agents and invasive nature, and makes this pro-

cedure unsuitable for screening or for follow-up purposes

[1-4].

Color Doppler imaging is not only a morphological

but also a functional study, providing information about

*Corresponding author.

A. B. JANDAGHI ET AL.

416

both the vessel hemodynamic and wall.

Some studies have found that not only color Doppler

could replace up to 97% of diagnostic arteriography of

the lower limb [5] but also it could safely and accurately

guide therapeutic vascular interventions [6], thus sug-

gesting that DSA which has been considered by many as

the gold standard, may no longer be regarded so.

Recent studies indicate that the sensitivity and speci-

ficity of an arterial duplex study and color flow imaging

have increased significantly, making it a highly effective

modality for non-invasive evaluation of PAD [7].

Current arterial duplex modalities offer significantly

better anatomic evaluation for lesions in PAD patients

[8-12]. In some recent studies it has shown that there are

good concordances between arterial duplex studies and

DSA in aorto-iliac and femoro-popliteal disease, and it’s

fair to poor concordances in popliteal and infrapopliteal

disease [9-12].

In recent studies, it has shown that color Doppler

sonography is useful in planning treatment in patients

with PAD [13,14].

Our aim in this study was to determine whether the

color Doppler arterial mapping would be useful in treat-

ment planning in patients with lower extremity peripheral

arterial disease (PAD) by providing an image of the arte-

rial tree for the clinician.

2. Materials and Methods

Totally 115 lower extremities (2045 arterial segments)

were evaluated in 90 patients suspected for lower limb

PAD [mean age: 60.8 ± 8.9 (range: 47 - 84 years old)] of

which 68 (75.6%) were men. Color and spectral Doppler

scan was done a day prior to the DSA which was done by

a vascular surgeon. All subjects were examined with

B-mode, color and duplex Doppler US using a 2 - 5-MHz

convex array transducer for intra-abdominal and pelvic

arterial evaluation, and a 7 - 12-MHz linear array trans-

ducer for infra-inguinal arterial assessment (SONIX OP).

The distal portion of superficial femoral artery in the

Hunter area was also evaluated with the 2 - 5-MHz con-

vex array probe.

Spectral analysis was recorded for at least two to three

cycles of the waveform and the Doppler angle was set at

less than 60˚. Measurements were performed on a frozen

spectral strip. The values of the maximum peak systolic

velocity (Vmax, in cm/s) were obtained in all subjects.

The grading for evaluated segments was normal, insig-

nificant stenosis (<50%), hemodynamically significant

stenosis (≥50%), and occlusion (Figure 1). We yielded

the diagnostic efficacy indices of Doppler for detecting

arterial stenosis in each 18 different arterial segments

below the renal arteries including, infrarenal aorta, com-

mon and external iliac, common femoral, deep femoral,

superficial femoral (proximal, middle and distal seg-

ments), popliteal artery, tibioperoneal trunk, anterior and

posterior tibial arteries (proximal, middle and distal seg-

ments) and peroneal artery (proximal and distal seg-

ments). The information from the color Doppler study

was entered on a data sheet containing the diagrams of

the lower limbs arteries (Figure 2). Then, we yielded the

kappa agreement between Doppler and DSA findings

considering the grade of stenosis in 18 arterial segments

separately.

For the patients who were candidates for endovascular

intervention based on the color Doppler arterial mapping

results, endovascular interventions were performed at the

same time if the DSA findings correlated with the color

Doppler map. However, diagnostic DSA angiography

was also performed on those patients who were candi-

dates for vascular surgery based on color Doppler map-

ping.

Written informed consent was obtained from all par-

ticipants.

All procedures were in accordance with the ethical

standards of the responsible committee on human ex-

(a)

(b)

Figure 1. Significant stenosis in superficial femoral artery. (a) Increased peak systolic velocity (PSV) in the proximal segment

of superficial femoral artery (more than 417 cm/s) indicating significant stenosis. (b) Corresponding DSA, indicating signifi-

cant stenosis in superficial femoral artery.

A. B. JANDAGHI ET AL. 417

perimentation (institutional and national) and with the

Helsinki Declaration of 1975, as revised in 2000 [15].

3. Results

In the infra renal aorta, external iliac, common femoral,

deep femoral, superficial femoral (proximal and middle

segments), popliteal, tibioperoneal trunk, anterior tibialis

(middle and distal segments), posterior tibialis (middle

and distal segments) and peroneal (distal segment) arter-

ies, color Doppler showed a sensitivity greater than 90%

in diagnosing stenosis and occlusion. On the other hand,

in common iliac, distal segment of superficial femoral

and proximal segments of anterior and posterior tibialis

and peroneal arteries, sensitivity was 82% to 90%. Also,

in all segments, the specificity was equal or greater than

89% (Table 1).

For all arterial segments, the kappa values were equal

or greater than 0.72 (All P Values lower than 0.0001).

(Table 2)

4. Discussion

In recent years, the role of duplex scanning as a prepro-

Table 1. Diagnostic indices of color Doppler sonography.

Sen. Spec. PPV NPV PLR NLR Efficacy

Infra renal aorta

(CI95%)

100%

(-----)

100%

(-----)

100%

(-----)

100%

(-----)

---

(-----)

----

(-----)

100%

(-----)

Common iliac artery

(CI95%)

88.9%

(74% - 100%)

95.9%

(92% - 99%)

80%

(62.5% - 97.5%)

97.9%

(95% - 100%)

21.7%

(14.2% - 29.2%)

8.6%

(3.5% - 13.7%)

94.8%

(90.7% - 98.9%)

External iliac artery

(CI95%)

93.8%

(82% - 100%)

100%

(------)

100%

(-----)

99%

(97% - 100%)

----

(-----)

16.1%

(9.4% - 22.8%)

99%

(97.2% - 100%)

Common femoral

artery (CI95%)

100%

(-----)

100%

(-----)

100%

(-----)

100%

(-----)

---

(-----)

----

(-----)

100%

(-----)

Deep femoral artery

(CI95%)

97.1%

(91.5% - 100%)

97.5%

(94.1% - 100%)

94.4%

(86.9% - 100%)

98.7%

(96.2% - 100%)

38.8%

(29.9% - 47.7%)

33.6%

(25% - 42.2%)

97.3%

(94.3% - 100%)

Superficial femoral

artery 1/3 proximal

(CI95%)

97.1%

(91.5% - 100% )

97.5%

(94.1% - 100% )

94.4%

(86.9% - 100%)

98.7%

(96.2% - 100% )

38.8%

(29.9% - 47.7%)

33.6%

(25% - 42.2%)

97.3%

(94.3% - 100% )

Superficial femoral

artery 1/3 middle

(CI95%)

95.9%

(90.3% - 100% )

97%

(92.9% - 100%)

95.9%

(90.3% - 100%)

97%

(92.9% - 100%)

31.9%

(23.4% - 40.4%)

23.6%

(15.8% - 31.4% )

96.5%

(93.1% - 99%)

Superficial femoral

artery 1/3 distal

(CI95%)

87.1%

(75.3% - 98.9%)

89.3%

(82.7% - 95.9%)

75%

(60.9% - 89.1%)

94.9%

(90% - 99.8%)

81.4%

(74.3% - 88.5%)

69.2%

(60.8% - 77.6%)

88.7%

(82.9% - 945%)

Popliteal artery

(CI95%)

94.4%

(83% - 100%)

96.9%

(93.5% - 100%)

85%

(69.4% - 100%)

98.9%

(96.8% - 100%)

30.4%

(22% - 38.8%)

17.3%

(10.4% - 24.2%)

96.5%

(93.1% - 99.9%)

Tibioproneal trunk

(CI95%)

90%

(76.9% - 100%)

96.8%

(93.3% - 100%)

85.7%

(70.7% - 100%)

97.9%

(95% - 100%)

28.1%

(19.9% - 36.3%)

9.7%

(4.3% - 15.1%)

95.6%

(91.9% - 99.3%)

Anterior tibial artery

proximal (CI95%)

85.3%

(73.4% - 97.2%)

92.6%

(86.9% - 98.3%)

82.9%

(70.4% - 95.4%)

93.8%

(88.5% - 99.1%)

11.5%

(5.7% - 17.3%)

63%

(1.9% - 10.7%)

90%

(84.5% - 95.5%)

Anterior tibial artery

middle (CI95%)

93.3%

(84.4% - 100%)

96.5%

(92.6% - 100%)

90.3%

(79.9% - 100%)

97.6%

(94.3% - 100%)

26.7%

(18.6% - 34.6%)

14.4%

(8% - 20.8%)

90%

(84.5% - 95.5%)

Anterior tibial artery

distal (CI95%)

100%

(-----)

100%

(-----)

100%

(-----)

100%

(-----)

---

(-----)

----

(-----)

100%

(-----)

Posterior tibial artery

proximal (CI95%)

89.8%

(81.3% - 98.3%)

90.9%

(84% - 97.8%)

88%

(79% - 97%)

92.3%

(85.8% - 98.8%)

9.8%

(4.4% - 15.2%)

8.9%

(3.7% - 14.1%)

90%

(84.5% - 95.5%)

Posterior tibial artery

middle (CI95%)

92.2%

(84.8% - 99.6%)

95.3%

(90.1% - 100%)

94%

(87.4% - 100%)

93.8%

(87.9% - 99.7%)

19.6%

(12.3% - 26.9%)

12.2%

(6.2% - 18.2%)

93.9%

(89.5% - 98.3%)

Posterior tibial artery

(CI95%)

96.4%

(89.5% - 100%)

100%

(-----)

100%

(-----)

98.9%

(96.7% - 100%)

100%

(-----)

17.9%

(10.9% - 24.9%)

96.5%

(93.1% - 99.9%)

Peroneal artery

proximal (CI95%)

82.8%

(69.1% - 96.5%)

93%

(87.6% - 98.4%)

80%

(65.7% - 94.3%)

94.1%

(89.1% - 99.1%)

11.8%

(5.9% - 17.7%)

13.9%

(7.6% - 20.2%)

90%

(84.5% - 95.5%)

Peroneal artery distal

(CI95%)

92.9%

(83.4% - 100%)

95.4%

(91% - 99.8%)

86.7%

(74.5% - 98.9%)

97.6%

(94.3% - 100%)

20.2%

(12.9% - 27.5%)

13.4%

(7.2% - 19.6%)

94.7%

(90.6% - 98.8%)

Sen: Sensitivity, Spec: Specificity, PPV: Positive Predictive Value, NPV: Negative Predictive Value, PLR: Positive Likelihood Ratio, NLR: Negative Likeli-

hood Ratio.

A. B. JANDAGHI ET AL.

418

Table 2. The kappa agreements for all arterial segments.

Kappa P-value

Infra renal aorta 1 P < 0.0001

Common iliac artery 0.811 P < 0.0001

External iliac artery 0.963 P < 0.0001

Common femoral artery 1 P < 0.0001

Deep femoral artery 0.939 P < 0.0001

Superficial femoral artery 1/3 proximal 0.939 P < 0.0001

Superficial femoral artery 1/3 middle 0.929 P < 0.0001

Superficial femoral artery 1/3 distal 0.727 P < 0.0001

Popliteal artery 0.874 P < 0.0001

Tibioproneal trunk 0.852 P < 0.0001

Anterior tibial artery proximal 0.772 P < 0.0001

Anterior tibial artery middle 0.888 P < 0.0001

Anterior tibial artery distal 1 P < 0.0001

posterior tibial artery proximal 0.805 P < 0.0001

posterior tibial artery middle 0.876 P < 0.0001

posterior tibial artery 0.976 P < 0.0001

Peroneal artery proximal 0.749 P < 0.0001

Peroneal artery distal 0.862 P < 0.0001

Figure 2. Color and Spectral Doppler ultrasound arterial

mapping.

cedural diagnostic imaging for detecting and grading

occlusive disease of the lower limbs has been under dis-

cussion comparing with angiography as a “gold stan-

dard” [13,14,16,17]. The ultimate purpose of the diag-

nostic tools is not only limited to draw an accurate

anatomic arterial mapping but also to establish an appro-

priate therapeutic strategy, either surgical or endovascu-

lar [16]. In these literatures, there is increasing evidence

to indicate the possibility that Duplex scanning should

replace angiography in many patients for the therapeutic

planning [13,14,16,17] especially in high risk patients

with diabetes, renal failure or contrast agent allergy

[18,19].

In the present study, to evaluate the efficacy of duplex

scanning in detecting the lower extremity arterial disease,

18 arterial segments (totally 2045) were evaluated in

details and the arterial mapping of arterial beds was

drawn. To our knowledge, in the previous studies [7,8,13]

such a segmental evaluation had not been done with this

detail. Good diagnostic agreement (k ≥ 0.72; P < 0.0001)

was achieved in the all arterial segments. Excellent

agreement was achieved in the infra-renal aorta, Com-

mon femoral artery and anterior tibial artery distal seg-

ments (k = 1; P < 0.0001).

The study by Favaretto et al., showed poor agreement

in infrapopliteal districts, with a low sensitivity and high

specificity in detecting significant stenosis or occlusions

[8]. Also Fontcuberta et al., showed lower values for

sensitivity, specificity, positive predictive value and

A. B. JANDAGHI ET AL. 419

negative predictive value in tibial arteries than for other

sectors [13]. In our study, good agreement was achieved

in all below the knee arterial segments (k ≥ 0.75; P <

0.0001); however, lower agreement was noted for

proximal segments of anterior tibialis and peroneal arter-

ies (k = 0.77 and 0.75, respectively). Also, distal portion

of SFA in Hunter canal was difficult to be evaluated. So,

we used convex probe to overcome the poor view of this

arterial segment. Nevertheless, the lowest agreement (k =

0.72) in our study was related to this segment. Although

duplex scanning has lower sensitivity and specificity in

distal segment of superficial femoral and proximal seg-

ments of anterior and posterior tibialis and peroneal ar-

teries (Table 1), it is effective for drawing arterial map-

ping and further clinical decision making.

The arterial mapping in our study helped our vascular

surgeon to be ready for possible interventional proce-

dures such as need for stenting or angioplasty at the same

time of diagnostic DSA angiography. This resulted in

less patient’s costs and necessity for second interven-

tional angiography. Moreover, the patients were satisfied

by one step intervention.

5. Conclusion

In conclusion, this study suggests that considering excel-

lent capability of color Doppler sonography in the

evaluation of lower extremity arterial disease, color

Doppler arterial mapping is sufficient for decision mak-

ing in treatment of these patients and can reduce the rate

of diagnostic angiography.

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