Lower

Extremity Arterial Protocol

Scan through each vessel prior to taking any images.

Protocol

1. Students should document all images identified below

2. Ankle-Brachial Indices (ABIs) should be performed after all images have been stored
• Utilizing an arterial machine
• Apply blood pressure cuffs to both ankles and both upper arms
• Record pressures at rest
3. If resting ABIs are normal and the patient’s symptoms include claudication (leg pain when walking and relieved with rest)
you must exercise the patient if they are able.
• Perform exercise with patient standing beside bed and holding onto bed, have patient raise up then down on
their toes until pain occurs, or 3-5 minutes if pain does not occur.
• Repeat ABI pressures immediately and every 2-3 minutes until pressures return to normal (or up to 10 minutes)

Structure Scan Plane Label Images Stored

Identify RT or LT
Sagittal EIA Gray Scale
External Iliac Artery Color Doppler
Color & Spectral Doppler - measure PSV
Sagittal CFA Gray Scale
Common Femoral
Color Doppler
Artery
Color & Spectral Doppler - measure PSV
Femoral Artery Sagittal FA PROX Gray Scale
Proximal Color Doppler
Color & Spectral Doppler - measure PSV
Sagittal FA MID Gray Scale
Femoral Artery Mid Color Doppler
Color & Spectral Doppler - measure PSV
Sagittal FA DIST Gray Scale
Femoral Artery Distal
Color Doppler

Color & Spectral Doppler - measure PSV
Sagittal POP ART Gray Scale
Popliteal Artery Color Doppler
Color & Spectral Doppler - measure PSV
Sagittal PTA Gray Scale
Posterior Tibial Artery Color Doppler
Color & Spectral Doppler - measure PSV
Sagittal DPA Gray Scale
Dorsalis Pedis Artery Color Doppler
Color & Spectral Doppler - measure PSV

Tips
• You should scan the whole leg without lifting the probe
• Follow the vessels in their entirety in color, taking the appropriate images at the described locations
• With diabetic patients, you may experience trouble getting accurate blood pressures for ABI’s due to calcification of the
vessel walls.

AK\backup\Vascular II\protocols
 Lower Extremity Arterial Protocol

Color Doppler
• Will vary with the presence/absence of pathology & curvature of the vessel
• Color images should relay the same information as your gray scale & spectral images
• Color box should be steered (angled) with the vessel direction
• Color in a normal vessel should be free of aliasing and extend to vessel walls
• Utilize preset color PRF (scale) and gain, and adjust according to the type of blood flow (velocities) being imaged
• If flow is normal and the color is outside the vessel wall or aliasing in center of vessel, slowly increase PRF and/or
decrease color gain until color is no longer outside the vessel wall or aliasing.
• If flow is normal and the color in the vessel is not filled in, slowly decrease PRF and/or increase color gain until the
color fills the vessel without aliasing or bleeding.

Spectral Doppler
• Must use angle correct – Angle correct must be less than 60 degrees
• Gate (SV length) must be in center of vessel & small width.
• Use color Doppler appearance to aid in placement of gate for spectral interrogation. Your goal is to document the highest
velocities present.
• Set the PRF (scale) appropriately for the velocities imaged.
• Adjust the PRF (scale) to display a large waveform.
• Adjust the spectral gain so that there is no background noise on the spectral trace.
• Normal waveforms in the extremities are high-resistive and triphasic, with a sharp systolic upstroke followed by a brief
period of diastolic flow reversal, ending with minimal forward flow in diastole
• Elevated velocities with spectral broadening indicate a stenosis
• Record velocities in the stenotic area as well as approximately 2 cm prior to (prestenotic) and after (poststenotic) the area
of stenosis
• Stenosis is considered significant if the flow in stenotic area is twice the velocity of an area just previous (prestenotic) to it
• Waveforms distal to a significant stenosis will become monophasic

Pathology Seen
• Atherosclerosis (plaque)
o Walls will appear thick
o Calcified plaque will produce acoustic shadowing
o Use color Doppler to evaluate for flow disturbances (aliasing)
• Aneurysm
o Vessel diameter will be 1.5 times larger than adjacent more proximal segment
o Measure in sagittal (AP) and transverse (width) from outer wall to outer wall
o Document intramural thrombus in sagittal and transverse with gray scale and color Doppler
• Document any soft tissue abnormalities seen in proximity to the arteries.
• Document any venous thrombosis seen.
• Document any pseudoaneurysms seen (size, residual lumen, and width of communicating channel/ neck).

Ankle-Brachial Indices (ABI) - a ratio of systolic pressures at the ankle to systolic pressures at brachial level
• Indicate the overall severity of peripheral artery disease
• Calculated by dividing the highest pressure at ankle level (obtained from either PTA or DPA) by the higher of the two
brachial pressures.
ABI Severity of PAD
> 1.30 Incompressible
0.90-1.30 Normal
0.75-0.89 Mild
0.50-0.74 Moderate
< 0.50 Severe
< 0.35 Tissue threatening
Source: Diagnostic Medical Sonography: The Vascular System
AK\backup\Vascular II\protocols