Chapter 12 Color Duplex Imaging- Lower Extremities Femoral -popliteal segment

Color Duplex Imaging Goals: Adjunct to physiologic testing Identify exact site of disease Determine stenosis versus occlusion Intraoperative and post-op evaluation of bypass grafts

Color duplex technique: Femoro-popliteal segment Color duplex technique: Patient supine (for CFA) Use 5 -7.5 MHz transducer with 3.5 - 5 MHz Doppler Start at inguinal crease Get close to the leg.

Color duplex technique: Femoro-popliteal segment Color duplex technique: Identify CFA in transverse (or palpate pulse), then go longitudinal

Optimize: Color steering Frame rate Color gain Color scale (PRF) Femoro-popliteal segment Optimize: Color steering Frame rate Color gain Color scale (PRF) EIA CFA SFA PFA

Obtain spectral waveforms from EIA, measure PSV Femoro-popliteal segment Obtain spectral waveforms from EIA, measure PSV If desired, measure Rise time Rt. EIA } RT

Obtain Spectral waveforms from CFA, SFA, PFA Femoro-popliteal segment Obtain Spectral waveforms from CFA, SFA, PFA Scan course of SFA- popliteal a. with CDI Map any areas of flow disturbance

X x x x

Femoro-popliteal segment Harris, Rt SFV

Femoro-popliteal segment Harris, Rt. prox SFA PSV 41 cm/s

Femoro-popliteal segment Harris, Lt SFA PSV 71 cm/s

Femoro-popliteal segment Harris, RT SFA Stenosis Mid SFA

Femoro-popliteal segment Harris, Rt SFA Stenosis PSV 413 cm/s

Femoro-popliteal segment Harris, post stenosis PSV 295 cm/s

Femoro-popliteal segment Harris, Distal Rt SFA

Stenosis criteria Cossman DV, Ellison JE, et al. Comparison of contrast angiography to arterial mapping with color flow duplex imaging in the lower extremities. J Vasc Surg 1989;10:522-32

Quantitiative, “bottom line” for stenosis by spectral Doppler 2:1 ratio = ≥ 50% stenosis

Occlusion Criteria No flow in artery by color and spectral Doppler Femoro-popliteal segment Occlusion Criteria No flow in artery by color and spectral Doppler Identify collateral run-off Identify distal reconstitution Chronically occluded arteries may be difficult to see.

Composite SFA occlusion Reconstitution Collateral run-off Transverse Collateral inflow Distal SFA

Femoro-popliteal segment scan with leg externally rotated or with patient prone obtain spectral waveforms. measure PSV overlap SFA in adductor canal

R. Krom. Acute onset left leg coolness & pain 136 150 130 ABI = 0.94 138 Brachial 134 ABI = 0.0

Pt. Krom. Diffuse SFA disease

Pt. Krom Lt Mid SFA PSV 67 cm/s

Pt. Krom Popliteal artery prox to occlusion Psv 9 cm/s

Pt .Krom Popliteal thrombo- embolus

Pt. Krom

Pt. Krom Proximal PTA

Pt. Krom

Aorto-iliac segment

Color duplex - lower extremities Disadvantages “Let’s have one more, then we’ll go for that ultrasound scan!!” time consuming and difficult aorto-iliacs are a bitch

Common Iliac a. External Iliac a. Internal Iliac a. Inferior Epigastric a Inguinal lig. CFA

A-I segment disease? Consider: Thigh PVR waveform Thigh pressure CFA Doppler waveform Femoral pulse A Normal study rules out significant A-I disease, but not minor stenosis.

Patient Preparation NPO for 8 hrs prior Perform exam in am. Patients may take clear liquids, medications Diabetics - appropriate nourishment

Imaging technique Use a 2.5 - 3.5 MHz transducer Apply appropriate transducer pressure Scan in “Zones”

Scan “zones” 1. 2. 3. CFA Aorta CIA SFA Ext Iliac PFA Int. Iliac

Pt April 46 Year old female Bilateral hip and buttock claudication Indirect test = A-I disease

Hx of bilateral hip and buttock claudication Pt April. 46 yr old female Hx of bilateral hip and buttock claudication R Brachial pressure 135 L Brachial Pressure 135 Rt ABI 0.49 Lt ABI 0.53

Pt. April Vel 184 cm/s x Distal aorta

Pt April. Post stenotic turbulence

Pt. April RT CFA LT CFA PSV 39 cm/s PSV 48 cm/s AT= 0.18 s

Tibial artery CDI pre-op for distal bypass time consuming in abnormals work from distal to proximal find out what’s necessary

Tibial anatomy Anterior tibial a Posterior tibial a Peroneal a Dorsalis pedis a

Tibial CDI

Color Duplex tips Learn anatomy on normals Allow sufficient time (reduce stress) Do not become excessively compulsive with stenosis versus occlusion Most common disease site below groin = SFA ADDUCTOR CANAL