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

2. 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

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

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

5. 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

6. 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

7. 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

8. X x x x

9. Femoro-popliteal segment
Harris, Rt SFV

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

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

12. Femoro-popliteal segment
Harris, RT SFA Stenosis
Mid SFA

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

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

15. Femoro-popliteal segment
Harris, Distal Rt SFA

16. 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

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

18. 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.

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

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

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

22. Pt. Krom. Diffuse SFA disease

23. Pt. Krom
Lt Mid SFA
PSV 67 cm/s

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

25. Pt .Krom Popliteal thrombo- embolus

26. Pt. Krom

27. Pt. Krom
Proximal PTA

28. Pt. Krom

29. Aorto-iliac segment

30. 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

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

32. 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.

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

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

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

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

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

39. Pt. April
Vel 184 cm/s x
Distal aorta

40. Pt April. Post stenotic turbulence

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

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

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

44. Tibial CDI

45. 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