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
Received August 9, 2013; revised August 31, 2013; accepted September 7, 2013
Copyright © 2013 Ali Babaei Jandaghi et al. This is an open access article distributed under the Creative Commons Attribution Li-
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.
C
opyright © 2013 SciRes. SS

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)
SF
A
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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