Diagnostic Approach to Peripheral Artery Disease

Rationale for Ultrasound

The American College of Radiology recommends duplex ultrasound as "usually appropriate" for patients with claudication symptoms and known arterial disease, with a rating of 8/9 1, 2
Duplex ultrasound provides hemodynamic confirmation of stenosis severity with 92% sensitivity and 96% specificity for detecting significant aortoiliac lesions 2, 3
The European Society of Cardiology designates duplex ultrasound as a Class I first-line imaging method to confirm lower extremity arterial disease lesions 4

The American College of Radiology recommends obtaining resting ankle-brachial index (ABI) bilaterally as the highest-rated initial test, with a rating of 9/9 1
Duplex ultrasound of bilateral lower extremities, including iliac segments, is recommended 1, 2
If ABI is normal at rest, exercise ABI testing should be performed to assess hemodynamic significance 2, 3

The American College of Radiology recommends initiating best medical management, including supervised exercise program, with a rating of 9/9, if duplex ultrasound confirms hemodynamically significant stenosis 1
Antiplatelet therapy is recommended, with a rating of 7/9, for patients with significant stenosis 1
Revascularization should be considered if symptoms are lifestyle-limiting despite medical therapy 1, 2

Spectral Doppler waveform analysis can detect abnormal flow patterns suggesting proximal obstruction 2
Peak systolic velocity at the stenosis site and velocity ratio across the stenosis can indicate significant narrowing 5
The American College of Cardiology recommends documenting spectral waveform patterns in the common femoral artery to assess proximal obstruction 2