Diagnostic Imaging Pathways - Suspected Peripheral Arterial Disease
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This pathway provides guidance on the imaging of adult patients with suspected peripheral arterial disease.
Date reviewed: May 2018
Date of next review: May 2021
Published: April 2019
Quick User Guide
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Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
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| 1a |  |
Superficial Femoral Artery Occlusion Image 1a, 1b, 1c and 1d (Doppler Ultrasound): Occlusion of the right superficial femoral artery over approximately 25cm which reforms distally via collaterals at the adductor canal. Doppler images and spectral analysis are shown at the level of (Images 1a and 1b) and distal to the occlusion (Images 1c and 1d). |
| 1b |  |
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| 1c |  |
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| 1d |  |
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Teaching Points
Teaching Points
- Intermittent claudication must be differentiated from lower extremity pain occurring as a result of non-vascular aetiologies
- Imaging studies are useful in defining the location and extent of vascular lesions before a revascularisation procedure
- Doppler US, magnetic resonance angiogram and computed tomography angiogram are alternatives in the non-invasive investigation of peripheral arterial disease
- Angiography may be required prior to open surgical re-vascularisation. In endovascular therapy, it is carried at the same time
pad
Peripheral Arterial Disease
- The diagnosis of peripheral arterial disease begins with an accurate history 1
- Intermittent claudication must be differentiated from lower extremity pain occurring as a result of non-vascular aetiologies 1
- Measurement of ankle-brachial index (ABI) is recommended as a first-line non-invasive test for screening and diagnosis of lower extremity arterial disease – toe-brachial index and Doppler wave form analysis or pulse volume recording are alternatives if ankle arteries are incompressible 2
- Non-invasive imaging studies are useful in defining the location and extent of vascular lesions to guide the optimal revascularisation strategy 2
- Ultrasound, CTA and MRA can all reliably confirm or exclude the presence of peripheral arterial disease. All modalities have their own technical limitations when classifying the location, extent and severity of disease
us
Doppler Ultrasonography
- Recommended as first-line imaging method to confirm lower extremity arterial disease lesions 2
- Duplex ultrasound includes grayscale images and images from colour or power Doppler
- Older studies report 90-95% sensitivity and specificity for the diagnosis of >50% stenosis from the iliac arteries to the popliteal arteries. 3-7 Subsequently there have been significant improvements in ultrasound technology
- Limitations
cta
Computed Tomography Angiography (CTA))
- Modern multislice CT scanners enable rapid scanning of the entire arterial system, including visualisation of collaterals and arteries distal to occlusions that may not appear on catheter angiography
- Images can be reformatted into an arterial road map 10
- Good soft tissue contrast can also demonstrate non-vascular findings
- Studies from over 10 years ago report sensitivity and specificity of 90-100% compared to catheter angiography as the gold standard; 11-20 CT technology has continued to rapidly improve in this time. A smaller recent study has reported similar accuracy 21
- Advantages
- Rapid and widely available
- Non-invasive
- Able to show segments immediately distal to a point of occlusion
- Less radiation exposure compared to catheter angiography with comparable or lower iodine loads
- Better visualisation of stents than MRI 2
- Limitations
- Click here for more information about the use of iodinated contrast in renal failure. For patients with eGFR <30, consider pre- and post-hydration before CTA, or MRA without contrast may be an alternative
mra
Magnetic Resonance Angiography (MRA)
- Older studies from over 10 years ago report sensitivity and specificity of 90-100%; 20,22-24 MR technology has continued to improve subsequently
- Advantages:
- Non-invasive
- No exposure to ionising radiation
- Can be performed without contrast for patients with renal impairment
- Better diagnostic accuracy for tibial arteries than CTA and ultrasound 2
- Limitations:
- Limited availability, cost
- Long scanning time, higher risk of motion artefact 2
- Contraindicated with some metallic implants and pacemakers; metallic objects adjacent to region of interest can also cause artefact including stents 2
- Gadolinium contrast contraindicated in renal failure
- Extent of calcification may be underestimated 2
dsa
Digital Subtraction Angiography
- Was the reference standard in vascular imaging but its diagnostic role has been mostly replaced by non-invasive methods 2
- Can be undertaken to guide percutaneous intervention or to identify patent arteries for distal bypass 2
- Disadvantages:
- Invasive procedure with a risk of morbidity and mortality 25,26
- Requires skilled operator
- Exposure to iodinated contrast and ionising radiation
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Ouriel K. Peripheral arterial disease. The Lancet. 2001;358(9289):1257-64. (Review article). View the reference
- Aboyans V, Ricco J-B, Bartelink M-LEL, Björck M, Brodmann M, Cohnert T, et al. 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries. endorsed by: the European Stroke Organization (ESO) the task force for the diagnosis and treatment of peripheral arterial diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J. 2018;39(9):763-816. (Guideline). View the reference
- Jager KA, Phillips DJ, Martin RL, Hanson C, Roederer GO, Langlois YE, et al. Noninvasive mapping of lower limb arterial lesions. Ultrasound Med Biol. 1985;11(3):515-21. (Level III evidence). View the reference
- Fletcher JP, Kershaw LZ, Chan A, Lim J. Noninvasive imaging of the superficial femoral artery using ultrasound Duplex scanning. J Cardiovasc Surg (Torino). 1990;31(3):364-7. (Level II-III evidence). View the reference
- Leng GC, Whyman MR, Donnan PT, Ruckley CV, Gillespie I, Fowkes FG, et al. Accuracy and reproducibility of duplex ultrasonography in grading femoropopliteal stenoses. J Vasc Surg. 1993;17(3):510-7. (Level II-III evidence). View the reference
- de Vries SO, Hunink MG, Polak JF. Summary receiver operating characteristic curves as a technique for meta-analysis of the diagnostic performance of duplex ultrasonography in peripheral arterial disease. Acad Radiol. 1996;3(4):361-9. (Level II evidence). View the reference
- Collins R, Cranny G, Burch J, Aguiar-Ibanez R, Craig D, Wright K, et al. A systematic review of duplex ultrasound, magnetic resonance angiography and computed tomography angiography for the diagnosis and assessment of symptomatic, lower limb peripheral arterial disease. Health Technol Assess. 2007;11(20):iii-iv, xi-xiii, 1-184. (Review article). View the reference
- de Vries M, Ouwendijk R, Flobbe K, Nelemans PJ, Kessels AG, Schurink GH, et al. Peripheral arterial disease: clinical and cost comparisons between duplex US and contrast-enhanced MR angiography--a multicenter randomized trial. Radiology. 2006;240(2):401-10. (Level II evidence). View the reference
- Ouwendijk R, de Vries M, Stijnen T, Pattynama PM, van Sambeek MR, Buth J, et al. Multicenter randomized controlled trial of the costs and effects of noninvasive diagnostic imaging in patients with peripheral arterial disease: the DIPAD trial. AJR Am J Roentgenol. 2008;190(5):1349-57. (Level II evidence). View the reference
- Kock MC, Dijkshoorn ML, Pattynama PM, Myriam Hunink MG. Multi-detector row computed tomography angiography of peripheral arterial disease. Eur Radiol. 2007;17(12):3208-22. (Review article). View the reference
- Catalano C, Fraioli F, Laghi A, Napoli A, Bezzi M, Pediconi F, et al. Infrarenal aortic and lower-extremity arterial disease: diagnostic performance of multi-detector row CT angiography. Radiology. 2004;231(2):555-63. (Level II-III evidence). View the reference
- Fine JJ, Hall PAX, Richardson JH, Butterfield LO. 64-slice peripheral computed tomography angiography: a clinical accuracy evaluation. J Am Coll Cardiol. 2006;47(7):1495-6. (Level II-III evidence). View the reference
- Heijenbrok-Kal MH, Kock MC, Hunink MG. Lower extremity arterial disease: multidetector CT angiography meta-analysis. Radiology. 2007;245(2):433-9. (Level I evidence). View the reference
- Martin ML, Tay KH, Flak B, Fry PD, Doyle DL, Taylor DC, et al. Multidetector CT angiography of the aortoiliac system and lower extremities: a prospective comparison with digital subtraction angiography. AJR Am J Roentgenol. 2003;180(4):1085-91. (Level II-III evidence). View the reference
- Ofer A, Nitecki SS, Linn S, Epelman M, Fischer D, Karram T, et al. Multidetector CT angiography of peripheral vascular disease: a prospective comparison with intraarterial digital subtraction angiography. AJR Am J Roentgenol. 2003;180(3):719-24. (Level III evidence). View the reference
- Ota H, Takase K, Igarashi K, Chiba Y, Haga K, Saito H, et al. MDCT compared with digital subtraction angiography for assessment of lower extremity arterial occlusive disease: importance of reviewing cross-sectional images. AJR Am J Roentgenol. 2004;182(1):201-9. (Level II-III evidence). View the reference
- Willmann JK, Baumert B, Schertler T, Wildermuth S, Pfammatter T, Verdun FR, et al. Aortoiliac and lower extremity arteries assessed with 16–detector row CT angiography: prospective comparison with digital subtraction angiography. Radiology. 2005;236(3):1083-93. (Level II-III evidence). View the reference
- Willmann JK, Wildermuth S, Pfammatter T, Roos JE, Seifert B, Hilfiker PR, et al. Aortoiliac and renal arteries: prospective intraindividual comparison of contrast-enhanced three-dimensional MR angiography and multi–detector row CT angiography. Radiology. 2003;226(3):798-811. (Level II evidence). View the reference
- Met R, Bipat S, Legemate DA, Reekers JA, Koelemay MJ. Diagnostic performance of computed tomography angiography in peripheral arterial disease: a systematic review and meta-analysis. JAMA. 2009;301(4):415-24. (Level I evidence). View the reference
- Jens S, Koelemay MJ, Reekers JA, Bipat S. Diagnostic performance of computed tomography angiography and contrast-enhanced magnetic resonance angiography in patients with critical limb ischaemia and intermittent claudication: systematic review and meta-analysis. Eur Radiol. 2013;23(11):3104-14. (Level I evidence). View the reference
- Mishra A, Jain N, Bhagwat A. CT angiography of peripheral arterial disease by 256-slice scanner: accuracy, advantages and disadvantages compared to digital subtraction angiography. Vasc Endovascular Surg. 2017;51(5):247-54. (Level II evidence). View the reference
- Leiner T, Kessels AG, Nelemans PJ, Vasbinder GB, de Haan MW, Kitslaar PE, et al. Peripheral arterial disease: comparison of color duplex US and contrast-enhanced MR angiography for diagnosis. Radiology. 2005;235(2):699-708. (Level II evidence). View the reference
- Leiner T, Tordoir JH, Kessels AG, Nelemans PJ, Schurink GW, Kitslaar PJ, et al. Comparison of treatment plans for peripheral arterial disease made with multi-station contrast medium-enhanced magnetic resonance angiography and duplex ultrasound scanning. J Vasc Surg. 2003;37(6):1255-62. (Level II-III evidence). View the reference
- Visser K, Hunink MG. Peripheral arterial disease: gadolinium-enhanced MR angiography versus color-guided duplex US--a meta-analysis. Radiology. 2000;216(1):67-77. (Level II evidence). View the reference
- Egglin TKP, O'Moore PV, Feinstein AR, Waltman AC. Complications of peripheral arteriography: a new system to identify patients at increased risk. J Vasc Surg. 1995;22(6):787-94. (Level II evidence). View the reference
- Hessel SJ, Adams DF, Abrams HL. Complications of angiography. Radiology. 1981;138(2):273-81. (Level II evidence). View the reference
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