Peripheral Arterial Disease (Suspected)

Population Covered By The Guidance

This pathway provides guidance on the imaging of adult patients with suspected peripheral arterial disease.

Lead Researcher: Sian Chin

Experts & Contributors: Ravinder Dhillon, Phillip Misur, Paul Norman

Editorial Panel: Core membership
Link to Editorial Panel

Date reviewed: May 2018

Date Published: April 2019

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).

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).

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).

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).

Superficial Femoral Artery Occlusion

  • 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

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

  1. Ouriel K. Peripheral arterial disease. The Lancet. 2001;358(9289):1257-64. (Review article). View the reference
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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
  15. 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
  16. 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
  17. 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
  18. 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
  19. 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
  20. 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
  21. 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
  22. 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
  23. 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
  24. 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
  25. 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
  26. Hessel SJ, Adams DF, Abrams HL. Complications of angiography. Radiology. 1981;138(2):273-81. (Level II evidence). View the reference

Pathway User Guide

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SYMBOL RRL EFFECTIVE DOSE RANGE
No radiation None 0
Minimal radiation Minimal < 1 millisieverts
Low radiation Low 1-5 mSv
Medium radiation Medium 5-10 mSv
High radiation High >10 mSv

Disclaimer

Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.

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