Table of Contents Basics 1. Carter 2. Zagzebski 3. Zwiebel and John Pellerito 4. Diethrich 7. Zwiebel 8. Zwiebel 9. Zwiebel and John Pellerito Bendick Transcranial Doppler Sonography Shirley M.
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Otis, E. Keck Eugene Zierler Galt Zwiebel The posterior tibial artery passes behind the medial malleolus of the tibia and bifurcates, forming the medial and lateral plantar arteries. The deep plantar arch from the medial and lateral plantar arteries gives rise to the plantar metatarsal and digital arteries of the foot [ 11 ].
Arteries can be differentiated from veins on US by several characteristics. First, arteries are round in transverse images, while veins are somewhat oval. Second, arteries are smaller than veins. Third, arteries have visible walls and sometimes have calcified plaques on the walls.
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Fourth, when the vessels are compressed by the transducer, arteries are partially compressed, while veins are completely collapsed [ 12 ]. Doppler US of the lower extremity begins at the inguinal crease by putting a transducer on the common femoral artery in the transverse plane with the patient in the supine position Fig.
The common femoral artery is seen lateral to the femoral vein, which is drained from the greater saphenous vein anteromedially at the inguinal area Fig. The common femoral artery, the bifurcated superficial femoral artery and deep femoral artery are seen in a fallen-Y configuration in a longitudinal scan Fig. From the proximal to distal thigh, scanning is performed by moving a transducer distally along the superficial femoral artery deep to the sartorius muscle.
The superficial femoral artery goes together with the femoral vein Fig. The red rectangular boxes are the essential scanning sites and planes for the femoral arteries and the popliteal artery. The numbers within the boxes represent the general steps of scanning.
The schema in the box demonstrates the typical US features of arteries and veins at each scanning site. The common femoral artery CFA is lateral to the femoral vein FV on a transverse scan at the inguinal crease. Note that the size of the color box is as small as possible.
The popliteal artery is evaluated from the knee crease level in the transverse plane and then traced proximally up to the adductor canal at the supracondylar level of the femur Fig. The popliteal artery is seen in the central portion of popliteal fossa between the medial and lateral heads of the gastrocnemius muscles. The evaluation of the posterior tibial artery can be started from its origins at the tibioperoneal trunk, if scanning distally, or from the ankle behind the medial malleolus, if scanning proximally Fig. The peroneal artery is scanned along the lateral side of the posterior calf and is visualized alongside the fibular bone Fig.
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The posterior tibial artery PTA is seen along the tibia Ti at the medial side of the posterior calf box 1 and behind the medial malleolus MM of the ankle box 2. The peroneal artery PA is depicted alongside the fibula F on the lateral side of posterior calf in the prone position box 3.
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The anterior tibial artery ATA is detected over interosseous memberane black dashed line between the tibia Ti and the fibula F at the anterolateral side of the calf box 4. At the ankle level, the ATA is seen anterior to the tibia plafond Ti and the talus T box 5 and continues to the dorsalis pedis artery DOA distal to the ankle and metatarsal artery MA between the metatarsal bones box 6. The evaluation of the anterior tibial artery can be started from the ankle anterior to the talus neck and continued proximally or started from the proximal anterolateral leg between the tibia and the fibula and continued distally Fig.
The transducer is traced from the anterior ankle to the dorsal foot to evaluate the dorsalis pedis artery, continuing to the first dorsal metatarsal artery between the first and second metatarsal bones Fig. A linear transducer with a variable ultrasound frequency of MHz is generally used, but a convex transducer with a lower frequency can be selected for the evaluation of iliac arteries in the pelvic cavity [ 13 ]. The artery should be scanned on a longitudinal plane as long as possible. The operator should rotate or move the transducer delicately to maintain visualization of the artery.
Pulsed-wave Doppler US is performed in the longitudinal plane. The examination is usually performed with the patient placed in the supine position. The left lateral decubitus position or the prone position are the alternatives for evaluating the popliteal artery, the posterior tibial artery, and the peroneal artery Fig.
The anterior tibial artery and dorsalis pedis artery are scanned in the supine position Fig. The operator should be aware of both color and pulsed-wave Doppler parameters and how to adjust these parameters to obtain an optimal Doppler image. Among these parameters, the color box, color gain, color velocity scale, and inversion are frequently used during color Doppler US scanning. The color box is a square area within the grayscale sonogram in which all color Doppler information is displayed Fig. The size and location of the box are adjustable, and the image resolution and quality are affected by the box size and depth [ 14 ].
The box should be made as small and placed as superficially as possible, thereby maximizing the frame rate.
Color gain refers to the amplification of flow data to improve the depiction of flow [ 14 ]. The color velocity is the range of flow velocities that are depicted in color Doppler US [ 14 ]. An operator can detect the color flow within an arterial lumen by increasing the gain or decreasing the scale. Color flow artifacts outside an artery should be removed by decreasing the gain. A homogeneous color of arterial flow can be obtained by increasing the scale.
Flow toward the transducer typically appears red on color Doppler sonograms when a red color appears above the baseline on the color bar. Inversion can electronically invert the direction of flow, which may complicate the interpretation of the flow direction. Therefore, the flow direction should be interpreted based on the setting of the color bar. The wall filter WF eliminate the low frequency noise that may arise from vessel wall motion below an operator-defined frequency threshold [ 9 , 14 ].
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WF settings are usually preset by manufacturer Fig. Bottom: On the Doppler spectrum, time seconds is represented on the x-axis. Flow direction relative to the transducer is shown in relation to the spectrum baseline arrow. The aliasing artifact on the Doppler spectrum can be adjusted by lowering the baseline arrowhead and increasing the scale. Note the spectral broadening arrow in the Doppler spectrum due to stenosis of the artery.
SV, sample volume.
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It is important to understand the meaning of the parameters of pulsed-wave Doppler US and how to adjust them. The sample volume cursor is composed of parallel lines on both sides of the arterial axis line. The sample volume should be placed within an arterial lumen, and the range of the sample volume size is generally from one-third to one-half of the luminal diameter [ 15 ].
On Doppler US, the line in the center of the artery indicates of the axis of arterial flow. The nearly vertical line is the Doppler line of sight Fig. The Doppler spectrum is a graph showing the mixture of frequencies over a short period of time [ 9 ].