How To: Arterial Duplex Mapping - SD

Introduction to Duplex Ultrasound Demonstration

My name is George Bjo.
I'm the director of Vascular Ultrasound Services at Medical
Center in New York City,
and today I'll be demonstrating the use of duplex ultrasound
to image the arteries from the level
of the aortic bifurcation down to the tibial arteries.

We're gonna start out today at the level
of the aorta, I'm using a curved five one transducer,
although not every examination starts at the level
of the aortic bifurcation.
For the purposes of this demonstration, I'll start here
and then I'll elaborate as we move along.

I got some help from Terry here. Thank you, Terry.
Liberal gel is always a good idea.
With the transducer, just the love above the level
of the umbilicus, as you can see here, we're gonna
identify an image, the distal aspect
of the aorta in a transverse orientation.
And I'm just working my way down now toward the feet
to identify the aortic bifurcation.
As you can see here on the image, a little bit of gas there.
But I can still see them pretty well.

Imaging the Aorta and Aortic Bifurcation

Once I've identified the aorta at this level,
what I'm gonna do now is turn longitudinal sagittal to the long axis of the vessel here
where I can see, lemme just get an arrow here
so I can make a point out my vessels.
This is the aorta,
this is the left common iliac vein.
And then closer to me here, if I can get a good image
of it is my right common, I'm sorry, common iliac artery
and left common iliac artery.
So here's the right, and we're gonna start out
by imaging the right common iliac artery.
And I'm gonna point out some landmarks here,
but let's very quickly just acquire a
velocity at this level.
First, let's turn on the color
flow to see what that looks like.
Very nice. And you can see here that the color
is normal.
I'm just gonna get the pulse wave dopp,
and let's listen to the signal at this level.
Let's get a 60 degree angle in there if we can.
Very nice. And we will update to listen.
As you can see, that's a nice normal multiphasic
waveform, and that's what you should expect at the level of the aorta.
And it's a good idea to look at the aorta from the level
of the renal arteries down to the aortic bifurcation.
Once you've done that and made sure
that everything is normal, you can work your way down
through the iliac arteries.
We're gonna scan his right iliac artery for the purpose
of today's demonstration.
So let's take a quick look at that.
And what I like to do in general is actually put the color
on and very quickly do a scan
of the iliac arteries from the level
of the aortic bifurcation down to the femoral artery.
And so that's what we'll do.
Now, I'm gonna actually try
to improve this image a little bit, and here we are.
Here's the iliac artery. You can see the vein below it.
I'm just gonna invert so
that we can make the arteries red and the veins blue.
And what I'm gonna try to identify
for you now is the first important landmark,
and that is the level of the hypogastric artery.
And here we are. There really is no external landmark.
The landmark really is a sonographic landmark.
And here we go.
Here is the external iliac artery.
This is the hypogastric or internal iliac artery.
And here we see the common iliac artery here.
Lemme just magnify that image a little bit
so we can display that just a little bit better.
So here we are, and I'm gonna,
what I'm gonna do is work my way back up to the origin
of the common iliac artery again,
which is not a very long vessel.
And let's get wave form here.
I can see that the artery is actually
displayed in blue here.
We'll invert that and
update, and let's listen to that wave form.
Very nice wave form phasic is what we would expect it to be.
So you can acquire your representative images
and spectral wave forms
and use the color as a guide to tell you where
along the level of the arterial system, you have
to stop if you suspect an issue based on the color flow or the to the image.
Again, this is the level of the common
iliac artery bifurcation.
What I'm gonna do is I'm gonna work my way down now
to the femoral, to the level of the common femoral artery.

Common Femoral Artery and Alternative Imaging Approach

What I think we're gonna do here is just actually freeze
this image because in this particular patient,
we may be able to image the distal external iliac,
common femoral artery with a linear array transducer.
So let's give it a shot, And
that would be my recommendation in
most patients, if you can.
And where you can use the highest frequency
transducer that you have available that will allow you
to image the vessels of interest.
So what I'm gonna do here,
and this is an alternate way,
you can start out your imaging.
And what I do actually in most patients,
I typically will start out at the level of the groin
where I identify the common femoral artery.
As you can see here on the image,
it's that postal vessel.
Let's just put the color on, help us identify
that even better, let's increase the scale
so we can elate some of that aliasing that we see there.
Very nice. So that what you're seeing now
is the common femoral artery and the common femoral vein.
Now, I'm going to increase the depth here
because we're gonna be going into the pelvis
where the vessel might dive just a little bit
and might be a little bit difficult to see.
But let's give it a shot.
Might require that you have to press a little bit here.
We're looking now at the very proximal common femoral artery.
And let's work our way up.
In fact, it looks like, I don't know that I'll be able
to see, but let's give it a shot because if we can't, we'll just switch back to the curve to transducer.
Now again, I'm pushing a little bit
and working my way approximately
and making the adjustments with my hand
to optimize the image.
And there it is.
Let's see if we can identify.
Then let, there is the
common iliac artery bifurcation using this
linear array transducer.
So some patients, again, you might be able to get away
with using a higher frequency linear array.
And we can, in this patient sometimes requires
a little bit more hand pressure.
But if you can, I would always recommend that you do that.
It allows for better spectral imaging.
So let's take a look at the origin
of this external iliac artery.
Now, with pulse wave
and how can this steer that
so that it's parallel to the wall?
And then just do a quick update and let's listen to that.
And again, nice normal wave form,
just increasing the gain a little bit.
And again, you would wanna,
after you get a few representative wave forms, freeze it
and then acquire your velocities.
Let's see, caliber, peak,
select, and then end diastole.
And the velocity, here's 119 centimeters per second
with a good, normal phasic wave form.
So then using these techniques,
I would just work my way down.
Now, from the origin of the external iliac artery to,
the common femoral artery bifurcation,
Okay, and again, we use color as a guide
to work our way down, allowing the color
to tell us where it is.
We need to stop along the way.
In fact, we need to acquire additional velocities
where we suspect that there may be stenosis.
So here I am down at the leg level of the inguinal ligament.
I'm just gonna steer this color box appropriately.
And now what I'm looking for is the femoral artery bifurcation,
the common femoral artery bifurcation.
Here just below the level of the inguinal ligament,
we see the origin of the deep femoral right here,
this would be the superficial femoral artery.
And here we have the common femoral artery.
Once I've identified that landmark,
what I'll do is just solely work my way back up
and then acquire
a common femoral artery wave form.
And let's see what that looks like.
I expect that it'll look normal.
I haven't yet identified.
Wow. Again,
nice normal fact.
I see four phases there, two forward,
and two reverse phases.
So this is normal. Let's just update this.
And again, I'm gonna put my color on.
One of the important things that you have
to do at this level when you get down
to the femoral artery bifurcation is always evaluate the origin of the deep femoral artery.
Access is always an issue.
And in this particular case, what I'm gonna do now is I'm
gonna freeze this image, and I'm going
to actually just wipe your belly off here.
'cause we won't be eating this part of your anatomy anymore.
And I'm gonna actually Just tuck this
towel in here, and I'm gonna ask you to just
to bend your knee a little bit there.
Perfect. And with the patient in this position,
we actually have access to all of the arteries
of interest on the medial side of the leg,
the common femoral, the superficial femoral
and above knee popliteal,
the popliteal artery behind the knee.
Although if I needed to, I could always turn him on his back
or turn him more sideways, the origins
of the tibial arteries and the arteries in the foot to evaluate the anterior tibial artery.
What I would do then is just straighten his leg out
and I can evaluate the origins
of the anterior tibial
artery on the lateral side of the leg.
So let's just bend your knee again. Very nice.
And I'm going to
go back up to the groin now.
And let's take a quick look at the origin
of your deep femoral artery at this point.
And we can see here in a transverse image.
This is the common femoral artery
and vein as I work my way down his leg distally.
Here is the bifurcation of the common femoral artery.
There it is. This is the deep femoral,
this is the superficial femoral.
I'll just turn the transducer into a long axis.
And let's take a quick look at that with color.
And that's a very nice image.
And let's take a quick look at the origin
of the deep femoral artery.
And again, I would question you always to pay careful attention to the origin of the deep femoral artery.
This can be an important vessel patients with disease.
So you always want to take a look at it.
If there's going to be an issue with the deep femoral artery,
we'll probably be at the origin.
So always evaluate the origin of the deep femoral artery.
And we're getting a nice normal waveform here.
Once that's been evaluated, what I would do then is what we call a quick scan in the thigh.
And what I like to do is put the color on at this level,
and then just very quickly evaluate the entirety
or the whole length of the superficial femoral artery,
just using the color flow image.
And I think this is a huge time saver because the color flow image, in fact,
will give me a good idea about whether
or not there is any significant disease along the length
of the SFA or in terms of occlusion and stenosis.
And in the absence of color flow changes
that would make me suspicious,
I just scan along the entire length of the leg.
I'm just gonna freeze this for a second
and get a little bit of gel
Again.
Just pick up where I left off.
Allow the color to be my guide, work my way down the leg.
As you can see on this, on the ultrasound image here,
the vessel is starting to take a dive deep
into the musculature at about the distal third of the leg.
This is the area where the superficial femoral artery is now referred to as the above knee popliteal artery.
So what I'm gonna do is just freeze that,
and I'm gonna show you a nice overlapping technique
for evaluating this area.
What I like to do is evaluate it from both
the medial aspect.
This is where I left off,
and again, this is above knee popliteal.
Sometimes a little pressure from the back will help
to push it up and make it just a little bit easier to see.
But as you can see it, it is kind of moving away from us.
What I'll do here is just keep an eye on
where it is I left off,
and then work my way back up the leg
from a posterior approach.
What I'll do is I'll identify the,
and that was just above knee
popliteal artery that I just looked at.
I'm just gonna turn the color off here,
and I just need a little bit of 2D gain.
And so what you're looking at here is popliteal
vein and artery.
There's the vein. It's just disappeared when I pushed down.
And here's the artery.
What I'll do is I'll turn long axis now And from the back
of the leg, work my way back up proximally
posterior approach.
Here's my popliteal artery.
And you can see here now that I've overlapped both
of those areas from both the medial approach
and a posterior approach, I'll put the color on
and optimize that image.
Now, sometimes because of the depth at this level and
because the angle is not optimal,
you can't get a good color flow image.
But in this case, I'm pretty happy with it.
And then again, just continue to work my way down the popliteal artery from this posterior approach,
it's actually steer that color box the opposite
way or the other way.
Very nice. And you can see good color filling.
It's decreased that gain and increase the PRF.
And again, I'll work my way down the leg.
And what I'm looking for now is
to identify the popliteal artery.
As you can see now, it's kind of cosing,
its way up more superficially.
I'm looking for the origin of the anterior
tibial artery at this point.
And I should be able to identify that about this level.
It will be moving away from the transducer. And there it is.
You can see that there in blue.
Let's get a straight steer on that box.
And there is the origin
of the anterior tibial artery from this approach.
And now you're not gonna see a lot
of the anterior tibial artery from here,
and that's because of the anatomy.
It starts, it actually goes
through the interosseous membrane
and crosses to the other side of the leg.
But before we get to the tibial arteries, I do want
to talk about the what you would conventionally do in the thigh in the presence
of color flow changes
that would suggest stenosis, sandal occlusion.
You should always go back, evaluate those stenosis in terms of elevations and velocity.
If you do document occlusions, you want to both locate
the occlusions and measure the length
of those occlusions in preparation
or in anticipation of drawing your arterial maps.
So let's go back again.
I wanna see if I can get a better image of the origin
of the anterior tibial artery.
Let's see if we can do that in him.
Okay, here we go. So
little bit of a more of a medial approach here.
And what you're seeing in this case is the anterior tibial
artery here.
This is the tib perineal trunk.
And again, I would also again remind you
that you should be acquiring velocities
and looking at waveform at every level
along the length of the leg.
I'm just gonna get this machine a little bit closer to me.
Let's go back up to the Pope
and see what the waveform looks like here for a second.
And we will invert
thank you.
And let's listen to this again, a good,
normal waveform at that level, which is
what we would expect in him.
Let's just take a quick listen to the anterior tibial artery.
And I think this is important
because again, there's going to be there will be a segment of the anterior tibial artery that won't be visualized.
And many times you will have to depend on changes or not in the wave form to tell you about
that short area of the anterior tibial that's not seen.
So let's take a quick look at the wave form in the
anterior tibial artery.
As you can see, the vessels moving away from us
and not quite a 60 degree angle, but that's okay.
I am more interested in the shape
of the waveform here than I am in the velocity.
So let's just listen to that.
And again, it's phasic.
I'm gonna freeze that for a second.
And I'm going to actually, I'm going to move out
to the lateral aspect of his leg
and see if we can identify
the anterior tibular artery out here.
Let's just, I'm gonna put your leg down where it comes out
of the interosseous membrane
and then works its way down the lateral aspect of the leg.
And there we are. And this
better identify that by putting the color on.
And as you can see, this is the anterior tibial
artery on the other side.
And then let's take a quick look at that
with doppler
and invert.
And you can see again no changes in the waveform there.
And that would tell me
that probably there's nothing going on in that short area
that we are just not able to visualize because of anatomy.
So now what I would do is just continue to follow
that anterior tibial artery down the length of his leg from this anterior approach.
Let's just go back to the 2D and the color,
and let's just steer that
as it comes outta the interosseous membrane.
And again, you can use the color
again as a guide in terms of helping you
or allowing you to document stenosis based on the changes in the color flow image.
And let's invert this.
So that's in the appropriate direction.
And what I'm doing now is just working my way down the leg,
allowing the color to tell me where I need to stop
slowly as you're observing changes in the color flow image, And I have, I don't see anything
that would signify stenosis.
There you go. You can see
the further I work my way down the leg,
the more superficial the vessel will be.
I'm working my way down to the level of the ankle here.
And what I'm gonna do actually, is I'm going to switch.
I'm actually gonna get lower here to a
higher frequency transducer when I get
to the level of the foot.
And along the way, by the way,
you should be acquiring representative wave forms at
what we'd like to refer to as predetermined sites
along the length of the leg,
proximal midden distal calf for us.
You can see here, starting to get very superficial.
And I'm going to start,
there's actually a point at which it crosses over.
Very nice wave if I'm gonna switch transducers.
Now, actually, before I do that, what I'm going
to do is look at the perineal
and the posterior tibial arteries,
and let's see how well we can see those.
I'm gonna ask you to just bend your knee again,
and we're gonna use a medial approach again to identify,
you can actually turn your body a little bit, it'll help you
to relax and just rest your knee.
Perfect.

Evaluating the Tibial-Peroneal Trunk and Posterior Tibial Artery

So again, back to the tib perineal trunk.
And there is the anterior tibial artery.
Again, here is the tib perineal trunk.
The tibial perineal trunk will in turn, divide
where it becomes the perineal, which will cause deeply
and the posterior tibial arteries, which
that's, this is the posterior tibial right here.
And we'll go back and This
is your perineal.
I'm gonna freeze this for a second.
That's from a kind of a posterior approach.
Let's use a more medial approach
and see if we can identify
that again from this approach.
Sometimes this approach works better.
I would again recommend that you try multiple approaches
until you find the one you think works best.
And this is a much nicer image in this model.
And what you can see here, again, is the tib perineal trunk,
the posterior tibial artery, and then the perineal artery.
So why don't we follow the posterior tibial
using the color flow image?
Again, color, as you can see, is a very important aspect
of this test, which really is an anatomic study more than it is anything else.
Although we use all the tools in the toolbox to help us
to make our diagnoses.
We use the color, we use the spectrum.
We use a 2D image.
Really what we're trying to do is put together a map
that the interventionalist
or the vascular surgeon can use in order to determine
what type of intervention would be best on, in a given patient.
So again, can we magnify that image just
to make it a little bit bigger, make it easier to see?
Very nice. Okay, so here's your posterior tibial artery,
and you can see the adjacent veins.
Let's do doppler here and let's just listen to this
and we'll invert that signal.
And again, nice normal phasic waveform.
One of the tricks that you can use here, let's just get out a zoom
for a second, is if you can't identify,
if you're having difficulty identifying the arteries,
we are all probably used to scanning the lower extremity veins.
And in fact, I didn't mention this,
but the probably the ideal position patient position in these patients is reverse trendelenberg.
And the reason for that is
because it allows the blood to pull in the veins.
And as you can see here, I'm compressing the veins
next to the artery.
If you can identify the veins,
the artery will be right in between there.
I'm just gonna push down. You can see here
that the artery is pulsatile.
It's pulsating there. I'm just gonna release the pressure.
And again, you can see the veins there.
For the peroneals, they'll be a little bit deeper.
Here are the perineals. These are your posterior tibials.
Here's the perineal. I'm gonna push down.
Again, you can see the veins collapsing
around this postal perineal artery.
And that's one of the tricks.
The other thing you can do is you can identify,
there's a groove here that you
can palpate with your fingers.
If you can find that and just drop your
transducer right in there.
And then just move your transducer medial
and lateral there is your posterior tib artery.
And let's just put the color on
for a second so we can show you that.
Can we make that box just a little bit bigger?
'cause I wanna see if I can show them the posterior tibial
and the perineals in one picture.
And maybe let's steer it a little straighter.
Good. So there's your
posterior tibial artery.
And let's see if I can increase the color
gain and show you the perineal.
There's the perineal at the very bottom.
I'm gonna push down a little bit. There it is.
So what you're seeing here is your perineal artery
and your posterior tibial artery in one image.
So again, identify that groove in the leg,
drop the transducer right in there, and rock it back
and forth medial to later
until you identify the vessels of interest.
And then the other way that you can do it is
by using the bony landmarks.
If you turn transversely here at the top
of your skin is your tibia, and this is your fibula.
If you look medial to the tibia, you should be able
to identify your posterior tibial artery and veins.
There they are again, I'm just gonna push down
and show you that compression right here.
And here by your fibula will be your peroneal arteries.
Artery and veins right in here,
Vein artery vein.
As I push down, you can see that the veins collapse,
the artery is pulsitile.
And of course, ultimately you can always use the color.
Although keep in mind that in patients
with multilevel occlusive disease and
with these low flow states,
the color may not be very helpful.
So the other landmarks might be a little better in terms of identifying the artery.
So here they go again. Is your perineal below
or in the far field
and your posterior tibial artery in the near field.
And again, you would want to use your color flow image
to evaluate the entire length of the posterior tibial
and perineal arteries down to the level of the foot.
Now what I'm gonna do is I'm gonna switch over
to a higher frequency transducer
to evaluate those vessels in the foot where they tend
to be more superficial.
And so am I using the 12 five? Thank you very much.
Okay, so let's, since we have the patient in this position,
now, why don't we just evaluate the posterior tibial artery.
You can always palpate if you need to a posterior tibial artery pulse.
But in most patients, if you're mapping them,
the posterior tibial artery pulse probably
won't be appreciated.
So let's just Medial
to the medial malleolus,
you can identify the posterior tibial artery and veins.
As you can see on the ultrasound image,
let's put the color on and see what that looks like.
And maybe why don't we zoom that a little bit, just
to make it a little bit easier to see.
You can see that the vessel is relatively superficial
and smaller in caliber at this level but
is very easily identified on the color flow image.
And you can see the veins adjacent to that.
I'm just gonna turn transverse for a second
and show you what it looks like.
Transversely, let's just turn the color off for a second.
So again, if you're having trouble transverse image,
you can push down the veins disappear,
and there's your artery.
And this is the malleolus here.
So once you've identified that image, again,
you can turn long axis
and put your color on
and then follow that vessel back up as far approximately
as you need to in order to assure
that you've evaluated the entire length of the posterior tibial artery.
And that's a great image there of the
posterior tibial artery.
And again, acquiring all the velocity
and waveform data that's necessary to complete your study.
As you can see here, I'm working my way up the leg to the level just where I left off
with the lower frequency transducer.
And then you can just take that again,
right back into the foot as far as you need to me actually invert this
to make the artery red and let's increase the scale.
Good. And I'll just work my way into
the foot as far as I can, making the adjustments
with the color flow box.
As I do that, you can see now that the vessel
is kind of moving away from us
as it works its way into the deeper
part of the foot here.
This is your very distal posterior tibial artery and veins.
And let's listen to see what that sounds like at this level.
Okay, Let's just decrease that scale
and increase the gain a bit.
Very nice, nice normal waveform at this level.

Evaluating the Anterior Tibial and Dorsalis Pedis Arteries

Let's take a quick look at the anterior tibial artery
as it crosses the extensor crease and becomes the dosed.
I'm just gonna ask you to straighten
out your leg a little bit.
And I, one of the mistakes I see quite often is
that the technologist
or the sonographer will try to scan the dors P artery
with the foot in plantar, you knows, severe plantar flexion.
And a patient with low flow states,
this could actually compress the dors peter artery
and make it appear as if there's no floor,
as if the vessel is occluded.
So I would just make sure the patient is dorsiflex
very little pressure and lots of gel,
and then identify the anterior tibial artery
as it crosses over and becomes the dorsalis peter artery.
And let's put the color flow on.
Okay, and there's your dorsal penis artery
and again, very little pressure here
and let's just increase the gain a little bit.
Very nice. And there's your dorsal penis artery.
I'm actually gonna move proximally a little bit.
And there it is.
So this is the dorsal penis artery.
What I want you to do for a second, do this
with your foot plantarflex,
and let's see if anything happens in
terms of the compression here.
In this case, not so much.
Although again, in patients with low flow states,
you have to be very careful about compressing
and occluding the vessel at this level,
you can go normal position again.
And so again, you just follow this into the foot as far
as possible and acquire all of the appropriate blood wave forms and blood flow velocities.
And let's take a quick listen to the dorsal PDUs artery here and see what it sounds like.
As you can see, it's a phasic wave
form In this normal patient.

Conclusion

So that's the evaluation of the patient with suspected peripheral arterial occlusive disease.
It's essentially a straightforward technique.
Of course, it's much more straightforward in this patient
who doesn't have any disease at all,
can be quite challenging in patients
with multi-level occlusive disease.
But if you use the techniques that we described,
I think you'll be able to facilitate a complete examination.
I wish you a lots of luck,
and if you need to send me an email
or have any questions, feel free to do that.
My email address is gb, those are my initials
and my credential RVT.
So it's gb rvt@aol.com. Good luck.