Segmental Doppler Pressures and Doppler Waveform Analysis in Peripheral Vascular Disease of the Lower Extremities



Segmental Doppler pressures and Doppler waveform analysis are important tools in the diagnosis of patients with peripheral vascular disease of the lower extremities. A complete arterial lower extremity Doppler examination consists of three components: (1) analysis of the arterial analog wave tracing, (2) measurement of the segmental systolic limb pressures, and (3) calculation of the ankle-brachial index (ABI).

Doppler segmental pressures have the same capabilities of analog wave tracing, i.e., to help in identifying the presence and severity of arterial occlusive disease, to provide an objective baseline to follow the progression of peripheral vascular disease of the lower extremity and/or the postoperative course, and to somewhat evaluate the treatment plan.

Four 12 × 40 pneumatic cuffs are applied at various levels on each leg: as high on the thigh as possible, just above the knee, just below the knee, and above the ankle. The examiner then listens to the posterior tibial and the dorsalis pedis arterial signals. Of these vessels, the one with the strongest Doppler signal is chosen for the ankle pressure. High-thigh, above-knee, below-knee, and ankle pressure readings are taken.

Another component of the arterial lower extremity Doppler examination is the calculation of the ABI. It is generally agreed upon that an ABI of 0.9–1.0 signifies normalcy or minimal arterial occlusive disease, an ABI of 0.5–0.9 signifies a claudication level, less than 0.5 signifies the presence of ischemic rest pain or severe arterial occlusive disease, and less than 0.3 is compatible with trophic changes of the lower extremities.


Noninvasive vascular testing Doppler Peripheral vascular disease Lower extremities 


  1. 1.
    Satomura S. Study of flow patterns in peripheral arteries by ultrasonics. J Acoust Soc Jpn. 1959;15:151–3.Google Scholar
  2. 2.
    Strandness Jr DE, McCutcheon EP, Rushmer RF. Application of transcutaneous Doppler flow meter in evaluation of occlusive arterial disease. Surg Gynecol Obstet. 1966;122:1039–45.PubMedGoogle Scholar
  3. 3.
    Kirkendall WM, Burton AC, Epstein FH, et al. Recommendation for human blood pressure determinations by sphygmomanometers: report of sub-committee of the postgraduate education committee, American Heart Association. Circulation. 1967;36:980–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Barnes RW. Noninvasive diagnostic techniques and peripheral vascular disease. Am Heart J. 1979;97:241–58.PubMedCrossRefGoogle Scholar
  5. 5.
    Holland T. Utilizing the ankle brachial index in clinical practice. Ostomy Wound Manage. 2002;48:38–40.PubMedGoogle Scholar
  6. 6.
    Adam DJ, Naik J, Hartshorne T, Bello M, London NJ. The diagnosis and management of 689 chronic leg ulcers in a single-visit assessment clinic. Eur J Vasc Endovasc Surg. 2003;25:462–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Carser DG. Do we need to reappraise our method of interpreting the ankle brachial pressure index? J Wound Care. 2001;10:59–62.PubMedGoogle Scholar
  8. 8.
    Yao JST, Bergan JJ. Predictability of vascular reactivity to sympathetic ablation. Arch Surg. 1973;106:676–80.CrossRefGoogle Scholar
  9. 9.
    AbuRahma AF, Robinson PA. Clinical parameters for predicting response to lumbar sympathectomy with severe lower limb ischemia. J Cardiovasc Surg. 1990;31:101–6.Google Scholar
  10. 10.
    Barnes RW, Shanik GD, Slaymaker EE. An index of healing of below knee amputation: leg blood pressure by Doppler ultrasound. Surgery. 1976;79:13–20.PubMedGoogle Scholar
  11. 11.
    Sumner DS, Strandness Jr DE. An abnormal finger pulse associated with cold sensitivity. Ann Surg. 1972;175:294–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Barnes RW. Noninvasive assessment of arteriovenous fistula. Angiology. 1978;29:691–704.PubMedCrossRefGoogle Scholar
  13. 13.
    McLafferty RB, Moneta GL, Taylor Jr LM, Porter JM. Ability of ankle-brachial index to detect lower extremity atherosclerotic disease progression. Arch Surg. 1997;132:836–40.PubMedCrossRefGoogle Scholar
  14. 14.
    Gornik HL, Garcia B, Wolski K, Jones DC, MacDonald KA, Fronek A. Validation of a method for determination of the ankle-brachial index in the seated position. J Vasc Surg. 2008;48(5):1204–10.PubMedCrossRefGoogle Scholar
  15. 15.
    Johnson KW, Maruzzo BC, Kassam M, et al. Methods for obtaining processing and quantifying Doppler blood flow velocity waveforms. In: Yao JST, Nicolaides AN, editors. Basic investigation in vascular disease. London: Churchill Livingstone, Inc.; 1981.Google Scholar
  16. 16.
    Van Tongeren RB, Bastiaansen AJ, Van Wissen RC, Le Cessie S, Hamming JF, Van Bockel JH. A comparison of the Doppler-derived maximal systolic acceleration versus the ankle pressure index or detecting and quantifying peripheral arterial occlusive disease in diabetic patients. J Cardiovasc Surg (Torino). 2010;51(3):391–8.Google Scholar
  17. 17.
    Gerhard-Herman M, Gardin JM, Jaff M, Mohler E, Roman M, Naqvi TZ. Guidelines for noninvasive vascular laboratory testing: a report from the American Society of Echocardiography and the Society for Vascular Medicine and Biology. Vasc Med. 2006;11(3):183–200.PubMedCrossRefGoogle Scholar
  18. 18.
    Khan TH, Farooqui FA, Niazik K. Critical review of the ankle brachial index. Curr Cardiol Rev. 2008;4(2):101–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Hirsch AT, Haskal ZT, Hertzer NR, et al. ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA ask Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients with Peripheral Arterial Disease). J Am Coll Cardiol. 2006;47:e1–192.CrossRefGoogle Scholar
  20. 20.
    Diehm C, Kareem S, Diehm N, Jansen T, Lawall H. Does calculation of ankle brachial pressure index need revision? Vasa. 2005;34:123–6.PubMedCrossRefGoogle Scholar
  21. 21.
    Murabito JM, Evans JC, Larson MG, Nieto K, Levy D, Wilson PW, Framingham Study. The ankle-brachial index in the elderly and risk of stroke, coronary disease and death. Arch Intern Med. 2003;63:1939–42.CrossRefGoogle Scholar
  22. 22.
    Newmann AB, Shemanski L, Manolio TA, et al. Ankle-arm index as a predictor of cardiovascular disease and mortality in the cardiovascular health study. Arterioscler Thromb Vasc Biol. 1999;19:538–45.CrossRefGoogle Scholar
  23. 23.
    Toursarkissian B, Mejia A, Smilanich RP, Schoolfield J, Shireman PK, Sykes MT. Noninvasive localization of infrainguinal arterial occlusive disease in diabetics. Ann Vasc Surg. 2001;15:73–8.PubMedGoogle Scholar
  24. 24.
    Brooks B, Dean R, Patel S, Wu B, Molyneaux L, Yue DK. TBI or not TBI: that is the question. Is it better to measure toe pressure than ankle pressure in diabetic patients? Diabet Med. 2001;18(12):528–32.PubMedCrossRefGoogle Scholar
  25. 25.
    Orchard TJ, Strandness DE. Assessment of peripheral vascular disease in diabetes: report and recommendations of an international workshop sponsored by the American Diabetes Association. Circulation. 1992;88(2):819–28.CrossRefGoogle Scholar
  26. 26.
    TASC. Management of peripheral arterial disease: transatlantic intersociety consensus. Eur J Vasc Endovasc Surg. 2000;19(SupplA):S1–250.Google Scholar
  27. 27.
    Bonham PA, Cappuccio M, Hulsey T, Michel Y, Kelechi T, Jenkins C, Robison J. Are ankle and toe brachial indices (ABI-TBI) obtained by a pocket Doppler interchangeable with those obtained by standard laboratory equipment? J Wound Ostomy Continence Nurs Soc. 2007;34(1):35–44.CrossRefGoogle Scholar
  28. 28.
    Williams DT, Price P, Harding KG. The influence of diabetes and lower limb arterial disease on cutaneous foot perfusion. J Vasc Surg. 2006;44:770–5.PubMedCrossRefGoogle Scholar
  29. 29.
    Cutajar CL, Marston A, Newcoumbe JF. Value of cuff occlusion pressures in assessment of peripheral vascular disease. BMJ. 1973;2:392–5.PubMedCrossRefGoogle Scholar
  30. 30.
    Sawka AM, Carter SA. The effect of temperature on digital systolic pressures in the lower limb in arterial disease. Circulation. 1992;85:1097–101.PubMedCrossRefGoogle Scholar
  31. 31.
    Carter SA, Tate RB. The effect of body heating and cooling on the ankle and toe systolic pressures in arterial disease. J Vasc Surg. 1992;16:148–53.PubMedCrossRefGoogle Scholar
  32. 32.
    AbuRahma AF, Diethrich EB, Reiling M. Doppler testing in peripheral vascular occlusive disease. Surg Gynecol Obstet. 1980;150:26–8.PubMedGoogle Scholar
  33. 33.
    AbuRahma AF, Diethrich EB. Doppler ultrasound in evaluating the localization and severity of peripheral vascular occlusive disease. South Med J. 1979;72:1425–8.PubMedCrossRefGoogle Scholar
  34. 34.
    McDermott MM, Liu K, Criqui MH, et al. Ankle-brachial index and subclinical cardiac and carotid disease. The multi-ethnic study of atherosclerosis. Am J Epidemiol. 2005;162:33–41.PubMedCrossRefGoogle Scholar
  35. 35.
    Diehm C, Schuster A, Allenberg JR, et al. High prevalence of peripheral arterial disease and co-morbidity in 6880 primary care patients: cross-sectional study. Atherosclerosis. 2004;172:95–105.PubMedCrossRefGoogle Scholar
  36. 36.
    Dormundy JA, Rutherford RB. Management of peripheral arterial disease (PAD). TASC working group. Trans Atlantic Inter Society Consensus (TASC). J Vasc Surg. 2000;31(1pt2):S1–296.Google Scholar
  37. 37.
    Schroder F, Diehm N, Kareem S, et al. A modified method of ankle-brachial pressure index is far more sensitive in the detection of peripheral arterial disease. J Vasc Surg. 2006;44(3):532–6.CrossRefGoogle Scholar
  38. 38.
    Niazi K, Khan TH, Easley KA. Diagnostic utility of the two methods of ankle brachial index in the detection of the peripheral arterial disease of lower extremities. Catheter Cardiovasc Interv. 2006;68(5):788–92.PubMedCrossRefGoogle Scholar
  39. 39.
    Espinola-Klein C, Rupprecht HJ, Bickel C, Lackner K, Savvidis S, Messow CM, Munzel T, Blankenberg S. AtheroGene investigators. Circulation. 2008;118(9):961–7.PubMedCrossRefGoogle Scholar
  40. 40.
    Lange SF, Trampisch HJ, Pittrow D, Darius H, Mahn M, Allenberg JR, Tepohl G, Haberl RL, Diehm C, getABI Study Group. Profound influence of different methods for determination of the ankle brachial index on the prevalence estimate of peripheral arterial disease. BMC Public Health. 2007;7:147.PubMedCrossRefGoogle Scholar
  41. 41.
    Hatsukami TS, Primozich JF, Zierler RE. Color Doppler imaging of infrainguinal arterial occlusive disease. J Vasc Surg. 1992;16:527–33.PubMedCrossRefGoogle Scholar
  42. 42.
    Moneta GL, Yeager RA, Lee RW. Noninvasive localization of arterial occlusive disease: a comparison of segmental Doppler pressures and arterial duplex mapping. J Vasc Surg. 1993;17:578–82.PubMedCrossRefGoogle Scholar
  43. 43.
    Collier P, Wilcox G, Brooks D. Improved patient selection for angioplasty utilizing color Doppler imaging. Am J Surg. 1990;160:171–3.PubMedCrossRefGoogle Scholar
  44. 44.
    Cossman DV, Ellison JE, Wagner WH, et al. Comparison of contrast arteriography to arterial mapping with color-flow duplex imaging in the lower extremities. J Vasc Surg. 1989;10:522–9.PubMedGoogle Scholar
  45. 45.
    AbuRahma AF, Khan S, Robinson PA. Selective use of segmental Doppler pressures and color duplex imaging in the localization of arterial occlusive disease of the lower extremity. Surgery. 1995;118:496–503.PubMedCrossRefGoogle Scholar
  46. 46.
    Feigelson HS, Criqui MH, Fronek A. Screening for peripheral arterial disease: the sensitivity, specificity, and predictive value of noninvasive tests in a defined population. Am J Epidemiol. 1994;140:526–34.PubMedGoogle Scholar
  47. 47.
    Gosling RG, King DH. Continuous wave ultrasound as an alternative and compliment to x-rays in vascular examination. In: Rebeman RS, editor. Cardiovascular applications of ultrasound. Amsterdam: North Holland Publishers; 1974.Google Scholar
  48. 48.
    Harris PL, Taylor LA, Cave FD, et al. The relationship between Doppler ultrasound assessment and angiography in occlusive arterial disease of the lower limbs. Surg Gynecol Obstet. 1974;138:911–4.PubMedGoogle Scholar
  49. 49.
    Johnson KW, Cobbold RSC, Kassam M, et al. Real time frequency analysis of peripheral arterial Doppler signals. In: Diethrich EB, editor. Noninvasive cardiovascular diagnosis. Littleton: PSG Publishing; 1980.Google Scholar
  50. 50.
    Gale SS, Scissons RP, Salles-Cunha SX, et al. Lower extremity arterial evaluation: are segmental arterial blood pressures worthwhile? J Vasc Surg. 1998;27:831–9.PubMedCrossRefGoogle Scholar
  51. 51.
    AbuRahma AF. Correlation of the resting and exercise Doppler ankle arm index to the symptomatology and to the angiographic findings. In: Diethrich EB, editor. Noninvasive assessment of the cardiovascular system. Littleton: John Wright-PSG, Inc.; 1982. p. 287–90.Google Scholar
  52. 52.
    Strandness Jr DE, Bell JW. An evaluation of the hemodynamic response of the claudicating extremity to exercise. Surg Gynecol Obstet. 1964;119:1237–42.PubMedGoogle Scholar
  53. 53.
    Quriel K, McDowell AE, Metz CE, et al. Critical evaluation of stress testing in the diagnosis of peripheral vascular disease. Surgery. 1982;91:686–93.Google Scholar
  54. 54.
    Carroll RM, Rose HB, Vyden J, et al. Cardiac arrhythmias associated with treadmill claudication testing. Surgery. 1978;83:284–7.PubMedGoogle Scholar
  55. 55.
    Baker JD, Daix D. Variability of Doppler ankle pressures with arterial occlusive disease: an evaluation of ankle index and brachial ankle gradient. Surgery. 1981;89:134–7.PubMedGoogle Scholar
  56. 56.
    Halperin JI. Evaluation of patients with peripheral vascular disease. Thromb Res. 2002;106:V303–11.PubMedCrossRefGoogle Scholar
  57. 57.
    Van Langen H, Van Gurp J, Rubbens L. Interobserver variability of ankle-brachial index measurements at rest and post exercise in patients with intermittent claudication. Vasc Med. 2009;14(3):221–6.PubMedCrossRefGoogle Scholar
  58. 58.
    Espeland MA, Regensteiner JG, Javamillo SA, Gregg E, Knowler WC, Wagenknecht LE, Bahnson J, Haffner S, Hill J, Hiatt WR, LookAHEAD Study Group. Measurement characteristics of the ankle-brachial index: results from the action for health in diabetes study. Vasc Med. 2008;13(3):225–33.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2013

Authors and Affiliations

  1. 1.Department of Surgery, Robert C. Byrd Health Sciences CenterWest Virginia University, Charleston Area Medical CenterCharlestonUSA
  2. 2.Department of Surgery, Robert C. Byrd Health Sciences CenterWest Virginia UniversityCharlestonUSA
  3. 3.Charleston Area Medical CenterCharlestonUSA

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