Noninvasive Imaging of Peripheral Arterial Disease

Publication Date: May 27, 2016




Bilateral ABI calculations should be performed, which include bilateral brachial arteries and bilateral ankle pressures. The ABI should take the clinical situation into context to avoid false-negative calculations. The absolute ankle pressures should also be included in conjunction with the ABI calculation. Finally, in heavily calcified arteries, a TBI should be considered.

Segmental Limb Pressures

An ABI is a mandatory part of a physiologic examination. For segmental pressures, four cuffs can be used. The recommended location of the blood pressure cuffs are the upper thigh, lower thigh, upper calf, and ankle.

Segmental PVRs

PVRs are ideal for evaluating segmental disease and are not affected by calcification. They should be considered as part of a complete noninvasive examination.

Continuous-Wave Doppler Waveforms

Continuous-wave Doppler analysis should be performed at multiple segments when assessing the lower extremities for PAD. Continuous-wave Doppler analysis should be available as part of a complete noninvasive examination.

Exercise Testing

Exercise testing is useful to assist in the diagnosis of PAD in patients with claudication, and should be available as a component of the evaluation because it unmasks PAD not evident at rest. Exercise testing is mandatory in all patients with normal resting examinations who have exertional symptoms. Exercise testing can also be used as a part of surveillance testing in posttherapeutic PAD patients.


Reflection Photoplethysmography

Reflection photoplethysmography has utility in patients PAD and should be considered in the diabetic and chronic renal failure PAD subgroups.

Oxygen Tension

Oxygen tension can be used as an adjunctive tool to predict benefit for revascularization therapy. Oxygen tension measurements should be made with the patient at rest in a supine or recumbent position in a comfortable, warm room with the extremity covered by a sheet or blanket, breathing normobaric oxygen for at least 10 minutes. An increase of greater than 10 mm Hg of foot oxygen tension between normobaric room air and at least 10 minutes of a normobaric 100% oxygen challenge with a pulmonary oxygen saturation of greater than 90% is recommended as a positive outcome from a revascularization procedure of the lower extremities. In the setting of tissue loss, oxygen tension studies should be considered before and after revascularization procedures to serve as the baseline and surveillance after intervention. Postintervention oxygen tension studies should be performed more than 1 week after the revascularization procedure, although oxygen tension values can exhibit continual increase for as long as 28 days.


US grayscale imaging and Doppler imaging are recommended for assessment of PAD of the lower extremities. Periodic follow-up in patients who have undergone interventions and surveillance of patients with PAD should occur with US imaging; a standard surveillance protocol should include US evaluation twice in the first postinterventional year and annually thereafter. Multiple sonographic modes (eg, grayscale, power Doppler, color Doppler) are required to appropriately assess PAD in a single imaging session.

Recommendation Grading




Noninvasive Imaging of Peripheral Arterial Disease

Authoring Organization

Publication Month/Year

May 27, 2016

Document Type


External Publication Status


Country of Publication


Document Objectives

The present document therefore reviews and provides recommendations for noninvasive lower-extremity imaging of PAD, which includes two broad categories: (i) functional tests and (ii) anatomic tests. The functional or physiologic tests include the ankle-brachial index (ABI), segmental limb pressures, pulse volume recordings (PVRs), segmental Doppler waveforms, and oxygen testing. The anatomic tests include duplex ultrasound (US), computed tomography (CT), and magnetic resonance (MR) imaging. 

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Hospital, Radiology services

Intended Users

Nurse, nurse practitioner, physician, physician assistant



Diseases/Conditions (MeSH)

D058729 - Peripheral Arterial Disease


ankle-brachial index, peripheral artery disease (P.A.D.), Peripheral artery disease

Source Citation

Position Statement on Noninvasive Imaging of Peripheral Arterial Disease by the Society of Interventional Radiology and the Canadian Interventional Radiology Association

Dhanoa, Deljit et al.
Journal of Vascular and Interventional Radiology, Volume 27, Issue 7, 947 - 951