Textbook/Part 1/Chapter 3

Vascular Diagnostics and Imaging

Imaging modalities, non-invasive testing, and diagnostic algorithms for vascular conditions

25 sections
85 references
Last updated today

Background

Summary: This chapter provides a comprehensive overview of diagnostic modalities in vascular surgery, ranging from bedside clinical examination to advanced imaging techniques and emerging artificial intelligence (AI) applications. The diagnostic approach must balance accuracy, safety, cost-effectiveness, and availability while adhering to evidence-based guidelines from major vascular societies. (Rutherford 2018) (Patel 2016)📄 (ESVS 2024) [4] (Gornik 2024)

Clinical Examination

Still fundamental despite imaging advances.

  • Arterial disease: pulse palpation, bruits, trophic changes, Buerger’s test.
  • Venous disease: Trendelenburg and Perthes tests (historic), now complemented by DUS.
  • Lymphatic disease: inspection for edema, Stemmer’s sign.
  • Limitations: subjective, low sensitivity in early disease, cannot localize lesions precisely. (Rutherford 2018) (Bergan 2006)📄 (International Society 2020)📄

Ankle-Brachial Index

  • Definition: ratio of ankle systolic pressure to brachial systolic pressure.
  • Normal values: 1.00–1.40.
  • Peripheral arterial disease (PAD) diagnosis: <0.90 indicates PAD; <0.50 indicates severe ischemia.
  • Noncompressible arteries: Values >1.40 suggest medial arterial calcification (common in diabetes and chronic kidney disease (CKD)). In such cases, measure toe pressures and toe-brachial index (TBI) instead.
  • Exercise testing: If symptoms suggest PAD but resting ankle-brachial index (ABI) is normal or borderline (0.91–0.99), perform post-exercise ABI. A decrease ≥20% in ABI or ≥30 mmHg drop in ankle pressure supports the diagnosis.
  • Guidelines: The 2024 ACC/AHA/SVS guideline reaffirms ABI as the primary diagnostic test for PAD (Gornik 2024). Previous recommendations from AHA/ACC (2016) and ESC (2017) also recommend ABI as first-line screening, with exercise ABI and TBI when indicated (Patel 2016)📄 (Aboyans 2017)📄 (Uyagu 2022).

Toe-Brachial Index

Segmental Pressure Measurements

Pulse Volume Recordings

  • Pulse volume recordings (PVR) provide waveform analysis of segmental volume changes.
  • Flattened or dampened waveforms indicate significant peripheral artery disease (PAD).
  • Advantage: not affected by medial arterial calcification. This makes PVR particularly useful in patients with diabetes or non-compressible vessels where the ankle-brachial index (ABI) may be unreliable (Patel 2016)📄 (Rutherford 2018) (Das 2025).

Transcutaneous Oxygen Pressure (TcPO₂)

  • Transcutaneous oxygen pressure (TcPO₂) assesses skin oxygenation and predicts wound healing potential.
  • >50 mmHg = good healing potential.
  • <20 mmHg = poor healing potential (Schepers 2010)📄 (Conte 2019)📄.
  • In patients with diabetic foot ulcers (DFU), TcPO₂ is a useful bedside predictor of wound healing and amputation risk, although its performance as a standalone tool varies (Chuter 2023).
  • It is also used to monitor microcirculatory response to advanced therapies, such as mesenchymal stem cell (MSC) therapy (Zhang 2026).

Venous Plethysmography

  • Air plethysmography: quantifies reflux and obstruction.
  • Replaced by duplex in many centers but still used in research. (Bergan 2006)📄

Duplex Ultrasound

  • Principle: Combines B-mode imaging with Doppler waveform analysis to provide both anatomic and hemodynamic information.
  • Applications:
    • Carotid artery stenosis grading (using NASCET and ESVS criteria); see 7Ch. 7 for complete grading tables and management thresholds.
    • peripheral arterial disease (PAD) severity assessment and lesion localization (Gornik 2024).
    • abdominal aortic aneurysm (AAA) diameter measurement and surveillance; see 4Ch. 4 for screening/surveillance protocols (Isselbacher 2022).
    • Venous disease: reflux assessment (valve incompetence) and deep vein thrombosis (DVT) detection.
    • Post-intervention graft surveillance (e.g., after bypass surgery or endovascular aneurysm repair (EVAR)).
  • Advantages: Portable, non-invasive, relatively inexpensive, and repeatable without radiation or nephrotoxic contrast.
  • Limitations: Operator-dependent technique with reduced accuracy in obesity, presence of bowel gas, or extensive vascular calcification.
  • Guidelines: Recommended as first-line imaging for carotid disease, venous disease, AAA surveillance, and PAD diagnosis (Moneta 2010)📄 (Grant 2003) (Naylor 2018)📄 (ESVS 2024) (Wittens 2015)📄 (Almasri 2018)📄 (Aburahma 2019)📄 (Isselbacher 2022) (Gornik 2024).

Computed Tomography Angiography

  • Gold standard for aortic disease, including abdominal aortic aneurysm (AAA), thoracoabdominal aortic aneurysm (TAAA), and thoracic endovascular aortic repair (TEVAR) planning (Isselbacher 2022)📄.
  • Technical essentials: Submillimeter collimation (≤1 mm), multiphasic acquisition (non-contrast, arterial phase with bolus-tracking, delayed phase for endoleak detection), electrocardiogram (ECG)-gating for thoracic aorta when assessing root or ascending segments, standardized contrast delivery (4–6 mL/s) with saline chaser, and iterative reconstruction algorithms to reduce radiation dose.
  • Applications:
    • AAA and TAAA morphology assessment and access vessel evaluation; see 4Ch. 4 for measurement standards and repair thresholds (Isselbacher 2022)📄.
    • Endovascular aneurysm repair (EVAR) and TEVAR planning and surveillance.
    • Carotid and aortic arch assessment; see 7Ch. 7 for carotid imaging protocols.
    • Peripheral arterial disease (PAD) mapping (Gaba 2024).
  • Surveillance protocols: Baseline computed tomography angiography (CTA) at 30 days post-procedure, follow-up at 12 months, then individualized surveillance based on aneurysm sac behavior and endoleak status. Consider duplex ultrasound or contrast-enhanced ultrasound (CEUS) in patients with stable anatomy or renal insufficiency.
  • Limitations: Ionizing radiation exposure and iodinated contrast risks (nephropathy, allergic reactions).
  • Guidelines: ESVS AAA (2024), ESVS carotid (2018), and ACC/AHA aortic (2022) guidelines recommend CTA as a primary planning tool, with aneurysm and post-repair imaging surveillance tailored to patient and device factors (Sun 2011)📄 (ESVS 2024) (Naylor 2018)📄 (Chaikof 2018)📄 (Aburahma 2019)📄 (Isselbacher 2022)📄. The 2024 multi-society PAD guidelines emphasize CTA for anatomic mapping and procedural planning in symptomatic patients (Gaba 2024).

Magnetic Resonance Angiography

  • Advantages: No ionizing radiation and excellent soft tissue contrast.
  • Techniques: Time-of-flight (TOF), contrast-enhanced magnetic resonance angiography (MRA) (CE-MRA), and non-contrast MRA options for patients with renal insufficiency or contrast allergy. Vessel-wall imaging sequences provide enhanced characterization of vasculitis and arterial dissection.
  • Applications:
    • Carotid and intracranial disease.
    • Aortic pathology, particularly in connective tissue disorders (Isselbacher 2022) (Writing Committee 2022).
    • Renal artery stenosis.
    • Lower extremity peripheral artery disease (PAD) mapping when computed tomography angiography (CTA) is unsuitable (Gornik 2024).
  • Limitations: Limited availability, higher cost, and contraindications including certain metallic implants, pacemakers, and claustrophobia.
  • Guidelines: Recommended as alternative first-line imaging when CTA is contraindicated; modality choice should be guided by specific disease characteristics and patient factors. (Prince 2016) (Patel 2016)📄 (Aboyans 2017)📄 (Naylor 2018)📄 (Wanhainen 2019) (Isselbacher 2022) (Gornik 2024)

Catheter Angiography (Digital Subtraction Angiography, DSA)

  • Historically the gold standard.
  • Now reserved for interventional procedures (angioplasty, stenting, embolization).
  • Advantages: real-time imaging, therapeutic capability.
  • Limitations: invasive, risk of complications (bleeding, dissection, contrast nephropathy). (White 2006)📄 (Patel 2016)📄

Intravascular Ultrasound

  • Provides lumen size, wall characteristics, and stent apposition assessment.
  • Widely used in endovascular aneurysm repair (EVAR) and iliac vein stenting.
  • Venous applications: In iliofemoral venous obstruction, venography often underestimates lesion severity. Intravascular ultrasound (IVUS) improves detection of non-thrombotic iliac vein lesions and optimizes stent sizing and landing zone selection (Raju 2006)📄 (Ali 2016).
  • Arterial applications: In aorto-iliac and femoropopliteal interventions, IVUS confirms vessel sizing, stent apposition, and detects complications such as dissection or underexpansion (Gornik 2024). In aortic interventions, IVUS is utilized to identify landing zones, confirm branch vessel patency, and assess for endoleaks (Isselbacher 2022).
  • Guideline Recommendations: The 2024 ACC/AHA/SVS guidelines recommend IVUS as a reasonable adjunct (Class 2a) during peripheral artery disease (PAD) interventions to improve procedural success and clinical outcomes (Gornik 2024). The 2022 ACC/AHA aortic guidelines support IVUS for optimizing thoracic endovascular aortic repair (TEVAR) and EVAR, particularly in complex anatomy (Isselbacher 2022). Recent evidence suggests that clinical adoption of IVUS may be outpacing current European Society for Vascular Surgery (ESVS) guideline recommendations (Tessarek 2023).

Optical Coherence Tomography

  • Ultra-high resolution (10–20 μm).
  • Limited penetration depth; mostly used in coronary arteries, but research ongoing for peripheral applications, such as evaluating the chronicity of deep vein thrombosis (DVT). (Ali 2016),(Patel 2025)

PET/CT and PET/MR

  • Indications:
    • (1) Large-vessel vasculitis/polymyalgia rheumatica—FDG PET/CT(A) supports diagnosis, maps extent, and monitors response per EANM/EULAR recommendations.
    • (2) Suspected vascular graft/endograft infection—FDG PET/CT (and WBC SPECT/CT) complements CT to improve diagnostic accuracy and delineate extent per ESVS VGEI guidelines.
  • Limitations: cost, access, radiation, and need for standardized protocols. (Slart 2018) (Chakf 2020)

Artificial Intelligence (AI) in Diagnostics

  • Automated ankle-brachial index (ABI)/DUS interpretation.
  • computed tomography angiography (CTA) segmentation for aneurysm planning.
  • Predictive models for rupture risk and outcome.
  • Growing role in personalized vascular medicine. [4]

Tables

Table 3.1. Comparison of Diagnostic Modalities

Exercise ABI, post-exercise testing, and handling noncompressible arteries

Exercise ankle-brachial index (ABI) and Noncompressible Arteries

When clinical symptoms suggest peripheral arterial disease (PAD) but the resting ankle-brachial index (ABI) is normal, post-exercise testing should be performed using treadmill or heel-raise protocols. A decrease in ABI ≥20% or an ankle pressure drop ≥30 mmHg after exercise supports the diagnosis of PAD (Aboyans 2012)📄 (Patel 2016)📄. In patients with diabetes, exercise testing is particularly valuable as resting hemodynamics may be masked by arterial stiffness (Das 2025).

An ABI >1.40 indicates noncompressible arteries due to medial arterial calcification (MAC), a condition highly prevalent in patients with diabetes and chronic kidney disease (CKD) (Das 2025). In such cases, toe systolic pressure and toe-brachial index (TBI) should be measured, as these metrics are less affected by calcification. A TBI <0.70 is generally considered diagnostic for PAD, while a toe pressure <30 mmHg suggests severe ischemia in chronic limb-threatening ischemia (CLTI) (Potier 2011)📄 (Mills 2014) (Conte 2019)📄 (Das 2025).

Objective perfusion metrics for CLTI: toe pressure, TcPO2, skin perfusion pressure (SPP) and WIfI staging

Objective Perfusion Metrics for chronic limb-threatening ischemia (CLTI): Toe Pressure, TcPO₂, Skin Perfusion Pressure (SPP), and Wound, Ischemia, and foot Infection (WIfI) Staging

In patients with chronic limb-threatening ischemia (CLTI), objective perfusion measurements are essential for assessing disease severity, predicting wound healing potential, and determining the risk of major amputation. (Conte 2019)📄 (Gornik 2024)

Key metrics and thresholds (per WIfI):

  • Toe pressure: <30 mmHg indicates severe ischemia (WIfI I2–I3); 30–39 mmHg moderate (I1); ≥40 mmHg adequate (I0).
  • Transcutaneous oxygen pressure (TcPO₂): <30 mmHg indicates severe ischemia with poor healing potential (WIfI I2–I3); 30–39 mmHg moderate (I1); ≥40 mmHg adequate perfusion favorable for wound healing (I0).
  • Skin perfusion pressure (SPP): <30–40 mmHg indicates poor healing potential.

These perfusion parameters should be integrated into the Society for Vascular Surgery (SVS) Wound, Ischemia, and foot Infection (WIfI) staging system and applied according to Global Vascular Guidelines (GVG) and the 2024 ACC/AHA/SVS guidelines for revascularization planning and risk stratification. (Mills 2014) (Conte 2019)📄 (Gornik 2024) (Potier 2011)📄 (Schepers 2010)📄 See 10Ch. 10 for complete WIfI classification and management.

Standardized duplex ultrasound protocols and criteria

Standardized Duplex Ultrasound Protocols and Criteria

Standardized protocols and interpretation criteria are essential for reliable duplex ultrasound (DUS) assessment:

  • Carotid artery stenosis: Stenosis severity is graded using peak systolic velocity (PSV) and internal carotid artery (ICA)/common carotid artery (CCA) ratio. Laboratory-validated thresholds should be used, typically PSV ≥125 cm/s for ≥50% stenosis and ≥230 cm/s for ≥70% stenosis according to consensus criteria. Reports should include plaque morphology and contralateral disease status, though significant global variation in reporting protocols highlights the need for further standardization (Mukabagorora 2025).
  • Lower extremity peripheral artery disease (PAD): Assessment includes PSV, velocity ratios (VR) across lesions, and waveform analysis. DUS is recommended as a primary diagnostic tool for the anatomical localization of stenosis and to guide revascularization strategies (Gornik 2024). Velocity ratio thresholds help identify hemodynamically significant stenoses, with documentation of inflow, outflow, and runoff status.
  • Post-intervention surveillance: Graft surveillance employs specific thresholds, with high PSV and velocity ratios indicating stenosis and low graft PSV suggesting risk of thrombotic failure. The 2024 multi-society guidelines emphasize the role of DUS in the surveillance of autogenous vein bypass grafts and following endovascular interventions (Gornik 2024). Endovascular aneurysm repair (EVAR) surveillance protocols integrate duplex findings with cross-sectional imaging.

These protocols align with ESVS carotid guidelines, Society of Radiologists in Ultrasound (SRU) consensus statements, and the 2024 ACC/AHA PAD guidelines. (Grant 2003) (Naylor 2018)📄 (Moneta 2010)📄 (Gornik 2024)

CTA technical parameters for aorta and peripheral arteries

Computed tomography angiography (CTA) Technical Parameters for Aorta and Peripheral Arteries

Optimal CTA imaging requires attention to specific technical parameters that vary by anatomic region:

Aortic and endovascular aneurysm repair (EVAR) imaging: High-quality aortic CTA employs submillimeter collimation (≤1 mm) with multiphasic acquisitions including non-contrast, arterial phase (using bolus tracking), and delayed phase for endoleak detection. ECG-gating is applied for thoracic aorta imaging when assessing the aortic root or ascending aorta to minimize motion artifact (Isselbacher 2022). Standardized contrast delivery protocols (4–6 mL/s with bolus tracking) ensure consistent arterial enhancement.

Lower extremity CTA: Imaging parameters including table speed and reconstruction kernels are optimized for distal runoff vessel assessment in patients with lower extremity peripheral artery disease (PAD), ensuring adequate visualization of tibial and pedal arteries (Gornik 2024).

These technical standards support the planning and surveillance protocols outlined in the European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms and recent multisociety recommendations for aortic and peripheral vascular disease. (Sun 2011)📄 (ESVS 2024) (Isselbacher 2022) (Gornik 2024)

MRA advances for PAD and aorta (non-contrast techniques, vessel wall imaging)

magnetic resonance angiography (MRA) Advances for peripheral arterial disease (PAD) and Aorta: Non-Contrast Techniques and Vessel Wall Imaging

Magnetic resonance angiography has evolved to include multiple technique options that expand its clinical applicability:

Non-contrast MRA techniques: When gadolinium-based contrast is contraindicated (e.g., severe renal insufficiency, prior allergic reaction), non-contrast MRA sequences provide viable alternatives for vascular imaging. These include time-of-flight (TOF) and various flow-based techniques that do not require exogenous contrast agents.

Contrast-enhanced MRA: Where safe, CE-MRA remains the preferred MR technique, offering superior image quality and faster acquisition times compared to non-contrast methods.

Vessel wall imaging: Specialized MR sequences enable direct visualization of the arterial wall, proving particularly valuable in diagnosing and monitoring large vessel vasculitis and characterizing arterial dissection. These techniques provide information beyond luminal assessment alone.

MRA serves as an alternative first-line imaging modality in patients for whom computed tomography angiography (CTA) is inappropriate, with modality selection guided by disease characteristics and patient-specific factors according to major PAD and disease-specific guidance. (Prince 2016) (Patel 2016)📄 (Wanhainen 2019) (Naylor 2018)📄

Intravascular imaging: IVUS for iliac venous outflow obstruction and arterial optimization; OCT scope

Intravascular ultrasound (IVUS) has become an important adjunctive imaging modality in both venous and arterial interventions:

Venous applications: In iliac venous disease, IVUS demonstrates superior sensitivity compared to venography for identifying non-thrombotic lesions, particularly May-Thurner syndrome and other extrinsic compression syndromes. IVUS guidance optimizes stent sizing and landing zone selection, and is routinely recommended for iliofemoral venous stenting procedures.

Arterial applications: During aortoiliac and femoropopliteal interventions, IVUS assists with accurate vessel sizing and identifies procedural complications including arterial dissection and stent underexpansion that may not be apparent on angiography alone.

Optical coherence tomography (OCT): While OCT provides higher resolution imaging than IVUS (10–20 μm), its clinical application in peripheral vascular surgery remains largely investigational, with selective use in specific research protocols and niche clinical scenarios. (Raju 2006)📄 (Ali 2016) (Chaikof 2018)📄

Nuclear medicine: PET/CT for large-vessel vasculitis and vascular graft/endograft infection

Positron emission tomography combined with computed tomography (PET/CT) has established specific indications in vascular surgery:

Large-vessel vasculitis and polymyalgia rheumatica: Fluorodeoxyglucose (FDG) PET/CT or PET/computed tomography angiography (CTA) improves diagnostic confidence in suspected vasculitis, maps disease extent throughout the vascular tree, and assesses disease activity. This modality is particularly valuable in large-vessel vasculitis involving the aorta and its major branches, where conventional imaging may be inconclusive.

Vascular graft and endograft infection: FDG PET/CT and radiolabeled white blood cell (WBC) SPECT/CT provide functional imaging that complements anatomic CT findings. These modalities improve diagnostic accuracy for prosthetic graft infection and help delineate the extent of infection to guide surgical planning.

These applications are supported by European Association of Nuclear Medicine (EANM) procedural recommendations and ESVS vascular graft and endograft infection guidelines. (Slart 2018) (Chakf 2020)

Contrast-enhanced ultrasound (CEUS) for EVAR surveillance

Contrast-Enhanced Ultrasound (CEUS) for endovascular aneurysm repair (EVAR) Surveillance

Contrast-enhanced ultrasound utilizes intravenous microbubble contrast agents to enhance ultrasound signal and improve visualization of blood flow. In the context of EVAR surveillance, CEUS demonstrates high sensitivity for detecting endoleaks, particularly type II endoleaks that may be subtle on conventional imaging.

CEUS serves as a valuable adjunct to computed tomography angiography (CTA) in EVAR surveillance protocols, offering several advantages including lack of ionizing radiation and use of non-nephrotoxic contrast agents. This makes CEUS particularly useful in patients with renal insufficiency or those requiring frequent surveillance imaging, where cumulative radiation exposure and contrast load are concerns.

The role of CEUS in EVAR surveillance is outlined in major abdominal aortic aneurysm (AAA) guideline recommendations, which recognize its utility in selected patient populations. (ESVS 2024) (Aburahma 2019)📄

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