Part 1/Chapter 3/15-min read

Vascular Diagnostics and Imaging

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

Edited by Tal M. Hörer MD, PhD · David T. McGreevy MD, PhD·Reviewed ·25 sections · 43 references

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.

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.

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, with exercise ABI and TBI when indicated . Previous recommendations from the ESC (2017) also recommend ABI as first-line screening .

Toe-Brachial Index

  • Advantage: less affected by medial calcification.
  • Useful: diabetes, elderly, dialysis patients.
  • Cutoff: <0.7 = peripheral arterial disease (PAD).

Segmental Pressure Measurements

  • Performed at thigh, calf, ankle.
  • A drop ≥20 mmHg at any level compared to the level above indicates significant disease at that segment.

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 .

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 .
  • 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 .
  • It is also used to monitor microcirculatory response to advanced therapies, such as mesenchymal stem cell (MSC) therapy .

Venous Plethysmography

  • Air plethysmography: quantifies reflux and obstruction.
  • Replaced by duplex in many centers but still used in research.

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 .
    • abdominal aortic aneurysm (AAA) diameter measurement and surveillance; see 4Ch. 4 for screening/surveillance protocols .
    • 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 .

Computed Tomography Angiography

  • Gold standard for aortic disease, including abdominal aortic aneurysm (AAA), thoracoabdominal aortic aneurysm (TAAA), and thoracic endovascular aortic repair (TEVAR) planning .
  • 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 .
    • 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 .
  • 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 . The 2024 multi-society PAD guidelines emphasize CTA for anatomic mapping and procedural planning in symptomatic patients .

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 .
    • Renal artery stenosis.
    • Lower extremity peripheral artery disease (PAD) mapping when computed tomography angiography (CTA) is unsuitable .
  • 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.

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).

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 .
  • Arterial applications: In aorto-iliac and femoropopliteal interventions, IVUS confirms vessel sizing, stent apposition, and detects complications such as dissection or underexpansion . In aortic interventions, IVUS is utilized to identify landing zones, confirm branch vessel patency, and assess for endoleaks .
  • 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 . The 2022 ACC/AHA aortic guidelines support IVUS for optimizing thoracic endovascular aortic repair (TEVAR) and EVAR, particularly in complex anatomy . Recent evidence suggests that clinical adoption of IVUS may be outpacing current European Society for Vascular Surgery (ESVS) guideline recommendations .

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).

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.

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.

Tables

Table 3.1DiagnosticComparison of Diagnostic Modalities
  • ankle-brachial index (ABI)/toe-brachial index (TBI)
    **Advantages**
    Quick, non-invasive, cheap
    **Limitations**
    Calcification, less localizing
    **Main Uses**
    peripheral arterial disease (PAD) screening, chronic limb-threatening ischemia (CLTI)
  • Segmental Pressures
    **Advantages**
    Localizes stenosis
    **Limitations**
    Time-consuming
    **Main Uses**
    PAD severity
  • TcPO₂
    **Advantages**
    Predicts wound healing
    **Limitations**
    Operator-dependent
    **Main Uses**
    CLTI, wound prognosis
  • duplex ultrasound (DUS)
    **Advantages**
    Portable, repeatable
    **Limitations**
    Operator-dependent
    **Main Uses**
    Carotid, venous, grafts
  • computed tomography angiography (CTA)
    **Advantages**
    High-resolution, 3D
    **Limitations**
    Radiation, contrast
    **Main Uses**
    abdominal aortic aneurysm (AAA), PAD, carotid
  • magnetic resonance angiography (MRA)
    **Advantages**
    No radiation
    **Limitations**
    Limited availability
    **Main Uses**
    Aorta, renal, carotid
  • Angio
    **Advantages**
    Diagnostic + therapeutic
    **Limitations**
    Invasive
    **Main Uses**
    Final planning, intervention
  • intravascular ultrasound (IVUS)/optical coherence tomography (OCT)
    **Advantages**
    High precision
    **Limitations**
    Cost, availability
    **Main Uses**
    Endovascular optimization
  • positron emission tomography/computed tomography (PET/CT)
    **Advantages**
    Functional info
    **Limitations**
    Expensive, research
    **Main Uses**
    Vasculitis, infection

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 . In patients with diabetes, exercise testing is particularly valuable as resting hemodynamics may be masked by arterial stiffness .

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) . 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) .

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

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. 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 .
  • 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 . 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 . 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.

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 . 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 .

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.

MRA advances for PAD and aorta (non-contrast techniques, 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.

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.

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.

Contrast-enhanced ultrasound (CEUS) for 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.

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