AIUM Practice Parameter for the Performance of Peripheral Arterial Ultrasound Using Color and Spectral Doppler, 2025 Revision

The American Institute of Ultrasound in Medicine (AIUM) is a multidisciplinary association dedicated to advancing the safe and effective use of ultrasound in medicine through professional and public education, research, development of clinical practice parameters, and accreditation of practices performing ultrasound examinations.

The AIUM Practice Parameter for the Performance of Peripheral Arterial Ultrasound Using Color and Spectral Doppler was revised by the AIUM in collaboration with other organizations whose members use ultrasound for performing this examination(s) (see “Acknowledgments”). Recommendations for personnel requirements, the request for the examination, documentation, quality assurance, and safety may vary among the organizations and may be addressed by each separately.

This practice parameter is intended to provide the medical ultrasound community with recommendations for the performance and recording of high‐quality ultrasound examinations. The parameter reflects what the AIUM considers the appropriate criteria for this type of ultrasound examination but is not intended to establish a legal standard of care. Examinations performed in this specialty area are expected to follow the Parameter with the recognition that deviations may occur depending on the clinical situation.

This practice parameter is intended to assist practitioners performing noninvasive evaluation of the peripheral arteries using color and Doppler waveform analysis ultrasound. The sonographic examination of patients with peripheral vascular disease will, in general, complement the use of other physiologic tests, such as pressure measurements, plethysmographic recordings, and continuous wave Doppler. In selected cases a tailored examination is used to answer a specific diagnostic question. Although it is not possible to detect every abnormality, adherence to the following practice parameter will maximize the probability of detecting most of the abnormalities that occur in the extremity arteries.

Indications

The indications for peripheral arterial ultrasound examination include, but are not limited to, the following:

1. The detection of stenoses or occlusions in segment(s) of the peripheral arteries in symptomatic patients with suspected arterial occlusive disease. These patients could present with recognized clinical indicators, such as claudication, rest pain, ischemic tissue loss, aneurysm, or arterial embolization. ¹ , ² , ³ , ⁴ , ⁵ , ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸

2. The monitoring of sites of previous surgical interventions, including sites of previous bypass surgery with either synthetic or autologous vein grafts. ¹⁹ , ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵

3. The monitoring of sites of various percutaneous interventions, including angioplasty, thrombolysis/thrombectomy, atherectomy, or stent placement. ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹

4. Follow‐up for progression of previously identified disease, such as documented stenosis in an artery that has not undergone intervention, aneurysms, atherosclerosis, or other occlusive diseases.

5. The evaluation of suspected vascular and perivascular abnormalities, including such entities as arteritis, fibromuscular dysplasia, masses, aneurysms, pseudoaneurysms, arterial dissections, vascular injuries, arteriovenous fistulae, thromboses, emboli, or vascular malformations. ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷

6. Mapping of arteries before surgical interventions. ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ , ⁴²

7. Clarifying or confirming the presence of significant arterial abnormalities identified by other imaging modalities.

8. Evaluation of arterial integrity in the setting of trauma.

9. Evaluation of patients suspected of thoracic outlet syndrome, such as those with positional numbness, pain, tingling, or a cold hand.

10. Allen's test to establish patency of palmar arch. ⁴³ , ⁴⁴

11. Temporal artery evaluation for temporal arteritis and/or to localize temporal arterial biopsy for suspected diagnosis of temporal arteritis. ³³ , ³⁴

Additional uses of Doppler ultrasound can include preoperative mapping for dialysis access and postoperative follow‐up (see the AIUM Practice Parameter for the Performance of Ultrasound Vessel Mapping Prior to Dialysis Access Creation ⁴⁵ and the AIUM Practice Parameter for the Performance of Vascular Ultrasound for Postoperative Assessment of Dialysis Access ⁴⁶ ).

Qualifications and Responsibilities of Personnel

Physicians interpreting or performing this type of ultrasound examination should meet the specified AIUM Training Guidelines ⁴⁷ in accordance with AIUM accreditation policies. ⁴⁸

Sonographers performing the ultrasound examination should be appropriately credentialed ⁴⁹ in the specialty area in accordance with AIUM accreditation policies. ⁴⁸

Physicians not personally performing the examination must provide supervision, as defined by the Centers for Medicare and Medicaid Services Code of Federal Regulations 42 CFR §410.32, ⁵⁰ which is available from the U.S. Government Publishing Office.

Request for the Examination

The written or electronic request for an ultrasound examination must originate from a physician or other appropriately licensed health care provider or under the provider's direction. The clinical information provided should allow for the performance and interpretation of the appropriate ultrasound examination and should be consistent with relevant legal and local health care facility requirements.

The sonographic examination consists of grayscale imaging and spectral Doppler waveforms in the appropriate arterial segments. Color Doppler should be used to improve detection of arterial lesions by identifying sites of narrowing and changes in color associated with stenoses and to guide placement of the sample volume for spectral Doppler assessment. ¹⁰

Specification of the Examination

Appropriate Techniques and Diagnostic Criteria

Specific sonographic techniques must be tailored to the clinical indication, the different arterial segments studied, and the specific pathology being evaluated. Diagnostic criteria for stenosis differ between native and postoperative and postprocedural arteries.

Velocity measurements are derived from angle‐corrected spectral Doppler waveforms obtained from longitudinal images. Every attempt should be made to acquire images in which the angle created by the direction of blood flow and the direction of the ultrasound beam is kept at ≤60°. Velocity estimates made from images using larger angles are less reliable.

There are published spectral Doppler criteria for velocity ratio, absolute velocity, pulsatility indices, and acceleration time. One or more criteria may be used. The criteria may be validated for some but not all arterial segments (eg, acceleration time has been studied in the iliac and common femoral arteries). Waveform shape, presence or absence of turbulence, and direction of flow may be described for appropriate indications.

For arterial stenoses, color Doppler should be optimized to detect narrowing of the lumen and high velocity in the stenotic region.

Peripheral Arterial Disease

Physiologic tests of the arterial system, such as ankle brachial index (ABI), segmental pressure, continuous wave Doppler, and plethysmographic waveform analysis, are other arterial examinations performed to determine the presence and degree of arterial disease and/or to identify patients appropriate for imaging. ¹ , ³⁷ , ⁵¹ These studies are complementary and not equivalent to the sonographic examination.

The ABI may help evaluate the hemodynamic consequences of lower extremity arterial disease. A contemporaneous ABI, along with imaging supports the imaging findings or may suggest nonvisualized disease, or if discrepant, helps avoid pitfalls.

Representative longitudinal color Doppler and/or gray scale images along with angle‐corrected spectral Doppler waveforms with velocity measurements should be documented for each normal arterial segment.

Suspected abnormalities should be documented with longitudinal gray scale and color Doppler images. Transverse images may be helpful. Documentation of flow abnormality can be performed by obtaining cine clips.

Angle‐corrected spectral Doppler waveforms should be obtained from longitudinal images and include sites proximal to, at, and distal to sites of suspected stenosis. The sonographer/technologist should evaluate the vessel thoroughly throughout the stenosis to determine the highest peak systolic velocity (PSV). The highest PSV within the abnormal segment should be compared with velocities in the proximal and distal normal segments. Velocities should generally rise in a stenosis unless the stenosis is unusually long or the stenosis is quite severe.

The highest angle‐corrected PSV in a stenosis should be recorded from a longitudinal image. A spectral Doppler waveform with velocity measurements should be recorded in the normal arterial segment 1–4 cm proximal (upstream) to a suspected stenosis. A waveform distal to a stenosis should be recorded because it is helpful to document a drop in velocity beyond the stenosis and poststenotic disturbed flow/turbulence. Distal abnormalities, such as a poststenotic tardus parvus waveform, are signs of hemodynamic significance. If present, collateral branches should be recorded and documented including direction of flow within the reconstituted artery.

The location of any diseased or occluded segment(s) should also be documented. Estimated lengths of diseased or occluded segments may be helpful.

Gray scale and color and spectral Doppler evaluation of the following arterial segments should generally be performed as indicated whether or not a stenosis is present or suspected. Documentation of stenosis requires additional images. The accessible portion of the entire vessel or the arterial segment(s) of interest should also be evaluated because stenoses may occur in different or multiple sites.

1. Lower extremity

   1. Common femoral artery
   2. Proximal deep femoral artery
   3. Proximal superficial femoral artery
   4. Mid superficial femoral artery
   5. Distal superficial femoral artery above the knee
   6. Popliteal artery PSVs above and below the knee

   If clinically appropriate, gray scale and color and spectral Doppler imaging of the common and external iliac, tibioperoneal trunk, anterior tibial, posterior tibial, peroneal, and dorsalis pedis arteries should be performed.

   A focused or limited examination may be appropriate in certain clinical situations.

• 2
  Upper extremity

  1. Subclavian artery
  2. Axillary artery
  3. Brachial artery

  If clinically appropriate, gray scale and color and spectral Doppler imaging of the innominate, radial, and ulnar arteries and the palmar arch should be performed.

  In cases of suspected thoracic outlet syndrome, provocative testing should be performed. See the Appropriate Use Criteria for Peripheral Vascular Ultrasound and Physiological Testing Part I: Arterial Ultrasound and Physiological Testing. ⁵²

  A focused or limited examination may be appropriate in certain clinical situations.

Evaluation of Surgical and Percutaneous Interventions

Bypass grafts

An attempt should be made to scan the full length of any arterial bypass graft using gray scale and color Doppler.

Representative longitudinal color Doppler and/or gray scale images should be documented for normal segments.

Angle‐corrected spectral Doppler waveforms should be obtained from longitudinal images.

Angle‐corrected spectral Doppler waveforms and PSV measurements should be documented in the native artery proximal to the graft anastomosis, at the proximal anastomosis, at representative sites along the graft, at the distal anastomosis, and in the native artery distal to the anastomosis.

Suspected abnormalities should also be imaged with longitudinal gray scale ultrasound. Representative longitudinal color and/or gray scale images of stenoses should be documented. Transverse images may be helpful.

Angle‐corrected spectral Doppler waveforms should be obtained from longitudinal images proximal to, at, and distal to sites of suspected stenosis. The sonographer/technologist should evaluate the graft conduit and the contiguous segments of the native arteries carefully along the entire length of the stenosis to determine the highest PSV.

The highest angle‐corrected PSV in a stenosis should be recorded from longitudinal images. A spectral Doppler waveform with velocity measurements should be recorded in the normal arterial segment 1–4 cm proximal (upstream) to a suspected stenosis. A waveform distal to a stenosis should be recorded because it is helpful to document a drop in velocity beyond the stenosis and poststenotic disturbed flow/turbulence. Distal abnormalities, as well as a poststenotic tardus parvus waveform, are signs of hemodynamic significance. The presence of low PSVs and low‐resistance waveforms within an otherwise normal graft should be noted because this can imply an increased risk of graft occlusion.

Endovascular Interventions

An attempt should be made to sample the site of arterial interventions as well as the segment immediately proximal (upstream) and distal (downstream) to the site of intervention. Stents should generally be scanned longitudinally along their entire length by gray scale and color Doppler, and representative images within the stent should be obtained. Transverse images may be useful to document stent distortion or luminal narrowing by the outside plaque.

Representative longitudinal color Doppler and/or gray scale images should be documented. All velocity measurements must be obtained from a longitudinal image.

Angle‐corrected spectral Doppler waveforms obtained from a longitudinal image and PSV measurements should be documented in the native artery proximal to the intervention, at representative sites within an area of intervention (eg, proximal stent, mid stent, distal stent), and in the native artery distal to the intervention.

Angle‐corrected spectral Doppler waveforms should be obtained from longitudinal images proximal to, at, and distal to sites of suspected stenosis. The sonographer/technologist should evaluate the vessel thoroughly throughout the stenosis to determine the highest PSV.

The highest angle‐corrected PSV in a stenosis should be recorded from a longitudinal image. A spectral Doppler waveform with PSV measurements should be recorded in the normal arterial segment 1 to 4 cm proximal (upstream) to a suspected stenosis. A waveform distal to a stenosis should be recorded because it is helpful to document a drop in velocity beyond the stenosis and poststenotic disturbed flow/turbulence. Distal abnormalities, as well as a poststenotic tardus parvus waveform, are signs of hemodynamic significance.

Other

Suspected soft tissue abnormalities in proximity to arteries

The entire area of a suspected soft‐tissue abnormality should be imaged. Spectral and color Doppler should be performed to document the presence or absence of blood flow in the region of the suspected abnormality.

Pseudoaneurysms

In evaluating patients with suspected pseudoaneurysms, the sonographer/technologist should evaluate vasculature and adjacent soft tissues in transverse and longitudinal planes, using color Doppler, at, above, and below the arterial puncture site because the vessel may have been punctured at or several centimeters away from the skin wound. For example, for evaluation of the groin area, Doppler interrogation should be performed from the distal external iliac artery to the proximal superficial femoral artery. Imaging in the longitudinal plane must also be obtained with representative color and spectral Doppler images.

When a pseudoaneurysm is identified, the overall size of the pseudoaneurysm sac, the size of the residual lumen (in cases of partially thrombosed pseudoaneurysm), and the length and width of the communicating channel (neck) should be documented with appropriate gray scale and/or color Doppler techniques. Spectral Doppler waveforms should be obtained in the communicating channel to demonstrate bidirectional “to‐and‐fro” flow.

In case of therapeutic intervention, color and/or spectral Doppler may be used as a guide to therapy and as a means of documenting therapeutic success. ³⁷ , ⁵² , ⁵³ , ⁵⁴ , ⁵⁵ , ⁵⁶

When present, the size and location of hematomas should be documented.

The presence of hematomas should be documented and differentiated from pseudoaneurysms with Doppler image optimization to demonstrate absence of flow.

Abnormal communication between artery and vein (arterio‐venous fistula)

Color and spectral Doppler may be used to document the location of abnormal vascular communications. Spectral Doppler waveforms should be documented from the artery proximal to, in the area of, and distal to abnormal communications. Flow within the fistula should be recorded if found. A spectral Doppler waveform from the draining vein should be documented above and below the fistula.

Color Doppler is particularly useful for identifying the level of such communications because the flow disturbances in a fistula often create color Doppler signals in the adjacent soft tissue from transmitted vibrations and pressure changes (color bruit).

Peripheral aneurysms

The location of aneurysms should be documented. The widest diameter of the artery or aneurysm should be measured (outer wall to outer wall) on gray scale images in short axis of the lumen. If present, patency of the vessel and the presence of intraluminal thrombus should be documented with gray scale and color and spectral Doppler images.

Documentation

Accurate and complete documentation is essential for high‐quality patient care. Written reports and ultrasound images/video clips that contain diagnostic information should be obtained and archived, with recommendations for follow‐up studies if clinically applicable, in accordance with the AIUM Practice Parameter for Documentation of an Ultrasound Examination. ⁵⁷

Equipment Specification

Peripheral arterial sonography should be performed with a linear array or curved array transducer equipped with pulsed Doppler and color Doppler capability (power Doppler may be used if needed). A linear array transducer helps visualize vessels with better resolution than most curved array transducers. The transducer should operate at the highest clinically appropriate frequency, recognizing that there is a trade‐off between resolution and penetration.

Equipment performance monitoring should be in accordance with the AIUM Routine Quality Assurance of Clinical Ultrasound Equipment. ⁵⁸

Quality and Safety

Policies and procedures related to quality assurance and improvement, safety, infection control, and equipment‐performance monitoring should be developed and implemented in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practices. ⁴⁸

ALARA Principle

The potential benefits and risks of each examination should be considered. The ALARA (as low as reasonably achievable) principle ⁵⁹ should be observed for factors that affect the acoustical output and by considering transducer dwell time and total scanning time. Further details on ALARA may be found in the current version of the AIUM's publication Medical Ultrasound Safety. ⁶⁰

Infection Control

Transducer preparation, cleaning, and disinfection should follow manufacturer recommendations and be consistent with the AIUM's Guidelines for Cleaning and Preparing External‐ and Internal‐Use Ultrasound Transducers Between Patients, Safe Handling, and Use of Ultrasound Coupling Gel. ⁶¹

Equipment Performance Monitoring

Monitoring protocols for equipment performance should be developed and implemented in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practice. ⁴⁸

Collaborative Subcommittees

AIUM

John Stephen Pellerito, MD

ACR

Gowthaman Gunabushanam, MBBS, MD, Chair

Constantine Burgan, MD

Laurence Needleman, MD

SRU

Jill A. Jones, MD

Harriet J. Paltiel, MD

AIUM Clinical Standards Committee

Rachel Bo‐ming Liu, MD, FACEP, FAIUM, chair

Margarita V. Revzin, MD, MS, FSRU, FAIUM, vice chair

Tracy Anton, BS, RDMS, RDCS, FAIUM

Creagh T. Boulger, MD, FAIUM

John R. Eisenbrey, PhD, FAIUM

Rob Goodman, MB, BChir, FAIUM

Ethan J. Halpern, MD, FAIUM

Oliver Daniel Kripfgans, PhD, FAIUM

Juliana Gevaerd Martins, MD

John Stephen Pellerito, MD, FACR, FAIUM, FSRU

James M. Shwayder, MD, JD, FAIUM

Jean Lea Spitz, MPH, CAE, RDMS, FAIUM, FSDMS

Original copyright 2006; Revised 2019, 2014, 2010, 2025; Renamed 2015

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.