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The natural course of arterial disease is one of the progression and modification via medical and interventional therapies. Peripheral vascular disease has an estimated prevalence of 12% to 20% with risk factors, such as smoking, diabetes, hyperlipidemia, and hypertension exacerbating atherosclerosis. The chronicity of peripheral vascular disease requires testing modalities that are repeatable, easily accessible, low cost, and with low risk to the patient. Vascular laboratory testing offers the ability to provide both anatomic and functional information of multiple vascular beds, in a noninvasive cost-effective manner, that can be serially followed over time and is readily available.

Noninvasive vascular laboratory testing is an integral and universally applied technology across the various vascular beds in contemporary vascular surgery. Despite its broad and deeply rooted application, it is striking to realize how fairly “young” this relationship is and how quickly technology is evolving.1 Dr. Eugene Strandness, at the University of Washington, pioneered this technology in the 1970s, and by the 1980s, there were commercially available ultrasound scanners being applied to mostly extracranial carotid disease. Fast track to 2020, there are very few vascular beds that are not being evaluated by sophisticated noninvasive ultrasound technologies that continue to evolve (B-mode, spectral analysis, color doppler) and amaze the eyes (power angio, B-flow, 3-d reconstruction). Such advances have allowed us to broaden their clinical application in the areas of screening, intraoperative assessment, surveillance, and procedural guidance.

Current technologies offer the ability to have three-dimensional vessel reconstruction, evaluate plaque morphology, and obtain real-time blood flow characteristics. It is the combination of the anatomic image acquisition (with b-mode imaging) and the blood flow evaluation (using color, pulsed and power Doppler, and spectral analysis) that allows us to make interpretative statements regarding the presence of disease in an arterial bed.

With the rapid expansion of vascular ultrasound, various societies across multiple fields have come together to provide best practice recommendations for indication and interpretation of noninvasive testing.2–4 The Intersocietal Accreditation Commission maintains and frequently updates its “IAC Standards and Guidelines for Vascular Testing Accreditation” document to assure a set of minimum image acquisition standards are met for labs with high-quality accreditation status.5 This chapter will focus on noninvasive imaging of the extracranial carotid arteries, renal arteries, mesenteric arteries, and evaluation of the lower extremities. Clinical indications, technical considerations, interpretation of noninvasive testing, and the role of surveillance of the various arterial beds affected by atherosclerosis will be highlighted.



Atherosclerotic disease in the extracranial internal carotid artery accounts for 10% to 20% of causes of ischemic stroke. Noninvasive imaging for the extracranial carotid artery serves various roles depending on where along the spectrum of disease a patient is located. It is endorsed as the primary study in both symptomatic and asymptomatic diseases.4 Primarily, it is used to screen for ...

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