What is the recommended imaging workup for evaluating Peripheral Artery Disease (PAD) in a patient with End-Stage Renal Disease (ESRD)?

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Last updated: July 15, 2025 • View editorial policy

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Imaging Workup for Peripheral Artery Disease in ESRD Patients

For patients with ESRD, Duplex Ultrasound (DUS) is recommended as the first-line imaging method to diagnose PAD, followed by toe pressure (TP) or toe-brachial index (TBI) measurements when ankle-brachial index (ABI) results are normal or non-diagnostic due to vessel calcification. 1

Initial Non-Invasive Assessment

Step 1: Ankle-Brachial Index (ABI) with Caution

  • ABI is typically the first screening test for PAD diagnosis
  • However, in ESRD patients, ABI has significant limitations:
    • Vessel calcification often leads to falsely elevated or non-compressible arteries (ABI >1.4)
    • May miss significant disease due to medial calcification common in ESRD 2

Step 2: Toe Pressure and Toe-Brachial Index

  • Measuring toe pressure (TP) or toe-brachial index (TBI) is specifically recommended in patients with ESRD if resting ABI is normal or non-diagnostic 1
  • Digital arteries are less prone to calcification, making these measurements more reliable in ESRD
  • TBI <0.7 is diagnostic of PAD in ESRD patients

Step 3: Duplex Ultrasound (DUS)

  • DUS is recommended as the first-line anatomic imaging method to confirm PAD lesions 1
  • Benefits in ESRD patients:
    • Non-invasive with no contrast exposure
    • Can assess anatomic location and degree of stenosis
    • Useful for selecting candidates for endovascular or surgical intervention 1
    • Avoids nephrotoxic contrast agents

Advanced Imaging for Revascularization Planning

When revascularization is being considered and more detailed anatomic information is needed:

For Patients with Contraindications to MRA:

  • Computed Tomographic Angiography (CTA) may be considered as a substitute for MRA in patients with contraindications to MRA 1
  • CTA considerations in ESRD:
    • Requires iodinated contrast which poses risk in ESRD
    • Should be used with extreme caution due to contrast nephropathy risk
    • Consider CO2 angiography as an alternative contrast medium

For Comprehensive Assessment:

  • In symptomatic patients with aorto-iliac or multisegmental/complex disease, CTA and/or MRA are recommended as adjuvant imaging techniques for preparation of revascularization procedures 1
  • MRA advantages in ESRD:
    • No ionizing radiation
    • Non-nephrotoxic gadolinium alternatives may be used (iron-based contrast agents)
    • Caution: Gadolinium-based contrast carries risk of nephrogenic systemic fibrosis in ESRD

Invasive Imaging (When Absolutely Necessary)

  • Digital Subtraction Angiography (DSA) should be reserved for cases where revascularization is planned and non-invasive imaging is insufficient 1
  • When performing DSA in ESRD patients:
    • Use selective or super-selective catheter placement to enhance imaging and reduce contrast dose 1
    • Ensure proper hydration before the procedure 1
    • Consider CO2 angiography as contrast alternative
    • Follow-up clinical evaluation and renal function measurement within 2 weeks post-procedure 1

Important Considerations for ESRD Patients

  • ESRD patients have significantly higher prevalence of PAD (32%) compared to general population 2
  • PAD in ESRD is associated with higher mortality and amputation rates 3
  • Vascular calcification is extremely common in ESRD patients, affecting diagnostic accuracy
  • Standard diagnostic techniques used in general population may be less accurate in ESRD 4
  • Patients with subclinical PAD and ESRD have higher mortality rates 5

Algorithm for PAD Imaging in ESRD

  1. Initial assessment: TBI/TP measurement (even if ABI is normal)
  2. Anatomic assessment: Duplex ultrasound
  3. If revascularization is considered:
    • MRA with non-gadolinium contrast if possible
    • CTA with minimal contrast and proper hydration if MRA contraindicated
    • DSA only when absolutely necessary for intervention with CO2 angiography when feasible

By following this evidence-based approach, clinicians can accurately diagnose PAD in ESRD patients while minimizing additional kidney injury risk from contrast exposure.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

4
Research

Lower-extremity peripheral arterial disease among patients with end-stage renal disease.

Journal of the American Society of Nephrology : JASN, 2001

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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