For intermittent claudication (leg pain during exertion), do you perform a duplex ultrasound of the arteries or veins?

From the Guidelines

For leg pain during exertion, a duplex ultrasound of the arteries is the recommended initial diagnostic test, not the veins. This is because exertional leg pain, especially pain that occurs with walking and resolves with rest (claudication), is most commonly caused by peripheral arterial disease (PAD), which involves narrowing or blockage of the arteries that supply blood to the legs 1. The arterial duplex ultrasound can visualize blood flow through the arteries, identify areas of stenosis or occlusion, and measure blood pressure at different points in the leg to calculate the ankle-brachial index (ABI) 1.

Key Points to Consider

• The 2024 ESC guidelines for the management of peripheral arterial and aortic diseases recommend duplex ultrasound as a first step in the vascular work-up for PAD screening and diagnosis 1.
• The 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease also recommends arterial duplex ultrasound for patients with PAD who have undergone lower extremity revascularization with new lower extremity signs or symptoms 1.
• Venous duplex ultrasound, on the other hand, is more appropriate for suspected deep vein thrombosis, venous insufficiency, or other venous disorders, which typically present with different symptoms such as swelling, warmth, or pain that worsens with prolonged standing rather than with exertion.
• The use of duplex ultrasound in conjunction with other diagnostic tools, such as ABI or TBI, can help determine the hemodynamic relevance of arterial lesions and estimate ABI 1.

Diagnostic Approach

• Arterial duplex ultrasound is the preferred initial test for patients with leg pain during exertion, as it is non-invasive and provides valuable information about arterial blood flow and the location and severity of any blockages 1.
• Other imaging modalities, such as computed tomography angiography (CTA) or magnetic resonance angiography (MRA), may be considered in certain cases, but arterial duplex ultrasound is generally the first line of diagnosis 1.

From the Research

Diagnostic Approaches for Leg Pain during Exertion

• For patients experiencing leg pain during exertion, diagnostic approaches often involve assessing blood flow and vessel integrity in the legs.
• Duplex ultrasound is a commonly used non-invasive method for evaluating blood flow and detecting stenosis or occlusions in the arteries of the lower extremities 2, 3.
• This technique combines Doppler ultrasound and conventional ultrasound to visualize the blood vessels and assess blood flow.

Comparison of Diagnostic Methods

• A systematic review compared the diagnostic accuracy of duplex ultrasound, magnetic resonance angiography (MRA), and computed tomography angiography (CTA) for assessing lower limb peripheral arterial disease 2.
• The review found that contrast-enhanced MRA had the highest diagnostic accuracy, followed by CTA, and then duplex ultrasound.
• However, duplex ultrasound was found to be the most cost-effective option for evaluating the whole leg, while MRA was more cost-effective for assessing specific sections of the leg.

Use of Duplex Ultrasound

• A study evaluated the efficacy of duplex ultrasound parameters, including acceleration time (AcT), peak systolic velocity (PSV), and waveform contour, in diagnosing lower extremity peripheral artery disease 3.
• The study found that AcT was a reliable parameter for evaluating aortoiliac and femoropopliteal artery disease, with high sensitivity and specificity.
• Duplex ultrasound is a useful tool for assessing peripheral artery disease, particularly in patients with intermittent claudication, and can help guide treatment decisions.

Treatment Options

• Cilostazol is a medication that has been shown to improve symptoms and increase walking distance in patients with intermittent claudication due to peripheral artery disease 4, 5, 6.
• However, the use of cilostazol should be carefully considered, particularly in patients with a history of heart failure or those taking other medications that may interact with cilostazol.