Mastering a basic lower extremity arterial duplex protocol

26th Feb 2021

There are five steps to performing a basic lower extremity arterial duplex ultrasound:

  1. Prepare and position the patient for the examination.
  2. Locate the Mickey Mouse view in the transverse plane.
  3. Examine the common femoral artery (CFA) in the longitudinal view.
  4. Examine the profunda femoris artery (PFA) and superficial femoral artery (SFA).
  5. Examine the popliteal artery.

Let’s take a look at each of these steps in a little more detail. 

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Step 1: Prepare and position the patient for the examination

Start by warning the patient that the exam initially requires the probe to be placed in their groin. Then, have the patient lie supine on the table and tuck a towel or washcloth into their underwear to keep the gel off of it. 

Next, ask the patient to relax and bend their knee out to the side in a frog-legged position. Keep in mind that too much of a bend can make it difficult to find the popliteal artery. 

Duplex ultrasound images in 2D, color, and waveforms. Capture two-dimensional (2D) images, color flow images, and Doppler waveforms. Keep in mind that every formal image is required to include two-dimensional (2D), color flow image, and Doppler waveforms. Thus, at each arterial segment, you will be performing those steps. Remember, duplex ultrasound machines allow color and Doppler on the same screen. Medmastery note.


Step 2: Locate the Mickey Mouse view in the transverse plane

As you begin the examination, the first thing you’ll be looking for is the Mickey Mouse view of the common femoral artery (CFA) in the transverse plane. Start by placing your probe in the middle of the slightly lateral inguinal crease. Slide the probe in the crease medially towards the inner thigh and you will cross the CFA. 

Mickey Mouse view. Ultrasound image.

Figure 1. To locate the common femoral artery (CFA) on an arterial duplex ultrasound, start by finding the Mickey Mouse view in the transverse plane.

Remember, transverse images are not recorded on an arterial duplex ultrasound. They are used to locate arteries as well as aneurysms. Medmastery note.


Step 3: Examine the CFA in the longitudinal view

Turn your probe 90° clockwise. Remember, this will move the notch towards the patient’s head so that you can obtain a longitudinal view of the artery. In the longitudinal viewlook for plaque and aneurysms on two-dimension (2D) and color modes. Then, Doppler for a waveform. 

Black and white two-dimensional image, color image, and Doppler waveforms at the common femoral artery (CFA) bifurcation. Ultrasound images.

Figure 2. In a longitudinal view on duplex ultrasound, examine the common femoral artery (CFA) bifurcation and obtain black and white two-dimensional images, color images, and Doppler waveforms.


Step 4: Examine the profunda femoris artery (PFA) and superficial femoral artery (SFA)

Evaluate the PFA off of the CFA bifurcation, and then the proximal, middle, and distal SFA. Ideally, you want to slowly track the arteries in the longitudinal view (with color) to continuously evaluate the entire artery. This takes practice because you can easily slide off the artery and miss a segment. But, it’s the most effective way to locate stenosis. If you slide off, you can go back into the transverse view and locate the artery again. 

If there is a blockage, waveforms can help you locate the blockage even if you don’t actually see it on the duplex ultrasound.

Pro tip: When performing an arterial ultrasound, do not simply spot-check the upper, middle, and distal thigh. Stenosis can be missed between the segments that you checked. Medmastery note.


Step 5: Examine the popliteal artery

Next, evaluate further down the leg by placing the probe behind the knee. Evaluate the entire popliteal artery behind the knee by moving the probe down the calf until the vessels bifurcate. Again, this action will produce the black and white 2D images, color images, and Doppler waveforms.

It’s as simple as that!

2D image, color image, and Doppler waveforms from the popliteal artery. Ultrasound image.

Figure 3. When examining the popliteal artery on a duplex ultrasound, you will capture two-dimensional black and white images, color images, and Doppler waveforms.

Lower torso illustration with right leg bent in a frog-legged position, and lower leg illustrations of ultrasound probe positions for a lower extremity arterial study.

Figure 4. The five steps to performing a basic lower extremity arterial duplex ultrasound include, 1) prepare and position the patient, 2) locate the Mickey Mouse view, 3) examine the common femoral artery, 4) examine the profunda femoris and superficial femoral arteries, 5) examine the popliteal artery.

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Recommended reading

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