Eur J Vasc Endovasc Surg (2008) 36, 325e330

Minimum Training Requirement in Ultrasound

Imaging of Peripheral Arterial Disease
J.P. Eiberg a,*, M.A. Hansen b, J.B. Grnvall Rasmussen b, T.V. Schroeder a
a
b

Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark

Department of Radiology, Rigshospitalet, Copenhagen, Denmark

Submitted 31 October 2007; accepted 3 June 2008

Available online 17 July 2008

KEYWORDS
Ultrasonography;
Doppler;
Duplex;
Angiography;
Peripheral arterial
diseases;
Vascular surgery;
Learning curve;
Minimum training
requirements

Abstract Objectives: To demonstrate the minimum training requirement when performing

ultrasound of peripheral arterial disease.
Design: Prospective and blinded comparative study.
Material: 100 limbs in 100 consecutive patients suffering from peripheral arterial disease, 74%
suffering critical limb ischemia, were enrolled during a 9 months period.
Methods: One physician with limited ultrasound experience performed all the ultrasound
examinations of the arteries of the most symptomatic limb. Before enrolling any patients 15
duplex ultrasound examinations were performed supervised by an experienced vascular
technologist. All patients had a digital subtraction arteriography performed by an experienced
vascular radiologist, unaware of the ultrasound result.
Results: The number of insufficiently insonated segments (non-diagnostic segments) was significantly reduced during the study; from 9% among the initial 50 limbs to 2% among the last
50 limbs (P < 0.0001). This improvement was evident only in the infragenicular segments, as
the performance within the supragenicular segments was good from the beginning. There
was no change in the agreement between ultrasound and arteriography from the initial 50
patients (overall Kappa Z 0.66, (95%-CI: 0.60e0.72); supragenicular Kappa Z 0.73 (95%-CI:
0.64e0.82); infragenicular Kappa Z 0.61 (95%-CI: 0.54e0.69)) to the last 50 patients (overall
Kappa Z 0.66 (95%-CI: 0.60e0.72), supragenicular Kappa Z 0.67 (95%-CI: 0.57e0.76); infragenicular Kappa Z 0.66 (95%-CI: 0.58e0.73)).
Conclusion: The minimum training requirement in ultrasound imaging of peripheral arterial
disease appears to be less than 50 ultrasound examinations (probably only 15 examinations)
for the supragenicular segments and 100 examinations for the infragenicular segments.
2008 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Jonas Peter Eiberg, MD, PhD., Department of Vascular Surgery, Rigshospitalet 3111, Blegdamsvej 9, DK-2100
Copenhagen , Denmark. Tel.: 45 3545 2586; fax: 45 3545 2303.
E-mail address: jonas@eiberg.org (J.P. Eiberg).
1078-5884/$34 2008 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.ejvs.2008.06.006

326

J.P. Eiberg et al.

Introduction
Adequate visualisation of lower limb arteries is essential
before arterial reconstruction. Digital subtraction arteriography (DSA) is considered the diagnostic standard for
imaging of lower limb arteries and used routinely in most
centres. However, within the last decade several reports
have found the diagnostic value of ultrasound in peripheral
arterial disease (PAD) comparable with that of DSA. In some
dedicated centres reconstruction has been performed
based on ultrasound alone.1e4 When a new imaging technique is introduced, it is vital to address how the technique
is learned and when the technique is mastered. Although
duplex ultrasound (DUS) of the peripheral arteries has
been used for years, the matter of appropriate training
and definition of a learning curve is still unsubstantiated.
The European Federation of Societies for Ultrasound in
Medicine and Biology (EFSUMB) recently suggested a minimum of 100 supervised examinations of PAD during a 3e6
months period.5 To the best of our knowledge, no available
data supports these figures.
The objective of this study was to estimate the minimum
training requirement necessary to perform ultrasound
imaging of lower limb arteries in patients suffering from
PAD. Moreover we wanted to differentiate between easy
and difficult arterial segments in terms of learning
sonography.

Method
Patients
During a 9-month period, 100 lower limbs in 100 consecutive patients were enrolled in the study. All patients
suffered chronic lower limb ischaemia (SVS-ISCVS category
3e6),6 with 74% presenting with critical limb ischaemia
(CLI) and 26% with intermittent claudication. The demographic characteristics of the studied cohort are presented
in Table 1. All patients were admitted for elective arterial

Table 1

reconstruction and scheduled for a routine DSA. Only one

limb per patient was studied and in patients with bilateral
PAD only the most symptomatic limb was assessed.

Study design
Primary endpoint was the agreement between duplex
ultrasonography and arteriography among the initial 50 as
compared to the last 50 limbs studied. In addition we
compared the number (%) of successfully insonated vessel
segments among the initial 50 and the last 50 limbs
assessed. Inspired by the EFSUMBs recommendations5 the
size of the studied cohort was defined to be 100 ultrasound
examinations. When ultrasound and arteriography were
compared arteriography served as the diagnostic standard
(the gold standard).
One vascular resident (JPE) with no prior ultrasound
experience but with basic vascular knowledge performed
all the ultrasound examinations one day before the DSA.
Before initiating the study, JPE completed a postgraduate 4
day course of general ultrasound organised by the Danish
Society of Diagnostic Ultrasound (www.duds.dk) followed
by a 5 days study visit to a vascular laboratory with experienced sonographers. Before enrolling the first patient 15
other PAD patients underwent DUS examinations of the
most ischaemic limb, supervised by an experienced vascular technologist (BC or SL, see acknowledgements). All
enrolled patients underwent a routine DSA performed by
either of two experienced radiologists (MH or JGBR) both
unaware of the ultrasound findings. The local ethical committee approved the study (KF 01-197/99) and informed
consent was obtained from all patients.

Duplex ultrasound scanning (DUS)

All limbs were scanned from the common femoral artery to
the pedal arteries using a colour DUS (Siemens, Elegra,
Issaquah, WA, USA and a 7.5 MHz linear array transducer).
All patients had 15 minutes of rest before the

Patients characteristics

Age (median and IQ-range)

Male sex
Ankle blood pressure in mmHg
(median and IQ-range),
Ankle-brachial pressure index
(median and IQ-range)
Symptoms
Claudication
Rest pain
Tissue loss
Diabetes, type I and II
Hyperlipidaemia (on medication)
Renal disease
(creatinine > 0,150 mmol/l or dialysis)

Entire
population

Subgroup
inexperienced
(limb no 1e50)

Subgroup
experienced
(limb no 51e100)

n Z 100

n Z 50

n Z 50

71 (60e77)
64%
60 (43e80)

71 (61e78)
62%
60 (45e85)

71 (60e76)
66%
55 (40e69)

ns
ns
ns

0.38 (0.29e0.53)

0.38 (0.29e0.56)

0.38 (0.28e0.50)

ns

26%
34%
40%
32%
15%
4%

33%
20%
47%
34%
15%
7%

19%
48%
33%
30%
14%
2%

ns
P < 0.01
P < 0.0001
ns
ns
ns

CLI: ns

Training Requirements in Vascular Ultrasound

examinations. The femoral and anterior tibial arteries were
scanned with the patient in the supine position whereas the
popliteal and the two other crural arteries were examined
with the patient in lateral decubitus. Arterial segments
were identified by the detection of a colour signal or
when the artery was occluded by the identification of a vessel wall accompanied by a vein. The following features
were used to diagnose occlusion: segmental loss of signal
in the insonated vessel, dampened distal signal compared
to the proximal signal and proximal exit collaterals as
well as distal re-entry collaterals. If it was impossible to
detect a colour signal or to identify a vessel wall due to
inadequate insonation, DUS was classified as non-diagnostic
regarding that specific vessel segment. Flow velocity measurements by means of spectral analysis were performed
when the colour-image suggested a velocity increase or turbulence or when the B-mode image suggested a diameter
changes. All velocities were determined in the centrestream of the vessels keeping the angel of insonation
between 0 and 60 . The peak systolic velocity ratio (PSVr)
was defined as the peak systolic velocity in the stenosis
divided by the peak systolic velocity just proximal to the
stenosis. All diagnostic segments were classified according
to diameter reduction: <50% or 50% based on a peaksystolic velocity ratio below or above two, respectively.7,8
To allow segment to segment comparison, the arterial
tree was divided into 15 segments; five supragenicular
(common femoral, profunda femoris, proximal (superficial)
femoral, distal (superficial) femoral and popliteal
above the knee) and ten infragenicular segments (popliteal
below the knee, tibio-peroneal trunk, anterior tibial, posterior tibial and peroneal arteries each divided into a proximal and distal half, and finally the dorsalis pedis and the
plantar artery). Because the aorto-iliac segment is difficult
to insonate it was assessed indirectly by analysis of the
spectral curve in the common femoral artery bearing in
mind that all patients had an aorto-iliac arteriography anyway. Screening for upstream lesions by analysing the common femoral waveform has been validated previously.9,10
The time taken to perform the examination was not
recorded systematically.

Digital subtraction arteriography (DSA)

In all limbs the vessels from the distal aorta to the pedal
arteries were visualized in one of the two standard
angiography suites (Integris 3000, Phillips, Amsterdam,
The Netherlands or Angiostar Plus, Siemens, Munich,
Germany) using Omnipaque 300 mg I/ml (Nycomed, Oslo,
Norway). The ipsilateral common femoral artery was punctured if a palpable femoral pulse was present. After imaging of the iliac arteries the 5F catheter (5F Nylex
catheter, Cordis Corporation, Miami, FL, USA) was withdrawn to the external iliac artery in order to visualise the
infrainguinal vessels of the diseased limb. In case of bilateral PAD a standard bolus chase DSA was performed. In
absence of a palpable femoral pulse in the most diseased
limb the contralateral common femoral artery was punctured and a 5F Rim catheter (Cook Inc., Bloomington, IN,
USA) was passed over the bifurcation into the iliac arteries.
All segments were classified as insignificantly diseased

327
z(0e49% diameter reduction) or significantly diseased
(50% diameter reduction and occlusion). Segments were
classified as non-diagnostic if neither the genuine vessel
nor unnamed collaterals could be visualised due to inadequate amount of contrast agent.

Data analysis and statistics

Results obtained by DUS and DSA were recorded in similar
diagrams. Demographical data were presented as median
with interquartile-range (IQ-range) in brackets and all other
results with 95% confidence interval of the mean in
brackets.11 The z-test (standard Normal deviate) was used
to compare proportions of categorical variables (i.e. number
of non-diagnostic segments, sex and symptoms) between the
two groups (the first and last 50 limbs) and the two-sample
t-test for comparing continuous variables (i.e. age and pressure). The two methods (DUS and DSA) were compared using
the kappa (k) statistics to analyse the agreement beyond
chance. A k-value of 1 represents perfect agreement and
a k-value of 0 represents agreement by purely chance.12 If
a segment was classified as non-diagnostic in one or both
methods the segment was left out of the k-calculations.
When assessing the frequency of non-diagnostic segments
the number of non-diagnostic segments among the first
and last 50 limbs was divided by 750 (i.e. 15 segments
in 50 patients). Sensitivity and specificity were calculated
using a two-way contingency table. Analyses were performed by the CIA statistical software (Confidence Interval Analysis for Windows version 2.0.0, Trevor Bryant,
University of Southampton, UK) and the SPSS 15.0 statistical software (SPSS Inc., Chicago, Illinois, USA).

Results
Comparing the two groups e the initial 50 limbs
and the last 50 limbs
When comparing the demographic data of the two groups
no significant difference could be demonstrated with
respect to the degree of PAD and factors known to
accelerate calcification of the vessels (diabetes and renal
insufficiency) potentially compromising DUS (Table 1). The
difference in distribution of limbs with critical limb ischemia (CLI) between the 2 groups was not significant, but if
further divided into rest pain and tissue loss significantly
more patients in the initial group suffered tissue loss.

Non-diagnostic segments and ultrasound

experience
The proportion of unsuccessfully insonated arterial
segments was reduced significantly from 69 (9%) among
the initial 50 examinations (DUS-inexperienced) to 16
(2%) (P < 0.0001) among the later 50 (DUS-experienced).
This corresponded to an increased overall technical success
from 91% to 98% (Table 2). Looking only at the supragenicular segments no significant difference could be
demonstrated between the DUS-inexperienced and
DUS-experienced(Table 2). In contrast, a marked

(3.2%)
(0.58e0.73)
(0.87e0.94)
(0.66e0.79)
(0.79e0.88)
(0.77e0.89)
16/500
0.66
0.91
0.73
0.84
0.84
(2%)
0/250 (0%)
(0.60e0.72)
0.67 (0.57e0.76)
(0.84e0.90)
0.81 (0.74e0.87)
(0.73e0.83)
0.86 (0.78e0.91)
(0.81e0.88)
0.88 (0.81e0.92)
(0.76e0.86)
0.79 (0.71e0.85)
16/750
0.66
0.88
0.78
0.85
0.82
(14%)
(0.54e0.69)
(0.81e0.90)
(0.68e0.81)
(0.79e0.88)
(0.71e0.84)
68/500
0.61
0.86
0.75
0.84
0.78
Nondiagnostic segments 69/750 (9%)
1/250 (0.4%)
Kappa
0.66 (0.60e0.72)
0.73 (0.64e0.82)
Sensitivity
0.86 (0.82e0.89)
0.85 (0.79e0.90)
Specificity
0.81 (0.75e0.85)
0.91 (0.83e0.95)
PPV
0.88 (0.84e0.91)
0.95 (0.90e0.97)
NPV
0.77 (0.72e0.82)
0.77 (0.68e0.84)

Supragenicular segments Infragenicular segments All segments

All segments

Subgroup inexperienced (limb no 1e50)

DUS and DSA agreement

Table 2

Supragenicular segments Infragenicular segments

J.P. Eiberg et al.

Subgroup experienced (limb no 51e100)

328

improvement with experience was noted in the infragenicular segments from 68 to 16 non-diagnostic segments
(P < 0.0001).

Agreement and ultrasound experience

In the 1500 arterial segments examined with both DUS and
DSA we could not demonstrate improved agreement with
increasing ultrasound experience, comparing the initial 50
limbs with the later 50 limbs, as summarize in Table 2.
Neither did subdividing the first and last 50 patients into
supra- and infragenicular segments reveal any significant
difference in agreement.

Discussion
Replacing diagnostic arteriography with ultrasound is persuasive due to its non-invasive nature and avoidance of
x-rays. On the other hand lower limb DUS has traditionally
been considered to be operator dependent and to be
difficult to learn. We have previously shown that DUS in
patients suffering PAD was highly reproducible. The overall
interobserver variation was comparable to that of DSA and
the results were similar in the supra- and infragenicular
arteries.13 In the present study we demonstrated that the
minimum training requirement in peripheral vascular ultrasound for an ultrasound novice was less than 50 examinations for the supragenicular arteries but at least 100
examinations for the infragenicular arteries. The supragenicular segments which are superficially situated and therefore relatively easy to insonate adequately. This explains
why we did not find any improvement within the reported
100 examinations. Already within the first 50 examinations,
probably shortly after the first 15 supervised examinations,
proficiency was obtained. Any difference in demographic
data between the two groups, the first inexperienced and
later experienced group, could not explain these results.
When designing the study we expected a more gradual
improvement in DUS skills e as proposed by EFSUMB.5 The
apparent very rapid development of adequate experience
in DUS of the supragenicular vessel segments was unexpected and because of our study design we were unable
to comment on the pre-study phase of training. Comparing
DUS with DSA we could not demonstrate improved agreement with increased experience using DSA as the gold standard although the agreement demonstrated in the present
study (k Z 0.66) was comparable to that of others.1,14 It
is possible that groups of 50 were too large to demonstrate
the exact minimum training requirement but a further
subdivision into smaller groups in order to pursue a possible
difference would not be appropriate to the original design
and endpoints of the study.
We found no comparative data available for ultrasound
examination of patients suffering from PAD. However, data
addressing the minimum training requirements for nonradiologist clinicians are available for a number of other
ultrasound examinations and summarised in Table 3. Not
surprisingly, DUS of infragenicular PAD is somewhat challenging and the minimum training requirement seems at
least to resemble that of cardiac echocardiography. The
recent recommendation from The European Federation of

Training Requirements in Vascular Ultrasound

Table 3 Minimum training requirements for ultrasound
examinations of different organs
Type of ultrasound
examination

Minimum training
requirements
(no of examinations)

Abdominal Aortic Aneurysm

Gallbladder/acute abdomen
Focused Assessment Sonogram
in Trauma (FAST)
Echocardiography, adult
DUS of supragenicular arteries
DUS of infragenicular arteries
Fetal anomalies

<1017,18
20e3019e21
30(100)19,22,23
20e4024e26
15(50) (present study)
100 (present study)
200027,28

329
The authors wish to thanks Sir Peter Bell and Mr Timothy
Hartshorne, Department of Vascular Surgery, Leicester
Royal Infirmary, Leicester, UK for a very instructive study
visit during the pre-study phase.

Ethical approval
Yes.

Funding
Funded.

Conflict of interest
No.
Societies for Ultrasound in Medicine and Biology (EFSUMB)
of a minimum of 100 supervised examinations of PAD during
a 3e6 months period seems overly cautious, at least for the
supragenicular segments.5 Thus this situation seems comparable with that of echocardiography in which the American Society of Echocardiography (ASE) recommend 300
echocardiograms per year,15 a figure much higher than
the 40 examinations recommended by several non-cardiologists (Table 3). In a survey among surgeons who have completed an ultrasound course offered by the American
College of Surgery, the surgeons felt competent after the
first 20 ultrasound examinations of breast, acute abdomen
and vascular disease.16 There seems to be a discrepancy between some of the official recommendations regarding the
necessary amount of training for different specialists. When
initiating the present study, ultrasound of the peripheral
arterial vasculature was a new method and specific courses
in vascular ultrasound were not readily available in Denmark, explaining why a general ultrasound course was completed instead. Thus the supervised scans and the study
visit to an experienced vascular laboratory was a most useful component from a practical and theoretical point of
view. Based on the above experiences and in order to comply with the growing demands for basic ultrasound scanning
techniques among vascular surgeons a hands-on course including a one week stay in a vascular laboratory was introduced in our institution.
In future studies seeking to define minimum training
requirement or learning curves several others elements of
the learning process would be of interest, e.g. the degree
of self-confidence of the operator, time consumption,
unnecessary transducer placements etc.
In conclusion, ultrasound of patients suffering PAD is
reliable and it seems possible to learn the technique after
<50 supervised supragenicular examinations and 50e100
infragenicular examinations.

Acknowledgements
The authors wish to thanks Ms. Susanne Lvgard and Ms.
Bente Culmsee, Vascular Technologists, Department of
Vascular Surgery, Rigshospitalet, Denmark for supervising
Mr. Jonas Eiberg during the pre-study phase of the project.

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