Can Common Femoral Artery Doppler Waveform Analysis Reliably Predict Hemodynamically Significant Disease of the...

Many guidelines recommend duplex scanning as the first-line investigation for peripheral arterial disease. Qualitative evaluation of the common femoral artery (CFA) waveform provides information regarding the likely presence of significant aortoiliac disease. Certain centers use a "triphasic-and-down" policy, proceeding directly to antegrade endovascular intervention of infra-inguinal disease if the CFA waveform is triphasic. Others mandate cross-sectional imaging regardless of CFA waveform to exclude occult aortoiliac disease. This review aims to analyze the reliability of CFA waveform in excluding significant aortoiliac disease.

MEDLINE, Embase, Cochrane library, and reference lists were searched for studies comparing CFA waveform analysis with reference tests assessing aortoiliac disease. Triphasic waveforms were considered "normal", while biphasic/monophasic were considered "abnormal." Meta-analyses using a bivariate model produced pooled diagnostic accuracy metrics, including negative and positive predictive values, sensitivity, and specificity.

Eight studies with 1,139 limbs were included. Where reported, the mean age was 67, 64.4% had claudication and 35.6% had critical limb ischemia, 42.3% were smokers, and 33.3% were diabetic. Reference investigations were catheter or cross-sectional angiography(n = 5), aortoiliac duplex(n = 2), and intra-arterial pressures(n = 1). The pooled negative predictive value was 84.7% (95% confidence interval [CI]: 59.3%-97.0%), meaning a triphasic waveform correctly excludes significant aortoiliac disease 84.7% of the time, and positive predictive value was 71.3% (95% CI: 36.1%-93.1%). Sensitivity was 0.86 (95% CI: 0.78-0.92), indicating 14% of patients with significant aortoiliac disease had triphasic waveforms, and specificity was 0.78 (95% CI: 0.61-0.89).

The best data available suggests Doppler waveform analysis lacks precision in identifying and excluding significant aortoiliac disease compared to heterogenous reference tests. A low threshold for cross-sectional imaging before antegrade endovascular intervention may be appropriate.