Ultrasound Evaluation of Lower Limb Arteries in Non-Diabetic Controls and Diabetic Patients

ORIGINAL ARTICLE
Adel Alzahrani, Omar Alserihy, Asma Alkhaldi, Khadijah Alshuqyfii, Ahmed Monis, Yaser Khojah, Nawaf Alsaedi, Reem T. Alturki, Salahaden R Sultan

 

For citation: Alzahrani A, Alserihy O, Alkhaldi A, Alshuqyfii K, Monis A, Khojah Y, Alsaedi N, Alturki RT, Sultan SR. Ultrasound Evaluation of Lower Limb Arteries in Non-Diabetic Controls and Diabetic Patients International Journal of Biomedicine. 2026;16(3):352-356. doi:10.21103/Article16(3)_OA4

Originally published September 5, 2026

Abstract: 

Background: Diabetes mellitus is associated with an increased risk of lower extremity arterial disease. Ultrasound imaging enables non-invasive assessment of both arterial morphology and hemodynamics. This study aimed to compare lower limb arterial morphology and hemodynamic characteristics assessed using ultrasound between asymptomatic diabetic patients and non-diabetic controls.

Methods and Results: This study included 71 participants comprising 38 diabetic patients and 33 non-diabetic controls. Duplex ultrasound examinations of the popliteal, anterior, and posterior tibial arteries were performed using a high-resolution ultrasound system. B-mode ultrasound was used to measure wall thickness, and Doppler imaging was used to assess flow velocity (FV), resistive index (RI), and acceleration time (AT). Comparisons between groups were performed using the Mann–Whitney U test, with statistical significance set at P ≤ 0.05.

A total of 406 arterial segments were evaluated. Diabetic patients demonstrated significantly greater wall thickness compared with controls (median 0.71 mm [IQR 0.33] vs. 0.62 mm [IQR 0.30]; P < 0.001). Doppler ultrasound revealed significantly higher RI values in diabetic patients (median 0.98 [IQR 0.03] vs. 0.94 [IQR 0.07]; P = 0.008) and prolonged AT (median 110 ms [IQR 37] vs. 103 ms [IQR 33.75]; P = 0.04). No significant difference in FV was observed between groups (P = 0.76).

Conclusion: Diabetic patients exhibit structural and hemodynamic alterations in lower limb arteries, characterized by increased arterial wall thickness, elevated vascular resistance, and prolonged systolic acceleration time. These findings suggest that triplex ultrasound-derived parameters may be useful pre-clinical markers of diabetes-associated vascular impairment and could facilitate earlier identification of lower extremity arterial disease.

Keywords: 
diabetes mellitus • peripheral artery disease • hemodynamics • vascular imaging • ultrasound
References: 
  1. Sun H, Saeedi P, Karuranga S, Pinkepank M, Ogurtsova K, Duncan BB, Stein C, Basit A, Chan JCN, Mbanya JC, Pavkov ME, Ramachandaran A, Wild SH, James S, Herman WH, Zhang P, Bommer C, Kuo S, Boyko EJ, Magliano DJ. IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes Res Clin Pract. 2022 Jan;183:109119. doi: 10.1016/j.diabres.2021.109119. Epub 2021 Dec 6. Erratum in: Diabetes Res Clin Pract. 2023 Oct;204:110945. doi: 10.1016/j.diabres.2023.110945. PMID: 34879977; PMCID: PMC11057359.
  2. Hussain A. Chronic hyperglycemia and cardiovascular dysfunction: an in-depth exploration of metabolic and cellular pathways in type 2 diabetes mellitus. Cardiovasc Diabetol Endocrinol Rep. 2025 Dec 12;11(1):39. doi: 10.1186/s40842-025-00247-3. PMID: 41382274; PMCID: PMC12699840.
  3. Beckman JA, Creager MA. Vascular Complications of Diabetes. Circ Res. 2016 May 27;118(11):1771-85. doi: 10.1161/CIRCRESAHA.115.306884. PMID: 27230641.
  4. Lu Y, Wang W, Liu J, Xie M, Liu Q, Li S. Vascular complications of diabetes: A narrative review. Medicine (Baltimore). 2023 Oct 6;102(40):e35285. doi: 10.1097/MD.0000000000035285. PMID: 37800828; PMCID: PMC10553000.
  5. Caturano A, Rocco M, Tagliaferri G, Piacevole A, Nilo D, Di Lorenzo G, Iadicicco I, Donnarumma M, Galiero R, Acierno C, Sardu C, Russo V, Vetrano E, Conte C, Marfella R, Rinaldi L, Sasso FC. Oxidative Stress and Cardiovascular Complications in Type 2 Diabetes: From Pathophysiology to Lifestyle Modifications. Antioxidants (Basel). 2025 Jan 9;14(1):72. doi: 10.3390/antiox14010072. PMID: 39857406; PMCID: PMC11759781.
  6. Mao L, Yin R, Yang L, Zhao D. Role of advanced glycation end products on vascular smooth muscle cells under diabetic atherosclerosis. Front Endocrinol (Lausanne). 2022 Aug 31;13:983723. doi: 10.3389/fendo.2022.983723. PMID: 36120471; PMCID: PMC9470882.
  7. Soyoye DO, Abiodun OO, Ikem RT, Kolawole BA, Akintomide AO. Diabetes and peripheral artery disease: A review. World J Diabetes. 2021 Jun 15;12(6):827-838. doi: 10.4239/wjd.v12.i6.827. PMID: 34168731; PMCID: PMC8192257.
  8. Meloni M, Vas PRJ. Peripheral Arterial Disease in Diabetic Foot: One Disease with Multiple Patterns. J Clin Med. 2025 Mar 14;14(6):1987. doi: 10.3390/jcm14061987. PMID: 40142794; PMCID: PMC11942964.
  9. Amamoo J, Xie L, Steffens A, Buysman E, Swift C, Mehanna S, Gronroos NN, Bonaca MP. Impact of peripheral artery disease (PAD) on risk of major adverse cardiovascular events (MACE) in patients with type 2 diabetes. Am J Prev Cardiol. 2025 Dec 29;25:101397. doi: 10.1016/j.ajpc.2025.101397. PMID: 41613358; PMCID: PMC12849000.
  10. Gagliardino JJ, Salazar MR, Espeche WG, Tolosa Chapasian PE, Gomez Garizoain D, Olano RD, Stavile RN, Balbín E, Martinez C, Leiva Sisnieguez BC, Leiva Sisnieguez CE, Carbajal HA. Arterial Stiffness: Its Relation with Prediabetes and Metabolic Syndrome and Possible Pathogenesis. J Clin Med. 2021 Jul 23;10(15):3251. doi: 10.3390/jcm10153251. PMID: 34362033; PMCID: PMC8348675.
  11. Palladino R, Tabak AG, Khunti K, Valabhji J, Majeed A, Millett C, Vamos EP. Association between pre-diabetes and microvascular and macrovascular disease in newly diagnosed type 2 diabetes. BMJ Open Diabetes Res Care. 2020 Apr;8(1):e001061. doi: 10.1136/bmjdrc-2019-001061. PMID: 32332069; PMCID: PMC7202749.
  12. Mantella LE, Liblik K, Johri AM. Vascular imaging of atherosclerosis: Strengths and weaknesses. Atherosclerosis. 2021 Feb;319:42-50. doi: 10.1016/j.atherosclerosis.2020.12.021. Epub 2021 Jan 6. PMID: 33476943.
  13. Bedi R, Nagra A, Fukumoto T, Lynum S, Sengupta P, Aw J, Mefford I, Panwar SR, Bansal N, Insaan P, Singh S, Panwar R, Vedanthan R, Fuster V, Narula J. Detection of subclinical atherosclerosis in peripheral arterial beds with B-mode ultrasound: a proposal for guiding the decision for medical intervention and an artifact-corrected volumetric scoring index. Glob Heart. 2014 Dec;9(4):367-78. doi: 10.1016/j.gheart.2014.10.007. PMID: 25592789.
  14. Kim ES, Sharma AM, Scissons R, Dawson D, Eberhardt RT, Gerhard-Herman M, Hughes JP, Knight S, Marie Kupinski A, Mahe G, Neumyer M, Poe P, Shugart R, Wennberg P, Williams DM, Zierler RE. Interpretation of peripheral arterial and venous Doppler waveforms: A consensus statement from the Society for Vascular Medicine and Society for Vascular Ultrasound. Vasc Med. 2020 Oct;25(5):484-506. doi: 10.1177/1358863X20937665.
  15. Kawamoto R, Tomita H, Ohtsuka N, Inoue A, Kamitani A. Metabolic syndrome, diabetes and subclinical atherosclerosis as assessed by carotid intima-media thickness. J Atheroscler Thromb. 2007 Apr;14(2):78-85. doi: 10.5551/jat.14.78.
  16. Antoniou S, Naka KK, Papadakis M, Bechlioulis A, Tsatsoulis A, Michalis LK, Tigas S. Effect of glycemic control on markers of subclinical atherosclerosis in patients with type 2 diabetes mellitus: A review. World J Diabetes. 2021 Nov 15;12(11):1856-1874. doi: 10.4239/wjd.v12.i11.1856. PMID: 34888012; PMCID: PMC8613661.
  17. Yuan T, Yang T, Chen H, Fu D, Hu Y, Wang J, Yuan Q, Yu H, Xu W, Xie X. New insights into oxidative stress and inflammation during diabetes mellitus-accelerated atherosclerosis. Redox Biol. 2019 Jan;20:247-260. doi: 10.1016/j.redox.2018.09.025. Epub 2018 Oct 19. PMID: 30384259; PMCID: PMC6205410.
  18. Edmonds ME, Shanahan C, Petrova NL. Diabetic Peripheral Arteriopathy: A Tale of Two Diseases. Front Diabetes [Internet]. 2017 Nov 16 [cited 2026 Jun 24];26:60–9. Available from: https://karger.com/books/book/233/chapter/5160166/Diabetic-Peripheral-Ar...
  19. Gärtner V, Eigentler TK. Pathogenesis of diabetic macro- and microangiopathy. Clin Nephrol. 2008 Jul;70(1):1-9. doi: 10.5414/cnp70001. PMID: 18793542.
  20. Ismail R, Gareeballah A, Abdelrahim A, Gameraddin M, Elzaki M, Alsharif W, et al. Impact of type 2 diabetes mellitus on hemodynamic and morphology of foot arteries: A duplex ultrasound evaluation. J Radiat Res Appl Sci [Internet]. 2022 Sep 1 [cited 2026 Jun 24];15(3):206–11. Available from: https://www.sciencedirect.com/science/article/pii/S1687850722082085
  21. Bude RO, Rubin JM. Relationship between the resistive index and vascular compliance and resistance. Radiology. 1999 May;211(2):411-7. doi: 10.1148/radiology.211.2.r99ma48411.
  22. Okasha A, Mahmoud HN, Askary ZM, Abdel-naser AA. Role of ultrasound and colorDoppler in evaluation of peripheral arterial occlusive disease in diabetic foot. SVU-International J Med Sci. 2021 Mar 29;0(0):0–0.
  23. Zhang T, Xia LH, Bian YY, Feng B, Wang C, Meng FX, Zhang YH, Chen M. Blood flow of the acral finger arterioles in patients with type 2 diabetes by quality Doppler profiles. Cell Biochem Biophys. 2013 Nov;67(2):717-25. doi: 10.1007/s12013-013-9561-4. PMID: 23526157; PMCID: PMC3825575.
  24. Trihan JE, Mahé G, Laroche JP, Dauzat M, Perez-Martin A, Croquette M, Lanéelle D. Arterial Blood-Flow Acceleration Time on Doppler Ultrasound Waveforms: What Are We Talking About? J Clin Med. 2023 Jan 31;12(3):1097. doi: 10.3390/jcm12031097. PMID: 36769746; PMCID: PMC9917724.
  25. Sommerset J, Karmy-Jones R, Dally M, Feliciano B, Vea Y, Teso D. Plantar Acceleration Time: A Novel Technique to Evaluate Arterial Flow to the Foot. AnnVasc Surg. 2019 Oct;60:308-314. doi: 10.1016/j.avsg.2019.03.002. Epub 2019 May 8. PMID: 31075481.
  26. Teso D, Sommerset J, Dally M, Feliciano B, Vea Y, Jones RK. Pedal Acceleration Time (PAT): A Novel Predictor of Limb Salvage. Ann Vasc Surg. 2021 Aug;75:189-193. doi: 10.1016/j.avsg.2021.02.038. Epub 2021 Apr 3. PMID: 33823258.
  27. Trihan JE, Mahé G, Croquette M, Coutant V, Thollot C, Guillaumat J, Lanéelle D. Accuracy of Acceleration Time of Distal Arteries to Diagnose Severe Peripheral Arterial Disease. Front Cardiovasc Med. 2022 Jan 20;8:744354. doi: 10.3389/fcvm.2021.744354. PMID: 35127845; PMCID: PMC8810631.

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Received June 27, 2026.
Accepted August 8, 2026.
© 2026 The Author(s). International Journal of Biomedicine is published by IMRDC. This is an open access article under the CC BY-NC-ND 4.0 license.