Role of continuous wave vs pulse wave and color doppler in identifying arterial perforators of lower limb

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Methods This study was conducted at Government Hospitals. This observational study was performed prospectively over a period of 2 years. One hundred healthy volunteers underwent Doppler evaluation of the lower limbs for perforator mapping. Continuous wave Doppler using a Huntleigh Doppler DMX handheld device and pulse wave and color Doppler evaluations were performed using a Samsung HS 40 machine. Results In our study, out of a total of 100 participants, 77 were male and 23 were female participants. Most commonly, four perforators were picked up by the pulse wave and color Doppler machine from the anterior and posterior tibial arteries. Data were recorded for analysis by sound engineers using a custom-made recording cable to meet the requirements of the audio output port of both Doppler Machines. A total of 189 sets of recordings were analyzed. Seventy percent of the recordings matched both Continuous Wave and Pulsed wave Doppler. Continuous wave Doppler correctly identified the better perforator, as suggested by the doctor, based on a blinded study. The echoes obtained from Continuous Wave Doppler supported the quality of the perforators. Conclusions The presence of a metallic intra- operative probe in Continuous Wave Doppler, which can be sterilized, allows intra-operative Doppler to confirm the dominant perforator for surgical flap planning. 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F1000Research 2025, 14 :143 ( https://doi.org/10.12688/f1000research.158181.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Role of continuous wave vs pulse wave and color doppler in identifying arterial perforators of lower limb [version 1; peer review: 1 not approved] Ajit Mahale https://orcid.org/0000-0001-6617-7333 1 , Sanyam Khatyal 1 , DEEPAK PINTO 2 , [...] DEEPU VIJAYSENAN 3 , Sonali Ullal 1 , Merwyn Fernandes https://orcid.org/0000-0001-7505-4386 1 , Sonali Prabhu 1 , Fathima Raeesa 1 Ajit Mahale https://orcid.org/0000-0001-6617-7333 1 , Sanyam Khatyal 1 , [...] DEEPAK PINTO 2 , DEEPU VIJAYSENAN 3 , Sonali Ullal 1 , Merwyn Fernandes https://orcid.org/0000-0001-7505-4386 1 , Sonali Prabhu 1 , Fathima Raeesa 1 PUBLISHED 28 Jan 2025 Author details Author details 1 Department of Radiodiagnosis, Katsurba Medical College Mangalore, Manipal Academy of Higher Education, Karnataka, Manipal, 576104, India 2 Department of Orthopaedics, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Karnataka, Manipal, 576104, India 3 Department of Communication and Electronics, Nitk Surathkal, Mangalore, Karnataka, 575001, India Ajit Mahale Roles: Formal Analysis, Investigation, Writing – Original Draft Preparation Sanyam Khatyal Roles: Conceptualization, Data Curation, Formal Analysis DEEPAK PINTO Roles: Funding Acquisition, Investigation, Methodology DEEPU VIJAYSENAN Roles: Resources, Software, Supervision Sonali Ullal Roles: Validation Merwyn Fernandes Roles: Visualization Sonali Prabhu Roles: Writing – Original Draft Preparation Fathima Raeesa Roles: Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Global Public Health gateway. This article is included in the Manipal Academy of Higher Education gateway. Abstract Background The purpose of this study was to evaluate arterial perforators in the lower limb using Doppler of the vascular territories in the lower extremity. Methods This study was conducted at Government Hospitals. This observational study was performed prospectively over a period of 2 years. One hundred healthy volunteers underwent Doppler evaluation of the lower limbs for perforator mapping. Continuous wave Doppler using a Huntleigh Doppler DMX handheld device and pulse wave and color Doppler evaluations were performed using a Samsung HS 40 machine. Results In our study, out of a total of 100 participants, 77 were male and 23 were female participants. Most commonly, four perforators were picked up by the pulse wave and color Doppler machine from the anterior and posterior tibial arteries. Data were recorded for analysis by sound engineers using a custom-made recording cable to meet the requirements of the audio output port of both Doppler Machines. A total of 189 sets of recordings were analyzed. Seventy percent of the recordings matched both Continuous Wave and Pulsed wave Doppler. Continuous wave Doppler correctly identified the better perforator, as suggested by the doctor, based on a blinded study. The echoes obtained from Continuous Wave Doppler supported the quality of the perforators. Conclusions The presence of a metallic intra- operative probe in Continuous Wave Doppler, which can be sterilized, allows intra-operative Doppler to confirm the dominant perforator for surgical flap planning. READ ALL READ LESS Keywords Perforator; Arterial; Continuous wave; Pulsed Dopper; Colour Doppler Perforator Corresponding Author(s) Ajit Mahale ( [email protected] ) Close Corresponding author: Ajit Mahale Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Mahale A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Mahale A, Khatyal S, PINTO D et al. Role of continuous wave vs pulse wave and color doppler in identifying arterial perforators of lower limb [version 1; peer review: 1 not approved] . F1000Research 2025, 14 :143 ( https://doi.org/10.12688/f1000research.158181.1 ) First published: 28 Jan 2025, 14 :143 ( https://doi.org/10.12688/f1000research.158181.1 ) Latest published: 28 Jan 2025, 14 :143 ( https://doi.org/10.12688/f1000research.158181.1 ) Introduction An arterial perforator is a vessel that arises from a main (parent) artery and passes through the intermuscular/septocutaneous/myocutaneous plane to supply blood to superficial structures. Defining the vascular territories of the lower extremities has greatly helped in safe flap design. Fasciocutaneous flaps based on random pedicles for lower extremity reconstruction demonstrated high necrosis rates of up to 25%. Careful anatomical study of cutaneous arteries has resulted in the emergence of the “angiosome” concept. 1 Presently arterial perforators have become the mainstay of perforator flap reconstructive surgeries after trophic or superficial soft tissue defects secondary to insults such as burns, trauma, or gangrene secondary to peripheral vaso-occlusive pathology. Despite voluminous and ever-increasing knowledge of anatomy, there is no systematic approach to locate perforating arteries in the lower limb. This is mainly due to the presence of anatomical variation among individuals, with asymmetry being the general rule in every individual. There is asymmetry in the anatomical spread of arterial perforators between the two lower limbs of one individual. Therefore, pre-operative planning before surgical flap surgery cannot be based on any previously established set of rules. Every individual must be evaluated independently and anatomical variations in perforator mapping must be considered. CW Doppler is a simpler configuration of Doppler imaging and consists of two different types of transducer crystals: receiving and transmitting transducer crystals. The main role of the transmitting transducer crystal was to produce a continuous ultrasound beam output at a predetermined frequency. This transmitted signal was then received by the receiving crystal. The received and transmitted signals are added, which leads to the formation of a waveform consisting of a beat frequency. The beat frequency is equal to the Doppler-shift frequency. There is no information or data provided for CWDoppler in terms of the depth of the point of analysis or at which the analyzed motion occurs, which causes the Doppler shift. 2 The main aim of the development of pulse-wave Doppler was to obtain primary information regarding depth perception of the region of interest, which leads to the Doppler shift phenomenon. In addition, the PW Doppler system comprises of only one transducer crystal. The same transducer crystal does the job of transmit and receive signals. There is a substantial difference in the pulse used for pulse wave Doppler compared to the pulse in B-mode imaging. Electronic gating was used to determine the time interval between transmitted and received pulses. This allows the operator to analyze a specific point along the long axis of the transmitted beam. The main output from PW Doppler is primarily an audible signal. When combined, PW Doppler and B-mode imaging are referred to as duplex ultrasound imaging. This allows the operator to analyze both entities together and to focus on a specific point in the B-mode image for Doppler analysis. 2 The recommended sites for sampling of continuous wave Doppler data in the lower limb are the dorsalis pedis artery, anterior tibial artery, distal posterior tibial artery, common femoral artery, and popliteal artery. Superficial and distal peroneal arteries can also be included sites. To obtain the best signal, the probe must be positioned along the longitudinal axis of the vessel to be analyzed and pointed cephalad. The Doppler signal should be optimized through manual adjustment of the orientation and angle until the maximum waveform amplitude is displayed on the grid and the clearest possible audible output is obtained. 3 Aim To identify and locate arterial perforators in the lower extremity using pulse wave color Doppler, and continuous-wave Doppler. Objectives 1. Mapping arterial perforators in lower limb using Continuous Wave Doppler and Pulse Wave Doppler. 2. Comparing outcomes of mapping of lower limb arterial perforators using the two doppler techniques. 3. Spectral analysis of waveforms of continuous wave doppler. 4. Achieving maximum accuracy in scanning methods of continuous wave Doppler in lower limb. 5. Collecting data for further spectral wave analysis. 6. Observing physiological and anatomical variations in lower limb arterial perforators and their effect on spectral waves. Methods Study settings: Department of Radiodiagnosis. Machines used: Samsung HS-40 Huntleigh Doppler DMX continuous wave hand held Doppler Study design: Cross sectional study Study participants: Patients referred to the Department of Radiodiagnosis for lower-limb arterial perforator identification and assessment. Inclusion criteria: 1. Age between 18 to 60 years. 2. No history of any lower limb arterial disease. Exclusion criteria: 1. Smokers 2. Known case of peripheral vascular disease. 3. Hypertensive patients/patients on anti-hypertensive therapy. 4. Diabetes with microvascular complications. 5. Recent orthopedic/surgical intervention in lower limb. 6. Any pathological data collected on Doppler study will lead to exclusion of the sample. Study duration: November 2018 to September 2020. Sample size: Calculated using prevalence and sensitivity. n = zα 2 × Sn ( 1 − Sn ) / L 2 × p Where Sn = 94% The minimum number of patients required for the study was 90. Sampling Method: Non-probability convenience sampling. The study was conducted after obtaining permission from the institutional ethic Committee-IEC KMC MLR 10-18/382). The study was conducted at Government Hospital. This was an observational study, with data collected prospectively over a period of 2 years. sample size was estimated based on a 5% alpha error and 95% confidence level, sample size of 90 was obtained. A total of 100 healthy volunteers underwent Doppler evaluation. Continuous wave Doppler was performed using a Huntleigh Doppler DMX handheld device, while pulse wave and color Doppler evaluations were performed using a Samsung HS 40 machine. Outcome variables: 7. PW Doppler: Distance from nearest anatomical landmark, depth from skin, diameter and velocity of blood flow in arterial perforator. 8. CW Doppler: Identification and site of arterial perforator with respect to nearest anatomical landmark. In this study, we localized arterial perforators using pulse-wave Doppler and performed anatomical mapping of these perforators for ATA and PTA. Later at the localized sites, we performed a continuous wave Doppler study and attempted to record the spectral wave and sound from the continuous wave Doppler. Data were also recorded from the pulse wave Doppler data in the form of sound output using a 3.5 mm jack and an indigenous in-house amplifier. This amplifier removed the background Doppler noise and improved efficacy of data analysis. Tabular data were obtained from the duplex ultrasound machine using a gray-scale display. The data provided were the depth of the vessel from the skin surface, maximum luminal caliber of the vessel, site of origin of the vessel from the nearest anatomical landmark, and peak systolic velocity of the wave. Any person with diseased vessels, biphasic or monophasic waveform on pulse Doppler, or extensive atherosclerotic changes was excluded from the data set. Tabular data and sound recordings from both continuous wave and pulse wave doppler were sent for for analysis. Sound data were analyzed using MATLAB software, and an algorithm was derived to extrapolate sound and tabular data from pulse and color Doppler onto sound recordings from continuous wave Doppler. Data Analysis: By Chi-square test. SPSS version 22.0 was used for the analysis. p value of <0.05 was considered at statistically significant after assuming all the rules of statistical tests. Data collection Tool: Pretested semi-structured data extraction sheet was developed based on a literature review and after consultation with experts. The study participants were informed about the objectives, and written informed consent was obtained. We Collected 3 sets of data for each sample • Color Doppler: recorded using a cable and mobile phone. • Handheld Doppler, recorded using a cable and mobile phone. • Handheld Doppler in raw data formatwas copied from the memory card of the handheld Doppler, and converted to wave. This was done to confirm that the mobile recording was proper and that there was no erroneous recoding. Results In our study, out of a total of 100 participants, 77 were male and 23 were female participants ( Table 1 ). Table 1. Gender distribution of volunteers. Frequency Percent F 23 23.0 M 77 77.0 Total 100 100.0 The participants were predominantly residents, interns, and the volunteering public with no prior comorbidities. Owing to maximum participation in the study by interns and postgraduate residents working in the hospital, the most common age group of participants was between 21 and 30 years, making up >40 percent of the total study participants ( Table 2 ). Table 2. Age distribution of volunteers. Frequency Percent 20 and below 4 4.0 21-30 42 42.0 31-40 36 36.0 >50 18 18.0 Total 100 100.0 Most commonly, four perforators were picked up by the pulse wave and color Doppler machine while performing below-knee arterial perforator assessments. This was true for the anterior tibial artery and posterior tibial artery, individually ( Table 3 ). Table 3. Distribution according to number of perforators in parent arteries- ATA and PTA. Parent artery ATA PTA Perforator 2 4.0% 1.5% 3 33.0% 18.5% 4 52.5% 46.5% 5 10.5% 27.5% 6 0% 6.0% Total 100.0% 100.0% There were no cases where ATA demonstrated 6 or more perforators. The Figures & tables depict the maximum number of perforators in a single vessel and its anatomical mapping based on the perforator count ( Figure 1 ). Figure 1. Distribution according to average number of perforators per parent vessel. Blue bar for ATA and red bar for PTA. Average caliber of arterial perforators was 1.49 mm for ATA, 1.53 mm for PTA and 1.51 mm overall for ATA and PTA combined ( Figure 2 ). Figure 2. Shows the average caliber of the perforators arising from the ATA and PTA. Light Blue bar ATA and Dark blue bar PTA. For the anterior tibial artery, when only two dominant perforators were selected, both were within 15 cm of the lateral malleolus. In PTA, approximately 63 percent of the perforators were within the 11-15 cm distance from the medial malleolus. This was applied when the perforator count was a mere two for PTA. When three perforators were picked, nearly 45 percent were within 15 cm of the lateral malleolus for the ATA. For PTA, nearly 50 percent of perforators were > 15 cm away from the medial malleolus when the total perforator count was 3. When five or more perforators were selected, the perforator that was farthest from the lateral malleolus for ATA was > 15 cm in all cases. The same is true for the posterior tibial artery from medial malleolus ( Tables 3 and 4 ). Table 4. Distribution according to number of perforators per parent artery in volunteers. Parent artery Total ATA PTA Count % Count % Count % Perforator 2 8 4.0% 3 1.5% 11 2.8% 3 66 33.0% 37 18.5% 103 25.8% 4 105 52.5% 93 46.5% 198 49.5% 5 21 10.5% 55 27.5% 76 19.0% 6 0 .0% 12 6.0% 12 3.0% Total 200 100.0% 200 100.0% 400 100.0% The average distance for an arterial perforator from lateral malleolus for the leg was 11 cm for ATA, with a standard deviation of 5.24 cm and a median value of 11 cm ( Table 5 ). Table 5. Depicting distance from nearest landmark. Perforator Parent artery Total ATA PTA Freq % Freq % Freq % 2 Distance from nearest landmark (cm) ≤5 0 0% 1 33.3% 1 9.1% 6-10 1 12.5% 2 66.7% 3 27.3% 11-15 7 87.5% 0 0% 7 63.6% Total 8 100.0% 3 100.0% 11 100.0% 3 Distance from nearest landmark (cm) 6-10 0 0% 1 2.7% 1 1.0% 11-15 >15 30 36 45.5% 54.5% 19 17 51.4% 45.9% 49 53 47.6% 51.5% Total 66 100.0% 37 100.0% 103 100.0% 4 Distance from nearest landmark (cm) 11-15 5 4.8% 13 14.0% 18 9.1% >15 100 95.2% 80 86.0% 180 90.9% Total 105 100.0% 93 100.0% 198 100.0% 5 Distance from nearest landmark (cm) 11-15 0 0% 1 1.8% 1 1.3% >15 21 100.0% 54 98.2% 75 98.7% Total 21 100.0% 55 100.0% 76 100.0% 6 Distance from nearest landmark (cm) 11-15 2 16.7% 2 16.7% >15 10 83.3% 10 83.3% Total 12 100.0% 12 100.0% For PTA, the mean was 11.9 cm from medial malleolus with a standard deviation of 5.89 cm and median value of 12 cm ( Figure 3 ). Figure 3. Shows the average distance from the nearest landmark to the perforators. Light Blue ATA and Dark blue PTA. The average depth from the skin surface for the anterior tibial artery perforators was 14.4 mm with a standard deviation of 3.4 mm and a median value of 14 mm ( Figure 4 ). Figure 4. Shows the average depth of the perforators from the skin surface. Light blue ATA and Dark blue PTA. The average depth from the skin surface for the posterior tibial artery perforators was 14.9 mm with a standard deviation of 3.7 mm and a medial of 15 mm. The average peak systolic velocity was 32.5 cm/s for the ATA, with a standard deviation of 5.24 cm/s and a median value of 32 cm/s ( Table 6 ). Table 6. Denoting mean, median and standard deviation of recorded parameters for ATA and PTA. Mean Std. Deviation Median ATA Distance from nearest landmark (cm) 11.01 5.24 11.00 Depth from skin (mm) 14.40 3.41 14.00 Caliber (mm) 1.49 .28 1.50 Peak systolic velocity (cm/s) 32.57 8.24 32.00 PTA Distance from nearest landmark (cm) 11.90 5.89 12.00 Depth from skin (mm) 14.98 3.79 15.00 Caliber (mm) 1.53 .96 1.50 Peak systolic velocity (cm/s) 32.30 8.41 32.00 Total Distance from nearest landmark (cm) 11.48 5.61 11.00 Depth from skin (mm) 14.71 3.63 15.00 Caliber (mm) 1.51 .72 1.50 Peak systolic velocity (cm/s) 32.43 8.33 32.00 For the posterior tibial artery, the mean PSV was 32.3 cm/s with a standard deviation of 8.4 cm/s and a median of 32 cm/s. Overall, the average PSV for both ATA and PTA was 32.4 cm/s with a standard deviation of 8.3 cm/s ( Table 7 ). Table 7. Gender distribution of recorded parameters. Gender Parent artery Mean Std. Deviation Median F ATA Depth from skin (mm) 15.09 3.47 15.00 Caliber (mm) 1.49 0.24 1.50 Peak systolic velocity (cm/s) 34.33 7.40 34.00 PTA Depth from skin (mm) 15.53 3.67 15.00 Caliber (mm) 1.49 0.25 1.50 Peak systolic velocity (cm/s) 33.91 7.87 33.00 Total Depth from skin (mm) 15.32 3.58 15.00 Caliber (mm) 1.49 0.25 1.50 Peak systolic velocity (cm/s) 34.11 7.65 34.00 M ATA Depth from skin (mm) 14.19 3.38 14.00 Caliber (mm) 1.50 0.29 1.50 Peak systolic velocity (cm/s) 32.01 8.41 32.00 PTA Depth from skin (mm) 14.81 3.82 15.00 Caliber (mm) 1.54 1.08 1.50 Peak systolic velocity (cm/s) 31.82 8.51 32.00 Total Depth from skin (mm) 14.52 3.63 14.00 Caliber (mm) 1.52 0.81 1.50 Peak systolic velocity (cm/s) 31.91 8.46 32.00 Preliminary analysis was provided by NITK Surathkal using MATLAB software ( Figure 5 ) ( Tables 8 and 9 ). Figure 5. Individual A: Spectrogram of multiple recordings. Spectral pattern for analysis. Table 8. Sensitivity of continuous wave doppler in picking up signal of perforators. Frequency Percent No 239 15.2 Yes 1336 84.8 Total 1575 100.0 Table 9. Sensitivity of continuous wave doppler in picking up signal of perforators arising from ATA and PTA. Parent artery Total ATA PTA Count % Count % Count % Continuous wave doppler (Y/N) N 97 13.1% 142 17.0% 239 15.2% Y 642 86.9% 694 83.0% 1336 84.8% Total 739 100.0% 836 100.0% 1575 100.0% Colour Doppler with pulse doppler and Continuous wave doppler Image recordings are shown in Figure 6 . Figure 6. Shows representative data of one recording on pulse wave and color Doppler (A) vs. continuous wave Doppler (B), depicting waveforms and color superimposition on B-mode ultrasound. Colour and pulse wave doppler on left and continuous wave spectrum on right side. Tables 10 & 11 shows that sample number 2 was graded as the best one by a radiologist based on the color Doppler image, perforator anatomy, and sound quality from the pulse wave Doppler. Table 10. Data Analysis of 1 volunteer provided. Patient Sample No. Leg/Artery PSV (PD) Diameter (PD) Energy (CW) Heartrate (CW) Fmax (CW) Pt A_341 2 R/PTA 45 2.6 1126.1 50.454 2087 Pt A_343 3 R/PTA 34 1.8 643.41 50.555 1640 Pt A_344 4 R/PTA 32 1.2 425.32 51.588 1139 Pt A_347 5 L/PTA 50 1.7 370.81 51.417 1291 Pt A_348 6 L/PTA 37 2 166.85 51.407 1177 Pt A_351 7 L/PTA 50 2 129.72 54.55 1393 Pt A_353 8 R/ATA 35 1.7 244.39 50.8 1610 Pt A_358 9/10 L/ATA 25 1 129.29 53.703 1070 Table 11. Individual A: Final analysis table demonstrating best perforator matching from pulse wave and continuous wave Doppler. Energy Heart rate Favg Fmax Velocity [CJ Diameter [C) Depth [C) leg 1126.1 50.454 1748.4 2087 45 2.6 10 R (PTA) 643.41 50.555 1575.4 1640 34 1.8 8 R (PTA) 425.32 51.588 1102.6 1139 32 1.2 12 R (PTA) 370.81 51.417 1051.2 1291 so 1.7 9 L (PTA) 166.85 51.407 1118 1177 37 2 14 L (PTA) 129.72 54.55 1190.6 1393 so 2 14 L (PTA) 244.39 50.8 1397.2 1610 35 1.7 14 R (ATA) 129.29 53.703 976.2 1070 25 1 13 L (ATA) Grading was performed by the doctor based on data from color Doppler => 2>3>4>7>(5,6,8,9/10) (Blinded study) . The average beat energy values of best 5 systolic beats (energy column in the table) almost correctly follow this trend. These energy values were obtained after the analysis of continuous wave sound recordings using an in-house algorithm for sound analysis to calculate the energy flow. Analysis algorithm in MATLAB Algorithm development was carried out using MATLAB. 1) Heart rate detection algorithm • Heart rate was detected using autocorrelation (first 4 ms data of each sample was used). 2) Best five beat extraction • We found that the perforators that medical experts deemed “best“for surgery were those corresponding to recordings with the highest energy in the systolic beat. • Beat extraction- • A 10 ms moving-window-based technique was followed for extracting only the beats from the data. • Selection of best 5 beats- • The total energy for each extracted beat bk is calculated as, where n is the number of samples in bk The beat energies were then sorted in descending order, and five beats with the highest energy values were selected. The average of these five energy values was calculated to determine the parameter for judging quality of the perforators. 3) Maximum frequency detection • The extracted beat is windowed using a 40ms Hanning window, with an overlap of 20ms. • The Short-Time Fourier Transform(FFT) is calculated for each window and stored in memory. • The Energy in the FFT of each window was calculated, and a scaled version of these energy values was set as the threshold to find prominent frequencies. • Out of all the frequencies with an FFT magnitude greater than the threshold, the maximum frequency was chosen. Data were recorded for analysis by sound engineers using a custom-made recording cable to meet the requirements of the audio output port of both Doppler Machines. A total of 189 sets of recordings were obtained. After analysis of data by the engineering department, the following was noted: a) It was surprising to note that multiple recordings of the same perforator using color Doppler machines showed huge variations in loudness as well as in peak systolic velocity (for example, in some cases, it varies from 45 cm/s to 80 cm/s) between two recordings taken within a short span of 1 min by the same practitioner. This was likely due to the change in the angle of intonation and the angle at which the Doppler probe was held. b) The perforator, which gave better quantitative numbers, was not always the right one chosen by an experienced doctor based on the anatomy for the surgical application. Approximately 70 percent of the recordings were matched with the best perforator (based on energy of blood flow) when taking an experienced radiologist’s opinion into account (radiologist opinion based on gray scale images and anatomical course of perforator). c) Perforators at right angles gave less quality sound, and those that were deeper from the skin showed less sound quality in the handheld Doppler. d) In most cases, handheld Doppler correctly identified the best perforator, as suggested by the doctor, based on a blinded study. The energy numbers obtained from handheld Doppler support the quality of the perforators. Discussion We commonly study venous perforators that become incompetent in varicose veins; arteries also have major perforators in the limbs that pass through the fasciocutaneous and septocutaneous planes to supply blood to different angiosomes. These perforators are responsible for supplying blood to tissues distant from the major arteries of the limb. The posterior tibial artery is a branch beyond the popliteal artery, as it exits the popliteal fossa and is the largest terminal branch of the tibioperoneal trunk. It extends behind the tendinous arch of the soleus, with the majority of its course behind the tibialis posterior after the origin of the peroneal artery. 4 The ankle is posterior to the medial malleolus and branches into the medial and lateral plantar arteries. The posterior tibial artery supplies the posterior compartment of the leg. The perforators from the posterior tibial artery are most commonly septocutaneous and emerge adjacent to the flexor digitorum longus and soleus muscle. 5 These perforators, located in the middle third of the lower leg, are some of the largest of the entire lower extremity. 6 They are most readily identifiable 10-12 cm above the medial malleolus. A flap can be designed anywhere up to 10 cm distal to the popliteal crease. 6 Peroneal artery perforators: The peroneal artery is a branch of the tibioperoneal trunk. It descends through the posterior compartment of the leg, next to the posterior intermuscular septum. Peroneal perforators, which are fewer in number can supply a perforator flap. The perforators in the middle third of the fibula are observed on Doppler. The musculocutaneous perforators emerge proximally from the soleus or peroneus longus muscles, and septocutaneous perforators emerge between the flexor hallucis longus and peroneus brevis muscles. Most perforators emerged 13-18 cm proximal to the lateral malleolus. Distally, these perforators often emerge superficial to the Achilles tendon. 7 Anterior tibial perforators: The lower extremity is supplied by the anterior tibial artery. The anterior tibial artery begins at the inferior border of the popliteus muscle. It passes anteriorly through a gap in the interosseous membrane and descends on the anterior surface of the membrane between the tibialis anterior and extensor digitorum longus. 8 Blood is supplied to the anterior compartment of the leg. The major perforators from the anterior tibial artery are located proximally - documented 21-26 cm proximal to the intermalleolar line between the tibia and tibialis anterior muscle. These are the largest perforators. Smaller perforators emerge 4-9 cm above the intermalleolar line between the tendons of the anterior compartment and supply the skin over both malleoli. 9 Arterial perforators have important clinical applications in planning flap reconstruction surgeries of the leg in cases such as diabetic foot, trauma, and trophic ulcers. These flap reconstructive surgeries are performed in cases of high-velocity trauma. Multiple studies have shown that selecting a suitable dominant perforator is key to the success of any flap surgery and the uneventful postoperative healing of the patient. Preoperative determination of the location and number of septocutaneous perforators provides multiple benefits for flap planning. The main benefit of preoperative flap planning is that any unplanned alteration in the operation theatre during flap reconstruction is avoided when there are no suitable dominant perforators available at the surgical site. In addition, pre-operative planning and assessment reduce the operating time and improve the outcome of the dissection. Another advantage of performing preoperative assessment via Doppler is that based on the location of the perforator, a flap may be preoperatively customized to meet all surgical requirements. Multiple authors have previously described the distribution pattern of arterial perforators and proved that achieving a systematic approach for mapping the precise location of the dominant septo-cutaneous perforator is quite difficult. This is primarily due to the fact that there is high degree of variation in the origin and course of these vessels between multiple individuals and also between different limbs of the same individual. In our study, we identified that an individual can have as few as two dominant arterial perforators below the knee and as many as six perforators arising from a parent artery. Color Doppler analysis associated with pulse wave Doppler allows analysis of the anatomical distribution and flow of superficial vessels in the limbs. However, this is not possible with the use of handheld continuous wave Doppler, which does not provide any information regarding the anatomical distribution of the perforators. The main disadvantage of a color Doppler machine is that the investment and economic costs are too high to procure the machine and the machine and probe footprint large for portable ultrasound usage, especially in places like the operation theatre due to logistical problems and problems related to the sterilization of equipment. In addition, pulse wave and color Doppler require skilled expertise in operating an ultrasound machine. Previously, many authors have recommended the use of pre-operative mapping of arterial perforators using acoustic handheld Doppler. However, the literature is limited to evidence-based evidence showing the reliability of this technique. Studies have demonstrated variable reproducibility and success in pre-operative localization of arterial perforators, while comparing handheld data with intraoperative findings. 10 In comparing intra-operative and handheld Doppler findings large underestimation (30 %) to an overestimation of 150 % for hand held Doppler findings. 11 Sound data were analyzed using MATLAB software, and an algorithm was derived to extrapolate sound and tabular data from pulse and color Doppler onto sound recordings from continuous wave Doppler. From a preliminary small dataset analysis of 45 recordings, it was found that the expected peak systolic velocity (expected PSV) from sound analysis of continuous wave Doppler was very close or nearly equal to the pulse wave Doppler actual peak systolic velocity (actual PSV) in 41 recordings. Only four recordings showed vast differences in the datasets of both ultrasound Doppler machines. The main aim of this study was to evaluate whether the sound output of a basic continuous-wave Doppler machine could reproduce the data provided by a technologically advanced handheld Doppler machine. While collecting data using the continuous wave handheld Doppler device, we found that the Doppler signal in the form of a spectral waveform and sound output varied drastically between different recordings of the same perforator by the same investigator (high intra-observer variation). This can be attributed to the fact that there is no way to fix the angle of insonation of the handheld Doppler ultrasound beam and that the output is dependent on the angle at which the probe is held. To counter this problem, we took multiple recordings of the same perforator and analyzed the recordings with the highest spectral peak and maximum sound output. By having multiple recordings of the same perforator using continuous wave Doppler and performing preliminary marking of the perforator site using pulse wave doppler, we were able to set basic scanning guidelines on using continuous wave Doppler for arterial perforator analysis. Another objective of the study was to conduct a never done before kind of pilot study for anatomical mapping of dominant arterial perforators of the below leg arteries (anterior tibial artery and posterior tibial artery). After analyzing the results, it was found that arterial perforators in the leg can be divided into clusters with 5 cm interval, with maximum perforators arising between 5 and 10 cm, 10–15 cm, and 15–20 cm from the nearest anatomical landmarks, that is, medial and lateral malleolus or intermalleolar line. This was consistent with other studies in which clusters of 4–9 cm, 13–18 cm, and 21–26 cm were used for the origin of lower limb arterial perforators. They followed the course of the perforators in the intermuscular septae, which was also noted in our study. 12 CW and PW interpretations based on years of sonographic experience analyzing 122 arterial perforators. Of all perforators, 102 originated from PTA, 4 originated from ATA, and 16 originated from the medial sural artery. 13 The existence of reliable levels of septocutaneous perforators of the lower limb allows one to do reconstruction of soft tissue defects of the lower limb, especially its foot and distal third, in a much easier manner. 14 Limitations of the study 1. Continuous wave Doppler cannot be used as a stand-alone modality to analyze arterial perforators of the lower limb owing to the lack of grayscale display and B mode to identify the artery of origin of the spectral waveform. 2. Spectral data obtained from continuous wave Doppler vary drastically between recordings (intra-observer variation) due to the difference in the angle of insonation during each recording. 3. Significant inter-observer variation while using continuous wave Doppler due to difference in expertise and technique of doing Doppler between 2 radiologists. 4. Spectral data cannot be used as stand-alone to analyze perforators and must be used in conjunction with B-mode display to identify a perforator with better blood flow dynamics based on its course. 5. Intraoperative and post-operative samples were not analyzed during the study. Conclusion Similar to the venous perforator anatomy, the arterial perforator anatomy has an important role and clinical application in perforator flap planning. Presently, there is a paucity of literature regarding the use of continuous wave Doppler for the assessment of arterial anatomy in the extremities. Their main advantage, in comparison to pulse wave and color Doppler, lies in their portability, ease of access, and economically cheaper devices. Another advantage is the presence of a metallic intra- operative probe in the CW Doppler, which can be sterilized. This may allow intra-operative Doppler imaging to confirm the dominant perforator during flap planning. However, the major limitation of using continuous wave Doppler lies in its dependence on pulse wave Doppler to first identify arterial perforators in the limb, due to the lack of gray-scale imaging in CW Doppler. Without prior anatomical mapping, there is no way to confirm whether the sound output arises from a perforator or parent artery. Analysis of the anatomical distribution of arterial perforators demonstrated that most commonly, there are 4 to 5 perforators below the knee arising from the anterior tibial artery and posterior tibial artery, with an average peak systolic velocity of ~ 30-35 cm/s. After performing cluster analysis for the distribution of arterial perforators arising from the anterior and posterior tibial arteries in the leg, we concluded that the perforators were present in the intermuscular septa and plane. Perforator clusters were found within distinct 5 cm intervals at approximately 5–10, 10–15, and 15–20 cm from the medial malleolus, lateral malleolus, or intermalleolar line. In conclusion, spectral analysis of a perforator could aid a surgeon in deciding a dominant arterial perforator, which will further improve the outcomes of flap surgeries and improve its planning. Ethics and consent The study was conducted after obtaining permission from the institutional ethic Committee- approval committee name-Institutional Ethics Committee Kasturba medical College Reg No.ECR/541/Inst/KA/2014/RR.17 study approved on Wednesday 17 th October 2018 as study no. IEC KMC MLR 10-18/382. The study participants were informed about the objectives, and written informed consent was obtained. Data availability Underlying data https://data.mendeley.com/datasets/9wpjrt5nfx/1 Repository name: Mendeley Data Title of project ROLE OF CONTINUOUS WAVE VS PULSE WAVE AND COLOR DOPPLER IN IDENTIFYING ARTERIAL PERFORATORS OF LOWER LIMB”, DOI 10.17632/9wpjrt5nfx.1 . 15 This project contains the following underlying data: • ANNEXURE VI MASTER CHART.docx The files associated with this dataset are licensed under a Creative Commons Attribution 4.0 International licence. References 1. Quaba O, Quaba A: Pedicled perforator flaps for the lower limb. Semin. Plast. Surg. 2006; 20 : 103–111. Publisher Full Text 2. Hwang JH, Kimme MB: Principles of Ultrasound.Hawes RH, Fockens P, editors. Endosonography. 2 ed.Saunders; 2011; pp. 2–12. 3. Poe P: Lower-Extremity Arterial Continuous-Wave Doppler Evaluation. The Journal for Vascular Ultrasound. 2012; 36 (2): 123–134. 4. Moore KL, Agur AMR, Dalley AF: Essential Clinical Anatomy. Lippincott Williams & Wilkins; 2011. 5. Drimouras G, Kostopoulos E, Agiannidis C, et al. : Redefining Vascular Anatomy of Posterior Tibial Artery Perforators: A Cadaveric Study and Review of the Literature. Ann. Plast. Surg. 2016 Jun; 76 (6): 705–712. PubMed Abstract | Publisher Full Text 6. Georgescu AV: Propeller perforator flaps in distal lower leg: Evolution and clinical applications. Arch. Plast. Surg. 2012; 39 : 94–105. PubMed Abstract | Publisher Full Text 7. Schaverien M, Saint-Cyr M: Perforators of the lower leg: analysis of perforator locations and clinical application for pedicled perforator flaps. Plast. Reconstr. Surg. 2008; 122 (1): 161–170. PubMed Abstract | Publisher Full Text 8. Saint-Cyr M, Wong C, Schaverien M, et al. : The perforasome theory: vascular anatomy and clinical implications. Plast. Reconstr. Surg. 2009; 124 : 1529–1544. PubMed Abstract | Publisher Full Text 9. Koshima I, Itoh S, Nanba Y, et al. : Medial and lateral malleolar perforator flaps for repair of defects around the ankle. Ann. Plast. Surg. 2003; 51 : 579–583. PubMed Abstract | Publisher Full Text 10. Yu P, Youssef: A Efficacy of the handheld doppler in preoperative identification of the cutaneous perforators in the anterolateral thigh flap. Plast. Reconstr. Surg. 2006; 118 : 928–933. PubMed Abstract | Publisher Full Text 11. Shaw RJ, Batstone MD, Blackburn TK, et al. : Preoperative doppler assessment of perforator anatomy in the anterolateral thigh flap. Br. J. Oral Maxillofac. Surg. 2010; 48 : 419–422. PubMed Abstract | Publisher Full Text 12. Hupkens P, Westland PB, Schijns W, et al. : Medial lower leg perforators: An anatomical study of their distribution and characteristics: An Anatomical Study on Medial Lower Leg Perforators. Microsurgery. 2017; 37 (4): 319–326. PubMed Abstract | Publisher Full Text 13. Kosutic D, Pejkovic B, Anderhuber F, et al. : Complete mapping of lateral and medial sural artery perforators: anatomical study with Duplex-Doppler ultrasound correlation. J. Plast. Reconstr. Aesthet. Surg. 2012; 65 (11): 1530–1536. Publisher Full Text 14. Stevanovic G, Djordjevic B, Dakovic M, et al. : Fasciocutaneous flaps of the lower leg: Anatomic study and clinical significance. Vojnosanit. Pregl. 2010; 67 (2): 136–144. PubMed Abstract | Publisher Full Text 15. Mahale AJIT, Khatyal S: ROLE OF CONTINUOUS WAVE VS PULSE WAVE AND COLOR DOPPLER IN IDENTIFYING ARTERIAL PERFORATORS OF LOWER LIMB. Dataset citation. Mendeley Data. 2024; V2 . Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 28 Jan 2025 ADD YOUR COMMENT Comment Author details Author details 1 Department of Radiodiagnosis, Katsurba Medical College Mangalore, Manipal Academy of Higher Education, Karnataka, Manipal, 576104, India 2 Department of Orthopaedics, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Karnataka, Manipal, 576104, India 3 Department of Communication and Electronics, Nitk Surathkal, Mangalore, Karnataka, 575001, India Ajit Mahale Roles: Formal Analysis, Investigation, Writing – Original Draft Preparation Sanyam Khatyal Roles: Conceptualization, Data Curation, Formal Analysis DEEPAK PINTO Roles: Funding Acquisition, Investigation, Methodology DEEPU VIJAYSENAN Roles: Resources, Software, Supervision Sonali Ullal Roles: Validation Merwyn Fernandes Roles: Visualization Sonali Prabhu Roles: Writing – Original Draft Preparation Fathima Raeesa Roles: Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 28 Jan 2025, 14:143 https://doi.org/10.12688/f1000research.158181.1 Copyright © 2025 Mahale A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Mahale A, Khatyal S, PINTO D et al. Role of continuous wave vs pulse wave and color doppler in identifying arterial perforators of lower limb [version 1; peer review: 1 not approved] . F1000Research 2025, 14 :143 ( https://doi.org/10.12688/f1000research.158181.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 28 Jan 2025 Views 0 Cite How to cite this report: Yoshida S. Reviewer Report For: Role of continuous wave vs pulse wave and color doppler in identifying arterial perforators of lower limb [version 1; peer review: 1 not approved] . F1000Research 2025, 14 :143 ( https://doi.org/10.5256/f1000research.173740.r363251 ) The direct URL for this report is: https://f1000research.com/articles/14-143/v1#referee-response-363251 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 10 Feb 2025 Shuhei Yoshida , Hiroshima University, Hiroshima, Japan Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.173740.r363251 Comments The aim of the study is obscure, which leads to the inconsistency of manuscript, introduction methods, results, discussion, and conclusion. The reviewer recommends the authors to make it clear what the problem is in current situations, and ... Continue reading READ ALL Comments The aim of the study is obscure, which leads to the inconsistency of manuscript, introduction methods, results, discussion, and conclusion. The reviewer recommends the authors to make it clear what the problem is in current situations, and what survey should be done to resolve the problem. There are some inappropriate manners for writing manuscripts. The reviewer recommends the authors to reconsider their survey and to reconstruct their survey from the start ABSTRACT The survey was conducted to compare the accuracy of detecting perforator arteries in lower legs between Continuous wave Doppler using a Huntleigh Doppler DMX handheld device and pulse wave and conventional color Doppler. The reviewer recommends the authors to clarify the purpose of the survey, and to described the conclusions based on the purpose and results of the survey Introduction The first, third line “An arterial perforator is --superficial structures.”, “Presently arterial perforators--- to peripheral vaso-occlusive pathology. “ needs to clarify the reference. “CW Doppler” , “PW Doppler”; abbreviations needs their formal terms on its first appearance in body of manuscript apart from abstract. The reviewer recommends the authors to revise the aim and methods of the study literary style, not itemized style, although it is easier to understand. Methods Please note companies which produces the software used by the authors. Results The reviewer thinks BMI data is necessary to assess the data of depth from skin surface. The reviewer recommends the authors to combine Table 1, 2, 3,4 and Figure 1,2 The reviewer thinks Figure 1 is not necessary, since it indicates the same data as Table3. Figure 2 needs numerical display, and good enough to display as Table. In addition, the data in figure 2 needs deviations. The reviewer thinks Table 5 is better to transfer into appropriate figures. The reviewer thinks figure 3 is not necessary. The line “Preliminary analysis --MATLAB software (Figure 5) (Tables 8 and 9).” Should be described in Methods section. The reviewer thinks Figure 4, 5,6 and Table 10, 11 are not necessary. The reviewer thinks the section of Analysis algorithm in MATLAB should be described in the Methods section. Discussion The line “Arterial perforators ---as diabetic foot, trauma, and trophic ulcers.”, “Multiple authors have previously described ----perforator is quite difficult.” need their references. Is the work clearly and accurately presented and does it cite the current literature? No Is the study design appropriate and is the work technically sound? No Are sufficient details of methods and analysis provided to allow replication by others? No If applicable, is the statistical analysis and its interpretation appropriate? No Are all the source data underlying the results available to ensure full reproducibility? No Are the conclusions drawn adequately supported by the results? No Competing Interests: No competing interests were disclosed. Reviewer Expertise: Plastic and reconstructive surgery, Microsurgery, Flap transfer, Lymphedema I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Yoshida S. Reviewer Report For: Role of continuous wave vs pulse wave and color doppler in identifying arterial perforators of lower limb [version 1; peer review: 1 not approved] . F1000Research 2025, 14 :143 ( https://doi.org/10.5256/f1000research.173740.r363251 ) The direct URL for this report is: https://f1000research.com/articles/14-143/v1#referee-response-363251 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 28 Jan 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 Version 1 28 Jan 25 read Shuhei Yoshida , Hiroshima University, Hiroshima, Japan Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Yoshida S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 10 Feb 2025 | for Version 1 Shuhei Yoshida , Hiroshima University, Hiroshima, Japan 0 Views copyright © 2025 Yoshida S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Comments The aim of the study is obscure, which leads to the inconsistency of manuscript, introduction methods, results, discussion, and conclusion. The reviewer recommends the authors to make it clear what the problem is in current situations, and what survey should be done to resolve the problem. There are some inappropriate manners for writing manuscripts. The reviewer recommends the authors to reconsider their survey and to reconstruct their survey from the start ABSTRACT The survey was conducted to compare the accuracy of detecting perforator arteries in lower legs between Continuous wave Doppler using a Huntleigh Doppler DMX handheld device and pulse wave and conventional color Doppler. The reviewer recommends the authors to clarify the purpose of the survey, and to described the conclusions based on the purpose and results of the survey Introduction The first, third line “An arterial perforator is --superficial structures.”, “Presently arterial perforators--- to peripheral vaso-occlusive pathology. “ needs to clarify the reference. “CW Doppler” , “PW Doppler”; abbreviations needs their formal terms on its first appearance in body of manuscript apart from abstract. The reviewer recommends the authors to revise the aim and methods of the study literary style, not itemized style, although it is easier to understand. Methods Please note companies which produces the software used by the authors. Results The reviewer thinks BMI data is necessary to assess the data of depth from skin surface. The reviewer recommends the authors to combine Table 1, 2, 3,4 and Figure 1,2 The reviewer thinks Figure 1 is not necessary, since it indicates the same data as Table3. Figure 2 needs numerical display, and good enough to display as Table. In addition, the data in figure 2 needs deviations. The reviewer thinks Table 5 is better to transfer into appropriate figures. The reviewer thinks figure 3 is not necessary. The line “Preliminary analysis --MATLAB software (Figure 5) (Tables 8 and 9).” Should be described in Methods section. The reviewer thinks Figure 4, 5,6 and Table 10, 11 are not necessary. The reviewer thinks the section of Analysis algorithm in MATLAB should be described in the Methods section. Discussion The line “Arterial perforators ---as diabetic foot, trauma, and trophic ulcers.”, “Multiple authors have previously described ----perforator is quite difficult.” need their references. Is the work clearly and accurately presented and does it cite the current literature? No Is the study design appropriate and is the work technically sound? No Are sufficient details of methods and analysis provided to allow replication by others? No If applicable, is the statistical analysis and its interpretation appropriate? No Are all the source data underlying the results available to ensure full reproducibility? No Are the conclusions drawn adequately supported by the results? No Competing Interests No competing interests were disclosed. Reviewer Expertise Plastic and reconstructive surgery, Microsurgery, Flap transfer, Lymphedema I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Yoshida S. Peer Review Report For: Role of continuous wave vs pulse wave and color doppler in identifying arterial perforators of lower limb [version 1; peer review: 1 not approved] . F1000Research 2025, 14 :143 ( https://doi.org/10.5256/f1000research.173740.r363251) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-143/v1#referee-response-363251 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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