Accuracy of Ultrasound for the Diagnosis of Peripheral Vascular Disease in Diabetic Foot: A Systematic Review

Abstract

Peripheral vascular disease is a significant cause of diabetic foot complications, resulting in delayed wound healing, ulceration, and amputation. This systematic review compared the diagnostic accuracy of ultrasound, such as duplex Doppler and color-flow imaging, in diagnosing peripheral vascular disease in diabetic foot patients. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, a systematic search of PubMed, Scopus, Web of Science, and Embase with gray literature sources yielded 687 English-language records from January 2015 up to July 15, 2025, the last day of searching. Forty-two studies that fulfilled the inclusion criteria, involving 6168 patients, were selected and evaluated for sensitivity, specificity, and methodological quality using the QUADAS-2 tool. Overall across studies, unweighted sensitivity varied from 79%-95.2% (mean 89.46%) and specificity from 80%-94.7% (mean 90.05%). Prospective study design and the use of high-frequency probes (≥12 MHz) were linked to greater accuracy, especially in the identification of superficial tibial vessel disease. Diagnostic performance was affected by probe frequency, operator skill, patient factors such as obesity or arterial calcification, and reference standard variability. Secondary results involved sparse venous information, where two-thirds of patients undergoing imaging for venous disease had deep vein thrombosis. No meta-analysis was undertaken because there was important heterogeneity between studies in terms of design, population, and endpoints. Ultrasonography—in particular duplex Doppler—is seen to have high diagnostic usefulness, providing a low-cost, non-invasive option for digital subtraction angiography, though protocols need to be standardized and more prospective studies conducted to maximize its use in diabetic foot treatment.