Abstract Aims This systematic review assessed literature concerning preoperative magnetic resonance angiography (MRA), computed tomography angiography (CTA), and duplex ultrasonography to determine the sensitivity and specificity at detecting lower limb arterial stenosis and/or occlusion, with digital subtraction angiography (DSA) as the reference standard. The aim was to see if any, or a combination of, methods could replace DSA in peripheral arterial disease diagnosis and treatment planning. Methods 10 databases were searched on Ovid for studies involving MRA, CTA and/or duplex ultrasonography of the lower limb arteries. The period of interest was 1995-April 2021. The papers were assessed for their relevance to the review against the exclusion criteria. Results 41 studies were included. For detecting ≥50% stenosis or occlusion, multi-detector CTA had the highest median sensitivity of 93.9% and specificity of 93.4%. Contrast-enhanced MRA and duplex ultrasonography reported median sensitivities and specificities of 91.1% and 91.9%, and 82.7% and 90.6%, respectively. For detecting occlusions, duplex ultrasonography had the best median sensitivity of 92.3% and specificity of 99.5%. Contrast-enhanced MRA and multi-detector CTA had median sensitivities and specificities 92.0% and 96.5%, and 88.6% and 98.3%, respectively. Conclusion Contrast-enhanced MRA had the best overall diagnostic accuracy. Multi-detector CTA detected ≥50% stenosis or occlusion well, but the sensitivity for occlusions was lower than MRA and duplex ultrasonography. Though duplex ultrasonography detected occlusions better than MRA and CTA, it was less sensitive and specific at detecting ≥50% stenosis or occlusion. Consequently, contrast-enhanced MRA could be used as an alternative to DSA.