ACCF/ACR/AIUM/ASE/IAC/SCAI/SCVS/SIR/SVM/SVS/SVU 2013 Appropriate Use Criteria for Peripheral Vascular Ultrasound and Physiological Testing Part II

Testing for Venous Disease and Evaluation of Hemodialysis Access

Heather L. Gornik, MD, FACC, FAHA, FSVM; Marie D. Gerhard-Herman, MD, FACC; Sanjay Misra, MD, FSIR, FAHAz; Emile R. Mohler III, MD, FACC; R. Eugene Zierler, MD, FACS; Reza Fazel, MD, MS; Laura Findeiss, MD, FSIR; Richard Fuchs, MD, FACC, FAHA; John Gillespie, MD; John Gocke, MD, MPH, RVT, RPVI; Michael H. Heggeness, MD, PHD; Joseph P. Hughes, RVT, RCS, FSVU; Michael P. Lilly, MD; Colleen Moore, MD; John S. Pellerito, MD, FACR, FSRU, FAIUM; Michelle L. Robbin, MD, FACR, FSRU, FAIUM; Thom W. Rooke, MD; Melvin Rosenblatt, MD; Fred A. Weaver, MD, MMM, FACS; Christopher J. White, MD; Michael J. Wolk, MD, MACC; Steven R. Bailey, MD, FACC, FSCAI, FAHA; John U. Doherty, MD, FACC, FAHA; Pamela S. Douglas, MD, MACC, FAHA, FASE Z; Jenissa Haidari, MPH; Robert C. Hendel, MD, FACC, FAHA, FASNC; Christopher M. Kramer, MD, FACC, FAHA; James K. Min, MD, FACC; Manesh R. Patel, MD, FACC; Leslee Shaw, PHD, FACC, FASNC; Raymond F. Stainback, MD, FACC, FASE; Joseph M. Allen, MA; Heather L. Gornik, MD, FACC, FAHA; Michael J. Wolk, MD, MACC


J Am Coll Cardiol. 2013;62(7):649-665. 

In This Article

3 Assumptions

To prevent any inconsistencies in interpretation, specific assumptions are provided that were considered by the technical panel in rating the relevant clinical indications for the appropriate use of peripheral vascular ultrasound and physiological testing:

  1. Clinical indications assume that a history and physical examination has been performed by a qualified healthcare provider before performance of the vascular ultrasound or physiological testing examination.

  2. A peripheral vascular ultrasound and physiological testing examination and report will include performance of the vascular ultrasound or physiological testing examination using a standardized scanning protocol and standardized documentation of gray scale (B-mode), color flow, and spectral Doppler wave form images as required for the specific test type. Scanning protocols may be developed by the laboratory based upon laboratory-specific considerations and techniques as well as recommended technical elements per appropriate organizations (e.g., American Institute of Ultrasound in Medicine, Society for Vascular Ultrasound) or laboratory accrediting organizations (Intersocietal Accreditation Commission [IAC] or American College of Radiology (ACR)).[4]

  3. Interpretation of the vascular ultrasound or physiological testing examination by a physician interpreter using standard, laboratory-specific diagnostic criteria that have been developed by the laboratory or adapted from the ultrasound literature and are validated internally for accuracy as part of ongoing quality assurance programs. It is implicit that diagnostic criteria will vary across laboratories, but adherence to pre-defined criteria within a laboratory is required. Laboratory-specific protocols should be compiled in written policy and procedure manuals that are made available to medical and technical staff for review and discussion.

  4. Appropriate equipment is used for each specific type of testing, including appropriate frequency ultrasound transducers and properly sized cuffs and others sensors for physiological testing.

  5. Documentation that the vascular sonographer used optimal angle correction techniques to ensure accurate angle of insonation for reporting of Doppler velocity measurements. In general, an angle of insonation of 60° or less is used with appropriate sample volume placement.

  6. All standard vascular ultrasound and physiological testing techniques have a sensitivity and specificity similar to those found in the published literature for the specific examination type.

  7. Testing should be performed by a credentialed technologist (registered vascular technologist [RVT] or registered vascular sonographer [RVS]) and interpreted by a credentialed physician (registered physician in vascular interpretation [RPVI]). Finally, the testing should be done in a facility accredited in vascular testing (e.g., IAC–Vascular Testing or ACR).

  8. If prior testing is of poor technical quality, repeat imaging may sometimes be appropriate in a different facility or after the conditions that restricted the prior testing are no longer present (e.g., bowel gas, open wounds) prior to the specified timeframes.

  9. The appropriate use of testing is assumed to have the potential to impact clinical decision making and to direct therapeutic interventions.

  10. The range of potential indications for vascular ultrasound and physiological testing is quite large, particularly in comparison with other cardiovascular imaging tests. Thus, the indications are, at times, purposefully broad to cover an array of vascular signs and symptoms as well as the ordering physician's best judgment as to the presence of vascular abnormalities. Additionally, there are likely clinical scenarios that are not covered by the current indications in this document.

  11. Venous duplex examinations that are performed to assess for suspected venous thrombosis in the limbs require performance of gray scale (B-mode) compression maneuvers in addition to color flow and spectral Doppler examination.

  12. Complete vascular examinations (ultrasound and physiological testing) require bilateral studies in the majority of clinical cases, though specific clinical indications may warrant a unilateral or limited study, (e.g., unilateral leg pain and swelling and suspected lower extremity deep vein thrombosis). The decision to perform a complete bilateral or unilateral examination should be determined by the study indications and the standardized laboratory scanning protocol.

  13. When a unilateral venous examination is performed, a spectral Doppler waveform from a contralateral proximal deep vein (e.g., subclavian or internal jugular vein for the upper extremities or common femoral vein for the lower extremities) should be recorded to allow for comparative assessment of flow patterns in the limbs.

  14. For the clinical scenarios presented in the section on Hemodialysis Vascular Access Duplex Ultrasound (l8) it is acknowledged that the appropriate vascular laboratory assessment might include more than duplex ultrasound of the extremity veins. Depending on the scenario, additional testing could include arterial duplex scanning and physiological tests such as segmental limb pressures and digit pressure measurements.

  15. To optimize patient care and minimize need for unnecessary repeat studies, it is generally recommended that repeat or serial scans (e.g., for surveillance of calf vein thrombosis with contraindication to anticoagulation) be performed in the same facility.

  16. Raters were instructed to consider cost implicitly when making the appropriate use determination.

  17. Raters were instructed to consider patient safety implicitly in the appropriate use determination.

  18. If the reason for a test can be assigned to more than 1 clinical indication, it should be matched to the indication with the highest appropriate use score.

  19. For each indication, the rating should reflect whether the test is reasonable for the patient according to the appropriate use definition, not whether the test is better or worse than another modality.

  20. The category of "maybe appropriate" should be used when insufficient clinical data are available for a definitive categorization or there is disagreement as defined in the methods. The designation of "maybe appropriate" is assumed to not provide grounds for denial of reimbursement.

  21. Unless explicitly stated, the indications in this document indicate only whether vascular ultrasound or physiological testing by itself is reasonable. The indications do not address whether it is reasonable to perform vascular ultrasound or physiological testing instead of or in conjunction with another test, either before or after the test.