This document discusses appropriate use criteria for various arterial tests developed by the American College of Cardiology Foundation. It describes 255 clinical scenarios that were scored on a scale of 1 to 9 for appropriateness. The document then defines and provides appropriateness criteria for various arterial exams, including carotid duplex screening, renal and mesenteric artery duplex, lower and upper extremity arterial testing, aortic and aortoiliac duplex exams. It provides examples of appropriate, inappropriate and gray zone indications for each test. The goal is to provide guidance to help ensure high quality care and rational use of imaging services.
2. Created in response to increased effort to rationally use imaging
services
Ensure high-quality care
Diagnostic imaging services Medicare reimbursement grew more
rapidly than any other physician service from 1999 to 2003
American College of Cardiology Foundation (ACCF) partnered with
specialty + subspecialty societies to review common clinical
scenarios
3. Appropriate Use Criteria Continued…
255 Clinical Scenarios (indications) scored on scale 1 to 9
Appropriate (7 to 9)
177 indications
Uncertain “Gray Zone” (4 to 6)
84 indications
Inappropriate (1 to 3)
54 indications
This effort has potential to impact physician decision making,
healthcare delivery, & reimbursement policy
Scenarios were evaluated for 8 different arterial tests
4. Types of Arterial Exams
Extracranial Cerebrovascular Duplex
Carotid Duplex Screening
Renal & Mesenteric Artery Duplex
Aortic & Aortoiliac Duplex
LE Artery Testing (Multilevel Physiological Testing Alone
or Duplex Ultrasound with Single-Level ABI & PVR)
LE Artery Testing with ABI only
LE Artery with Duplex only
UE Arterial Testing (Physiological Testing or Duplex
Ultrasound)
6. Appropriate
Neurological symptoms
Suspected vertebrobasilar symptoms (present circulation
symptoms)
Evaluation of TIA or stroke
Inappropriate
Carotid Artery Stenosis Surveillance (mild to moderate)
“Gray Zone”
Prior to open heart surgery
Syncope symptoms
7. Carotid Duplex Screening
What is it?
Limited ultrasound study done to assess blood flow of arteries
that supply blood from heart up through the neck into the brain
8. Appropriate
Dissection arising from aortic arch into arch vessels (CCA)
Inner lining tears allowing blood to flow into a “false
lumen”
Inappropriate
Trauma induced dissection
Normal baseline carotid follow-up
Repeat studies for moderate ICA lesions within first year
Low to moderate Framingham risk score
Risk of having heart attack in the next 10 years
“Gray Zone”
Surveillance beyond first year (normal carotid stenosis)
Intermediate to high Framingham risk score
9. Renal & Mesenteric Artery
Duplex
What is it?
Renal Duplex: Ultrasound study done to evaluate the renal
arteries that feed the kidneys.
Mesenteric Duplex: Ultrasound study done to evaluate the
arteries supplying blood flow to organs involved with digestion.
11. Aortic & Aortoiliac Duplex
What is it?
Ultrasound study performed to evaluate the aorta (the main
artery in the abdomen) and surrounding arteries that
deliver blood to major organs in the body.
13. LE Artery Testing:
Multi-level Physiological Testing Alone or Duplex
Ultrasound with Single-level ABI & PVR
What is it?
Multi-level Physiological Testing: Segmental Pressures are taken
from the ankle up to the thigh (3 cuffs or 4 cuffs) to determine if
pressure differences exist (>30 mmHg)
Single Level: Ankle Brachial Index (ABI) is found by dividing
highest arm pressure by highest ankle pressure. Pulse Volume
Recording (PVR) is used to measure volume changes in limb
pressures from the thigh down to the ankle.
14. Appropriate
LE Claudication, rest pain
Ulcers, gangrene, ischemia
Normal/Abnormal ABI (new or worsening symptoms)
Inappropriate
Symptoms present along with normal pulses
Ex. Nocturnal leg cramps, neuropathy, LE swelling
or hair loss
15. LE Artery Testing:
ABI only
What is it?
Physiological test done to determine the ratio of ankle systolic
pressure to arm systolic pressure, which the numerical index
serving as an indicator of arterial insufficiency (Normal= > 1.0)
17. LE Artery Testing:
Duplex only
What is it?
Ultrasound study performed to evaluate the arteries of the legs
in order to identify narrowing of vessels.
18. Appropriate
Groin symptoms
o Ex. Pulsatile mass, Bruit or thrill, severe pain post-
procedure
Significant hematoma
(solid swell of blood in tissues)
“Gray Zone”
Ecchymosis
(Discoloration of skin resulting from bleeding underneath)
19. UE Arterial Testing:
Physiological Test or Duplex Ultrasound
What is it?
Physiological: segmental pressures are taken in the upper
extremity arteries to determine presence, severity, and
location of arterial occlusive disease
Duplex: Ultrasound study performed to evaluate the arteries
of the arms in order to identify narrowing of vessels.
20. Appropriate
Claudication, ulceration, ischemia, bruit
Unilateral cold painful hand
UE trauma due to vascular harvest
“Gray Zone”
Raynaud’s phenomenon
Vasospastic disorder
>20 mmHg brachial pressure difference
Periclavicular (around the clavicle) bruit
21. A 72 year old male complains of rest pain symptoms. He is
diabetic and has smoked 2 packs per day for 50 years.
LE Arterial Testing with ABI only
A 75 yr old woman presents with temporal headaches.
Additionally, she complains of muscle aching in shoulders +
arm fatigue with physical activity.
UE Arterial Physiological Test (segmental pressures) +
Duplex (if pressure difference is found)
Patient Example