Perspective:

The following are 10 points to remember about these appropriate use criteria:

1. An appropriate imaging study is one in which the expected incremental information, combined with clinical judgment, exceeds the expected negative consequence by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication.

2. Upper extremity venous duplex ultrasound was rated as an appropriate test in the setting of limb swelling, nonarticular upper extremity pain or palpable cord, and when new pain or swelling is noted in the presence of known upper extremity deep vein thrombosis (DVT).

3. It was deemed rarely appropriate to perform an upper extremity venous ultrasound for evaluation of fever of unknown origin in the absence of an indwelling upper extremity venous catheter, or for evaluation of shortness of breath in a patient with known upper extremity DVT.

4. Screening for upper or lower extremity DVT in an asymptomatic patient was rated as rarely appropriate.

5. Lower extremity venous duplex ultrasound was rated an appropriate test in the setting of limb swelling, nonarticular lower extremity pain or palpable cord, pulmonary embolism, and when new pain or swelling is noted in the presence of known lower extremity DVT.

6. Testing was also rated as appropriate for certain surveillance indications, namely surveillance of calf vein thrombosis for proximal extension of DVT when anticoagulation is contraindicated, and for superficial thrombophlebitis of the legs (i.e., great or small saphenous vein) located near a deep vein junction.

7. Venous physiological testing was rated as appropriate in the setting of significant clinical symptoms and signs of chronic venous insufficiency, including: active venous ulcer, symptomatic varicose veins, and chronic skin changes such as lipodermatosclerosis or hyperpigmentation.

8. Scanning of the inferior vena cava (IVC) and iliac veins was rated as appropriate when performed selectively with a positive lower extremity venous duplex demonstrating proximal DVT or when an abnormal flow pattern was found in one or both common femoral veins.

9. Duplex scanning of the hepatoportal system was rated as appropriate for the evaluation of cirrhosis without ascites, hepatomegaly and/or splenomegaly, and portal hypertension.

10. Duplex ultrasound was rated as an appropriate test for most clinical scenarios related to upper extremity symptoms in the patient with mature dialysis access, including mass associated with an autogenous arteriovenous fistula/prosthetic arteriovenous graft, arm swelling, or signs of digital ischemia due to steal phenomenon (hand pallor, pain, or ulceration).