New Appropriate Use Criteria (AUC) released by the ACC and developed in collaboration with 10 other leading professional societies provides detailed criteria to help clinicians optimize the appropriate use of peripheral vascular ultrasound and physiological testing when caring for patients with known or suspected venous disease. Also included are first-time recommendations for when and how to use these tests to plan for or evaluate dialysis access placement.

The new AUC offers comprehensive, at-a-glance guidance on when — and when not — to refer patients for vascular laboratory testing in 116 different clinical scenarios, including venous duplex ultrasound evaluation of the arms, lower extremities, and vena cava for venous thrombosis; duplex evaluation of the legs for venous incompetency (reflux); duplex evaluation of the renal and hepatoportal system; evaluation prior to (in planning) and after dialysis access placement (arteroivenous fistula and grafts); and venous physiological testing.

"Vascular lab testing is central to the care of patients with most peripheral vascular disorders, but appropriate use criteria for these [technologies] have lagged behind those for cardiac testing," said Heather Gornik, MD, FACC, cardiologist and vascular medicine specialist at the Cleveland Clinic and chair of the writing committee. "With this report, we now have multidisciplinary criteria upon which we can start maximizing the quality and appropriateness of what we do in the vascular lab every day."

In general, vascular studies were deemed appropriate when clinical signs and symptoms were the primary reason for testing. For example, duplex ultrasound evaluation of the legs to determine whether there might be a DVT or clot was rated appropriate for patients with swelling, discoloration or pain in one leg. In contrast, the writing committee said it is rarely appropriate to use these tests to screen for DVT in patients without symptoms — even in those who are more prone to clotting or who have had an extended intensive care unit or hospital stay, recent (major) orthopedic surgery or a positive D-dimer blood test.

The writing committee also rated pre-operative vascular testing for preparing a dialysis access site as appropriate as long as it was done within three months of the procedure; however, vascular testing was rarely appropriate for general surveillance of a functioning AV fistula or graft unless there is some indication of a problem (e.g., palpable mass or arm swelling, low volume flow during dialysis sessions).

The report also highlights the central role that vascular labs play in evaluating patients with chronic venous insufficiency, provided that the lab is accredited and staffed by appropriately trained and credentialed personnel and results are interpreted by appropriately trained and credentialed reading physicians. "Vascular laboratory testing has multiple advantages relative to other types of test including absence of exposure to ionizing radiation or contrast dye, portability of testing, and relatively low cost," said Gornik. "That being said, it is important to have the right vascular laboratory test ordered for the right reasons/indication."

Moving forward the AUC includes suggestions for additional research. For example, should patients with blood clots in their calf should be treated with blood thinning medication versus duplex ultrasound surveillance. Another area requiring more research is how ultrasound of the veins in the legs and arms can be used as part of clinical algorithms to diagnose and manage pulmonary embolism. Similarly, the role of duplex ultrasound for follow-up after venous procedures (e.g., venous stenting procedures) or to assess dialysis access maturity is not as well established. According to Gornik, there is also increasing need for comparative and cost-effectiveness research of vascular laboratory testing in the care and diagnosis of patients with deep vein thrombosis and pulmonary embolism.

*The AUC was developed in collaboration with the American College of Radiology, American Institute of Ultrasound in Medicine, American Society of Echocardiography, American Society of Nephrology, Intersocietal Accreditation Commission, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Interventional Radiology, Society for Vascular Medicine, and Society for Vascular Surgery.

Keywords: Renal Dialysis, Follow-Up Studies, Radiation, Ionizing, Pulmonary Embolism, Ultrasonography, Doppler, Duplex, Varicose Ulcer, Venous Thrombosis, Hematologic Tests, Fistula, United States