Perspective:

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

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. Appropriateness of the use of cerebrovascular duplex ultrasound to assess for carotid stenosis in the patient with syncope with no obvious cardiac cause was rated as uncertain by the panel.

3. The technical panel rated as uncertain all clinical scenarios for cerebrovascular duplex examination prior to cardiac surgery, including evaluation of any asymptomatic patient (i.e., no prior hemispheric symptoms, no bruit) prior to coronary artery bypass grafting and evaluation of an asymptomatic patient prior to valvular heart surgery, including patients with or without risk factors or comorbidities associated with cerebrovascular disease.

4. Obtaining a baseline bilateral cerebrovascular duplex examination after carotid artery revascularization (endarterectomy or stenting) was highly rated as appropriate by the technical panel.

5. Renal artery ultrasound is appropriate in patients with hypertension, elevated creatinine, and heart failure to assess for renal artery stenosis.

6. The only appropriate indication for duplex investigation of mesenteric artery stenosis was for the patients with symptoms of postprandial pain and weight loss and who have undergone a gastrointestinal evaluation.

7. Signs and symptoms considered as appropriate indications for duplex evaluation of the abdominal aorta and iliac arteries included intermittent claudication, an aneurismal femoral or popliteal pulse, a pulsatile abdominal mass, a decreased or absent femoral pulse, and an abdominal or femoral bruit.

8. The appropriate indications for lower extremity artery testing with ankle brachial index only were diminished pulses, femoral bruit, age >50 years with diabetes or smoking, and age >70 years, which is consistent with American College of Cardiology/American Heart Association peripheral artery disease guidelines.

9. The appropriate indications for lower extremity duplex ultrasound evaluation included a pulsatile groin mass, bruit or thrill, significant hematoma, or groin pain postprocedure.

10. In general, a consensus of ‘appropriate’ was found for most vascular studies where clinical signs and symptoms were the indication for testing, and to establish a ‘baseline’ after a revascularization procedure.