Appropriate-Use Criteria Issued for Peripheral Vascular Ultrasound and Testing for Venous Disease

July 19, 2013―The American College of Cardiology (ACC) announced the publication of detailed criteria to help clinicians optimize the appropriate use of certain noninvasive vascular tests when caring for patients with known or suspected disorders of the venous system. Also included are first-time recommendations for when and how to use these tests to plan for or evaluate dialysis access placement. The authors stress that these criteria should not supersede sound clinical judgment for individual patients.

The document, “2013 Appropriate Use Criteria for Peripheral Vascular Ultrasound and Physiological Testing Part II: Testing for Venous Disease and Evaluation of Hemodialysis Access,” by writing committee chair Heather L. Gornik, MD, et al, is available online ahead of print in the Journal of the American College of Cardiology. The appropriate-use criteria were developed in collaboration with ten medical societies, including the Society for Cardiovascular Angiography and Interventions and the Intersocietal Accreditation. Part I of the appropriate-use criteria for peripheral vascular ultrasound and physiological testing, which address arterial ultrasound and physiological testing, were published last year in the Journal of the American College of Cardiology (2012;60:242–276).

“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,” commented Dr. Gornik in the ACC press release. “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.”

Dr. Gornik noted that because venous thromboembolism, including deep vein thrombosis (DVT) and pulmonary embolism (PE), can be fatal and result in hospitalizations and long-term complications, identifying the best methods for detecting clots in the veins early on can be lifesaving. She added, “But we must know that we are ordering the right test for the right reasons.”

According to the ACC's outline of the criteria, the new report offers comprehensive, at-a-glance guidance on when and when not to refer patients for vascular laboratory testing (for example, duplex ultrasound and physiological testing using blood-flow sensors) to help detect such problems as venous insufficiency; varicose veins; blood clots in the veins of the leg, arm or abdomen; and PE.

To develop the criteria, a diverse writing group including representatives from vascular medicine, cardiology, interventional radiology, and orthopedic and vascular surgery identified 116 clinical scenarios when the use of vascular testing might be considered. A separate group of experts then used a rating scale to determine whether vascular testing for each circumstance would be appropriate, possibly appropriate, or rarely appropriate.

Overall, vascular studies were deemed appropriate when clinical signs and symptoms were the main reason for testing. For example, if a patient has swelling, discoloration or pain in one leg, experts agree that it is reasonable to order a duplex ultrasound evaluation of the legs to determine whether there might be a DVT or clot. In contrast, 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.

“Vascular ultrasound is now the best, most accurate test we have for diagnosing DVT, and it has clear advantages, including its low risk to the patient with no exposure to radiation or contrast dye and the fact that it is less expensive relative to other tests,” Dr. Gornik said. “But a lot of screening ultrasounds are done indiscriminately for asymptomatic patients, and we found there is little evidence to support that practice.”

The report also shows that the vascular lab plays a central role in evaluating patients with chronic venous insufficiency. The writing committee also rated preoperative vascular testing for preparing a dialysis access site as appropriate as long as it was done within 3 months of the procedure; however, vascular testing was rarely appropriate for general surveillance of a functional dialysis fistula or graft unless there was some indication of a problem (eg, palpable mass or arm swelling, low volume flow during dialysis sessions).

The ACC noted that compared with arterial disease, there are far fewer clinical scenarios in which vascular testing is deemed useful for repeat monitoring of venous disease, and further research is needed. Dr. Gornik stated, “There is also growing 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. There are also a number of controversial areas that have not yet been fully explored, which we have outlined.”

One example is whether patients with blood clots in their calf should be treated with anticoagulant 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 PE. Similarly, the role of duplex ultrasound for follow-up after venous procedures (eg, venous stenting procedures) or to assess dialysis access maturity is not as well established, concluded the ACC's summary of the document.