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March 4, 2020

Multisociety 2020 Appropriate Use Criteria Address Chronic Lower Extremity Venous Disease

March 4, 2020—The 2020 appropriate use criteria (AUC) for chronic lower extremity venous disease were published by Elna Masuda, MD, et al online in Journal of Vascular Surgery (JVS): Venous and Lymphatic Disorders. Dr. Masuda announced the publication of these AUC during AVF 2020, the annual meeting of the American Venous Forum held March 3–6 in Amelia Island, Florida. The creation of the document was stimulated by published reports of potentially inappropriate application of venous procedures. 

The AUC document was drafted by the American Venous Forum and its ethics task force in collaboration with multiple other professional societies including the Society for Vascular Surgery, the American Vein and Lymphatic Society, and the Society of Interventional Radiology. The document seeks to provide clarity to the application of venous procedures, duplex ultrasound imaging, timing, and reimbursements.

The authors noted that the AUC were developed using the RAND/UCLA Appropriateness Method, a validated method of developing appropriateness criteria in health care. The AUC were developed and scored by conducting a modified Delphi exercise and incorporating the best available evidence and expert opinion.

As summarized in JVS: Venous and Lymphatic Disorders, there were 119 scenarios rated by an expert panel on a scale of 1 ("never appropriate") to 9 ("appropriate") including the following main categories:

  • Saphenous vein ablation
  • Nontruncal varicose veins with or without telangiectasia
  • Management decisions for diseased tributaries associated with saphenous ablation
  • Perforator veins
  • Iliac vein or inferior vena cava (IVC) stenting as first-line treatment
  • Duplex ultrasound for chronic venous disease
  • Timing and reimbursement decisions

The AUC determinations included:

  • The majority of scenarios consisted of symptomatic indications and were deemed "appropriate" for venous intervention.
  • For scenarios with anatomically short segments of reflux and/or no symptoms, the indications were rated "less appropriate."
  • For the indication of edema, wide dispersion of ratings was observed especially for short segments of saphenous reflux or stenting for iliac/IVC disease, noting that there are multifactorial causes of edema, some of which could coexist with venous disease and possibly impact the effectiveness of treatment.
  • Several scenarios were considered "never appropriate," including treatment of saphenous veins with no reflux, iliac vein or IVC stenting for iliac vein compression as an incidental finding by imaging with minimal or no symptoms or signs, and incentivizing sonographers to find reflux.

In conclusion, the document authors advised, "The AUC statements are intended to serve as a guide to patient care, particularly in areas where high-quality evidence is lacking to aid clinicians in making day-to-day decisions for common venous interventions. This may also prove useful when applied on a population level, such as practice patterns, and not necessarily to dictate decision making for individual cases."

"As a product of a collaborative effort, it is hoped that this could be utilized by physicians and multiple stakeholders committed toward improving patient care and to identify and stimulate future research priorities," stated the authors in JVS: Venous and Lymphatic Disorders.

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