Table 9.
Appropriate Indications (Median Rating 7–9)
| Indication | Appropriate Use Score (1–9) | |
|---|---|---|
| Extracranial Cerebrovascular Ultrasound | ||
| Evaluation for Cerebrovascular Disease—Potential Signs and/or Symptoms | ||
| 1. | • New or worsening hemispheric
neurological symptoms (eg, unilateral motor or sensory deficit,
speech impairment, or amaurosis fugax) • Evaluation of transient ischemic attack or stroke |
A (9) |
| 2. | • Hollenhorst plaque visualized on retinal examination | A (8) |
| 3. | • Lightheadedness or impaired
vision in the setting of upper extremity exertion • Evaluation for subclavian-vertebral steal phenomenon |
A (7) |
| 5. | • Suspected symptomatic vertebrobasilar occlusive disease in the symptomatic patient (eg, vertigo, ataxia, diplopia, dysphagia, dysarthria) | A (7) |
| 6. | • Evaluation for suspected carotid artery dissection | A (8) |
| 7. | • Pulsatile neck mass | A (8) |
| 8. | • Cervical bruit • No prior carotid artery assessment |
A (7) |
| Evaluation for Cerebrovascular Disease—Asymptomatic With Comorbidities or Risk Factors for Carotid Artery Stenosis | ||
| 9. | • No cervical
bruit • Atherosclerotic disease in other vascular beds (eg, lower extremity PAD, coronary artery disease, abdominal aortic aneurysm) |
A (7) |
| Follow-up or Surveillance for Carotid Artery Stenosis—Asymptomatic*† | ||
| Surveillance Frequency During First Year | ||
| 20. | • Severe ICA stenosis (eg,
70% to 99%) • At 6 to 8 months |
A (7) |
| Surveillance Frequency After First Year | ||
| 23. | • Moderate ICA stenosis (eg,
50% to 69%) • Every 12 months |
A (7) |
| 24. | • Severe ICA stenosis (eg,
70% to 99%) • Every 6 months |
A (7) |
| 24. | • Severe ICA stenosis (eg,
70% to 99%) • Every 12 months |
A (7) |
| Surveillance After Carotid Artery Intervention | ||
| Surveillance Frequency During First Year | ||
| 25. | • Baseline (within 1 month) after carotid intervention | A (8) |
| 26. | • Following normal ipsilateral ICA
baseline study • Surveillance at 6 to 8 months |
A (7) |
| 26. | • Following normal ipsilateral ICA
baseline study • Surveillance at 9 to 12 months |
A (7) |
| 27. | • Following abnormal ipsilateral
ICA baseline study • Surveillance at 6 to 8 months |
A (7) |
| Surveillance Frequency After First Year | ||
| 28. | • Following normal ipsilateral ICA
baseline study • Surveillance every 12 months |
A (7) |
| 29. | • Following abnormal ipsilateral
ICA baseline study • Surveillance every 12 months |
A (7) |
| Renal and Mesenteric Artery Duplex | ||
| Evaluation for Renal Artery Stenosis—Potential Signs and/or Symptoms | ||
| Creatinine Elevation and/or Hypertension | ||
| 34. | • Malignant hypertension (>160/80 mm Hg) | A (8) |
| 35. | • Resistant hypertension (>140/90 mm Hg on ≥3 meds) | A (8) |
| 36. | • Worsening blood pressure control in long-standing hypertensive patient | A (8) |
| 37. | • Hypertension in young person (age <35 years) | A (8) |
| 38. | • Unexplained size discrepancy between kidneys (>1.5 cm; in longest dimension) | A (7) |
| 39. | • Unknown cause of azotemia (eg, unexplained increase in creatinine) | A (7) |
| 40. | • Increased creatinine (>50% baseline or above normal levels) after the administration of ACE/ARBs | A (8) |
| 41. | • Acute renal failure with aortic dissection | A (8) |
| 42. | • Epigastric bruit | A (7) |
| Heart Failure of Unknown Origin | ||
| 43. | • Refractory heart failure | A (7) |
| 44. | • “Flash” pulmonary edema | A (8) |
| Evaluation for Mesenteric Artery Stenosis—Potential Signs and/or Symptoms | ||
| Symptomatic | ||
| 48. | • Post prandial pain or weight
loss not otherwise explained • GI evaluation previously completed |
A (8) |
| Follow-up Testing for Renal Artery Stenosis—Asymptomatic | ||
| 53. | • Prior imaging indicates renal
artery stenosis • Determine hemodynamic significance |
A (7) |
| Surveillance After Renal or Mesenteric Artery Revascularization | ||
| Asymptomatic | ||
| 55. | • Baseline surveillance (within 1 month) after revascularization | A (8) |
| New or Worsening Symptoms After Baseline | ||
| 56. | • After renal or mesenteric artery revascularization | A (8) |
| Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency After First Year | ||
| 58. | • After first 12 months after
endovascular revascularization • Surveillance every 12 months |
A (7) |
| Aortic and Aortoiliac Duplex | ||
| Evaluation for Abdominal Aortic Disease—Signs and/or Symptoms | ||
| 59. | • Lower extremity claudication | A (7) |
| 62. | • Aneurysmal femoral or popliteal pulse | A (8) |
| 63. | • Pulsatile abdominal mass | A (9) |
| 64. | • Decreased or absent femoral pulse | A (7) |
| 65. | • Abdominal or femoral bruit | A (7) |
| 68. | • Evidence of atheroemboli in the lower extremities, including ischemic toes | A (8) |
| 70. | • Abnormal physiologic testing indicating aortoiliac occlusive disease | A (8) |
| 72. | • Abnormal abdominal x-ray suggestive of aneurysm | A (8) |
| 73. | • Presence of a lower extremity arterial aneurysm (eg, femoral or popliteal) | A (8) |
| 74. | • Presence of a thoracic aortic aneurysm | A (8) |
| Screening for Abdominal Aortic Aneurysm—Asymptomatic | ||
| 75. | • Men age >60
years • First degree relative with an abdominal aortic aneurysm |
A (8) |
| 76. | • Women age >60
years • First degree relative with an abdominal aortic aneurysm |
A (8) |
| 77. | • Men age 65 to 75
years • Current or former smoker |
A (8) |
| 78. | • Women age 65 to 75
years • Current or former smoker |
A (7) |
| 79. | • Age >75
years • Current or former smoker |
A (7) |
| Surveillance of Known Abdominal Aortic Aneurysm | ||
| New or Worsening Symptoms | ||
| 82. | • Known abdominal aortic aneurysm (any size) | A (9) |
| Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency During First Year | ||
| 83. | • Men, aneurysm 3.0 to 3.9 cm in
diameter • Surveillance at 9 to 12 months |
A (7) |
| 84. | • Women, aneurysm 3.0 to 3.9 cm in
diameter • Surveillance at 9 to 12 months |
A (7) |
| 85. | • Aneurysm 4.0 to 5.4 cm in
diameter • Surveillance at 6 to 8 months |
A (7) |
| 85. | • Aneurysm 4.0 to 5.4 cm in
diameter • Surveillance at 9 to 12 months |
A (7) |
| 86. | • Aneurysm ≥5.5 cm in
diameter • Surveillance at 3 to 5 months |
A (7) |
| 86. | • Aneurysm ≥5.5 cm in
diameter • Surveillance at 6 to 8 months |
A (7) |
| Asymptomatic or Stable Symptoms, No or Slow Progression During First Year, Surveillance Frequency After First Year | ||
| 87. | • Men, aneurysm 3.0 to 3.9 cm in
diameter • Surveillance every 12 months |
A (7) |
| 87. | • Men, aneurysm 3.0 to 3.9 cm in
diameter • Surveillance every 24 months or greater |
A (7) |
| 88. | • Women, aneurysm 3.0 to 3.9 cm in
diameter • Surveillance every 12 months |
A (7) |
| 88. | • Women, aneurysm 3.0 to 3.9 cm in
diameter • Surveillance every 24 months or greater |
A (7) |
| 89. | • Aneurysm 4.0 to 5.4 cm in
diameter • Surveillance every 12 months |
A (7) |
| 90. | • Aneurysm ≥5.5 cm in
diameter • Surveillance every 6 months |
A (8) |
| 90. | • Aneurysm ≥5.5 cm in
diameter • Surveillance every 12 months |
A (7) |
| Asymptomatic or Stable Symptoms, Rapid Progression During First Year, Surveillance Frequency After First Year | ||
| 91. | • Men, aneurysm 3.0 to 3.9 cm in
diameter • Surveillance every 6 months |
A (7) |
| 91. | • Men, aneurysm 3.0 to 3.9 cm in
diameter • Surveillance every 12 months |
A (7) |
| 92. | • Women, aneurysm 3.0 to 3.9 cm in
diameter • Surveillance every 6 months |
A (8) |
| 92. | • Women, aneurysm 3.0 to 3.9 cm in
diameter • Surveillance every 12 months |
A (7) |
| 93. | • Aneurysm 4.0 to 5.4 cm in
diameter • Surveillance every 6 months |
A (8) |
| 93. | • Aneurysm 4.0 to 5.4 cm in
diameter • Surveillance every 12 months |
A (7) |
| 94. | • Aneurysm ≥5.5 cm in
diameter • Surveillance every 6 months |
A (9) |
| Surveillance After Aortic Endograft or Aortoiliac Stenting | ||
| Baseline (Within 1 Month After the Intervention) | ||
| 95. | • Aortic or iliac endograft | A (8) |
| 96. | • Aortic and iliac artery stents | A (7) |
| New or Worsening Lower Extremity Symptoms After Baseline Exam | ||
| 97. | • Aortic or iliac endograft | A (8) |
| 98. | • Aortic and iliac artery stents | A (8) |
| Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency During First Year | ||
| 100. | • Aortic endograft with endoleak
and/or increasing residual aneurysm sac size • Surveillance at 6 to 8 months |
A (8) |
| 100. | • Aortic endograft with endoleak
and/or increasing residual aneurysm sac size • Surveillance at 9 to 12 months |
A (7) |
| Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency After First Year | ||
| 102. | • Aortic endograft without
endoleak stable and/or decreasing residual aneurysm sac
size • Surveillance every 12 months |
A (7) |
| 103. | • Aortic endograft with endoleak
and/or increasing residual aneurysm sac size • Surveillance every 6 months |
A (8) |
| 103. | • Aortic endograft with endoleak
and/or increasing residual aneurysm sac size • Surveillance every 12 months |
A (7) |
| Lower Extremity Artery Testing Using Multilevel Physiological Testing Alone or Duplex Ultrasound With Single Level ABI and PVR Evaluation for Lower Extremity Atherosclerotic Disease—Potential Signs and/or Symptoms | ||
| 105. | • Lower extremity claudication | A (9) |
| 106. | • Leg/foot/toe pain at rest | A (9) |
| 107. | • Foot or toe ulcer or gangrene | A (9) |
| 108. | • Infection of leg/foot without palpable pulses | A (9) |
| 109. | • Suspected acute limb ischemia (eg, cold, painful limb with pallor, pulselessness, parasthesias) | A (9) |
| 112. | • Evidence of atheroemboli in the lower extremities | A (8) |
| Surveillance of Known Lower Extremity PAD | ||
| New or Worsening Symptoms | ||
| 115. | • Normal baseline study | A (7) |
| 116. | • Abnormal baseline ABI (ie, ABI <0.90) | A (8) |
| Surveillance of Lower Extremity PAD After Revascularization (Duplex/ABI) | ||
| 123. | • Baseline Surveillance (within 1 month) | A (8) |
| New or Worsening Symptoms | ||
| 124. | • After revascularization (angioplasty ± stent or bypass) | A (9) |
| Asymptomatic or Stable Symptoms | ||
| Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency During First Year | ||
| 126. | • After vein bypass
graft • Surveillance at 6 to 8 months |
A (8) |
| 127. | • After prosthetic bypass
graft • Surveillance at 6 to 8 months |
A (7) |
| Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency After First Year | ||
| 128. | • After angioplasty ±
stent placement • Surveillance every 12 months |
A (7) |
| 129. | • After vein bypass
graft • Surveillance every 12 months |
A (7) |
| 130. | • After prosthetic bypass
graft • Surveillance every 12 months |
A (7) |
| Lower Extremity Artery Testing With ABI Only | ||
| Screening for Lower Extremity Atherosclerotic Disease—Potential Signs | ||
| 131. | • Diminished pulses | A (7) |
| 132. | • Femoral bruit | A (7) |
| Lower Extremity Artery Testing With ABI Only | ||
| Screening for Lower Extremity Atherosclerotic Disease—Asymptomatic With Comorbidities | ||
| 133. | • Age >50
years • With diabetes |
A (7) |
| 135. | • Age >50
years • Cigarette smoking (current or past) |
A (7) |
| 136. | • Age >70 years | A (7) |
| Lower Extremity Artery Testing With Duplex Ultrasound Only | ||
| Evaluation for Groin Complication After Femoral Access | ||
| 137. | • Pulsatile groin mass | A (9) |
| 138. | • Bruit or thrill over the groin | A (8) |
| 140. | • Significant hematoma | A (7) |
| 141. | • Severe pain within groin post procedure | A (7) |
| Upper Extremity Arterial Testing—Physiological Testing or Duplex Ultrasound Study | ||
| Evaluation for Upper Extremity PAD—Potential Signs and/or Symptoms | ||
| 142. | • Arm or hand claudication | A (8) |
| 143. | • Finger discoloration or ulcer | A (8) |
| 144. | • Unilateral cold painful hand | A (8) |
| 146. | • Suspected positional arterial obstruction (eg, thoracic outlet syndrome) | A (7) |
| 147. | • Upper extremity trauma with suspicion of vascular injury | A (8) |
| 150. | • Pre-op radial artery harvest (eg, for CABG) | A (7) |
| 151. | • Presence of pulsatile mass or hand ischemia after upper extremity vascular access | A (8) |
| 152. | • Presence of bruit after upper extremity access for intervention | A (8) |
| Upper Extremity Arterial Testing—Physiological Testing or Duplex Ultrasound Study | ||
| Surveillance of Upper Extremity PAD After Revascularization | ||
| 153. | Baseline (within 1 month) | A (8) |
| New or Worsening Symptoms | ||
| 154. | • After revascularization (stent or bypass) | A (8) |
| 155. | • Post trauma | A (8) |
| 156. | • After vein bypass
graft • Surveillance at 6 to 8 months |
A (7) |
| Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency After First Year | ||
| 158. | • After vein bypass
graft • Surveillance every 12 months |
A (7) |
| 159. | • After prosthetic bypass
graft • Surveillance every 12 months |
A (7) |
A = appropriate; ABI = ankle-brachial index; ACE = angiotensin-converting enzyme inhibitor; ARB = angiotensin II receptor blocker; CABG = coronary artery bypass graft; CHF = congestive heart failure; CT = computed tomography; GI = gastrointestinal; ICA = internal carotid artery; PAD = peripheral artery disease; PVR = pulse volume recording.
*
In the setting of interval development of clinical symptoms in a previously asymptomatic patient or for rapid progression of stenosis during subsequent follow-up (eg, stenosis category change during a limited period of time), more intensive surveillance may be indicated.
†
Carotid artery occlusion to be addressed in the text of the document. Periodic surveillance duplex ultrasound should be performed according to the severity of stenosis of the contralateral side.