Table 10.

Uncertain Indications (Median Score 4–6)

Indication		Appropriate Use Score (1–9)
Extracranial Cerebrovascular Ultrasound
Evaluation for Cerebrovascular Disease—Potential Signs and/or Symptoms
4.	• Syncope of uncertain cause after initial cardiovascular evaluation	U (5)
Evaluation for Cerebrovascular Disease—Asymptomatic with Comorbidities or Risk Factors for Carotid Artery Stenosis
10.	• No cervical bruit • History of neck irradiation ≥10 years ago	U (5)
11.	• Known renal fibromuscular dysplasia	U (5)
Prior to Open Heart Surgery
12.	• Planned coronary artery bypass grafting (CABG)	U (6)
13.	• Atherosclerotic disease in other vascular beds (eg, lower extremity PAD, coronary artery disease, abdominal aortic aneurysm), or history of neck irradiation ≥10 years ago • Planned valve repair/replacement surgery (without CABG)	U (6)
14.	• Atherosclerotic risk factors present • Planned valve repair/replacement surgery (without CABG)	U (6)
15.	• No atherosclerotic risk factors • Planned valve repair/replacement surgery (without CABG)	U (4)
Follow-Up or Surveillance for Carotid Artery Stenosis—Asymptomatic*†
Surveillance Frequency During First Year
19.	• Moderate ICA stenosis (eg, 50% to 69%) • At 6 to 8 months	U (6)
19.	• Moderate ICA stenosis (eg, 50% to 69%) • At 9 to 12 months	U (6)
20.	• Severe ICA stenosis (eg, 70% to 99%) • At 3 to 5 months	U (5)
20.	• Severe ICA stenosis (eg, 70% to 99%) • At 9 to 12 months	U (6)
Surveillance Frequency After First Year
21.	• Plaque without significant stenosis of the ICA (plaque, normal ICA velocity) • Every 24 months or greater	U (5)
22.	• Mild ICA stenosis (eg, <50%) • Every 12 months	U (5)
22.	• Mild ICA stenosis (eg, <50%) • Every 24 months or greater	U (6)
23.	• Moderate ICA stenosis (eg, 50% to 69%) • Every 24 months or greater	U (6)
24.	• Severe ICA stenosis (eg, 70% to 99%) • Every 24 months or greater	U (6)
Surveillance After Carotid Artery Intervention
27.	• Following abnormal ipsilateral ICA baseline study • Surveillance at 3 to 5 months	U (4)
27.	• Following abnormal ipsilateral ICA baseline study • Surveillance at 9 to 12 months	U (5)
Surveillance Frequency After First Year
28.	• Following normal ipsilateral ICA baseline study • Surveillance every 24 months or greater	U (5)
29.	• Following abnormal ipsilateral ICA baseline study • Surveillance every 6 months	U (4)
29.	• Following abnormal ipsilateral ICA baseline study • Surveillance every 24 months or greater	U (5)
Carotid Duplex Screening Ultrasound
Limited Screening Study for Carotid Artery Plaque—Asymptomatic‡
31.	• Intermediate Framingham risk score • No prior risk assessment imaging study, such as coronary calcium scoring or carotid IMT measurement	U (4)
33.	• High Framingham risk score	U (5)
Screening for Renal Artery Stenosis—Asymptomatic
46.	• Unexplained size discrepancy between kidneys (>1.5 cm; in longest dimension) as discovered by CT or ultrasound	U (4)
Evaluation for Mesenteric Artery Stenosis—Potential Signs and/or Symptoms
Symptomatic
49.	• Post prandial pain or discomfort • GI evaluation not yet undertaken	U (5)
51.	• Unexplained or unintended weight loss	U (5)
52.	• Abdominal or epigastric bruit	U (4)
Follow-up Testing for Renal Artery Stenosis—Asymptomatic
54.	• Surveillance of known renal artery stenosis	U (6)
Surveillance After Renal or Mesenteric Artery Revascularization
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency During First Year
57.	• During first 12 months after endovascular revascularization • Surveillance at 6 to 8 months	U (6)
57.	• During first 12 months after endovascular revascularization • Surveillance at 9 to 12 months	U (6)
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency After First Year
58.	• After first 12 months after endovascular revascularization • Surveillance every 24 months or greater	U (5)
Aortic and Aorto-Iliac Duplex
Evaluation for Abdominal Aortic Disease—Signs and/or Symptoms
61.	• New onset abdominal or back pain	U (6)
69.	• Erectile dysfunction	U (4)
Screening for Abdominal Aortic Aneurysm—Asymptomatic
80.	• Age ≥65 years • No history of smoking	U (5)
Surveillance of Known Abdominal Aortic Aneurysm
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 6 to 8 months	U (4)
84.	• Women, aneurysm 3.0 to 3.9 cm in diameter • Surveillance at 6 to 8 months	U (4)
85.	• Aneurysm 4.0 to 5.4 cm in diameter • Surveillance at 3 to 5 months	U (4)
86.	• Aneurysm ≥5.5 cm in diameter • Surveillance at 9 to 12 months	U (6)
Asymptomatic or Stable Symptoms, No or Slow Progression During First Year, Surveillance Frequency After First Year
89.	• Aneurysm 4.0 to 5.4 cm in diameter • Surveillance every 6 months	U (5)
89.	• Aneurysm 4.0 to 5.4 cm in diameter • Surveillance every 24 months or greater	U (6)
90.	• Aneurysm ≥5.5 cm in diameter • Surveillance every 24 months or greater	U (5)
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 24 months or greater	U (4)
92.	• Women, aneurysm 3.0 to 3.9 cm in diameter • Surveillance every 24 months or greater	U (4)
93.	• Aneurysm 4.0 to 5.4 cm in diameter • Surveillance every 24 months or greater	U (4)
94.	• Aneurysm ≥5.5 cm in diameter • Surveillance every 12 months	U (5)
Surveillance After Aortic Endograft or Aortoiliac Stenting
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency During First Year
99.	• Aortic endograft without endoleak stable and/or decreasing residual aneurysm sac size • Surveillance at 6 to 8 months	U (5)
99.	• Aortic endograft without endoleak stable and/or decreasing residual aneurysm sac size • Surveillance at 9 to 12 months	U (6)
100.	• Aortic endograft with endoleak and/or increasing residual aneurysm sac size • Surveillance at 3 to 5 months	U (6)
101.	• Aortic or iliac artery stents • Surveillance at 6 to 8 months	U (5)
101.	• Aortic or iliac artery stents • Surveillance at 9 to 12 months	U (6)
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 24 months or greater	U (5)
103.	• Aortic endograft with endoleak and/or increasing residual aneurysm sac size • Surveillance every 24 months or greater	U (5)
104.	• Aortic or iliac artery stents • Surveillance every 12 months	U (5)
104.	• Aortic or iliac artery stents • Surveillance every 24 months or greater	U (5)
Surveillance of Known Lower Extremity PAD
No Change in Symptom Status (No Revascularization)
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency During First Year
118.	• Mild or moderate disease (eg, ABI >0.4) • Surveillance at 9 to 12 months	U (4)
119.	• Severe (eg, ABI <0.4) • Surveillance at 6 to 8 months	U (5)
119.	• Severe (eg, ABI <0.4) • Surveillance at 9 to 12 months	U (5)
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency After First Year
121.	• Mild or moderate disease (eg, ABI >0.4) • Surveillance every 24 months or greater	U (4)
122.	• Severe (eg, ABI <0.4) • Surveillance every 6 months	U (4)
122.	• Severe (eg, ABI <0.4) • Surveillance every 12 months	U (4)
Surveillance of Lower Extremity PAD After Revascularization (Duplex/ABI)
Asymptomatic or Stable Symptoms
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency During First Year
125.	• After angioplasty ± stent placement • Surveillance at 6 to 8 months	U (6)
125.	• After angioplasty ± stent placement • Surveillance at 9 to 12 months or greater	U (6)
126.	• After vein bypass graft • Surveillance at 3 to 5 months	U (6)
126.	• After vein bypass graft • Surveillance at 9 to 12 months	U (6)
127.	• After prosthetic bypass graft • Surveillance at 3 to 5 months	U (5)
127.	• After prosthetic bypass graft • Surveillance at 9 to 12 months	U (5)
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency After First Year
128.	• After angioplasty ± stent placemen • Surveillance every 24 months or greater	U (5)
129.	• After vein bypass graft • Surveillance every 6 months	U (5)
129.	• After vein bypass graft • Surveillance every 24 months or greater	U (5)
130.	• After prosthetic bypass graft • Surveillance every 24 months or greater	U (5)
Lower Extremity Artery Testing With ABI Only
Screening for Lower Extremity Atherosclerotic Disease—Asymptomatic With Comorbidities
134.	• Age <50 years • With diabetes	U (5)
Lower Extremity Artery Testing with Duplex Ultrasound Only
Evaluation for Groin Complication After Femoral Access
139.	• Ecchymosis	U (4)
Upper Extremity Arterial Testing—Physiological Testing or Duplex Ultrasound Study
Evaluation for Upper Extremity PAD—Potential Signs and/or Symptoms
145.	• Raynaud’s phenomenon	U (5)
148.	• Discrepancy in arm pulses or blood pressure discrepancy of >20 mm Hg between arms	U (6)
149.	• Periclavicular bruit	U (5)
Upper Extremity Arterial Testing—Physiological Testing or Duplex Ultrasound Study
Surveillance of Upper Extremity PAD After Revascularization
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency During First Year
156.	• After vein bypass graft • Surveillance at 3 to 5 months	U (6)
156.	• After vein bypass graft • Surveillance at 9 to 12 months	U (5)
157.	• After prosthetic bypass graft • Surveillance at 6 to 8 months	U (6)
157.	• After prosthetic bypass graft • Surveillance at 9 to 12 months	U (4)
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency After First Year
158.	• After vein bypass graft • Surveillance every 6 months	U (4)
158.	• After vein bypass graft • Surveillance every 24 months or greater	U (5)
159.	• After prosthetic bypass graft • Surveillance every 6 months	U (4)
159.	• After prosthetic bypass graft • Surveillance every 24 months or greater	U (4)

ABI = ankle-brachial index; CABG = coronary artery bypass graft; CT = computed tomography; GI = gastrointestinal; ICA = internal carotid artery; IMT = intima-media thickness; PAD = peripheral artery disease; PVR = pulse volume recording; U = uncertain.

^*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.

^‡A screening carotid duplex examination includes assessment for the presence of atherosclerotic plaque within the common and internal carotid arteries using grey-scale imaging and assessment for stenosis of the proximal internal carotid artery using spectral Doppler. The screening carotid duplex examination is performed using a limited but clearly defined screening protocol (see ICAVL 2010 standards 5.1.5).³ A screening study for carotid artery plaque does not include formal measurement of carotid IMT.