Table 11.

Inappropriate Indications (Median Score 1–3)

Indication		Appropriate Use Score (1–9)
Extracranial Cerebrovascular Ultrasound
Follow-Up or Surveillance for Carotid Artery Stenosis—Asymptomatic
16.	• Normal prior examination (no plaque, no stenosis)	I (1)
Surveillance Frequency During First Year
17.	• Plaque without significant stenosis of the ICA (plaque, normal ICA velocity) • At 3 to 5 months	I (1)
17.	• Plaque without significant stenosis of the ICA (plaque, normal ICA velocity) • At 6 to 8 months	I (1)
17.	• Plaque without significant stenosis of the ICA (plaque, normal ICA velocity) • At 9 to 12 months	I (1)
18.	• Mild ICA stenosis (eg, <50%) • At 3 to 5 months	I (1)
18.	• Mild ICA stenosis (eg, <50%) • At 6 to 8 months	I (1)
18.	• Mild ICA stenosis (eg, <50%) • At 9 to 12 months	I (1)
19.	• Moderate ICA stenosis (eg, 50% to 69%) • At 3 to 5 months	I (2)
Surveillance Frequency After First Year
21.	• Plaque without significant stenosis of the ICA (plaque, normal ICA velocity) • Every 6 months	I (1)
21.	• Plaque without significant stenosis of the ICA (plaque, normal ICA velocity) • Every 12 months	I (3)
22.	• Mild ICA stenosis (eg, <50%) • Every 6 months	I (2)
23.	• Moderate ICA stenosis (eg, 50% to 69%) • Every 6 months	I (3)
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency During First Year
26.	• Following normal ipsilateral ICA baseline study • Surveillance at 3 to 5 months	I (2)
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency After First Year
28.	• Following normal ipsilateral ICA baseline study • Surveillance every 6 months	I (2)
Carotid Duplex Screening Ultrasound
Limited Screening Study for Carotid Artery Plaque—Asymptomatic*
30.	• Low Framingham risk score • No prior risk assessment imaging study, such as coronary calcium scoring or carotid IMT measurement	I (2)
32.	• Low or intermediate Framingham risk score • Normal prior risk assessment imaging study, such as coronary calcium scoring or carotid IMT measurement	I (3)
Screening for Renal Artery Stenosis—Asymptomatic
45.	• Atherosclerotic vascular disease in other beds (eg, peripheral artery disease) and well controlled hypertension	I (3)
Evaluation for Mesenteric Artery Stenosis—Potential Signs and/or Symptoms Symptomatic
47.	• Evaluate for acute abdominal pain ‘out of proportion to exam’ • Leukocytosis, ‘thumbprinting’, pnuematosis or hemoconcentration and acidosis with or without elevated amylase, alkaline phosphatase or CPK	I (3)
50.	• Chronic constipation or diarrhea • GI evaluation not yet undertaken	I (3)
Surveillance After Renal or Mesenteric Artery Revascularization Asymptomatic
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency During First Year
57.	• During first 12 months after endovascular revascularization • Surveillance at 3 to 5 months	I (3)
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency After First Year
58.	• After first 12 months after endovascular revascularization • Surveillance every 6 months	I (3)
Aortic and Aorto-Iliac Duplex
Evaluation for Abdominal Aortic Disease—Signs and/or Symptoms
60.	• Nonspecific lower extremity discomfort	I (3)
66.	• Fever of unknown origin	I (3)
67.	• Lower extremity swelling	I (2)
71.	• Hypertension	I (3)
Screening for Abdominal Aortic Aneurysm—Asymptomatic
81.	• Age <65 years • No history of smoking	I (3)
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 3 to 5 months	I (1)
84.	• Women, aneurysm 3.0 to 3.9 cm in diameter • Surveillance at 3 to 5 months	I (1)
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 6 months	I (2)
88.	• Women, aneurysm 3.0 to 3.9 cm in diameter • Surveillance every 6 months	I (2)
Asymptomatic or Stable Symptoms, Rapid Progression During First Year, Surveillance Frequency After First Year
94.	• Aneurysm ≥5.5 cm in diameter • Surveillance every 24 months or greater	I (3)
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 3 to 5 months	I (3)
101.	• Aortic or iliac artery stents • Surveillance at 3 to 5 months	I (2)
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 6 months	I (3)
104.	• Aortic or iliac artery stents • Surveillance every 6 months	I (2)
Lower Extremity Artery Testing Using Multi-Level Physiological Testing Alone or Duplex Ultrasound With Single Level ABI and PVR
Evaluation for Lower Extremity Atherosclerotic Disease—Potential Signs and/or Symptoms
110.	• Nocturnal leg cramps • Normal pulses	I (2)
111.	• Lack of hair growth on dorsum of foot or toes • Normal pulses	I (2)
113.	• Lower extremity swelling • Normal pulses	I (2)
114.	• Diabetes with peripheral neuropathy • Normal pulses	I (3)
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
117.	• Normal baseline ABI (no stenosis) • Surveillance at 3 to 5 months	I (1)
117.	• Normal baseline ABI (no stenosis) • Surveillance at 6 to 8 months	I (1)
117.	• Normal baseline ABI (no stenosis) • Surveillance at 9 to 12 months	I (1)
118.	• Mild or moderate disease (eg, ABI >0.4) • Surveillance at 3 to 5 months	I (2)
118.	• Mild or moderate disease (eg, ABI >0.4) • Surveillance at 6 to 8 months	I (2)
119.	• Severe (eg, ABI <0.4) • Surveillance at 3 to 5 months	I (3)
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency After First Year
120.	• Normal baseline ABI (no stenosis) • Surveillance every 6 months	I (1)
120.	• Normal baseline ABI (no stenosis) • Surveillance every 12 months	I (1)
120.	• Normal baseline ABI (no stenosis) • Surveillance every 24 months or greater	I (2)
121.	• Mild or moderate disease (eg, ABI >0.4) • Surveillance every 6 months	I (2)
121.	• Mild or moderate disease (eg, ABI >0.4) • Surveillance every 12 months	I (2)
122.	• Severe (eg, ABI <0.4) • Surveillance every 24 months or greater	I (3)
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 3 to 5 months	I (2)
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency After First Year
128.	• After angioplasty ± stent placement • Surveillance every 6 months	I (3)
130.	• After prosthetic bypass graft • Surveillance every 6 months	I (3)
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
157.	• After prosthetic bypass graft • Surveillance at 3 to 5 months	I (3)

ABI = ankle-brachial index; CABG = coronary artery bypass graft; CPK = creatine phosphokinase; GI = gastrointestinal; I = inappropriate; ICA = internal carotid artery; IMT = intima-media thickness; ICA = internal carotid artery; PAD = peripheral artery disease; PVR = pulse volume recording.

^*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.