Appropriate use criteria offered for noninvasive vascular tests of more than 100 clinical scenarios

Eleven medical societies drafted detailed criteria to help clinicians optimize the appropriate use of noninvasive vascular tests in patients with known or suspected disorders of the venous system, such as venous insufficiency; varicose veins; blood clots in the leg, arm or abdomen; and pulmonary embolism.

Also included for the first time are recommendations for when and how to use these tests to plan for or evaluate dialysis access placement.

The document states, “Due to the diversity of peripheral vascular disorders, it is likely that many potential clinical indications are not included in this document. Rather than an exhaustive compendium of clinical indications, it is intended that this document address the most common and important clinical scenarios encountered in the patient with manifestations of peripheral vascular disease.”

All recommendations are rated as appropriate (median score, 7 to 9; effective option for individual care plans, although not always necessary depending on physician judgment and patient-specific preferences); possibly appropriate (median score, 4 to 6; variable evidence or agreement regarding the benefits/risks ratio, potential benefit based on practice experience in the absence of evidence, and/or variability in the population); or rarely appropriate (median score, 1 to 3; lack of a clear benefit/risk; rarely an effective option for individual care plans; exceptions should have documentation of the clinical reasons for proceeding with this care option).

The report appeared online July 19 at the website of the American College of Cardiology, and will appear in the Aug. 13 Journal of the American College of Cardiology.

Overall, vascular studies were deemed appropriate when clinical signs and symptoms are the main reason for testing. For example, if a patient has swelling, discoloration or pain in one leg, the document states that it is reasonable to order a duplex ultrasound evaluation of the legs to determine whether there might be deep venous thrombosis (DVT) or a 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.

The report also shows that the vascular lab plays a central role in evaluating patients with chronic venous insufficiency, a condition in which blood pools in the veins of the legs and causes swelling, non-healing ulcers and worsening varicose veins. The document also rates preoperative vascular testing for preparing a dialysis access site as appropriate as long as it is done within three months of the procedure; however, vascular testing is rarely appropriate for general surveillance of a functional dialysis fistula or graft unless there is some indication of a problem, such as a palpable mass or arm swelling, or low volume flow during dialysis sessions.

The authors noted that controversial areas included in the report are whether patients with blood clots in their calf should be treated with blood-thinning medication 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 pulmonary embolism. Similarly, the authors wrote, the role of duplex ultrasound for follow-up after venous procedures such as stents or to assess dialysis access maturity is not as well established.

The appropriate use criteria were developed in collaboration with the American College of Cardiology, American College of Radiology, American Institute of Ultrasound in Medicine, American Society of Echocardiography, American Society of Nephrology, Intersocietal Accreditation Commission, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Interventional Radiology, Society for Vascular Medicine, and Society for Vascular Surgery.