This document discusses appropriate use criteria for various arterial tests developed by the American College of Cardiology Foundation. It describes 255 clinical scenarios that were scored on a scale of 1 to 9 for appropriateness. The document then defines and provides appropriateness criteria for various arterial exams, including carotid duplex screening, renal and mesenteric artery duplex, lower and upper extremity arterial testing, aortic and aortoiliac duplex exams. It provides examples of appropriate, inappropriate and gray zone indications for each test. The goal is to provide guidance to help ensure high quality care and rational use of imaging services.

1. Appropriate Arterial Testing
By: Hollie Peterson

2. Created in response to increased effort to rationally use imaging
services
Ensure high-quality care
Diagnostic imaging services Medicare reimbursement grew more
rapidly than any other physician service from 1999 to 2003
American College of Cardiology Foundation (ACCF) partnered with
specialty + subspecialty societies to review common clinical
scenarios

3. Appropriate Use Criteria Continued…
255 Clinical Scenarios (indications) scored on scale 1 to 9
Appropriate (7 to 9)
177 indications
Uncertain “Gray Zone” (4 to 6)
84 indications
Inappropriate (1 to 3)
54 indications
This effort has potential to impact physician decision making,
healthcare delivery, & reimbursement policy
Scenarios were evaluated for 8 different arterial tests

4. Types of Arterial Exams
Extracranial Cerebrovascular Duplex
Carotid Duplex Screening
Renal & Mesenteric Artery Duplex
Aortic & Aortoiliac Duplex
LE Artery Testing (Multilevel Physiological Testing Alone
or Duplex Ultrasound with Single-Level ABI & PVR)
LE Artery Testing with ABI only
LE Artery with Duplex only
UE Arterial Testing (Physiological Testing or Duplex
Ultrasound)

5. Extracranial Cerebrovascular
Duplex Ultrasound
What is it?
Ultrasound study done to assess blood flow of carotid and
vertebral arteries outside the skull

6. Appropriate
 Neurological symptoms
 Suspected vertebrobasilar symptoms (present circulation
symptoms)
 Evaluation of TIA or stroke
Inappropriate
 Carotid Artery Stenosis Surveillance (mild to moderate)
“Gray Zone”
 Prior to open heart surgery
 Syncope symptoms

7. Carotid Duplex Screening
What is it?
Limited ultrasound study done to assess blood flow of arteries
that supply blood from heart up through the neck into the brain

8. Appropriate
 Dissection arising from aortic arch into arch vessels (CCA)
 Inner lining tears allowing blood to flow into a “false
lumen”
Inappropriate
 Trauma induced dissection
 Normal baseline carotid follow-up
 Repeat studies for moderate ICA lesions within first year
 Low to moderate Framingham risk score
 Risk of having heart attack in the next 10 years
“Gray Zone”
 Surveillance beyond first year (normal carotid stenosis)
 Intermediate to high Framingham risk score

9. Renal & Mesenteric Artery
Duplex
What is it?
Renal Duplex: Ultrasound study done to evaluate the renal
arteries that feed the kidneys.
Mesenteric Duplex: Ultrasound study done to evaluate the
arteries supplying blood flow to organs involved with digestion.

10. Renal Mesenteric
 Appropriate
 HTN
 Creatinine (elevated)
 Heart failure
 Inappropriate
 PAD
 “Gray Zone”
 Enlarged Kidney
 Appropriate
 Postprandial (after
dinner/lunch) pain
 Weight loss
 GI evaluation completed
 Inappropriate
 Incomplete GI exam
 Acute abdominal pain
 “Gray Zone”
 Abdominal bruit

11. Aortic & Aortoiliac Duplex
What is it?
Ultrasound study performed to evaluate the aorta (the main
artery in the abdomen) and surrounding arteries that
deliver blood to major organs in the body.

12. Appropriate
 Intermittent claudication
 Aneurysmal femoral/Popliteal Pulse
 Abdominal/femoral bruit
Inappropriate
 LE discomfort
 Fever
 LE swelling
 HTN
“Gray Zone”
 Erectile Dysfunction

13. LE Artery Testing:
Multi-level Physiological Testing Alone or Duplex
Ultrasound with Single-level ABI & PVR
What is it?
Multi-level Physiological Testing: Segmental Pressures are taken
from the ankle up to the thigh (3 cuffs or 4 cuffs) to determine if
pressure differences exist (>30 mmHg)
Single Level: Ankle Brachial Index (ABI) is found by dividing
highest arm pressure by highest ankle pressure. Pulse Volume
Recording (PVR) is used to measure volume changes in limb
pressures from the thigh down to the ankle.

14. Appropriate
 LE Claudication, rest pain
 Ulcers, gangrene, ischemia
 Normal/Abnormal ABI (new or worsening symptoms)
Inappropriate
 Symptoms present along with normal pulses
 Ex. Nocturnal leg cramps, neuropathy, LE swelling
or hair loss

15. LE Artery Testing:
ABI only
What is it?
Physiological test done to determine the ratio of ankle systolic
pressure to arm systolic pressure, which the numerical index
serving as an indicator of arterial insufficiency (Normal= > 1.0)

16. Appropriate
 Diminished pulses
 Femoral Bruit
 >50 years old with diabetes or smoking
“Gray Zone”
 <50 years old with diabetes

17. LE Artery Testing:
Duplex only
What is it?
Ultrasound study performed to evaluate the arteries of the legs
in order to identify narrowing of vessels.

18. Appropriate
 Groin symptoms
o Ex. Pulsatile mass, Bruit or thrill, severe pain post-
procedure
 Significant hematoma
(solid swell of blood in tissues)
“Gray Zone”
 Ecchymosis
(Discoloration of skin resulting from bleeding underneath)

19. UE Arterial Testing:
Physiological Test or Duplex Ultrasound
What is it?
Physiological: segmental pressures are taken in the upper
extremity arteries to determine presence, severity, and
location of arterial occlusive disease
Duplex: Ultrasound study performed to evaluate the arteries
of the arms in order to identify narrowing of vessels.

20. Appropriate
 Claudication, ulceration, ischemia, bruit
 Unilateral cold painful hand
 UE trauma due to vascular harvest
“Gray Zone”
 Raynaud’s phenomenon
 Vasospastic disorder
 >20 mmHg brachial pressure difference
 Periclavicular (around the clavicle) bruit

21.  A 72 year old male complains of rest pain symptoms. He is
diabetic and has smoked 2 packs per day for 50 years.
 LE Arterial Testing with ABI only
 A 75 yr old woman presents with temporal headaches.
Additionally, she complains of muscle aching in shoulders +
arm fatigue with physical activity.
 UE Arterial Physiological Test (segmental pressures) +
Duplex (if pressure difference is found)
Patient Example

22. Policy Recommendations:
Cost Effective Research
Educate students
Education seminar for physicians

23. References
• https://bb.clemson.edu/bbcswebdav/pid-2583164-dt-content-rid-
23095847_2/courses/faltad-
HLTH4180/AUC%20for%20Extracranial%20and%20Arterial%20Testing-ACC.pdf