Guidelines on Standards for Follow-up of Patients with Vascular Disease

Duplex ultrasound and other non invasive vascular testing offer cost effective ways to: support clinical diagnosis; follow disease progression; determine time for surgical intervention and survey the outcome of intervention for a myriad of vascular diseases.

Although the application and informative value of these tests have been widely accepted, there are no national standards available regarding a consensus for their use. However, accreditation bodies such as the ICAVL (Intersocietal Commission for the Accreditation of Vascular Laboratory) and the AIUM (American Institute of Ultrasound in Medicine) are working in that direction.

In an effort to offer some guidelines in the use of non invasive vascular testing from our practice, a review of the literature was performed and the following standards were drawn:

Extracranial Cerebrovascular Disease:   

Duplex ultrasound shall be used as the primary diagnostic test for:

1. asymptomatic bruit(s)
2. symptomatic patients
3. some pre-operative circumstances not necessarily related to vascular disease but patients with high risk factors, despite the absence of bruits or symptoms.
4. follow-up of known stenosis (as described below under not required or not recommended surgery).             

Peripheral Arterial Disease:
(part 1: non imaging test)

A combination of tests such as Doppler waveforms analysis, Segmental limb pressure measurements (including ABIs), Pulse volume recordings or other plethysmographic methods, in addition to a thorough physical examination and patient history, are well accepted as being appropriate and accurate tools for the diagnosis of peripheral arterial disease (in the upper and/or lower extremities).

Segmental pressure measurements with ABIs, PVR and Doppler waveforms analysis are routinely performed for symptomatic PVD indicated by the following:

1. Intermittent claudication
2. Decreased pulses
3. ischemia/rest pain
4. thoracic outlet syndrome
5. ulcer/gangrene
6. Raynaud's and Buerger's disease

 

 

Peripheral Arterial Disease:
(part 2: imaging test)

1. Duplex ultrasound offer an imaging technique comparable to angiography in terms identification, localization and extent of lesion in the lower and upper extremities, as well as to diagnose and/or monitor aortic aneurysm. In addition, ultrasound imaging with Doppler gives us physiologic information not available with angiography. This technique is used on a routine basis in our practice for the diagnosis and monitoring of aortic aneurysm, as follow: aortic aneurysms not thought to require immediate surgery are followed every 6 months until it reaches a size when the risk of rupture outweight the risk of surgical procedure. Duplex ultrasound is also used in patients with PVD, prior to surgery in place of a conventional arteriogram (as mentioned above).
2. Duplex ultrasound with ABIs is also one of the best primary tool for survey of bypass graft. It has been shown that "the vast majority of graft stenosis or lesion develop within the first year", and that "the repair of these lesions prior to graft thrombosis provides a sustained patency of approximately 80% after 5 years". "In contrast, following graft thrombosis, satisfactory longterm patency is seldom achieved eventhough the causative stenosis or defect is appropriately repaired".

Dr. Anthony Whittemore's presentation on Current Controversies in Vascular Surgery. "Is graft surveillance after lower extremitybypass cost effective and beneficial?" May 9-11, 1996