Table 11

Inappropriate Indications (Median Score 1–3)

IndicationAppropriate 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 (e.g., <50%)

  • At 3 to 5 months

I (1)
18.
  • Mild ICA stenosis (e.g., <50%)

  • At 6 to 8 months

I (1)
18.
  • Mild ICA stenosis (e.g., <50%)

  • At 9 to 12 months

I (1)
19.
  • Moderate ICA stenosis (e.g., 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 (e.g., <50%)

  • Every 6 months

I (2)
23.
  • Moderate ICA stenosis (e.g., 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 (e.g., 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’, pneumatosis 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 Aortoiliac 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 Multilevel 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 (e.g., ABI >0.4)

  • Surveillance at 3 to 5 months

I (2)
118.
  • Mild or moderate disease (e.g., ABI >0.4)

  • Surveillance at 6 to 8 months

I (2)
119.
  • Severe (e.g., 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 (e.g., ABI >0.4)

  • Surveillance every 6 months

I (2)
121.
  • Mild or moderate disease (e.g., ABI >0.4)

  • Surveillance every 12 months

I (2)
122.
  • Severe (e.g., 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.