Table 10

Uncertain Indications (Median Score 4–6)

IndicationAppropriate Use Score (1–9)
Extracranial Cerebrovascular Ultrasound
Evaluation for Cerebrovascular Disease—Potential Signs and/or Symptoms
4.
  • Syncope of uncertain cause after initial cardiovascular evaluation

U (5)
Evaluation for Cerebrovascular Disease—Asymptomatic with Comorbidities or Risk Factors for Carotid Artery Stenosis
10.
  • No cervical bruit

  • History of neck irradiation ≥10 years ago

U (5)
11.
  • Known renal fibromuscular dysplasia

U (5)
Prior to Open Heart Surgery
12.
  • Planned coronary artery bypass grafting (CABG)

U (6)
13.
  • Atherosclerotic disease in other vascular beds (e.g., lower extremity PAD, coronary artery disease, abdominal aortic aneurysm), or history of neck irradiation ≥ 10 years ago

  • Planned valve repair/replacement surgery (without CABG)

U (6)
14.
  • Atherosclerotic risk factors present

  • Planned valve repair/replacement surgery (without CABG)

U (6)
15.
  • No atherosclerotic risk factors

  • Planned valve repair/replacement surgery (without CABG)

U (4)
Follow-Up or Surveillance for Carotid Artery Stenosis—Asymptomatic
Surveillance Frequency During First Year
19.
  • Moderate ICA stenosis (e.g., 50% to 69%)

  • At 6 to 8 months

U (6)
19.
  • Moderate ICA stenosis (e.g., 50% to 69%)

  • At 9 to 12 months

U (6)
20.
  • Severe ICA stenosis (e.g., 70% to 99%)

  • At 3 to 5 months

U (5)
20.
  • Severe ICA stenosis (e.g., 70% to 99%)

  • At 9 to 12 months

U (6)
Surveillance Frequency After First Year
21.
  • Plaque without significant stenosis of the ICA (plaque, normal ICA velocity)

  • Every 24 months or greater

U (5)
22.
  • Mild ICA stenosis (e.g., <50%)

  • Every 12 months

U (5)
22.
  • Mild ICA stenosis (e.g., <50%)

  • Every 24 months or greater

U (6)
23.
  • Moderate ICA stenosis (e.g., 50% to 69%)

  • Every 24 months or greater

U (6)
24.
  • Severe ICA stenosis (e.g., 70% to 99%)

  • Every 24 months or greater

U (6)
Surveillance After Carotid Artery Intervention
27.
  • Following abnormal ipsilateral ICA baseline study

  • Surveillance at 3 to 5 months

U (4)
27.
  • Following abnormal ipsilateral ICA baseline study

  • Surveillance at 9 to 12 months

U (5)
Surveillance Frequency After First Year
28.
  • Following normal ipsilateral ICA baseline study

  • Surveillance every 24 months or greater

U (5)
29.
  • Following abnormal ipsilateral ICA baseline study

  • Surveillance every 6 months

U (4)
29.
  • Following abnormal ipsilateral ICA baseline study

  • Surveillance every 24 months or greater

U (5)
Carotid Duplex Screening Ultrasound
Limited Screening Study for Carotid Artery Plaque—Asymptomatic
31.
  • Intermediate Framingham risk score

  • No prior risk assessment imaging study, such as coronary calcium scoring or carotid IMT measurement

U (4)
33.
  • High Framingham risk score

U (5)
Screening for Renal Artery Stenosis—Asymptomatic
46.
  • Unexplained size discrepancy between kidneys (>1.5 cm; in longest dimension) as discovered by CT or ultrasound

U (4)
Evaluation for Mesenteric Artery Stenosis—Potential Signs and/or Symptoms
Symptomatic
49.
  • Post prandial pain or discomfort

  • GI evaluation not yet undertaken

U (5)
51.
  • Unexplained or unintended weight loss

U (5)
52.
  • Abdominal or epigastric bruit

U (4)
Follow-up Testing for Renal Artery Stenosis—Asymptomatic
54.
  • Surveillance of known renal artery stenosis

U (6)
Surveillance After Renal or Mesenteric Artery Revascularization
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency During First Year
57.
  • During first 12 months after endovascular revascularization

  • Surveillance at 6 to 8 months

U (6)
57.
  • During first 12 months after endovascular revascularization

  • Surveillance at 9 to 12 months

U (6)
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency After First Year
58.
  • After first 12 months after endovascular revascularization

  • Surveillance every 24 months or greater

U (5)
Aortic and Aortoiliac Duplex
Evaluation for Abdominal Aortic Disease—Signs and/or Symptoms
61.
  • New onset abdominal or back pain

U (6)
69.
  • Erectile dysfunction

U (4)
Screening for Abdominal Aortic Aneurysm—Asymptomatic
80.
  • Age ≥65 years

  • No history of smoking

U (5)
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 6 to 8 months

U (4)
84.
  • Women, aneurysm 3.0 to 3.9 cm in diameter

  • Surveillance at 6 to 8 months

U (4)
85.
  • Aneurysm 4.0 to 5.4 cm in diameter

  • Surveillance at 3 to 5 months

U (4)
86.
  • Aneurysm ≥5.5 cm in diameter

  • Surveillance at 9 to 12 months

U (6)
Asymptomatic or Stable Symptoms, No or Slow Progression During First Year, Surveillance Frequency After First Year
89.
  • Aneurysm 4.0 to 5.4 cm in diameter

  • Surveillance every 6 months

U (5)
89.
  • Aneurysm 4.0 to 5.4 cm in diameter

  • Surveillance every 24 months or greater

U (6)
90.
  • Aneurysm ≥5.5 cm in diameter

  • Surveillance every 24 months or greater

U (5)
Asymptomatic or Stable Symptoms, Rapid Progression During First Year, Surveillance Frequency After First Year
91.
  • Men, aneurysm 3.0 to 3.9 cm in diameter

  • Surveillance every 24 months or greater

U (4)
92.
  • Women, aneurysm 3.0 to 3.9 cm in diameter

  • Surveillance every 24 months or greater

U (4)
93.
  • Aneurysm 4.0 to 5.4 cm in diameter

  • Surveillance every 24 months or greater

U (4)
94.
  • Aneurysm ≥5.5 cm in diameter

  • Surveillance every 12 months

U (5)
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 6 to 8 months

U (5)
99.
  • Aortic endograft without endoleak stable and/or decreasing residual aneurysm sac size

  • Surveillance at 9 to 12 months

U (6)
100.
  • Aortic endograft with endoleak and/or increasing residual aneurysm sac size

  • Surveillance at 3 to 5 months

U (6)
101.
  • Aortic or iliac artery stents

  • Surveillance at 6 to 8 months

U (5)
101.
  • Aortic or iliac artery stents

  • Surveillance at 9 to 12 months

U (6)
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 24 months or greater

U (5)
103.
  • Aortic endograft with endoleak and/or increasing residual aneurysm sac size

  • Surveillance every 24 months or greater

U (5)
104.
  • Aortic or iliac artery stents

  • Surveillance every 12 months

U (5)
104.
  • Aortic or iliac artery stents

  • Surveillance every 24 months or greater

U (5)
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
118.
  • Mild or moderate disease (e.g., ABI >0.4)

  • Surveillance at 9 to 12 months

U (4)
119.
  • Severe (e.g., ABI <0.4)

  • Surveillance at 6 to 8 months

U (5)
119.
  • Severe (e.g., ABI <0.4)

  • Surveillance at 9 to 12 months

U (5)
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency After First Year
121.
  • Mild or moderate disease (e.g., ABI >0.4)

  • Surveillance every 24 months or greater

U (4)
122.
  • Severe (e.g., ABI <0.4)

  • Surveillance every 6 months

U (4)
122.
  • Severe (e.g., ABI <0.4)

  • Surveillance every 12 months

U (4)
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 6 to 8 months

U (6)
125.
  • After angioplasty ± stent placement

  • Surveillance at 9 to 12 months or greater

U (6)
126.
  • After vein bypass graft

  • Surveillance at 3 to 5 months

U (6)
126.
  • After vein bypass graft

  • Surveillance at 9 to 12 months

U (6)
127.
  • After prosthetic bypass graft

  • Surveillance at 3 to 5 months

U (5)
127.
  • After prosthetic bypass graft

  • Surveillance at 9 to 12 months

U (5)
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency After First Year
128.
  • After angioplasty ± stent placement

  • Surveillance every 24 months or greater

U (5)
129.
  • After vein bypass graft

  • Surveillance every 6 months

U (5)
129.
  • After vein bypass graft

  • Surveillance every 24 months or greater

U (5)
130.
  • After prosthetic bypass graft

  • Surveillance every 24 months or greater

U (5)
Lower Extremity Artery Testing With ABI Only
Screening for Lower Extremity Atherosclerotic Disease—Asymptomatic With Comorbidities
134.
  • Age <50 years

  • With diabetes

U (5)
Lower Extremity Artery Testing with Duplex Ultrasound Only
Evaluation for Groin Complication After Femoral Access
139.
  • Ecchymosis

U (4)
Upper Extremity Arterial Testing—Physiological Testing or Duplex Ultrasound Study
Evaluation for Upper Extremity PAD—Potential Signs and/or Symptoms
145.
  • Raynaud's phenomenon

U (5)
148.
  • Discrepancy in arm pulses or blood pressure discrepancy of >20 mm Hg between arms

U (6)
149.
  • Periclavicular bruit

U (5)
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
156.
  • After vein bypass graft

  • Surveillance at 3 to 5 months

U (6)
156.
  • After vein bypass graft

  • Surveillance at 9 to 12 months

U (5)
157.
  • After prosthetic bypass graft

  • Surveillance at 6 to 8 months

U (6)
157.
  • After prosthetic bypass graft

  • Surveillance at 9 to 12 months

U (4)
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency After First Year
158.
  • After vein bypass graft

  • Surveillance every 6 months

U (4)
158.
  • After vein bypass graft

  • Surveillance every 24 months or greater

U (5)
159.
  • After prosthetic bypass graft

  • Surveillance every 6 months

U (4)
159.
  • After prosthetic bypass graft

  • Surveillance every 24 months or greater

U (4)

ABI = ankle-brachial index; CABG = coronary artery bypass graft; CT = computed tomography; GI = gastrointestinal; ICA = internal carotid artery; IMT = intima-media thickness; PAD = peripheral artery disease; PVR = pulse volume recording; U = uncertain.

  • In the setting of interval development of clinical symptoms in a previously asymptomatic patient or for rapid progression of stenosis during subsequent follow-up (e.g., stenosis category change during a limited period of time), more intensive surveillance may be indicated.

  • Carotid artery occlusion to be addressed in the text of the document. Periodic surveillance duplex ultrasound should be performed according to the severity of stenosis of the contralateral side.

  • 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.