Table 9

Appropriate Indications (Median Score 7–9)

IndicationAppropriate Use Score (1–9)
Extracranial Cerebrovascular Ultrasound
Evaluation for Cerebrovascular Disease—Potential Signs and/or Symptoms
1.
  • New or worsening hemispheric neurological symptoms (e.g., unilateral motor or sensory deficit, speech impairment, or amaurosis fugax)

  • Evaluation of transient ischemic attack or stroke

A (9)
2.
  • Hollenhorst plaque visualized on retinal examination

A (8)
3.
  • Lightheadedness or impaired vision in the setting of upper extremity exertion

  • Evaluation for subclavian-vertebral steal phenomenon

A (7)
5.
  • Suspected symptomatic vertebrobasilar occlusive disease in the symptomatic patient (e.g., vertigo, ataxia, diplopia, dysphagia, dysarthria)

A (7)
6.
  • Evaluation for suspected carotid artery dissection

A (8)
7.
  • Pulsatile neck mass

A (8)
8.
  • Cervical bruit

  • No prior carotid artery assessment

A (7)
Evaluation for Cerebrovascular Disease—Asymptomatic With Comorbidities or Risk Factors for Carotid Artery Stenosis
9.
  • No cervical bruit

  • Atherosclerotic disease in other vascular beds (e.g., lower extremity PAD, coronary artery disease, abdominal aortic aneurysm)

A (7)
Follow-up or Surveillance for Carotid Artery Stenosis—Asymptomatic
Surveillance Frequency During First Year
20.
  • Severe ICA stenosis (e.g., 70% to 99%)

  • At 6 to 8 months

A (7)
Surveillance Frequency After First Year
23.
  • Moderate ICA stenosis (e.g., 50% to 69%)

  • Every 12 months

A (7)
24.
  • Severe ICA stenosis (e.g., 70% to 99%)

  • Every 6 months

A (7)
24.
  • Severe ICA stenosis (e.g., 70% to 99%)

  • Every 12 months

A (7)
Surveillance After Carotid Artery Intervention
Surveillance Frequency During First Year
25.
  • Baseline (within 1 month) after carotid intervention

A (8)
26.
  • Following normal ipsilateral ICA baseline study

  • Surveillance at 6 to 8 months

A (7)
26.
  • Following normal ipsilateral ICA baseline study

  • Surveillance at 9 to 12 months

A (7)
27.
  • Following abnormal ipsilateral ICA baseline study

  • Surveillance at 6 to 8 months

A (7)
Surveillance Frequency After First Year
28.
  • Following normal ipsilateral ICA baseline study

  • Surveillance every 12 months

A (7)
29.
  • Following abnormal ipsilateral ICA baseline study

  • Surveillance every 12 months

A (7)
Renal and Mesenteric Artery Duplex
Evaluation for Renal Artery Stenosis—Potential Signs and/or Symptoms
Creatinine Elevation and/or Hypertension
34.
  • Malignant hypertension (>160/80 mm Hg)

A (8)
35.
  • Resistant hypertension (>140/90 mm Hg on ≥3 meds)

A (8)
36.
  • Worsening blood pressure control in long-standing hypertensive patient

A (8)
37.
  • Hypertension in young person (age <35 years)

A (8)
38.
  • Unexplained size discrepancy between kidneys (>1.5 cm; in longest dimension)

A (7)
39.
  • Unknown cause of azotemia (e.g., unexplained increase in creatinine)

A (7)
40.
  • Increased creatinine (>50% baseline or above normal levels) after the administration of ACE/ARBs

A (8)
41.
  • Acute renal failure with aortic dissection

A (8)
42.
  • Epigastric bruit

A (7)
Heart Failure of Unknown Origin
43.
  • Refractory heart failure

A (7)
44.
  • “Flash” pulmonary edema

A (8)
Evaluation for Mesenteric Artery Stenosis—Potential Signs and/or Symptoms
Symptomatic
48.
  • Post prandial pain or weight loss not otherwise explained

  • GI evaluation previously completed

A (8)
Follow-up Testing for Renal Artery Stenosis—Asymptomatic
53.
  • Prior imaging indicates renal artery stenosis

  • Determine hemodynamic significance

A (7)
Surveillance After Renal or Mesenteric Artery Revascularization
Asymptomatic
55.
  • Baseline surveillance (within 1 month) after revascularization

A (8)
New or Worsening Symptoms After Baseline
56.
  • After renal or mesenteric artery revascularization

A (8)
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency After First Year
58.
  • After first 12 months after endovascular revascularization

  • Surveillance every 12 months

A (7)
Aortic and Aortoiliac Duplex
Evaluation for Abdominal Aortic Disease—Signs and/or Symptoms
59.
  • Lower extremity claudication

A (7)
62.
  • Aneurysmal femoral or popliteal pulse

A (8)
63.
  • Pulsatile abdominal mass

A (9)
64.
  • Decreased or absent femoral pulse

A (7)
65.
  • Abdominal or femoral bruit

A (7)
68.
  • Evidence of atheroemboli in the lower extremities, including ischemic toes

A (8)
70.
  • Abnormal physiologic testing indicating aortoiliac occlusive disease

A (8)
72.
  • Abnormal abdominal x-ray suggestive of aneurysm

A (8)
73.
  • Presence of a lower extremity arterial aneurysm (e.g., femoral or popliteal)

A (8)
74.
  • Presence of a thoracic aortic aneurysm

A (8)
Screening for Abdominal Aortic Aneurysm—Asymptomatic
75.
  • Men age >60 years

  • First degree relative with an abdominal aortic aneurysm

A (8)
76.
  • Women age >60 years

  • First degree relative with an abdominal aortic aneurysm

A (8)
77.
  • Men age 65 to 75 years

  • Current or former smoker

A (8)
78.
  • Women age 65 to 75 years

  • Current or former smoker

A (7)
79.
  • Age >75 years

  • Current or former smoker

A (7)
Surveillance of Known Abdominal Aortic Aneurysm
New or Worsening Symptoms
82.
  • Known abdominal aortic aneurysm (any size)

A (9)
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 9 to 12 months

A (7)
84.
  • Women, aneurysm 3.0 to 3.9 cm in diameter

  • Surveillance at 9 to 12 months

A (7)
85.
  • Aneurysm 4.0 to 5.4 cm in diameter

  • Surveillance at 6 to 8 months

A (7)
85.
  • Aneurysm 4.0 to 5.4 cm in diameter

  • Surveillance at 9 to 12 months

A (7)
86.
  • Aneurysm ≥5.5 cm in diameter

  • Surveillance at 3 to 5 months

A (7)
86.
  • Aneurysm ≥5.5 cm in diameter

  • Surveillance at 6 to 8 months

A (7)
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 12 months

A (7)
87.
  • Men, aneurysm 3.0 to 3.9 cm in diameter

  • Surveillance every 24 months or greater

A (7)
88.
  • Women, aneurysm 3.0 to 3.9 cm in diameter

  • Surveillance every 12 months

A (7)
88.
  • Women, aneurysm 3.0 to 3.9 cm in diameter

  • Surveillance every 24 months or greater

A (7)
89.
  • Aneurysm 4.0 to 5.4 cm in diameter

  • Surveillance every 12 months

A (7)
90.
  • Aneurysm ≥5.5 cm in diameter

  • Surveillance every 6 months

A (8)
90.
  • Aneurysm ≥5.5 cm in diameter

  • Surveillance every 12 months

A (7)
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 6 months

A (7)
91.
  • Men, aneurysm 3.0 to 3.9 cm in diameter

  • Surveillance every 12 months

A (7)
92.
  • Women, aneurysm 3.0 to 3.9 cm in diameter

  • Surveillance every 6 months

A (8)
92.
  • Women, aneurysm 3.0 to 3.9 cm in diameter

  • Surveillance every 12 months

A (7)
93.
  • Aneurysm 4.0 to 5.4 cm in diameter

  • Surveillance every 6 months

A (8)
93.
  • Aneurysm 4.0 to 5.4 cm in diameter

  • Surveillance every 12 months

A (7)
94.
  • Aneurysm ≥5.5 cm in diameter

  • Surveillance every 6 months

A (9)
Surveillance After Aortic Endograft or Aortoiliac Stenting
Baseline (Within 1 Month After the Intervention)
95.
  • Aortic or iliac endograft

A (8)
96.
  • Aortic and iliac artery stents

A (7)
New or Worsening Lower Extremity Symptoms After Baseline Exam
97.
  • Aortic or iliac endograft

A (8)
98.
  • Aortic and iliac artery stents

A (8)
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency During First Year
100.
  • Aortic endograft with endoleak and/or increasing residual aneurysm sac size

  • Surveillance at 6 to 8 months

A (8)
100.
  • Aortic endograft with endoleak and/or increasing residual aneurysm sac size

  • Surveillance at 9 to 12 months

A (7)
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 12 months

A (7)
103.
  • Aortic endograft with endoleak and/or increasing residual aneurysm sac size

  • Surveillance every 6 months

A (8)
103.
  • Aortic endograft with endoleak and/or increasing residual aneurysm sac size

  • Surveillance every 12 months

A (7)
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
105.
  • Lower extremity claudication

A (9)
106.
  • Leg/foot/toe pain at rest

A (9)
107.
  • Foot or toe ulcer or gangrene

A (9)
108.
  • Infection of leg/foot without palpable pulses

A (9)
109.
  • Suspected acute limb ischemia (e.g., cold, painful limb with pallor, pulselessness, parasthesias)

A (9)
112.
  • Evidence of atheroemboli in the lower extremities

A (8)
Surveillance of Known Lower Extremity PAD
New or Worsening Symptoms
115.
  • Normal baseline study

A (7)
116.
  • Abnormal baseline ABI (i.e, ABI <0.90)

A (8)
Surveillance of Lower Extremity PAD After Revascularization (Duplex/ABI)
123.
  • Baseline Surveillance (within 1 month)

A (8)
New or Worsening Symptoms
124.
  • After revascularization (angioplasty ± stent or bypass)

A (9)
Asymptomatic or Stable Symptoms
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency During First Year
126.
  • After vein bypass graft

  • Surveillance at 6 to 8 months

A (8)
127.
  • After prosthetic bypass graft

  • Surveillance at 6 to 8 months

A (7)
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency After First Year
128.
  • After angioplasty ± stent placement

  • Surveillance every 12 months

A (7)
129.
  • After vein bypass graft

  • Surveillance every 12 months

A (7)
130.
  • After prosthetic bypass graft

  • Surveillance every 12 months

A (7)
Lower Extremity Artery Testing With ABI Only
Screening for Lower Extremity Atherosclerotic Disease—Potential Signs
131.
  • Diminished pulses

A (7)
132.
  • Femoral bruit

A (7)
Lower Extremity Artery Testing With ABI Only
Screening for Lower Extremity Atherosclerotic Disease—Asymptomatic With Comorbidities
133.
  • Age >50 years

  • With diabetes

A (7)
135.
  • Age >50 years

  • Cigarette smoking (current or past)

A (7)
136.
  • Age >70 years

A (7)
Lower Extremity Artery Testing With Duplex Ultrasound Only
Evaluation for Groin Complication After Femoral Access
137.
  • Pulsatile groin mass

A (9)
138.
  • Bruit or thrill over the groin

A (8)
140.
  • Significant hematoma

A (7)
141.
  • Severe pain within groin post procedure

A (7)
Upper Extremity Arterial Testing—Physiological Testing or Duplex Ultrasound Study
Evaluation for Upper Extremity PAD—Potential Signs and/or Symptoms
142.
  • Arm or hand claudication

A (8)
143.
  • Finger discoloration or ulcer

A (8)
144.
  • Unilateral cold painful hand

A (8)
146.
  • Suspected positional arterial obstruction (e.g., thoracic outlet syndrome)

A (7)
147.
  • Upper extremity trauma with suspicion of vascular injury

A (8)
150.
  • Pre-op radial artery harvest (e.g., for CABG)

A (7)
151.
  • Presence of pulsatile mass or hand ischemia after upper extremity vascular access

A (8)
152.
  • Presence of bruit after upper extremity access for intervention

A (8)
Upper Extremity Arterial Testing—Physiological Testing or Duplex Ultrasound Study
Surveillance of Upper Extremity PAD After Revascularization
153.Baseline (within 1 month)A (8)
New or Worsening Symptoms
154.
  • After revascularization (stent or bypass)

A (8)
155.
  • Post trauma

A (8)
156.
  • After vein bypass graft

  • Surveillance at 6 to 8 months

A (7)
Asymptomatic or Stable Symptoms After Baseline Study, Surveillance Frequency After First Year
158.
  • After vein bypass graft

  • Surveillance every 12 months

A (7)
159.
  • After prosthetic bypass graft

  • Surveillance every 12 months

A (7)

A = appropriate; ABI = ankle-brachial index; ACE = angiotensin-converting enzyme inhibitor; ARB = angiotensin II receptor blocker; CABG = coronary artery bypass graft; CHF = congestive heart failure; CT = computed tomography; GI = gastrointestinal; ICA = internal carotid artery; PAD = peripheral artery disease; PVR = pulse volume recording.

  • 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.