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Report provides guidance for ordering vascular lab tests for venous system disorders
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A report issued by the American College of Cardiology, developed in collaboration with 10 other societies, provides detailed criteria to help doctors decide when it is appropriate to order certain noninvasive vascular lab tests for patients with known or suspected venous system disorders.
A diverse writing group identified 116 common clinical scenarios for which venous ultrasound and/or physiological testing are frequently considered. The panel scored each indication on a scale from 1 to 9, designating appropriate use (median score, 7 to 9), maybe appropriate use (median, 4 to 6) and rarely appropriate use (median, 1 to 3).
According to the report, the panel used the following definition of appropriate use: “An appropriate imaging study is one in which the expected incremental information, combined with clinical judgment, exceeds the expected negative consequence by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication.”
Heather Gornik*
In general, the panel deemed vascular studies appropriate when the main reason for testing is clinical signs and symptoms, such as swelling, discoloration or pain in the leg. By contrast, it generally deemed inappropriate to use these tests to screen for deep vein thrombosis (DVT) in patients without symptoms.
“Vascular ultrasound is now the best, most accurate test we have for diagnosing DVT and it has clear advantages, including its low risk to the patient with no exposure to radiation or contrast dye and the fact that it is less expensive relative to other tests,” Heather Gornik, MD, FACC, cardiologist and vascular medicine specialist at the Cleveland Clinic and chairwoman of the writing committee, said in a press release. “But a lot of screening ultrasounds are done indiscriminately for asymptomatic patients, and we found there is little evidence to support that practice.”
The report also includes recommendations for when and how to use venous ultrasound and physiological testing to determine whether and plan for when a patient needs kidney dialysis. The panel rated preoperative vascular testing for preparing a dialysis access site as appropriate, but only if done within 3 months of the procedure. Conversely, it rated vascular testing as rarely appropriate for general surveillance of a functional dialysis fistula or graft absent an indication of a problem.
“There is also growing need for comparative and cost-effectiveness research of vascular laboratory testing in the care and diagnosis of patients with deep vein thrombosis and pulmonary embolism,” Gornik said. “There are also a number of controversial areas that have not yet been fully explored, which we have outlined.”
One example is whether patients with isolated calf DVT should be treated with anticoagulation therapy vs. duplex ultrasound surveillance. Another area requiring more research is the clinical and cost-effectiveness of clinical algorithms that incorporate venous duplex testing for the diagnosis of pulmonary embolism. Similarly, the role and timing of duplex ultrasound for follow-up after venous procedures or to assess dialysis access maturity is not well established, according to the release.
The group had previously issued a report evaluating use of the vascular lab for tests for patients with known or suspected arterial system disorders.
For more information:
Gornik HL. J Am Coll Cardiol. 2013;doi:10.1016/j.jacc.2013.05.001.
Disclosure: The members of the writing committee and the technical panel report no relevant financial disclosures.
*Source: Tom Merce © Cleveland Clinic.