Venous Disease and Evaluation of Hemodialysis Access
Venous Disease and Evaluation of Hemodialysis Access
Summary: Upper Extremity Venous Duplex Ultrasound Upper extremity venous duplex ultrasound was rated as an appropriate test in the setting of limb swelling, non-articular upper extremity pain or palpable cord, and when new pain or swelling is noted in the presence of known upper extremity deep vein thrombosis (DVT). It was deemed rarely appropriate to perform an upper extremity venous ultrasound for evaluation of fever of unknown origin in the absence of an indwelling upper extremity venous catheter or for evaluation of shortness of breath in a patient with known upper extremity DVT.
Screening for upper extremity DVT in an asymptomatic patient was rated as rarely appropriate across 6 of 6 clinical scenarios, including the patient with prolonged intensive care unit (ICU) stay (with or without an upper extremity venous catheter), prior to pacemaker or defibrillator placement, for monitoring of a functional upper extremity venous catheter, or for upper extremity DVT screening in those with hypercoagulable state or with positive D-dimer test.
Upper extremity vein mapping (e.g., of cephalic and basic veins) prior to coronary or peripheral bypass surgery was rated as an appropriate test in the absence of adequate leg vein for harvest and as maybe appropriate in certain settings when adequate leg vein conduit is present.
Summary: Lower Extremity Venous Duplex Ultrasound Lower extremity venous duplex ultrasound (l2) was rated an appropriate test in the setting of limb swelling, nonarticular lower extremity pain or palpable cord, pulmonary embolism, and when new pain or swelling is noted in the presence of known lower extremity DVT. Testing was also rated as appropriate for certain surveillance indications, namely surveillance of calf vein thrombosis for proximal extension of DVT when anticoagulation is contraindicated and for superficial thrombophlebitis of the legs (i.e., great or small saphenous vein) located near a deep vein junction. Venous ultrasound was rated as appropriate for early procedural follow-up after endovenous saphenous ablation procedures (in the patient with or without symptoms). Lower extremity venous duplex ultrasound was rated as appropriate for further evaluation of the patient with patent foramen ovale with suspected paradoxical embolism and for the patient with evidence of lower extremity venous obstruction on venous physiological testing (plethysmography) that suggests the possibility of DVT.
Screening for lower extremity DVT with duplex ultrasound in an asymptomatic patient was rated as rarely appropriate across multiple clinical scenarios, including the patient with a prolonged ICU stay, following orthopedic surgery, for those with hypercoagulable state, or with a positive D-dimer test. This was consistent with the rarely appropriate ratings for upper extremity venous duplex ultrasound discussed in the preceding text.
Lower extremity vein mapping (of the saphenous veins) prior to coronary or peripheral bypass surgery was rated as an appropriate test regardless of whether or not the patient has previously undergone lower extremity vein harvest or ablation procedure.
Similar to the upper extremities, lower extremity venous duplex ultrasound for evaluation of fever of unknown etiology was rated as maybe appropriate in certain clinical scenarios, though the evidence to support this practice is limited.
Duplex ultrasound evaluation for venous incompetency, with provocative physiological maneuvers such as distal limb augmentation and/or Valsalva, was rated as appropriate in the setting of significant clinical symptoms and signs of venous disease, including: active or healed venous ulcer, varicosities with lower extremity discomfort, swelling, or chronic skin changes (l3). Duplex ultrasound for venous incompetency was rated as maybe appropriate for evaluation of the patient with significant, though asymptomatic, varicose veins (e.g., large, disfiguring varicose veins) or for the patient with lower extremity pain or heaviness without signs of venous disease.
Duplex ultrasound was rated as rarely appropriate for evaluation of isolated spider veins (telangiectasias) without other stigmata of venous disease or for the patient with prior saphenous vein ablation with no residual symptoms (although initial follow-up duplex for within the initial 10 days after the procedure was rated as appropriate, see the preceding text).
Summary: Venous Physiological Testing Selected clinical indications for venous physiological testing (plethysmography) with provocative maneuvers were evaluated. Venous physiological testing was rated as appropriate in the setting of significant clinical symptoms and signs of chronic venous insufficiency, including: active venous ulcer, symptomatic varicose veins, and chronic skin changes such as lipodermatosclerosis or hyperpigmentation. Similar to the indications for venous duplex ultrasound for venous incompetency, venous physiological testing was rated as maybe appropriate for evaluation of the patient with asymptomatic varicose veins or for the patient with lower extremity pain or heaviness without signs of venous disease.
Importantly, venous physiological testing was rated as rarely appropriate for evaluation of the patient with suspected acute lower extremity DVT or pulmonary embolism. In the case of suspected acute lower extremity DVT, duplex ultrasound would be the best initial test.
Summary: Duplex Evaluation of the Inferior Vena Cava and Iliac Veins In the setting of evaluation for suspected DVT, iliocaval duplex was rarely appropriate as a "stand-alone test," but was rated as appropriate or maybe appropriate for use either routinely or selectively in conjunction with lower extremity venous duplex scanning (l5). Scanning of the inferior vena cava (IVC) and iliac veins was rated as appropriate when performed selectively with a positive lower extremity venous duplex demonstrating proximal DVT or when an abnormal flow pattern was found in 1 or both common femoral veins. Similarly, in the setting of suspected pulmonary embolism, iliocaval duplex was rated as rarely appropriate as a "stand-alone test" but as maybe appropriate when combined routinely with a lower extremity venous duplex examination in this setting. The indications of abdominal pain, abdominal bruit, and fever of unknown origin were all rated as rarely appropriate for IVC and iliac vein duplex. Duplex ultrasound of the IVC and iliac veins was rated as maybe appropriate for procedural planning prior to IVC filter placement.
Summary: Hepatoportal and Renal Venous Duplex Ultrasound Duplex scanning of the hepatoportal system (l6) was rated as appropriate for the evaluation of cirrhosis without ascites, hepatomegaly and/or splenomegaly, and portal hypertension. Duplex scanning was rated as rarely appropriate as an initial diagnostic test in patients with jaundice but maybe appropriate for evaluation of patients with abnormal liver function tests and jaundice with no alternative diagnosis identified after an initial workup. Follow-up after a transjugular intrahepatic portosystemic shunt (TIPS) procedure was rated as appropriate for duplex scanning. Hepatoportal scanning was rated as maybe appropriate for abdominal pain and rarely appropriate for fever of unknown origin and cor pulmonale or pulmonary symptoms.
Likely reflecting the uncommon nature of isolated renal vein pathology as a cause of genitourinary symptoms or signs, there were no clinical indications rated as appropriate for assessment of the native renal veins with duplex ultrasound (l7) in this document. For the indications of acute renal failure and acute flank pain, symptoms of renal vein thrombosis, renal vein duplex ultrasound was rated as maybe appropriate. Renal venous duplex was rated as rarely appropriate for evaluation of gross or microscopic hematuria, pulmonary symptoms, or fever of unknown origin. Renal venous duplex was rated as rarely appropriate for evaluation of epigastric bruit or drug-resistant hypertension, scenarios for which arterial duplex testing would be a more appropriate test.
Summary: Hemodialysis Vascular Access Duplex Ultrasound For vascular assessment (or mapping) prior to the placement of hemodialysis access, duplex ultrasound was rated as appropriate when performed less than 3 months prior to the procedure. Vascular assessment prior to access placement was rated as rarely appropriate when performed earlier than this time, reflecting the potential for interval development of vascular lesions in the hemodialysis patient (e.g., superficial or deep vein thromboses). Following dialysis access placement, indications were rated according to presence and nature of symptoms and time interval following access placement. For the assessment of access that has failed to mature on the basis of physical examination findings, duplex ultrasound was rated as an appropriate test beyond 6 weeks after access placement and maybe appropriate within 0 to 6 weeks of placement. Duplex ultrasound was rated as an appropriate test for most clinical scenarios related to upper extremity symptoms in the patient with mature dialysis access, including mass associated with an autogenous arteriovenous fistula (AVF)/prosthetic arteriovenous graft (AVG), arm swelling, or signs of digital ischemia due to steal phenomenon (hand pallor, pain, or ulceration). Similarly, duplex ultrasound was rated as an appropriate test for signs of malfunction and/or occlusion in a mature and previously functional AVF/AVG, including repeated difficulties with access cannulation, low flow or other signs of malfunction during dialysis sessions, and loss of palpable thrill over the access. Evaluation of a cool, but otherwise entirely asymptomatic, upper extremity with duplex ultrasound was rated as rarely appropriate. The technical panel rated routine duplex surveillance of a functional AVF/AVG in an asymptomatic patient with no signs of access malfunction as rarely appropriate.
6 Peripheral Vascular Ultrasound and Physiological Testing Part II: Testing for Venous Disease and Evaluation of Hemodialysis Access Appropriate Use Criteria (by Indication)
Section 1: Upper Extremity Venous Duplex Ultrasound
Summary: Upper Extremity Venous Duplex Ultrasound Upper extremity venous duplex ultrasound was rated as an appropriate test in the setting of limb swelling, non-articular upper extremity pain or palpable cord, and when new pain or swelling is noted in the presence of known upper extremity deep vein thrombosis (DVT). It was deemed rarely appropriate to perform an upper extremity venous ultrasound for evaluation of fever of unknown origin in the absence of an indwelling upper extremity venous catheter or for evaluation of shortness of breath in a patient with known upper extremity DVT.
Screening for upper extremity DVT in an asymptomatic patient was rated as rarely appropriate across 6 of 6 clinical scenarios, including the patient with prolonged intensive care unit (ICU) stay (with or without an upper extremity venous catheter), prior to pacemaker or defibrillator placement, for monitoring of a functional upper extremity venous catheter, or for upper extremity DVT screening in those with hypercoagulable state or with positive D-dimer test.
Upper extremity vein mapping (e.g., of cephalic and basic veins) prior to coronary or peripheral bypass surgery was rated as an appropriate test in the absence of adequate leg vein for harvest and as maybe appropriate in certain settings when adequate leg vein conduit is present.
Section 2: Lower Extremity Venous Duplex Ultrasound
Summary: Lower Extremity Venous Duplex Ultrasound Lower extremity venous duplex ultrasound (l2) was rated an appropriate test in the setting of limb swelling, nonarticular lower extremity pain or palpable cord, pulmonary embolism, and when new pain or swelling is noted in the presence of known lower extremity DVT. Testing was also rated as appropriate for certain surveillance indications, namely surveillance of calf vein thrombosis for proximal extension of DVT when anticoagulation is contraindicated and for superficial thrombophlebitis of the legs (i.e., great or small saphenous vein) located near a deep vein junction. Venous ultrasound was rated as appropriate for early procedural follow-up after endovenous saphenous ablation procedures (in the patient with or without symptoms). Lower extremity venous duplex ultrasound was rated as appropriate for further evaluation of the patient with patent foramen ovale with suspected paradoxical embolism and for the patient with evidence of lower extremity venous obstruction on venous physiological testing (plethysmography) that suggests the possibility of DVT.
Screening for lower extremity DVT with duplex ultrasound in an asymptomatic patient was rated as rarely appropriate across multiple clinical scenarios, including the patient with a prolonged ICU stay, following orthopedic surgery, for those with hypercoagulable state, or with a positive D-dimer test. This was consistent with the rarely appropriate ratings for upper extremity venous duplex ultrasound discussed in the preceding text.
Lower extremity vein mapping (of the saphenous veins) prior to coronary or peripheral bypass surgery was rated as an appropriate test regardless of whether or not the patient has previously undergone lower extremity vein harvest or ablation procedure.
Similar to the upper extremities, lower extremity venous duplex ultrasound for evaluation of fever of unknown etiology was rated as maybe appropriate in certain clinical scenarios, though the evidence to support this practice is limited.
Duplex ultrasound evaluation for venous incompetency, with provocative physiological maneuvers such as distal limb augmentation and/or Valsalva, was rated as appropriate in the setting of significant clinical symptoms and signs of venous disease, including: active or healed venous ulcer, varicosities with lower extremity discomfort, swelling, or chronic skin changes (l3). Duplex ultrasound for venous incompetency was rated as maybe appropriate for evaluation of the patient with significant, though asymptomatic, varicose veins (e.g., large, disfiguring varicose veins) or for the patient with lower extremity pain or heaviness without signs of venous disease.
Duplex ultrasound was rated as rarely appropriate for evaluation of isolated spider veins (telangiectasias) without other stigmata of venous disease or for the patient with prior saphenous vein ablation with no residual symptoms (although initial follow-up duplex for within the initial 10 days after the procedure was rated as appropriate, see the preceding text).
Summary: Venous Physiological Testing Selected clinical indications for venous physiological testing (plethysmography) with provocative maneuvers were evaluated. Venous physiological testing was rated as appropriate in the setting of significant clinical symptoms and signs of chronic venous insufficiency, including: active venous ulcer, symptomatic varicose veins, and chronic skin changes such as lipodermatosclerosis or hyperpigmentation. Similar to the indications for venous duplex ultrasound for venous incompetency, venous physiological testing was rated as maybe appropriate for evaluation of the patient with asymptomatic varicose veins or for the patient with lower extremity pain or heaviness without signs of venous disease.
Importantly, venous physiological testing was rated as rarely appropriate for evaluation of the patient with suspected acute lower extremity DVT or pulmonary embolism. In the case of suspected acute lower extremity DVT, duplex ultrasound would be the best initial test.
Section 3: Duplex Evaluation of the Inferior Vena Cava and Iliac Veins
Summary: Duplex Evaluation of the Inferior Vena Cava and Iliac Veins In the setting of evaluation for suspected DVT, iliocaval duplex was rarely appropriate as a "stand-alone test," but was rated as appropriate or maybe appropriate for use either routinely or selectively in conjunction with lower extremity venous duplex scanning (l5). Scanning of the inferior vena cava (IVC) and iliac veins was rated as appropriate when performed selectively with a positive lower extremity venous duplex demonstrating proximal DVT or when an abnormal flow pattern was found in 1 or both common femoral veins. Similarly, in the setting of suspected pulmonary embolism, iliocaval duplex was rated as rarely appropriate as a "stand-alone test" but as maybe appropriate when combined routinely with a lower extremity venous duplex examination in this setting. The indications of abdominal pain, abdominal bruit, and fever of unknown origin were all rated as rarely appropriate for IVC and iliac vein duplex. Duplex ultrasound of the IVC and iliac veins was rated as maybe appropriate for procedural planning prior to IVC filter placement.
Section 4: Hepatoportal and Renal Venous Evaluation
Summary: Hepatoportal and Renal Venous Duplex Ultrasound Duplex scanning of the hepatoportal system (l6) was rated as appropriate for the evaluation of cirrhosis without ascites, hepatomegaly and/or splenomegaly, and portal hypertension. Duplex scanning was rated as rarely appropriate as an initial diagnostic test in patients with jaundice but maybe appropriate for evaluation of patients with abnormal liver function tests and jaundice with no alternative diagnosis identified after an initial workup. Follow-up after a transjugular intrahepatic portosystemic shunt (TIPS) procedure was rated as appropriate for duplex scanning. Hepatoportal scanning was rated as maybe appropriate for abdominal pain and rarely appropriate for fever of unknown origin and cor pulmonale or pulmonary symptoms.
Likely reflecting the uncommon nature of isolated renal vein pathology as a cause of genitourinary symptoms or signs, there were no clinical indications rated as appropriate for assessment of the native renal veins with duplex ultrasound (l7) in this document. For the indications of acute renal failure and acute flank pain, symptoms of renal vein thrombosis, renal vein duplex ultrasound was rated as maybe appropriate. Renal venous duplex was rated as rarely appropriate for evaluation of gross or microscopic hematuria, pulmonary symptoms, or fever of unknown origin. Renal venous duplex was rated as rarely appropriate for evaluation of epigastric bruit or drug-resistant hypertension, scenarios for which arterial duplex testing would be a more appropriate test.
Section 5: Hemodialysis Vascular Access Duplex Ultrasound
Summary: Hemodialysis Vascular Access Duplex Ultrasound For vascular assessment (or mapping) prior to the placement of hemodialysis access, duplex ultrasound was rated as appropriate when performed less than 3 months prior to the procedure. Vascular assessment prior to access placement was rated as rarely appropriate when performed earlier than this time, reflecting the potential for interval development of vascular lesions in the hemodialysis patient (e.g., superficial or deep vein thromboses). Following dialysis access placement, indications were rated according to presence and nature of symptoms and time interval following access placement. For the assessment of access that has failed to mature on the basis of physical examination findings, duplex ultrasound was rated as an appropriate test beyond 6 weeks after access placement and maybe appropriate within 0 to 6 weeks of placement. Duplex ultrasound was rated as an appropriate test for most clinical scenarios related to upper extremity symptoms in the patient with mature dialysis access, including mass associated with an autogenous arteriovenous fistula (AVF)/prosthetic arteriovenous graft (AVG), arm swelling, or signs of digital ischemia due to steal phenomenon (hand pallor, pain, or ulceration). Similarly, duplex ultrasound was rated as an appropriate test for signs of malfunction and/or occlusion in a mature and previously functional AVF/AVG, including repeated difficulties with access cannulation, low flow or other signs of malfunction during dialysis sessions, and loss of palpable thrill over the access. Evaluation of a cool, but otherwise entirely asymptomatic, upper extremity with duplex ultrasound was rated as rarely appropriate. The technical panel rated routine duplex surveillance of a functional AVF/AVG in an asymptomatic patient with no signs of access malfunction as rarely appropriate.
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