Guidelines for Ultrasound Surveillance
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1 Guidelines for Ultrasound Surveillance Carotid & Lower Extremity by Ian Hamilton, Jr, MD, MBA, RPVI, FACS Corporate Medical Director BlueCross BlueShield of Tennessee
2 guidelines for ultrasound surveillance overview Contents Carotid Lower Extremity Recommendation Sources Asymptomatic Patient Recommendation Sources Asymptomatic Patient High-Risk Asymptomatic Claudication Symptomatic Symptomatic Surveillance Surveillance 2
3 carotid guidelines 3
4 guidelines for ultrasound surveillance sources Carotid Sources for Recommendations SVS Guidelines - Updated SVS Guidelines for Management of Extracranial Carotid Disease. J Vasc Surg 2011; 54(3):e1-31. DOI: /j.jvs CMS Policy - Noninvasive Cerebrovascular Studies, LCD L AIM Specialty Health /Mar12/AdministrativeGuideline.pdf 4
5 asymptomatic patient Carotid Bruit Preoperative evaluation of patient scheduled for major cardiovascular surgical procedure when there is evidence of systemic atherosclerosis. Routine screening not recommended to detect clinically asymptomatic carotid stenosis in general population. Screening not recommended for presence of neck bruit alone w/o other risk factors. No criteria that would allow the asymptomatic patient to be approved. Recommendation based on low prevalence of disease in population at large, including those w/ neck bruits and/or the potential harm of indiscriminate application of carotid bifurcation intervention to a large number of asymptomatic individuals (GRADE 1, Level of Evidence A). 5
6 high-risk asymptomatic patient Carotid Preoperative evaluation of patient scheduled for major cardiovascular surgical procedure when evidence of systemic atherosclerosis. Asymptomatic patients w/ multiple risk factors who are fit for and willing to consider carotid intervention if a significant stenosis is discovered. Risk factors include: - Sig PAD - >65 w/ CAD - Tob - Lipids - CABG No criteria that would allow the asymptomatic patient to be approved. 6
7 symptomatic patient Carotid Patients with: - Amaurosis fugax (transient monocular blindness.) - CVA or focal cerebral or ocular transient ischemic attacks. - Ocular micro embolism. - Drop attack or syncope only covered w/ vertebro-basilar or bilateral carotid artery disease (via patient s history.) - Subclavian steal syndrome. - Neck trauma or injury to the carotid artery. - Suspected aneurysm of carotid. - Evaluation of suspected dissection. - Vasculitis involving extracranial carotid arteries. - Pulsatile tinnitus w/ other symptoms involving cardiovascular system. Patients w/ symptoms of carotid territory ischemia. Patients w/ the following are candidates for CEA: - Amaurosis fugax. - Evidence of retinal artery embolization on funduscopic examination. - Asymptomatic cerebral infarction. Patients w/ suspected extracranial arterial disease (any of below): - New/worsening anterior or posterior neuro symptoms. - Evaluation of syncope when cardiovascular causes excluded, e.g. rhythm disturbance, valvular disease. - Hollenhorst plaque on retinal examination. - Evaluation for subclavian or vertebral steal syndrome in patients who develop lightheadedness or impaired vision in setting of upper extremity exertion. - Evaluation for spontaneous carotid artery dissection in patients w/ a pulsatile neck mass. - Iatrogenic or traumatic dissection is better evaluated w/ CTA or MRA. 7
8 surveillance Carotid Follow-up after a carotid endarterectomy or carotid stenting. Re-evaluation of existing carotid stenosis (no interval given). Postoperative DUS study 30 days recommended to assess status of endarterectomized vessel. In patients w/ 50% stenosis, further follow-up imaging to assess progression or resolution indicated. In patients w/ normal DUS study result and primary closure of the endarterectomy site, ongoing imaging is recommended to identify recurrent stenosis. Patients w/ normal DUS after patch or eversion endarterectomy, further imaging of endarterectomized vessel may be indicated if patient has multiple risk factors for atherosclerosis progression. Insufficient data to make recommendations on imaging after CAS (GRADE 2, Level of Evidence C). Although data in area are not robust concerning intervals for follow-up imaging, committee recommendation was unanimous, recognizing follow-up DUS carries little risk. Baseline study (usually <1 mth following revascularization) is appropriate. New/worsening neurological symptoms. Two imaging studies (6 and 12 mths) are appropriate within the first year following revascularization. Annual surveillance studies (after first year) are appropriate. Following abnormal surveillance study revealing severe stenosis (>70%) additional studies at 6 mth intervals are appropriate provided patient is candidate for repeat revascularization. 8
9 lower extremity guidelines 9
10 guidelines for ultrasound surveillance sources Lower Extremity Sources for Recommendations SVS Guidelines - SVS Practice Guidelines for Atherosclerotic Occlusive Disease of the Lower Extremities: Management of Asymptomatic Disease and Claudication. J Vasc Surg. March 2015 Volume 61, Issue 3, Supplement, Pages 2S-41S.e1. CMS Policy - Noninvasive Peripheral Arterial and Venous Studies LCD L37639 (Palmetto). AIM Specialty Health /Mar12/AdministrativeGuideline.pdf 10
11 asymptomatic patient Lower Extremity Routine monitoring of a patient's vascular access/system/device/ bypass graft/angioplasty or stenting, etc. is not covered. Incremental value and frequency of repeat ABI testing in asymptomatic PAD not established but may be useful in higher-risk patients (e.g., diabetic patients) or those w/ a lower baseline ABI. Screening for asymptomatic PAD has not been shown to affect outcomes and is therefore not considered medically necessary. Evidence lacking that treatment of asymptomatic PAD delays onset of symptomatic PAD. 11
12 claudication Lower Extremity Claudication of such severity that it interferes significantly w/ the patients occupation or lifestyle. Patients treated w/ open or endovascular interventions for IC can be monitored w/ a clinical surveillance program that consists of interval history to detect new symptoms, ensure compliance w/ medical therapies, record subjective functional improvements, pulse examination, and measurement of resting and post exercise ABIs. G2EC. Patients treated w/ lower extremity vein grafts for IC be monitored w/ surveillance program w/ clinical follow-up and duplex scanning. G2EC. Duplex imaging is appropriate for patients w/ claudication who have normal, borderline, or inconclusive physiological testing (ABI> 0.90). Patients who have persistent claudication despite a trial of conservative therapy who are being evaluated for revascularization. Patients w/ previous vein bypass surgery for IC plus developed significant graft stenosis on DUS can be considered for prophylactic reintervention (open or endovascular) to promote long-term bypass graft patency. G1EC. Optimal intervals for DUS are not well defined. Current practice of many vasc surgeons in US is to obtain postoperative duplex ultrasound assessment of vein grafts in first mth, then 3, 6, and 12 mths, then every 6 to 12 mths thereafter. 12
13 symptomatic patient Lower Extremity Rest pain Tissue-loss, defined as gangrene or pre-gangrenous changes of the extremity, or ischemic ulceration of the extremity occurring w/ reduced pulses. Aneurysmal disease. Evidence of thromboembolic events. Symptomatic patients in whom revascularization is being considered, anatomic imaging such as duplex, CTA, MRI or agram. 1B. Patients w/ resting ischemic pain. Patients w/ evidence of atheroembolic disease of the lower extremities (ischemic or discolored toes, livedo reticularis, etc.) 13
14 surveillance Lower Extremity Monitoring previous surgical intervention sites, including previous bypass surgery site w/ synthetic or autologous vein grafts when signs and symptoms of ischemic or aneurysmal disease are present. Monitoring of various percutaneous intervention sites, including angioplasty, thrombosis/thrombectomy, atherectomy, or stent placement when signs and symptoms of ischemic or aneurysmal disease are present. Routinely monitoring patient's vascular access/system/ device/bypass/graft/ angioplasty or stenting, etc. is not covered. Vein grafts for can be monitored w/ clinical follow up and duplex scanning. 2C. Routine baseline study - Appropriate for patients who have undergone revascularization (percutaneous or surgical). Appropriate for patients who have undergone revascularization when surveillance (no new/worsening symptoms) physiological testing is inconclusive (ABI >1.40), borderline (ABI ) or abnormal (ABI< or = 0.90). Follow-up surveillance (no new/worsening symptoms) study at 6-12 mths following surgical revascularization. This guideline not applicable following percutaneous revascularization (angioplasty, stent placement, etc.) An annual follow-up surveillance (no new/worsening symptoms) study starting 1 year after surgical revascularization. Note this guideline not applicable following percutaneous revascularization (angioplasty, stent placement, etc.) Duplicative testing or repeat imaging of same anatomic area w/ same/similar technology may be subject to high-level review. May not be medically necessary unless persistent diagnostic problem, change in clinical status (e.g. deterioration) or medical intervention which warrants interval reassessment. 14
15 Questions? 15
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