Heather L. Gornik, MD, RVT, RPVI

The second half of 2010 and first quarter of 2011 have been active in terms of intersocietal practice guidelines and performance measures focused on improving and standardizing the quality of care for patients with peripheral vascular disorders. Many of these publications have implications for non-invasive vascular testing and the ultrasound community. In addition, the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) made a major announcement regarding future requirements for certification of vascular technologists. A summary of these important developments follows:

PAD Performance Measures. 2010 Performance Measures for Adults with Peripheral Artery Disease (PAD) were published in November 2010, reflecting a joint effort of the American College of Cardiology (ACC), American Heart Association (AHA), American College of Radiology (ACR), the Society for Cardiac Angiography and Interventions (SCAI), the Society for Interventional Radiology (SIR), the Society for Vascular Medicine (SVM), the Society for Vascular Nursing (SVN), and the Society for Vascular Surgery (SVS). This document, which was published in print and online, defines seven evidence-based performance measures related to the care of patients with lower extremity PAD and abdominal aortic aneurysms. Performance measures related to vascular diagnostic testing include: (1) measurement of the ankle-brachial index (ABI) in patients at risk for PAD (age ≥ 70 years, age 50–69 years with diabetes mellitus or significant tobacco history, or age ≥ 18 years with walking impairment, claudication, or non-healing wounds); (2) annual surveillance of lower extremity infrainguinal vein bypass grafts with ABI and duplex ultrasound; and (3) at least annual surveillance of asymptomatic abdominal aortic aneurysms between 4.0 and 5.4 centimeters in size. It is intended that these performance measures be incorporated into quality improvement initiatives related to the care of patients with peripheral vascular disorders.

For the full text of the PAD performance measures, visit: http://content.onlinejacc.org/cgi/reprint/56/25/2147.pdf

Extracranial Carotid and Vertebral Artery Disease Guidelines. This much anticipated tome of intersocietal practice guidelines, the ASA/ACCF/AANN/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients with Extracranial Carotid and Vertebral Artery Disease, has just been released on-line and simultaneously published in Circulation , Stroke, and JACC . This comprehensive document, which represents a collaboration of more than 10 professional vascular, neuroscience, and imaging organizations, is a useful tool for any clinician who cares for patients with vascular disease or practices vascular imaging.

Specific recommendations pertinent to vascular testing include the choice of vascular ultrasound for the initial evaluation of the asymptomatic patient with known or suspected carotid stenosis with the caveat that it is performed by a qualified technologist in a certified laboratory (Class I, level of evidence C). Duplex ultrasound is also recommended as an initial modality to evaluate the patient with focal neurological symptoms consistent with internal carotid artery stenosis (Class I, LOE C) and for surveillance of certain asymptomatic patients with > 50% internal carotid artery stenosis (Class IIa, LOE C). The guidelines recommend against carotid ultrasound screening for patients without risk factors for atherosclerosis or manifestations of carotid artery disease (Class III, LOE C), but does identify certain asymptomatic at-risk patients for whom screening carotid duplex ultrasound may be considered, including those with atherosclerosis in other vascular beds (e.g., lower extremity PAD) or multiple atherosclerotic risk factors (Class IIB, LOE C), and certain patients who are scheduled to undergo coronary artery bypass grafting (e.g., age > 65 years, prior stroke/TIA, left main disease, tobacco smoking history, cervical bruit) (IIA, LOE C). The document also provides recommendations regarding the use of computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) in place of ultrasound for non-invasive assessment of carotid and vertebral artery disease. While ultrasound is strongly recommended for assessment of internal carotid artery stenosis within the document, CTA and MRA are preferred modalities for the evaluation of the vertebral arteries in the patient with posterior circulation symptoms and suspected cerebellar ischemia (Class I, LOE C). The document also reviews recommended medical therapy for patients with established carotid and vertebral artery disease and indications for and approach to revascularization (e.g., carotid endarterectomy and carotid artery stenting).

While the document focuses primarily on atherosclerotic disease of the internal carotid and vertebral arteries, fibromuscular dysplasia, carotid artery dissection, and subclavian steal syndrome are also touched upon.

For the full text of the guidelines, visit:

ICAVL to require certification of technical staff by 2017. In October, 2010, the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) announced an amendment to its accreditation standards document. It was announced that as of January 1, 2017 as a requirement of accreditation, all technical staff within a vascular laboratory must hold a valid vascular credential. This is an extension of the previous ICAVL standard that the laboratory technical director maintain a vascular credential. According to ICAVL, approved vascular credentials for technical staff will include the Registered Vascular Technologist—RVT (ARDMS), Registered Vascular Specialist—RVS (CCI), and Registered Technologist Vascular Sonography RT(VS) (ARRT). ASE is a sponsor of ICAVL.

For more details on vascular laboratory accreditation through ICAVL or this new certification requirement, visit: www.icavl.org

For details regarding specific vascular technologist credentials:

Registered Vascular Technologist, RVT: www.ardms.org

Registered Vascular Specialist, RVS: www.cci-online.org

Registered Technologist Vascular Sonography, RT(VS) www.ARRT.org