With the rapid proliferation of effective, safe, and minimally invasive alternatives to treat patients with a myriad of noncoronary vascular disorders, it is no surprise that interest in understanding the intricacies of vascular testing has risen to previously unmatched levels among cardiovascular specialists. As many interventional cardiologists gain experience in the endovascular treatment of peripheral vascular disease (PVD), the need to develop testing algorithms for the diagnosis and surveillance of these disorders is critical. In addition, the Core Curriculum in Cardiology for Adult Cardiovascular Training Programs (COCATS-2) recently described mandatory training for all fellow candidates in adult cardiovascular training programs in vascular medicine, including knowledge of vascular diagnostic testing (1). This chapter is designed to provide a broad overview of the available tests, including advantages, limitations, and alternatives. Obviously, there is insufficient space to provide a level of detail that would allow for the development of expertise solely by reviewing this chapter. However, the information provided will allow for an assessment of areas of interest and need for further study.

Contrary to many other disorders in which diagnostic testing is often the most important component in the evaluation of patients, the history and physical examination is critical. Peripheral arterial disease (PAD) is the optimal example. Without a thorough understanding of the symptoms and physical findings, diagnostic testing will only provide an anatomic assessment, but will not assist in determining optimal therapy. If a patient has minimal symptoms of intermittent claudication which does not particularly limit physical functioning, the finding of a 30-cm occlusion of the superficial femoral artery is superfluous.

In addition, cardiovascular specialists, already possessing skills in the physical examination of the heart, must gain expertise in the peripheral vascular examination. Auscultation for bruits over the cervical, abdominal, flank, and femoral regions must be routinely performed. Palpation of all pulses, including superficial temporal (a diminished superficial temporal pulse may suggest an important carotid bifurcation stenosis), carotid, subclavian, axillary, brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial pulses, is important to perform and record. Grading of pulse intensity is commonly noted as follows: absent (grade 0); diminished (grade 1); and normal (grade 2). An aneurysm of the popliteal artery should be noted as such and not as grade 2 + or grade 4. Examination of the feet and toes must become a routine component of the physical examination. Subtle findings of tinea pedis in the intertriginous regions of the toes may result in ischemic ulcerations in patients with PAD and diabetes mellitus, for example (Fig. 106.1).

Once the suspicion for PVD has been raised, the initial objective diagnostic testing commonly begins in the vascular diagnostic
laboratory. Although ranging in size and scope of services, a comprehensive vascular diagnostic laboratory provides objective testing for physiologic evaluation of lower and upper extremity arterial disease, as well as of cerebrovascular, aortic, renal mesenteric, and venous diseases. Current commercially available equipment includes limb blood pressure cuff devices continuous wave hand-held Doppler units, color duplex ultrasonography (DUS) units, and, more recently, portable DUS devices.

Tests are performed by trained vascular technologists, preferably possessing the registered vascular technologist (RVT) certification demonstrating a minimum level of training, expertise, and experience. Physicians who interpret these studies commonly receive formal training during fellowship, or they must receive training in an accredited vascular diagnostic laboratory, proctored by physicians with appropriate credentials. Images are commonly stored on Picture Archiving Computerized Systems in digital format that provide the highest-quality images for evaluation and interpretation.

Vascular diagnostic laboratories may be found in large tertiary urban medical centers, rural community hospitals, multispecialty physician outpatient facilities, and single physician offices. Despite the variability in location and scope of services, certain components of organization, credentialing, testing algorithms, quality assurance, accuracy, and continuing education must be constant from laboratory to laboratory. Although compliance is still voluntary, many vascular laboratories around the United States submit comprehensive applications for credentialing by either the American College of Radiology (http://www.acr.org/s_acr/sec.asp?CID=594&DID=14258) or the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) (http://www.icavl.org). The ICAVL is sponsored by multiple professional vascular organizations and provides a rigorous application process to ensure the public and physicians of a minimum degree of accuracy and quality. There is a trend among many state legislators to require accreditation for full reimbursement of vascular laboratory tests.