|
The IAC Standards
and Guidelines |
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Testing Standards |
4.1B Peripheral
venous testing must be performed for appropriate clinical indications.
4.1.1B The
indication for testing must be documented prior to performing the examination.
(See Guidelines below for further recommendations.)
4.2B Equipment
must provide accurate data.
4.2.1B Imaging
Equipment – Duplex ultrasound with color flow Doppler must be
provided with:
4.2.1.1B imaging
frequencies appropriate for the structures evaluated;
4.2.1.2B Doppler
frequencies appropriate for the vessels evaluated;
4.2.1.3B range-gated
spectral Doppler with the ability to adjust the depth and position of the range
gate within the area of interest;
4.2.1.4B a
Doppler angle which is measurable and adjustable;
4.2.1.5B a
visual display and a permanent recording of the image; and
4.2.1.6B a
visual display, an audible output, and a permanent recording of the Doppler
waveform and corresponding image which includes the Doppler angle.
4.2.2B Equipment
Quality Control
4.2.2.1B Equipment
used for diagnostic testing must be maintained in good operating condition.
4.2.2.2B Equipment
maintenance must include, but is not necessarily limited to:
i. recording
of the method and frequency of maintenance of all imaging equipment and
non-imaging equipment;
ii. establishment
of and adherence to a policy regarding routine safety inspections and testing
of all facility electrical equipment; and
iii. establishment
of and adherence to an equipment cleaning schedule that includes routine
cleaning of equipment parts, including filters and transducers, according to
specifications of the manufacturer.
(See Guidelines below for further recommendations.)
4.3B Each
examination performed in the facility must have a written protocol. The
protocol must include:
4.3.1B equipment
to be used for each examination.
4.3.2B elements
of proper technique (also see STANDARD –
Techniques);
4.3.3B anatomic
extent that constitutes a complete examination includes evaluation of the
entire course of the accessible portion of each vessel:
4.3.3.1B
variations in technique following vascular interventions, including dialysis
access;
4.3.3.2B
variations in technique and documentation for limited exams.
4.3.4B
documentation that must be acquired for normal examinations and the additional
documentation that must be acquired to describe abnormalities, if present (also
see STANDARD – Documentation);
4.3.5B
a description of how color Doppler or other flow imaging modes (e.g., power
Doppler) are used to supplement grayscale imaging and spectral Doppler
measurements.
4.4B Appropriate
techniques must be used for the evaluation of the peripheral venous deep and superficial systems,
stents, hemodialysis access arteriovenous fistulae (AVF)/dialysis access
grafts to assess for the presence of any abnormalities and to document their
severity, location, extent and whenever possible etiology.
4.4.1B
Elements of proper technique include, but are not limited to:
4.4.1.1B
performance of an examination according to the facility specific, written
protocol;
4.4.1.2B
proper patient positioning;
i.
When the primary
assessment is for valvular function, the limb must be placed in a dependent
position. Standing is the preferred position if not constrained by the
patient’s physical condition. Sitting or reverse Trendelenburg may be
used if the patient cannot stand. Patient position must be noted in the final
report.
4.4.1.4B
appropriate equipment and transducer selection;
4.4.1.5B
appropriate transducer positioning and orientation;
4.4.1.6B
proper Doppler
sample volume size and positioning;
4.4.1.7B
optimization of equipment gain and display settings;
4.4.1.8B
proper measurements as required by the protocol:
i. vein diameter
measurements must:
· be acquired with the
extremity(s) in a dependent position;
·
be
acquired anterior wall to posterior wall, consistently, as required by the protocol
· assure that no
external pressure is applied to the vein.
4.4.1.9B
identification of vessels by imaging and Doppler using appropriate terminology for vessel nomenclature and
anatomic level;
4.4.1.10B
transverse grayscale imaging without and with transducer compressions;
4.4.1.11B
long axis spectral Doppler evaluation with or without color imaging.
4.5B Each
examination performed in the facility must provide documentation as required by
the protocol that is sufficient to allow proper interpretation, including but
not limited to:
4.5.3B Doppler
spectral waveforms with reflux duration time
documented;
4.5.4B other
images and waveforms as required by the protocol;
4.5.5B other
measurements as required by the protocol.
4.6B Abnormalities
will require additional images and waveforms that demonstrate the severity,
location, extent and whenever possible etiology.
4.6.1B
Areas of suspected obstruction must include representative Doppler waveforms
recorded at and distal to the obstruction.
4.6.2B
Superficial reflux must be
traced to its source whenever possible and documented with additional images as
indicated; with reflux duration time documented.
4.7B
Peripheral Venous Documentation
4.7.1B
Lower Extremity Venous Duplex for Thrombosis and Patency
4.7.1.1B
Transverse grayscale images without and with transducer compressions (when
anatomically possible or not contraindicated) must be documented as required by
the protocol and must include at a minimum:
i.
common femoral vein;
ii.
saphenofemoral junction;
iii.
proximal femoral
vein;
iv.
mid femoral vein;
v.
distal femoral
vein;
vi.
popliteal vein;
vii.
posterior tibial veins;
viii.
peroneal veins;
ix.
additional images to document areas of suspected thrombus including the gastrocnemius
veins, soleal veins and superficial veins when clinically relevant;
x.
additional images as required by the protocol).
(See Guidelines below for further recommendations.)
4.7.1.2B
Spectral Doppler waveforms demonstrating spontaneous venous flow, phasicity
and/or flow augmentation must be documented as required by the protocol and
must include at a minimum:
i.
right and left common femoral veins;
ii.
popliteal vein;
iii.
additional waveforms if required by the protocol.
Comment: For unilateral examinations,
spectral Doppler waveforms must be documented from the right and left common
femoral veins.
(See Guidelines below for further recommendations.)
4.7.1.3B
Abnormalities require additional images, waveforms and velocity measurements.
4.7.2B
Lower Extremity Venous Duplex for Reflux
4.7.2.1B
Transverse grayscale images without and with transducer compressions (when
anatomically possible or not contraindicated) must be documented as required by
the protocol and must include at a minimum:
i.
common femoral vein;
ii.
saphenofemoral junction;
iii.
mid femoral vein;
iv.
great saphenous vein;
v.
popliteal vein;
vi.
small saphenous vein;
vii. additional images to document
areas of suspected reflux and as required by the protocol.
(See Guidelines below for further recommendations.)
4.7.2.2B
Spectral Doppler waveforms with the extremity(s) in a dependent position (refer to Section 4.4.1.2B), demonstrating baseline
flow and response to distal augmentation and if reflux is present, duration of retrograde
flow measured with calipers and documented as required by the protocol and must
include at a minimum:
i.
common femoral vein;
ii.
saphenofemoral junction;
iii.
great saphenous vein at
proximal thigh;
iv.
great saphenous vein at
mid thigh;
v. femoral
vein mid thigh;
vi.
popliteal vein;
vii.
small saphenous vein at
saphenopopliteal junction if visualized; if not visualized there, the small
saphenous vein at the proximal calf must be documented.
viii. additional waveforms as required by the protocol.
(See Guidelines below for further recommendations.)
4.7.2.3B
Transverse grayscale images of diameter measurement must be documented as
required by the protocol and must include at a minimum:
i.
saphenofemoral junction;
ii.
great saphenous vein at proximal thigh;
iii.
great saphenous vein at knee;
iv.
small saphenous vein at saphenopopliteal
junction if visualized; if not visualized there, the small saphenous vein at
the proximal calf must be documented.
4.7.3B
Upper Extremity Venous Duplex for Thrombosis and Patency
4.7.3.1B
Transverse grayscale images without and with transducer compressions (when
anatomically possible or not contraindicated) must be documented as required by
the protocol and must include at a minimum:
i.
internal jugular vein;
ii.
subclavian vein;
iii.
axillary vein;
iv.
brachial vein(s);
v.
basilic vein;
vi.
cephalic vein;
vii.
additional images to document areas of suspected thrombus;
viii.
additional images if required by the protocol.
(See Guidelines below for further recommendations.)
4.7.3.2B
Spectral Doppler waveforms demonstrating spontaneous venous flow, phasicity
and/or flow augmentation must be documented as required by the protocol and
must include at a minimum:
i.
internal jugular vein;
ii.
right and left subclavian veins;
iii.
axillary vein;
iv.
additional waveforms if required by the protocol.
Comment: For unilateral examinations,
spectral Doppler waveforms must be documented from the right and left subclavian
vein.
(See Guidelines
below for further recommendations.)
4.7.4B
Vein mapping, if performed, must include:
4.7.4.1B
assessment of the veins, including
tourniquet use as required by the facility protocol;
4.7.4.2B
vein patency and diameter.
4.7.5B
Venous stents (if present) must include at
a minimum:
4.7.5.1B
Spectral Doppler waveforms with color Doppler images as required by the
protocol and must include at a minimum:
ii. proximal stent;
iii. mid stent;
iv. distal stent;
v. native vessel
adjacent to the proximal end of the stent;
vi. native vessel
adjacent to distal end of the stent.
4.7.6B Hemodialysis access
arteriovenous fistula (AVF)/dialysis access grafts, if performed, must be
documented as required by the protocol and must include at a minimum:
4.7.6.1B A description of
the type of fistula or graft.
4.7.6.2B Long axis
grayscale images and/or color Doppler images must be documented as required by
the protocol and must include at a minimum:
i. inflow artery
proximal to graft or fistula;
ii. anastomotic
site(s);
iii. outflow vein;
iv. axillary and
subclavian veins as
required by the protocol.
4.7.6.3B Spectral Doppler
waveforms and velocity measurements must be documented as required by the
protocol and must include at a minimum:
i. inflow artery;
ii. proximal and
distal anastomoses (graft);
iii. anastomosis site
(fistula);
iv. outflow vein
beyond anastomosis.
v.
subclavian vein as
required by the protocol.
4.7.6.4B
Blood
flow volume must be documented from at least one site.
4.7.6.5B If evaluation
includes provocative maneuvers for steal phenomenon, digital image
documentation of findings with and without maneuvers.
Comment: Spectral Doppler imaging of the ipsilateral axillary and subclavian
veins should be obtained to document proximal patency.
4.7.6.6B Abnormalities
require additional images, waveforms and velocity measurements.