Click here to view the clickable sidebar

The IAC Standards and Guidelines for Vascular Testing Accreditation

Click here for a printer-friendly PDF of the Vascular Testing Standards

Part B:
Examinations and Procedures

Section 4B: Peripheral Venous Testing

STANDARD – Indications

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.)

STANDARD – Equipment

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.)

STANDARD – Protocols

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.

STANDARD – Techniques

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.

4.4.1.3B         patient preparation;

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 in the depended position;
• be acquired in transverse, anterior wall to posteriror wall, consistently, or as required by the protocol;
• As required by the protocol for active or healed venous ulcers, perforator bein diameter measurements must be acqired where hte perforator traverses the deep fascia;
• 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.

4.4.1.12B      Manual distal compression or automated rapid cuff inflation/deflation devices must be used as provocative maneuvars assessing valvular function, to determine competency or reflux in all lower extremity venous segments evaluated.

i. Valsalva maneuvars may be substituted for distal compression when examining the common femoral vein and the saphenofemoral junction.

STANDARD – Documentation

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:

4.5.1B         grayscale images;

4.5.2B         color Doppler images;

4.5.3B         Doppler spectral waveforms with reflux duration time documented;

4.5.3.1B         Venous flow must be documented below the baseline prior to augmentation to validate flow reversal above the baseline.

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 (e.g., saphenous junctions, great, small, anterior accessory saphenous vein, perforating vein, pelvic origin varicose veins). 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.     symptomatic superficial veins / varicosities  (areas of pain and tenderness);

• when identified, superficial venous thrombosis must be documented as:
• name of the involved vein;
• tributary involvement, if any;
• thrombus distance from the saphenofemoral junction/saphenopopliteal junction;
• additional images (e.g., length of the thrombus); 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;

• If common femoral vein thrombus is visualized or asymmetrical common femoral vein spectral Doppler is present, the examination should include iliac 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.      proximal femoral vein;

iv.      mid femoral vein;

v.       distal femoral vein;

vi.      great saphenous vein;

vii.     popliteal vein;

viii.    small saphenous vein;

ix.       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, demonstrating baseline flow and response to distal augmentation. If present, reflux duration of retrograde flow must be 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.     anterior accessory saphenous vein (when identified);

viii.    small saphenous vein at saphenopopliteal junction if visualized; if not visualized there, the small saphenous vein at the proximal calf must be documented.

ix.       perforator vein waveforms in the setting of active or healed venous ulcers, as required by the protocol;

x. 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 with the extremity(s) in a dependent position and must include at a minimum:

i.        saphenofemoral junction;

ii.       great saphenous vein at proximal thigh;

iii.      great saphenous vein at knee;

iv.      anterior accessory saphenous vein (when identified);

v.       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.

STANDARD – Procedure Volumes

4.8B         Records must be maintained that permit evaluation of annual procedure volumes. These records must include:

4.8.1B indication for the examination;

4.8.2B technologist performing the examination;

4.8.3B examination(s) performed;

4.8.4B examination findings;

4.8.5B the physician interpreting the examination.

Section 4B: Peripheral Venous Testing
Guidelines

4.1B        When available, appropriateness criteria published by medical professional organizations should be utilized.

Comment: An accepted indication is generally written by the referring health care provider. In some instances it can only be assessed at the time of the examination.

4.2.2.2B                 The maintenance schedule for each system will depend on the degree of use and should be frequent enough to allow for accurate collection of data.

4.3B        The protocol should include the indications for a limited examination and the descriptions of the limited examination. Separate limited examination protocols may also be written.

4.7.1.1B Additional sites may be required by the facility protocol or when indicated – common iliac, external iliac, great saphenous, small saphenous, proximal deep femoral, gastrocnemius, soleal, anterior tibial or perforating veins or inferior vena cava.

•            When indicated or required by the facility’s written protocol, vein size measurements must be recorded.

4.7.1.2B, 4.7.2.1B                Additional sites may be required by the facility protocol or when indicated – common iliac, external iliac, proximal deep femoral, deep calf, or perforating veins or inferior vena cava.

.

4.7.2.2B Additional sites may be required by the facility protocol or when indicated – common iliac, external iliac, proximal deep femoral, deep calf, perforating veins or other accessory venous tributaries, inferior vena cav.

4.7.3.1B Additional sites may be required by the facility protocol or when indicated – jugular/subclavian vein junction, brachiocephalic (innominate) vein or forearm veins.

•            When indicated or required by the facility’s written protocol, vein size measurements must be recorded.

4.7.3.2B Additional sites may be required by the facility protocol or when indicated – jugular/subclavian confluence, brachiocephalic (innominate) vein, brachial vein, basilic vein, cephalic vein or forearm veins.

4.8B        The annual procedure volume should be sufficient to maintain proficiency in examination techniques and interpretation.

•            In general, a facility should perform a minimum of 100 complete examinations annually.