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• W4367052012 abstract "Journal of Ultrasound in MedicineEarly View Practice ParameterFree Access AIUM Practice Parameter for the Performance of Physiologic Evaluation of Extremity Arteries First published: 26 April 2023 https://doi.org/10.1002/jum.16246AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Introduction The American Institute of Ultrasound in Medicine (AIUM) is a multidisciplinary association dedicated to advancing the safe and effective use of ultrasound in medicine through professional and public education, research, development of clinical practice parameters, and accreditation of practices performing ultrasound examinations. The AIUM Practice Parameter for the Performance of Physiologic Evaluation of Extremity Arteries was revised by the American Institute of Ultrasound in Medicine (AIUM) in collaboration with other organizations whose members use ultrasound for performing this examination(s) (see “Acknowledgments”). Recommendations for personnel requirements, the request for the examination, documentation, quality assurance, and safety may vary among the organizations and may be addressed by each separately. This Practice Parameter is intended to provide the medical ultrasound community with recommendations for the performance and recording of high-quality ultrasound examinations. The parameters reflect what the AIUM considers the appropriate criteria for this type of ultrasound examination but is not intended to establish a legal standard of care. Examinations performed in this specialty area are expected to follow the Parameter with recognition that deviations may occur depending on the clinical situation. This practice parameter has been revised to assist physicians and allied health care professionals performing a noninvasive physiologic examination of the extremity arteries. Although it is not possible to detect every abnormality with physiologic testing, following this practice parameter will maximize the detection of abnormalities of arterial blood supply to the extremities. Indications Indications for the examination include, but are not limited to: Evaluation of exercise-induced limb pain (claudication)1 Assessment of digital or extremity ulceration, gangrene, and/or pain at rest1, 2 Follow-up of surgical and endovascular procedures3 Evaluation of wound healing potential1 Preprocedure assessment of patients with chronic kidney disease requiring dialysis4, 5 Evaluation of cold sensitivity or discoloration of extremities or digits6 Evaluation of suspected thoracic outlet syndrome6 Evaluation of suspected steal distal to an arteriovenous fistula or graft7, 8 Preoperative assessment for arterial harvesting9, 10 Assessment for the presence of peripheral vascular disease as part of an assessment of overall atherosclerosis burden2, 11, 12 Preoperative assessment for renal transplantation Screening in selected populations—patients 50 to 69 years with cardiovascular risk factors, all patients 70 years or greater, or patients with Framingham Risk Score of 10–20%13 Assessment of risk of amputation14 Allen test for preoperative evaluation prior to radial free arm flap There are no absolute contraindications for this examination. Qualifications and Responsibilities of Personnel Physicians interpreting or performing this type of ultrasound examination should meet the specified AIUM Training Guidelines15 in accordance with AIUM accreditation policies.16 Sonographers performing the ultrasound examination should be appropriately credentialed17 in the specialty area in accordance with AIUM accreditation policies.16 Physicians not personally performing the examination must provide supervision, as defined by the Centers for Medicare and Medicaid Services Code of Federal Regulations 42 CFR §410.32.18 Request for the Examination The written or electronic request for an ultrasound examination must originate from a physician or other appropriately licensed healthcare provider or under the provider's direction. The clinical information provided should allow for the performance and interpretation of the appropriate ultrasound examination and should be consistent with relevant legal and local healthcare facility requirements. Specification of the Examination The written or electronic request for a physiologic evaluation of extremity arteries should provide sufficient information to demonstrate the medical necessity of the examination and allow for its proper performance and interpretation. Documentation that satisfies medical necessity includes 1) signs and symptoms and/or 2) relevant history (including known diagnoses). Additional information regarding the specific reason for the examination or a provisional diagnosis would be helpful and may at times be needed to allow for the proper performance and interpretation of the examination.19 Physiologic tests are noninvasive and indirect. Results are used to infer the presence or absence of peripheral arterial atherosclerotic and microvascular disease and its severity. Specific locations in the arterial tree are not assessed directly with physiologic techniques; instead, various segments of the arterial system are evaluated for presence of peripheral arterial disease based on pulse volume recordings (PVRs) and segmental pressures. Arterial waveforms are also commonly obtained during noninvasive testing. Perfusion testing may also be included as part of physiologic testing. This is in contrast to duplex ultrasound, which provides direct visualization of the arterial lumen and wall and allows waveform analysis and assessment of absolute peak systolic velocities at any point of interest throughout the arterial system. See the AIUM Practice Parameter for the Performance of Peripheral Arterial Ultrasound Examinations Using Color and Spectral Doppler Imaging20 for duplex evaluation of the arteries. The physiologic examination may be done at a single level or multiple levels along the upper or lower extremity as required by the examination. The examination should be bilateral whenever possible so that flow in both limbs can be compared. Physiologic testing of the extremities may include PVRs and continuous wave (CW) Doppler of the ankle to be internally validated. This is particularly helpful in cases of non-compressible calcified arteries for which a toe-brachial index should be performed because the distal small caliber arteries are not as susceptible to medial arterial calcification.21 The examination is best performed in a warm room so that the effects of peripheral vasoconstriction are minimized. The patient should be recumbent for the examination and ideally should be at rest for at least 5 minutes before starting the examination to diminish any effects that prior physical activity might have on the examination. Smoking should be prohibited for 10 minutes prior to the study because this may falsely lower the ankle-brachial index (ABI).22 Physiologic tests, particularly ankle pressure measurements, may be repeated after exercise of the involved limb when indicated.20 This is particularly valuable for the assessment of claudication when the ABI at rest is normal or higher than would be clinically anticipated. When patients are exercised, use of a treadmill is recommended at 2 mph at a 12-degree grade for 5 minutes or until they become symptomatic and cannot continue.23 Treadmill exercise provides for reproducible quantification of exercise while allowing simultaneous assessment of symptoms produced during exercise. Symptoms that occur during exercise should also be recorded as well as the elapsed time from the start of exercise to the point at which the symptoms occurred. Total time of exercise should be recorded. Pressure measurements that are taken after cessation of exercise should be done as quickly as possible to achieve the highest accuracy and compared with the brachial pressure in the arm with the higher pressure. Serial postexercise pressure measurements can be obtained in both legs at 1- to 3-minute intervals for the first 5–10 minutes or until the ABI returns to baseline. Exercise performed without the use of a treadmill, such as calf raises, may also be used and may provide sufficient diagnostic information. Description of the component parts of the examination: Segmental limb Ulnar Doppler waveforms should also be recorded at these locations. Segmental or digital blood pressure readings can be assessed using spectral Doppler tracings or photoplethysmography (PPG) to determine when blood flow returns as the blood pressure cuff is deflated. The method used to assess return of blood flow should be consistent. Digital pressure can be assessed using CW Doppler or PPG to determine when blood flow returns. Bilateral brachial pressure measurements are obtained when possible. The higher brachial pressure is the pressure used in index calculations (eg, ABI) for the lower extremities, upper extremities, or digits.12, 24 CW Doppler waveforms8, 24 Continuous wave Doppler waveforms can be obtained from 1 or more arteries. In the lower extremity, the arteries most commonly assessed are the common femoral, superficial femoral, popliteal, posterior tibial, and dorsalis pedis. In the upper extremity, arteries that may be assessed are the subclavian, axillary, brachial, radial, and ulnar. Those performing the examination should be familiar with the appropriate external anatomic landmarks to ensure accurate performance of the examination. Waveforms should be audibly and visually optimized. Doppler angle should be constant throughout the examination when possible (technical constraints may prevent this), and either legs or arms should be evaluated using a similar technique. A consistent Doppler angle will allow waveforms at one site to more readily be compared with those from a different site and from the contralateral leg/arm. Pulse volume recordings (PVRs) Air-calibrated plethysmography PVRs can be obtained at one or more levels. In the lower extremity, the most common places to obtain waveforms are in the upper thigh, lower thigh, calf, ankle, and metatarsals. In the upper extremity, the analogous locations are the upper arm, upper forearm, and above the wrist. Waveforms can be obtained in the toes and digits using a PPG cell.8 Unlike CW Doppler waveforms, plethysmographic tracings reflect global tissue perfusion at a particular location rather than a specific artery. Unlike segmental pressures, readings are not affected by arterial calcification. Transcutaneous oxygen tension (tcPO2) measurements Measurement of the tcPO2 can be used to assess the delivery of oxygen to the skin in an area of questionable viability.25 The usual locations on the lower extremities are on the foot, ankle, and calf, with a reference point on the chest. After the desquamated cells are cleaned from the skin, a coupling solution such as distilled water is applied to the skin, and the tcPO2 sensor is affixed to the testing site with an overlying occlusive adhesive dressing that prevents exposure to room air. TcPO2 measurements, when used for a determination of ulcer healing, have had variable sensitivity and specificity. Photoplethysmography (PPG) Photoplethysmography is a technique to measure the blood volume changes in a microvascular bed.26 PPG probes can be placed on digits through which light-emitting diodes and photodiode receptors will measure the transmission in the tissue creating waveforms. These waveforms provide additional information to the perfusion of the measured tissue bed and presence of atherosclerotic disease.27 Documentation Accurate and complete documentation is essential for high-quality patient care. Written reports and ultrasound images/video clips that contain diagnostic information should be obtained and archived, with recommendations for follow-up studies if clinically applicable, in accordance with the AIUM Practice Parameter for Documentation of an Ultrasound Examination.19 Equipment Specification Peripheral arterial waveforms are obtained with a CW Doppler instrument operating at 5–10 MHz with a zero-crossing detector (waveforms may also be sampled using standard duplex imaging equipment). The instrument should have audio output through a speaker or headphones. The instrument may also have digital or analog recording connectivity so that waveforms can be saved. The same CW Doppler instrument can be used to detect arterial waveforms for the performance of segmental pressures. Appropriately sized blood pressure cuffs attached to a manometer are necessary to perform segmental blood pressures. A rapid inflation device is helpful. Small cuffs are necessary to measure digital pressures. A photoelectric plethysmograph can be used for digital pressure measurement. A treadmill with adjustable speed and incline is recommended for reproducible, quantifiable exercise testing for lower extremities. Exercise parameters used should be recorded. PVRs can be performed with the same cuffs used to measure pressures, connected to an air-calibrated plethysmograph. Equipment performance monitoring should be in accordance with the AIUM Routine Quality Assurance of Clinical Ultrasound Equipment.28 Quality and Safety Policies and procedures related to quality assurance and improvement, safety, infection control, and equipment-performance monitoring should be developed and implemented in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practices.16 ALARA Principle The potential benefits and risks of each examination should be considered. The ALARA (As Low as Reasonably Achievable) principle29 should be observed for factors that affect the acoustical output and by considering transducer dwell time and total scanning time. Further details on ALARA may be found in the current AIUM publication Medical Ultrasound Safety.30 Infection Control Transducer preparation, cleaning, and disinfection should follow manufacturer recommendations and be consistent with the AIUM's Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers Between Patients, Safe Handling, and Use of Ultrasound Coupling Gel.31 Equipment Performance Monitoring Monitoring protocols for equipment performance should be developed and implemented in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practice.2 Acknowledgments This parameter was developed by the AIUM in collaboration with the American College of Radiology (ACR), the Society of Interventional Radiology (SIR), and the Society of Radiologists in Ultrasound (SRU). We are indebted to the many volunteers who contributed their time, knowledge, and energy to developing this document. Collaborative Subcommittees AIUM Gowthaman Gunabushanam, MD, MBBS John S. Pellerito, MD ACR Claire Kaufman, MD, Chair Raisa Durrani, MD Christopher Fung, MD SIR Brian Schiro, MD Thomas Tullius, MD Matthew Walsworth, MD SRU Margarita V. Revzin, MD, MS, FSRU, FAIUM AIUM Clinical Standards Committee James M. Shwayder, MD, JD, Chair Rachel Bo-ming Liu, MD, Vice Chair Bryann Bromley, MD, FAIUM Rachel Bo-ming Liu, MD, FACEP, FAIUM Juliana Gevaerd Martins, MD Creagh T. Boulger, MD, FAIUM John R. Eisenbrey, PhD, FAIUM Rob Goodman, MB, BChir Margarita V. Revzin, MD, MS, FSRU, FAIUM Oliver Daniel Kripfgans, PhD, FAIUM Jean Lea Spitz, MPH, CAE, RDMS, FAIUM, FSDMS Nirvikar Dahiya, MD, FAIUM John Stephen Pellerito, MD, FACR, FAIUM, FSRU Ethan J. Halpern, MD, FAIUM Original copyright 2007; Revised 2012, 2014, 2019, 2022 References 1Orchard TJ, Strandness DE Jr. Assessment of peripheral vascular disease in diabetes. Report and recommendations of an international workshop sponsored by the American Diabetes Association and the American Heart Association September 18-20, 1992 New Orleans, Louisiana. Circulation 1993; 88: 819– 828. 2Begelman SM, Jaff MR. Noninvasive diagnostic strategies for peripheral arterial disease. Cleve Clin J Med 2006; 73: S22– S29. 3Weiss N, Bergert H. Structured surveillance of patients with peripheral arterial occlusive disease after peripheral vascular interventions. VASA 2009; 38: 302– 315. 4DeLoach SS, Mohler ER 3rd. Peripheral arterial disease: a guide for nephrologists. Clin J Am Soc Nephrol 2007; 2: 839– 846. 5Ono K, Tsuchida A, Kawai H, et al. Ankle-brachial blood pressure index predicts all-cause and cardiovascular mortality in hemodialysis patients. J Am Soc Nephrol 2003; 14: 1591– 1598. 6Ouriel K. Noninvasive diagnosis of upper extremity vascular disease. Semin Vasc Surg 1998; 11: 54– 59. 7Padberg FT Jr, Calligaro KD, Sidawy AN. 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Position statement on the use of the ankle brachial index in the evaluation of patients with peripheral vascular disease. A consensus statement developed by the standards division of the Society of Interventional Radiology. J Vasc Interv Radiol 2003; 14:S389. 13Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg 2007; 45: S5– S67. 14Nirala N, Periyasamy R, Kumar A. Noninvasive diagnostic methods for better screening of peripheral arterial disease. Ann Vasc Surg 2018; 52: 263– 272. 15 Training Guidelines. American Institute of Ultrasound in Medicine website. https://www.aium.org/resources/training-guidelines. Accessed March 3, 2023. 16 Standards and Guidelines for the Accreditation of Ultrasound Practices. American Institute of Ultrasound in Medicine website. https://www.aium.org/resources/official-statements/view/standards-and-guidelines-for-the-accreditation-of-ultrasound-practices. Accessed March 3, 2023. 17 Employment of Credentialed Sonographers. American Institute of Ultrasound in Medicine website. https://www.aium.org/resources/official-statements/view/employment-of-credentialed-sonographers. Accessed March 3, 2023. 1842 CFR § 410.32 - Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. U.S. Government Publishing Office website. https://www.govinfo.gov/app/details/CFR-2021-title42-vol2/CFR-2021-title42-vol2-sec410-32/summary. Accessed April 24, 2023. 19 AIUM. AIUM practice parameter for documentation of an ultrasound examination. J Ultrasound Med 2019; 39: E1– E4. 20AIUM practice parameter for the performance of peripheral arterial ultrasound examinations using color and spectral Doppler imaging. J Ultrasound Med 2021; 40: E17– E24. 21Prasad R, Kamath T, Ginsberg C, et al. The association of the ankle-brachial index, the toe-brachial index, and their difference, with mortality and limb outcomes in dialysis patients. Hemodial Int 2019; 23: 214– 222. 22Aboyans V, Criqui MH, Abraham P, et al. Measurement and interpretation of the ankle-brachial index: a scientific statement from the American Heart Association. Circulation 2012; 126: 2890– 2909. 23Hass SM, AbuRahma AF. Segmental Doppler pressures and Doppler waveform analysis in peripheral vascular disease of the lower extremities. In: AF AbuRahma, DF Bandyk (eds). Noninvasive Vascular Diagnosis: A Practical Guide to Therapy. 3rd ed. New York: Springer; 2013: 290. 24Rose SC. Noninvasive vascular laboratory for evaluation of peripheral arterial occlusive disease: part II—clinical applications: chronic, usually atherosclerotic, lower extremity ischemia. J Vasc Interv Radiol 2000; 11: 1257– 1275. 25Rose SC. Noninvasive vascular laboratory for evaluation of peripheral arterial occlusive disease: part I—hemodynamic principles and tools of the trade. J Vasc Interv Radiol 2000; 11: 1107– 1114. 26Allen J. Photoplethysmography and its application in clinical physiological measurement. Physiol Meas 2007; 28: R1– R39. 27Allen J, Overbeck K, Nath AF, Murray A, Stansby G. A prospective comparison of bilateral photoplethysmography versus the ankle-brachial pressure index for detecting and quantifying lower limb peripheral arterial disease. J Vasc Surg 2008; 47: 794– 802. 28 AIUM. Routine quality Assurance of Clinical Ultrasound Equipment, version 2. https://www.aium.org/docs/default-source/aium-publications/rqa2.pdf. Accessed March 23, 2003. 29 AIUM. Official statement: As low As reasonably achievable (ALARA) principle. https://www.aium.org/resources/official-statements/view/as-low-as-reasonably-achievable-(alara)-principle. Accessed March 23, 2023. 30 AIUM. Medical Ultrasound Safety. 4th ed. Laurel, Maryland: American Institute of Ultrasound in Medicine; 2020. 31 AIUM. Guidelines for cleaning and preparing external- and internal-use ultrasound transducers and equipment between patients as well as safe handling and use of ultrasound coupling gel. https://www.aium.org/resources/official-statements/view/guidelines-for-cleaning-and-preparing-external--and-internal-use-ultrasound-transducers-and-equipment-between-patients-as-well-as-safe-handling-and-use-of-ultrasound-coupling-gel. Accessed March 23, 2023. Early ViewOnline Version of Record before inclusion in an issue ReferencesRelatedInformation" @default.
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