AIUM Practice Parameter for the Performance of a ...

1 AIUM Practice Parameter for the Performance ofPeripheral Venous UltrasoundExaminations 2015 by the American Institute of Ultrasound in Medicine Parameter developed in collaboration with the American College of Radiology, the Society of Pediatric Radiology, and the Society of Radiologists in Ultrasound. peripheralVenous_1115 12/1/15 3:28 PM Page 1 The American Institute of Ultrasound in Medicine (AIUM) is a multi dis-ciplinary association dedicated to advancing the safe and effective useof ultrasound in medicine through professional and public education,research, development of parameters , and accreditation. To promotethis mission, the AIUM is pleased to publish in conjunction with theAmerican College of Radiology (ACR), the Society of PediatricRadiology (SPR), and the Society of Radiologists in Ultrasound (SRU)this AIUM Practice Parameter for the Performance of PeripheralVenous Ultrasound Examinations.

2 We are indebted to the many volun-teers who contributed their time, knowledge, and energy to bringingthis document to AIUM represents the entire range of clinical and basic scienceinterests in medical diagnostic ultrasound, and, with hundreds of vol-unteers, this multidisciplinary organization has promoted the safe andeffective use of ultrasound in clinical medicine for more than 50 document and others like it will continue to advance this parameters of the AIUM are intended to provide the medicalultrasound community with parameters for the Performance andrecording of high-quality ultrasound examinations. The parametersreflect what the AIUM considers the minimum criteria for a completeexamination in each area but are not intended to establish a legal stan-dard of care. AIUM-accredited practices are expected to generally fol-low the parameters with recognition that deviations from these param-eters will be needed in some cases, depending on patient needs andavailable equipment.

3 practices are encouraged to go beyond theparameters to provide additional service and information as Sweitzer Ln, Suite 100 Laurel, MD 20707-5906 USA800-638-5352 2015 American Institute of Ultrasound in MedicineperipheralVenous_1115 12/1/15 3:28 PM Page 2I. IntroductionThe clinical aspects contained in specific sections of this Parameter (Introduction, Indications,Specifications of the Examination, and Equipment Specifications) were developed collabora-tively by the American Institute of Ultrasound in Medicine (AIUM), the American College ofRadiology (ACR), the Society of Pediatric Radiology (SPR), and the Society of Radiologistsin Ultrasound (SRU). Recommendations for physician requirements, written request for theexamination, procedure documentation, and quality control vary among the three organiza-tions and are addressed by each parameters are intended to assist practitioners performing noninvasive ultrasound eval-uation of peripheral venous structures.

4 Occasionally, an additional and/or specialized exami-nation may be necessary. While it is not possible to detect every abnormality, adherence to thefollowing parameters will maximize the probability of detecting most of the abnormalities thatoccur in the veins of the extremities. II. Qualifications and Responsibilities of the Physician See for AIUM Official Statements including Standards and guidelines for theAccreditation of Ultrasound Practicesand relevant Physician Training Indications The indications for peripheral venous ultrasound examinations include but are not limited to1 5 of possible venous thromboembolic disease or venous obstruction in sympto-matic or high-risk asymptomatic evaluation may be necessary in some high-risk individuals (eg, based on history,pretest probability, and/or D-dimer test) whose initial examination is negative for deepvenous of venous insufficiency, reflux, and Postprocedural assessment of venous ablation or other of dialysis access.

5 Mapping before surgical procedures (see also the AIUM-ACR-SRU PracticeParameter for the Performance of Ultrasound Vascular Mapping for Preoperative Planning ofDialysis Access7). of veins before venous for patients with known venous thrombosis at or near the anticipated end ofanticoagulation to determine if residual venous thrombosis is AIUM Practice Parameter Peripheral Venous 12/1/15 3:28 PM Page 39. Follow-up of patients with known calf (distal) deep venous thrombosis who are not beingtreated but are being monitored for Follow-up of patients with known venous thrombosis on therapy and who undergo a clin-ical change and where a change in the response will alter Written Request for the ExaminationThe written or electronic request for an ultrasound examination should provide sufficientinformation to allow for the appropriate Performance and interpretation of the request for the examination must be originated by a physician or other appropriatelylicensed health care provider or under their direction.

6 The accompanying clinical informationshould be provided by a physician or appropriate health care provider familiar with thepatient s clinical situation and should be consistent with relevant legal and local health carefacility Specifications of the ExaminationThe requesting health care provider should be encouraged to provide the pretest probability ofacute deep venous thrombosis and/or the results of a D-dimer assay if ,10,11 Note: The words proximalanddistalrefer to the relative distance from the attached end of thelimb, per Gray s Anatomy. For example, the proximal femoral vein is closer to the hip, and the distalfemoral vein is closer to the knee. The longitudinal or long axis is parallel to or along the lengthof the vein. The transverse or short axis is perpendicular to the long axis of the can be documented using cine clips or without and with compression Venous Thromboembolic Disease: Lower Extremity1.

7 Technique ultrasound: The fullest visualized extent of the common femoral,femoral (formerly known as the superficial femoral12), and popliteal veins must beimaged using an optimal gray scale compression technique. The popliteal vein isexamined distally to the tibioperoneal trunk. The proximal deep femoral and proxi-mal great saphenous veins should also be examined. Venous compression is appliedevery 2 cm or less in the transverse (short axis) plane with adequate pressure on theskin to completely obliterate the normal vein symptoms will generally require evaluation of those AIUM Practice Parameter Peripheral Venous 12/1/15 3:28 PM Page a minimum (even if the examination is otherwise unilateral), right and left com-mon femoral or right and left external iliac venous spectral Doppler waveforms shouldbe recorded to evaluate for asymmetry or loss of respiratory sidesshould be assessed with similar patient posture so symmetry can be assessed.

8 A popliteal venous spectral Doppler waveform of the symptomatic leg should also beobtained. All spectral Doppler waveforms should be obtained from the long or spectral Doppler evaluation can be used to support the presence or absenceof an normal examinations, at a minimum: scale images (or cine loops) should be recorded without and with compression at each of the following levels, at a femoral vein; of the common femoral vein with the great saphenous vein; deep femoral vein separately or along with the proximal femoral vein; femoral vein; femoral vein; Color and Spectral Doppler waveforms from the long axis should be recorded at each of the following levels, at a minimum: a. Right common femoral or external iliac vein;b. Left common femoral or external iliac vein;c. Popliteal vein on symptomatic side or on both sides if the examination is symptoms or findings generally require additional images to document thecomplete extent of the abnormalities: areas such as the calf generally require additional evaluation and additional images if the cause of the symptoms is not readily elucidated by the standard examination.

9 Extent and location of sites where the veins fail to compress completely should be clearly recorded and generally require additional images. Long-axis views without compression may be helpful to characterize the abnormal patient presentation, clinical indication, or clinical management pathways mayrequire protocol adjustments such as more detailed evaluation of the superficialvenous system, evaluation of the deep calf veins, or a bilateral vascular and nonvascular abnormalities, if found, should be recorded but mayrequire additional imaging for diagnosis or further characterization. Anatomic varia-tions such as duplications should be AIUM Practice Parameter Peripheral Venous 12/1/15 3:28 PM Page 52015 AIUM Practice Parameter Peripheral Venous Venous Insufficiency: Lower Extremity1. evaluating for venous insufficiency, the location and duration of reversed bloodflow should be determined during the Performance of accepted ,18 interrogation should be performed at as many levels as necessary to ensure acomplete examination based on the clinical 21 Veins in the superficialand deep systems should be evaluated.

10 With squeezing of the calf musculature should generally be used. TheValsalva maneuver may be used at the groin. A cuff inflator may also be used. patient should be situated in the erect position for the detection or exclusion ofreflux. The reverse Trendelenburg position can be used if erect scanning is not possi-ble. The examined leg should be in a non weight-bearing position. The patientshould not be studied for reflux in the supine spectral Doppler waveforms should be obtained from the long should document the presence, absence, and location of and abnormal perforating veins should generally also be documented. Ata minimum, abnormal reflux times should be measured and the size of vessels may be helpful for clinical variations such as hypoplastic or aplastic segments, significant accessoryveins, or duplications should be patient presentation, clinical indication, or clinical management pathways mayrequire protocol adjustments such as more detailed evaluation of the deep venous sys-tem or a bilateral vascular and nonvascular abnormalities, if found, should be recorded but mayrequire additional imaging for diagnosis or further Venous Thromboembolic Disease: Upper Extremity22 241.