11家学会联合制订血管检查合理使用标准

根据美国心脏病学会(ACC)日前发布的最新非侵入性血管实验室检查合理使用标准，在缺乏疼痛或肿胀表现的情况下，静脉多普勒超声通常不适用于筛查上肢或下肢深静脉血栓形成(DVT)。

那些涉及使用静脉多普勒超声筛查DVT的临床情境均被视为“很少合理”，例外情况是对长期住在ICU的患者和DVT高危患者进行这种筛查。而这只是本篇报告涉及的116种情境中的很小部分。这篇报告是由ACC和另外10个权威专业学会联合撰写的，旨在促进临床对外周血管超声和生理学检查的有效使用。这篇报告发表在《美国心脏病学会杂志》7月19日在线版上(J. Am. Coll. Cardiol. 2013 July 19 [doi:10.1016/j.jacc.2013.05.001])，是去年发表的报告的延续。去年发表的报告第1部分(J. Am. Coll. Cardiol. 2012;60:242-76)针对的是外周动脉疾病，而本次发表的报告第2部分则围绕静脉疾病和血液透析入路。


报告第2部分编写委员会主席 、克利夫兰医院的Heather Gornik医生

Gornik医生在接受采访时表示：“血管实验室检查实际上在对外周血管疾病患者的评估中扮演着关键角色。它们无创、可得出准确数据，而且不需要射线或染色剂。但是我们想要确保临床上出于正确的理由使用正确的检查。”由于这些检查风险较低、易于开展，不少人担心它们可能被过度使用。Gornik医生专门提到，多普勒超声在DVT筛查中的应用就是一种常见的过度检查。“仅有很少的证据支持在无症状人群中广泛筛查血栓。”

ACC基金会合理使用标准特别工作组之所以建立标准，是为了帮助临床医生尽可减少不必要的检查，同时尽可能高效地使用最有效的检查。

本篇报告描述的每种情境都被评为“合理”、“可能合理”或“很少合理”。在8幅一览表中，我们可以看到这116种情境被归入了8个类别：采用静脉多普勒检查上肢，评估血管是否通畅或发生了血栓形成；采用静脉多普勒检查下肢，评估血管是否通畅或发生了血栓形成；采用多普勒评估静脉功能不全；采用激发性的静脉生理学检查，评估血管是否通畅和(或)功能不全；采用多普勒检查下腔静脉和髂静脉，评估血管是否通畅或发生了血栓形成；采用多普勒评估肝门系统是否通畅或发生了血栓形成，以及血流方向；采用多普勒评估肾静脉是否通畅或发生了血栓形成；术前计划或术后评估某条血管通路。

对于急性单侧肢体水肿患者，是否考虑行静脉多普勒超声检查？编写组认为在这种情境下的使用是合理的。对于无症状性静脉曲张患者，采用多普勒评估静脉功能不全是否合理？答案是“可能合理”，但需要注意的是，假如患者合并蜘蛛状血管病，那么这种检查就属于“很少合理”。

这篇报告还涵盖了在建立血液透析通路前后进行血管检查的指征，原因是“对上肢浅表、深部和中心静脉的评估是此类检查的重要组成部分”。

一般而言，在有临床症状和体征的情况下，血管检查被认为是“合理”的。这篇报告还显示，血管实验室在慢性静脉功能不全患者的评估中扮演着关键角色，为了准备透析通路而在术前3个月内进行血管检查，是“合理”的——但在缺乏指征(例如有可扪及的包块或手臂水肿)的情况下，采用血管检查对功能性透析瘘管或移植物进行监测，是不合理的。

Gornik医生指出：“这篇报告的美妙之处在于，它是一个跨学科合作的产物。很多学会都对外周血管疾病感兴趣，很多专科都在使用血管实验室检查。”除了ACC之外，参与撰写本篇报告的学术组织还包括：美国放射学会(ACR)、美国医学超声研究所(AIUM)、美国超声心动学会(ASE)、美国肾病学会(ASN)、学会认证委员会(IAC)、心血管造影与介入学会(SCAI)、心血管计算机断层扫描学会(SCCT)、介入放射学会(SIR)、血管医学会(SVM)和血管外科学会(SVS)。

Gornik医生承认与Zin Medical、Summit多普勒系统有限公司、美国肌纤维发育不良学会和学会认证委员会有经济或其他关联。本篇报告的全文中详细列出了所有编写组成员的利益冲突。

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By: SHARON WORCESTER, Cardiology News Digital Network

Venous duplex ultrasound is rarely appropriate as a screening tool for upper or lower extremity deep vein thrombosis in the absence of pain or swelling, according to new appropriate use criteria for noninvasive vascular laboratory testing issued by the American College of Cardiology.

The clinical scenarios involving venous duplex ultrasound for DVT screening that were deemed rarely appropriate – such as screening in those with a prolonged ICU stay and those with high DVT risk – represent just a few of the 116 scenarios included in the report, which was developed in collaboration with 10 other leading professional societies to promote the most effective and most efficient use of peripheral vascular ultrasound and physiological testing in clinical practice.

The report, published online on July 19 in the Journal of the American College of Cardiology, is the second in a two-part series evaluating noninvasive testing for peripheral vascular disorders. Part I, published last year (J. Am. Coll. Cardiol. 2012;60:242-76), addressed peripheral arterial disorders, and Part II (J. Am. Coll. Cardiol. 2013 July 19 [doi:10.1016/j.jacc.2013.05.001]) addresses venous disease and evaluation of hemodialysis access, according to Dr. Heather Gornik, chair of the Part II writing committee.

"Vascular laboratory tests really play a central role in evaluating patients with peripheral vascular disorders. They are noninvasive, they have good accuracy data, and they don’t require radiation or dye. But we want to make sure the right tests are being ordered for the right reasons," Dr. Gornik, a cardiologist and vascular medicine specialist at the Cleveland Clinic, said in an interview.

Because these tests are low risk and easily accessible, there is concern that they are sometimes used excessively, she explained – specifically mentioning the use of duplex ultrasound for DVT screening as a commonly overused procedure.

"The is very little evidence, if any, to support broad screening for blood clots in someone who has no symptoms," she said.

The goal of the ACC Foundation Appropriate Use Criteria Task Force responsible for developing the criteria was to help clinicians minimize unnecessary testing, and maximize the most effective and efficient testing, she added.

Each of the clinical scenarios that were developed by the writing committee were rated by a technical panel as to whether they represent an "appropriate use," or whether they are "maybe appropriate" or "rarely appropriate."

The various scenarios are listed, along with their rating, in eight "at-a-glance" tables that address the following more general categories: venous duplex of the upper extremities for assessing patency and thrombosis; venous duplex of the lower extremities for assessing patency and thrombosis; duplex evaluation for venous incompetency; venous physiological testing with provocative maneuvers to assess for patency and/or incompetency; duplex of the inferior vena cava and iliac veins for patency and thrombosis; duplex of the hepatoportal system for patency, thrombosis, and flow direction; duplex of the renal vein for patency and thrombosis; and preoperative planning and postoperative assessment of a vascular access site.

Considering venous duplex ultrasound in a patient with acute unilateral limb swelling? Table 1 lists this as an appropriate use. How about duplex evaluation for venous incompetency in a patient with asymptomatic varicose veins? Table 3 says this may be appropriate, but notes that it is rarely appropriate in a patient with spider veins.

The report also covers indications for vascular testing prior to or after placement of hemodialysis access, because "evaluation of the superficial, deep, and central veins of the upper extremity constitutes a large component of these examinations," the report states.

In general, vascular studies were deemed appropriate in the presence of clinical signs and symptoms. The report also shows that the vascular laboratory plays a central role in the evaluation of patients with chronic venous insufficiency, and that preoperative vascular testing for preparing a dialysis access site is appropriate within three months of the procedure – but not for general surveillance of a functional dialysis fistula or graft in the absence of an indication of a problem, such as a palpable mass or swelling in the arm.

The report is not intended to be comprehensive, but rather is an attempt to address common and important clinical scenarios encountered in the patient with manifestations of peripheral vascular disease, the authors noted.

"The beauty of this report is that it spans many disciplines," Dr. Gornik said, noting that numerous parties have an interest in peripheral vascular disease, and that many specialties order vascular laboratory tests.

A number of them were represented in the development of these appropriate use criteria. Collaborating organizations included the American College of Radiology, the American Institute of Ultrasound in Medicine, the American Society of Echocardiography, the American Society of Nephrology, Intersocietal Accreditation Commission, Society for Cardiovascular Angiography and Interventions, the Society of Cardiovascular Computed Tomography, the Society for Interventional Radiology, the Society for Vascular Medicine, and the Society for Vascular Surgery.

While other organizations have developed appropriate use criteria for other modalities, such as cardiac testing, few have specifically addressed vascular testing.

"I hope that these criteria will allow clinicians and vascular laboratories to really focus on doing the highest quality work, and to evaluate their use of vascular testing, maximize the use of the vascular lab, and assure that the right test is done for the right indication and that tests that are not needed are not performed just because they are readily available," she said.

Dr. Gornik disclosed financial or other relationships with Zin Medical, Summit Doppler Systems Inc., the Fibromuscular Dysplasia Society of America, and the Intersocietal Accreditation Commission. A detailed list of disclosures for all Appropriate Use Criteria Task Force Members is included with the full text of the report.