T.J.,
 
I agree with you.  People appropriately refered to the vascular lab with normal ABI's should be exercised.  The point was we should never see asymptomatic patients with nromal ABI's for evaluation of occlusive arterial disease.  When we do, what should we do with them?  If we proceed beyond this point we are no longer a diagnostic vascular lab but a screening entity and should proceed under screening guidelines.  I f we do not have screening guidelines, then the patient should be sent home.   
 
As far as the post exercise comment, it was a poor attempt at trying to be facetious and regret the implication that a drop in post exercise pressure was possible without disease.  I apologize.  
 
Brian
 
 
Terry J Zwakenberg <[log in to unmask]> wrote:


Brian,

 

I would like to address a couple of your comments, no offense to you or Ms Marsha.  I know a number of ICAVL accredited, medicare reimbursed, full service vascular labs that utilize this very approach.  When a patient presents to the vascular lab for initial evaluation of lower extremity vascular disease with normal ABI’s and a resting study that is essentially normal, exercise is not only indicated, but in my opinion a significant disservice to the patient if left out.  As a matter of fact, the best utilization of time for both the lab and the patient is not to complete a full (normal) resting exam if the ABI’s are normal, but rather go straight to an exercise protocol.  If the exercise is positive then duplex is indicated to determine location and severity.  The other appropriate use of exercise is for serial followup on patients being managed medically.  On these patients the absolute pressure is not the significant factor as much as the pulse volume recording to evaluate
 collateral flow.  No matter what type of exercise medium the most important factor is reproducibility.  The time to onset and severity of symptoms with exercise is what determines the efficacy of the treatment regimen. 

 

One final note, an asymptomatic patient without disease will not show a drop in pressure no matter how hard you push them.  An asymptomatic patient with disease will drop their pressures with an appropriately done exercise test.

 

Terry J Zwakenberg BS RVT RDCS

 

Lee,

 

The process suggested here is a methodology to aggressively diagnosis arterial disease and amounts to no more than screening for peripherial arteial disease.  This is outside the scope of the traditional vascular lab whose goals (referencing a presentation by Marsha Neumyer) are to confirm arterial occlusive disease and to determine if arterial disease is the cause of the patient's symptoms.  (The other two goals have nothing to do with this converstion).   Bearing that in mind, for diagnostic purposes one should only stress patients with claudication symptoms.  Medicare in the states I have worked is even more restrictive in that the patients accepted for arterial examinations must have abnormal ABI's or true claudication symptoms and be candidates for intervention.

 

I do believe there is a time and place for screening, however the fee charged should reflect a screening procedure and Medicare must not be billed for it.

 

I realize this did not directly answer your inquiry, but I have an additional comment.  One does not use post exercise ABI's but instead looks for a decrease in the post exercise ankle pressure as compared to the pre exercise ankle pressure (and measure the recovery time).  The protocol for exercise studies uses treadmill walking for a limited time, at a limited speed with limited elevation. A nonsymptomatic patient with normal ABI's would usually have to be pushed well beyond those limits to show a drop in post exercise ankle pressures. 

 

Hopefully these comments are helpful.

 

Brian Stockard       

Lee Tyler <[log in to unmask]> wrote:

Has there ever been a study comparing the accuracy for detecting disease 
between static ABI'S and post-exercise ABI'S? Doesn't the addition of a 
good exercise regimen and post exercise ABI'S markedly increase the 
sensitivity of the initial static ABI study? If so, by approximately what 
percentage/value? 2-fold? 4-fold?



Thanks in advance----LT




 

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