>Bravo!
>
>[log in to unmask] wrote:
>
>> To Flownetters:
>> >From Rob Daigle.
>> To play the devils advocate on the issue of physiologic segmental studies
>> versus duplex, I'd like to voice an opinion. This opinion has been sculpted
>> by my mentors in vascular surgery and radiology, experience in the trenches,
>> and by comments,criticisms, and attacks when I've lectured in support of
>> Duplex imaging of native arteries.
>>
>> #1) Although a bilateral duplex scan from aorta to the ankles takes 5-10
>> minutes for those who have been scanning arteries since before sliced bread
>> was invented, for most of us it takes a lot longer. For a patient with
>> bilateral disease in the iliacs and fem -popliteal segments, a two hour exam
>> duration is more likely. (time flies when you're having fun). Sure, the exam
>> could take 30 minutes, but sometimes the quality of the test is severely
>> compromised. There is always a tendency to forget how much time it takes
to do
>> the tough ones. The memory of pain is short!
>>
>> #2 . For many of us, the iliacs are a bitch, in terms of scheduling time,
>> technical difficulty, bowel gas and frustration, one does not approach this
>> potentially very difficult segment without a good indication that you need to
>> scan there. Often the patient must return another day with bowel prep, NPO to
>> accomplish this exam.
>>
>> The question posed by Jean Primozich, of why not take just take ankle
>> pressures and then scan, is important, for technical and reimbursement
issues.
>> Ankle pressures, as long as the patient does not have calcific medial
>> sclerosis, and many do, will indicate normal versus abnormal, but if you want
>> to find where the disease is, with this protocol, you've got to scan the
>> entire limb(s). (Waveform analysis at the CFA is only good at detecting
>> severe aorto-iliac disease.) And the tibial arteries, all three of them, are
>> no picnic either!
>>
>> #3) Reimburse is an issue for many that rely on medicare and insurance
>> carriers to keep their labs going. An ankle- brachial pressure index
is not
>> reimbursable without other physiologic testing, waveforms etc. Many states
>> will not reimburse for a duplex exam unless surgery or intervention is
>> planned, nor will they reimburse for a normal duplex exam.
>>
>> Guidelines have been written to suggest appropriate methods for arterial
>> testing. The Medical Policy manual from the mid western states (KA, MO NE),
>> reads "Duplex scanning and physiologic studies are reimbursed during the same
>> encounter if the physiologic studies are abnormal or to evaluate trauma,
>> thromboembolic events and aneurysms."
>>
>> The guidelines further state " In most patients, segmental blood pressure
>> measurements (not just ABI, rd) before and after exercise should be the
>> preferred procedure in evaluating arterial insufficiency." Many states are
>> adopting similar guidelines. So what we feel is the best way to do things,
>> might not be the way we get paid for doing them. This is fine if you're
funded
>> by grants or Powerball.
>>
>> 4) Physiologic segmental testing, when performed for appropriate indications,
>> is reimbursable in all states, whether the result is negative or positive.
>> It takes 15 minutes (ABI with waveform) - 60 minutes max (for a full test
with
>> exercise) , regardless of tech experience.
>>
>> Indirect testing accurately ( numerous articles) predicts whether the
disease
>> is above or below the inguinal ligament, an important consideration for
>> patient management.
>> It provides objective, physiologic information about the effect of stenosis
>> and occlusion on the patients' distal perfusion. Duplex data does not provide
>> this.
>>
>> It tremendously helps to differentiate vascular claudication from pseudo-
>> claudication, especially in referrals from non-vascular specialists.
>>
>> And finally, unless the vascular surgeon is prepared to operate without a
>> preoperative angiogram (some do, but most do not) ( and I feel that Duplex
>> imaging in the hands of the true experts with many years experience, Bill
>> Schroeder comes to mind, is more accurate that angiography) duplex
imaging of
>> the arteries is redundant to the angiogram, a waste of time ( a precious
>> commodity in a busy lab) and someones money. Ditto for angioplasty.
>> Duplex imaging is fun though.
>>
>> Just an opinion from an average tech who is now an average product
manager for
>> Nicoletvascular, manufacturer of physiologic testing equipment.
>> Thanks
>> Rob Daigle
>
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