[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
> 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.
> Rob Daigle