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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