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>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
>
>Please remove me from E-mail list.