Journal of Angiology & Vascular Surgery Category: Medical Type: Case Report
Analysis of Upper Extremity Arterial Duplex Indications May Reduce Unnecessary Tests
- Mounir J Haurani1*, Michael R Go2, Jean E Starr2, Patrick S Vaccaro2, Bhagwan Satiani2
- 1 Division Of Vascular Diseases And Surgery, The Ohio State University, 376 W., 10th Ave., Prior Hall 701, Columbus, OH 43210, United States
- 2 Division Of Vascular Diseases And Surgery, Ohio State University, Prior Hall, Columbus, United States
*Corresponding Author:Mounir J Haurani
Division Of Vascular Diseases And Surgery, The Ohio State University, 376 W., 10th Ave., Prior Hall 701, Columbus, OH 43210, United States
Tel:+1 614 293 8536,
Received Date: Feb 02, 2016 Accepted Date: May 19, 2016 Published Date: Jun 03, 2016
Introduction and Objectives: There is constant pressure on Vascular Laboratories (VL) to produce accurate and timely testing. Others have studied cost savings related to reducing unnecessary venous duplex testing and after hour studies; however, little has been written regarding Upper Extremity Arterial Duplex (UEAD) and reduction of unnecessary testing. As transradial interventions increase in frequency, so too will UEAD. By evaluating the indications for the studies and the results, we hope to identify a subset of patients for whom UEAD testing is specifically indicated.
Methods: We queried our prospectively maintained database for all UEAD performed between January, 2006 and December, 2013. We excluded tests for which the Testing Indications (TI) was not clearly noted or unrelated. UEAD were then separated broadly based on TI into objective or subjective findings, and then further subcategorized based on the specifics of the TI. The results of the UEAD were categorized as positive (abnormal) or negative (normal). Statistical analysis was performed with Chi Squared for nominal categorical data.
Results: Overall 130 (35%) of 368 UEAD had positive (abnormal) findings. There was no difference in the number of abnormal UEAD when categorized broadly into objective or subjective indications (36% vs. 34%, p=0.4). When subdivided by their more specific indications, UEAD whose TI were findings such as a pulse deficit or bruit had the highest rate of abnormal tests. When the TI was for a presumed complication without objective findings, the UEAD displayed had the lowest rates of abnormal findings.
Conclusion: Abnormal UEAD is found more often in patients who have objective findings on physical examination than, pre-existing diagnosis of vascular disease, or presumed complications without objective findings. However, not all objective findings were found to be highly correlated with abnormal UEAD. With further studies of patient characteristics we can develop guidelines for eliminating unnecessary UEAD.
The objective of this study was to analyze the documented indication for and the results of UEAD, and to then use that data to create ordering guidelines and educate physicians as to the role of UEAD.
Overall there were an equal number of studies done for each broad TI (N=182 objective, 186 subjective). In the objective group, 66 (36%) had an abnormal finding vs. 64(35%) in the subjective group but this was not significantly different (P=0.71). In patients with hard signs of vascular injury (Physical Exam findings), the incidence of abnormal studies was 78%. This was significantly higher than in those who had objective findings without hard signs (the suspected complications and complications of hemodialysis groups, 34%, P<0.001). Despite there not being any difference in the rate of abnormal studies when broadly categorized into objective and subjective findings, when grouped according to the subgroups in figure 1, those with hard signs were significantly more likely to have positive (abnormal) findings (Table 1).
|Physical Exam (Bruit / Pulse Deficit**||5||18||23||78%*|
|Complications or Hematoma **||56||17||73||23%|
|Hem dialysis Access Complications**||55||31||86||36%|
|Complaints of blue fingers, cold hands etc. ++||69||32||101||32%|
|Diagnosis of Vascular Disease ++||53||32||85||38%|
Based on this, one could argue that many of the UEAD are unnecessary. By using clinical criteria such as the objective findings of hard signs, we can increase the pre-test probability of an abnormal exam. This study was not designed to test that hypothesis, as it was a retrospective review of our UEAD. However, it may help frame future algorithms and strategies for ordering UEAD. We have already employed this strategy to reduce unnecessary after hour lower extremity duplex scanning for Deep Venous Thrombosis (DVT) in our lab. Patients with a high probability of DVT based on clinical signs are started on anticoagulation and their DVT scan was delayed until regular hours, while patients with low pre-test probability are not scanned at all . This elimination of afterhours testing and institution of low-molecular weight heparin for high probability patients was estimated to save over $11,000 annually in one lab alone . This cost savings even included the cost of the low-molecular weight heparin. As UEAD becomes increasingly ordered, we could establish a similar strategy to increase the pre-test probability of an abnormal study based on clinical findings and reduce unnecessary tests.
Reduction in unnecessary testing is necessary in all VL because of the potential cost savings, reduction in sonographer burnout and turnover, and overall improvement in patient and physician satisfaction. For example, in our institution patients remained highly satisfied with their care despite testing being delayed until normal hours for DVT. However, physicians were dissatisfied with having to wait . The implementation of our afterhours DVT scan policy has the potential of providing physicians with an objective way of assessing patients and then being able to provide the patient with a logical treatment plan.
During the time period of our study, the national incidence of transradial catheterizations increased dramatically. In 2006, less than 1% of cardiac catheterizations were transradial access whereas by 2012 16.1% were transradial [4,5]. From the time period between 2007 and 2012 over 178,000 transradial catheterizations were performed nationally. The reported rate of vascular complication or major hemorrhage nationally is 2.83% for transradial PCI [4,5]. Considering there has been a 6 fold increase in the frequency of radial catheterization in the time period of this study, the expectation is that an increasing number of patients will need screened for complications post catheterization Surgeons may be reluctant to operate on a patient based on physical examination alone without imaging to help demonstrate the extent and location of the injury and appropriate, high quality imaging can help guide intervention. Our objective was to determine which patients might have a low enough pretest probability that they can be safely followed clinically rather than ordering UEAD to determine that. Patient’s with subjective findings should perhaps undergo a more thorough evaluation or be seen by a vascular specialist before ordering unnecessary testing. Often, a physiologic test may have been a better choice in these patients than arterial duplex.
Another potential reason for increased UEAD utilization is to assess the adequacy of the radial artery prior to transradial catheterization, especially when it has been previously accessed. While physical exam alone may not always be adequate to screen for radial artery adequacy, we excluded those studies from this review for several reasons. To begin with, 15% to 23% of patients being considered for coronary artery bypass graft had an abnormal Allen’s test . Of those patients with an abnormal modified Allen’s test, only 11.6% will have an abnormal duplex ultrasound examination . So the use of precatheterization screening of radial arteries would not necessarily prevent complications because of the low rate of abnormal studies. Furthermore, no guidelines have been established for differentiating radial artery adequacy. So routine screening of the radial artery we propose would not prevent any more complications than a good physical examination.
- Feldman DN, Swaminathan RV, Kaltenbach LA, Baklanov DV, Kim LK, et al. (2013) Adoption of radial access and comparison of outcomes to femoral access in percutaneous coronary intervention: an updated report from the national cardiovascular data registry (2007-2012). Circulation 127: 2295-2306.
- Lee MS, Wolfe M, Stone GW (2013) Transradial versus transfemoral percutaneous coronary intervention in acute coronary syndromes: re-evaluation of the current body of evidence. JACC Cardiovasc interv 6: 1149-1152.
- Langan EM 3rd, Coffey CB, Taylor SM, Snyder BA, Sullivan TM, et al. (2002) The impact of the development of a program to reduce urgent (off-hours) venous duplex ultrasound scan studies. J Vasc Surg 36: 132-136.
- Go MR, Kiser D, Wald P, Haurani MJ, Moseley M, Satiani B. (2013) Clinical evaluation of suspected deep vein thrombosis guides the decision to anticoagulate prophylactically but does not impact the decision to perform after hours duplex venous scanning or increase its yield. J Vasc Surg 57: 1597-602.
- Arnaoutakis GJ, Pirrucello J, Brooke BS, Reifsnyder T. (2010) Venous duplex scanning for suspected deep vein thrombosis: results before and after elimination of after-hours studies. Vasc Endovascular Surg 44: 329-333.
- Haurani MJ KD, Satiani B (2015) Physician satisfaction with the vascular lab is highly dependent on after hour’s availability. Global Surgery.
- Habib J, Baetz L, Satiani B (2012) Assessment of collateral circulation to the hand prior to radial artery harvest. Vasc Med 17: 352-361.
Citation:Haurani MJ, Go MR, Starr JE, Vaccaro PS, Satiani B (2016) Analysis of Upper Extremity Arterial Duplex Indications May Reduce Unnecessary Tests. J Angiol Vasc Surg 1: 004.
Copyright: © 2016 Mounir J Haurani, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.