In 2002, the diagnosis of vascular disease is made first at the bedside and then confirmed with a non-invasive technique. Arteriograms, though quite accurate carry an unacceptable degree of risk when utilized for pure diagnostic purposes. These considerations are notable when one considers that nearly 20% of the strokes suffered during the Asymptomatic Carotid Artery Stenosis Trial (ACAS) occurred with diagnostic arteriography. Furthermore, inter and intra-observer variability and error in the range of 10 to 12% have been reported with diagnostic arteriography of both the carotid and peripheral arterial system. If this werenít enough, complications associated with these invasive diagnostic procedures are significant resulting in serious life-altering diseases and the need for emergent surgical procedures. Vascular surgeons perform arteriography for ìintention-to-treatî purposes, meaning once the diagnosis has been made invasive imaging is utilized for operative planning. This is not to say that arteriography is a relic of the past never to be utilized, but its use as a diagnostic tool now is rarely indicated.

Noninvasive alternatives include vascular ultrasound and magnetic resonance angiography. An alternative in the future may include CT angiography. All satisfy the goal of serving as a non-invasive tool but considerable differences exist in the areas of cost, patient accessibility, and scheduling.

MRA when correlated with other diagnostic studies can prove reliable. The difficulties with MRA from a patient perspective lie in the requirement to remain motionless for long periods of time. Unless an open MRA is available, claustrophobia is an additional limitation. These issues are not trivial to the patient and often will have a negative influence on their desire to use MRA in the future. Cochlear implants, recent surgery, pacemakers, and the need for monitoring in the inpatient setting further limit its use. CT angiography may prove more patient friendly but its accuracy has yet to be established. From a cost-effective standpoint, neither CT angiography nor MRA are practical for initial screening or when multiple follow-up studies are required. Finally, these modalities require some preparation regarding scheduling, premedication, evaluation of baseline renal function (CT angio), and admission to the hospital for outpatient diagnostic testing.

Vascular ultrasound is now considered the first line diagnostic test for carotid stenosis, renal/mesenteric artery stenosis, aortic aneurysms, and peripheral arterial and venous disease. The Intersocietal Commission of Accredidated Vascular Laboratories (ICAVL) recognizes quality labs by accrediting vascular labs performing at high standards. Accreditation is granted only after documentation of the use of nationally accepted standardized techniques, quality assurance evaluations verifying accuracy, certification of the technology staff, and education of the physician readers. This relationship between accreditation and quality has not gone unrecognized. Presently Medicare and HCFA require vascular labs to be accredited to receive reimbursement

Carotid and aortic imaging, arterial duplex mapping, bypass graft surveillance, renal and mesenteric imaging and diagnosis of deep vein thrombosis are examples where vascular ultrasound serves as the sole diagnostic tool prior to surgery or treatment. The use of ankle-brachial indices has been supplemented by complete duplex arterial mapping, which serves as the state of the art tool for diagnosis of arterial blockage. There are no contraindications to the use of ultrasound, there are no risks, the results are immediate, and there are no complications. Importantly, these patients can be followed with serial or surveillance studies with little variation or error. The product is a comprehensive treatment plan when these studies are combined with the insight gained from a thoughtful evaluation by the vascular surgeon.

Coastal Carolina Surgical Associates has an accredited vascular lab with certified vascular technologists and performs over 4000 studies per year. Our physician readers specialize in vascular surgery and have over 25 cumulative years in vascular ultrasound. These studies are conveniently performed in an office setting, without patient risk or discomfort, on an emergent basis if necessary, and with 100% patient compliance.

Well, what does all this mean? It means that if a patient is suspected of having peripheral vascular disease, this can be confirmed within a matter of minutes, with absolutely no risk to the patient, and at a fraction of the cost of any other test. And if that study needs repeating in 1 month or 1 year, the same level of convenience, cost and accuracy can be delivered.