A stepwise approach
After balancing the accuracy, cost, and risk of available tests, an appropriate stepwise approach to evaluation for PVD is:
First, do a complete history and targeted physical examination (palpation of pulses).
Next, obtain an ankle-brachial index to confirm the diagnosis.
Then, proceed directly to either duplex ultrasonography or magnetic resonance angiography when revascularization is clearly needed.9
TABLE
Commonly used tests for peripheral vascular disease
| TEST | COMPARISON/STANDARD | SENSITIVITY % (95% CI, IF REPORTED) | SENSITIVITY % (95% CI, IF REPORTED) | SPECIFICITY % (95% CI, IF REPORTED) | PPV* | LR- | LR+ | REIMBURSEMENT ESTIMATE† |
|---|---|---|---|---|---|---|---|---|
| MEDICAL HISTORY | CPT CODE | ESTIMATED COST | ||||||
| Edinburgh Claudication Questionnaire4 | Claudication by clinician assessment | 91.0 (88.1-94.5) | 99.0 (98.9-100.0) | 0.955 | 0.09 | 91.0 | 99203 | $87.29 |
| PHYSICAL EXAMINATION | ||||||||
| Color abnormality of extremity skin (pale, red, or blue)5 | ABI<0.9 | 35.0 | 87.0 | 0.305 | 0.75 | 2.7 | 99203 | $87.29 |
| Cool skin unilaterally5 | ABI<0.9 | 10.0 | 98.0 | 0.449 | 0.92 | 5.0 | 99203 | $87.29 |
| Any abnormal pulse by palpation6 | Multiple criteria‡ | 76.9 | 86.4 | 0.479 | 0.27 | 5.7 | 99203 | $87.29 |
| Presence of femoral bruit6 | Multiple criteria‡ | 20.0 | 95.7 | 0.431 | 0.84 | 4.7 | 99203 | $87.29 |
| Absent pedal pulses (dorsalis pedis and posterior tibial)7 | ABI<0.9 | 63.0 | 99.0 | 0.912 | 0.37 | 63.9 | 99203 | $87.29 |
| LABORATORY INVESTIGATIONS | ||||||||
| ABI <0.93 | Conventional angiography | 79.0 | 96.0 | 0.763 | 0.22 | 19.8 | 93923 | $165.18 |
| Duplex ultrasound8 | Conventional angiography | 87.6 (84.4-90.8) | 94.7 (93.2-96.2) | 0.729 | 0.13 | 16.5 | 93923 | $165.18 |
| Gadolinium-enhanced magnetic resonance angiography8 | Conventional angiographyy | 97.5 (95.7-99.3) | 96.2 (94.4-97.9) | 0.807 | 0.03 | 25.7 | 73725 | $504.00 |
| ABI, ankle-brachial index; CI, confidence interval; LR, likelihood ratio; PPV, positive predictive value. | ||||||||
| *Based on a prevalence of peripheral vascular disease of 14% (Pasternak RC et al1). | ||||||||
| † Based on estimated Medicare-approved CPT reimbursement rates, https://catalog.ama-assn.org/Catalog/cpt/cpt_search.jsp. Accessed December 2, 2007. History and physical items based on a new-patient visit of moderate complexity, CPT Code 99203. Cost estimate for conventional invasive angiography (angiography, extremity, unilateral, radiological supervision and interpretation, CPT Code 75710) $426.14 (Downstate Illinois estimates). | ||||||||
| ‡ Multiple criteria = segmental blood pressure, flow velocity by Doppler, postocclusive reactive hyperemia, pulse reappearance half-time, small or large vessel peripheral arterial disease, and surgery. | ||||||||
The major advantages of the ankle-brachial index include low cost and non-invasiveness (low potential for harm). However, it doesn’t detect proximal aneurysms or PVD distal to the ankle, and it may be difficult to perform on patients with noncompressible distal vasculature. Adequately evaluating such patients may require invasive testing.
Recommendations
The US Preventive Services Task Force recommends against (D recommendation) any screening tests for PVD in patients without symptoms.10 The American College of Cardiology gives a class I recommendation (tests for which there is evidence or general agreement that a procedure is useful, beneficial, or effective) to the ankle-brachial index as the baseline diagnostic tool for establishing peripheral vascular disease, except in elderly patients or those with advanced diabetes, for whom the test is unreliable.11