Straub Medical Center, Hawaii Pacific Health, Honolulu, Hawaii.
Albany Medical College, The Vascular Group, Albany, NY.
J Vasc Surg Venous Lymphat Disord. 2020 Jul;8(4):505-525.e4. doi: 10.1016/j.jvsv.2020.02.001. Epub 2020 Mar 3.
Stimulated by published reports of potentially inappropriate application of venous procedures, the American Venous Forum and its Ethics Task Force in collaboration with multiple other professional societies including the Society for Vascular Surgery (SVS), American Vein and Lymphatic Society (AVLS), and the Society of Interventional Radiology (SIR) developed the appropriate use criteria (AUC) for chronic lower extremity venous disease to provide clarity to the application of venous procedures, duplex ultrasound imaging, timing, and reimbursements.
The AUC were developed using the RAND/UCLA Appropriateness Method, a validated method of developing appropriateness criteria in health care. By conducting a modified Delphi exercise and incorporating best available evidence and expert opinion, AUC were developed and scored.
There were 119 scenarios rated on a scale of 1 to 9 by an expert panel, with 1 being never appropriate and 9 being appropriate. The majority of scenarios consisted of symptomatic indications were deemed appropriate for venous intervention. For scenarios with anatomically short segments of reflux and/or no symptoms, the indications were rated less appropriate. For the indication of edema, a wide dispersion of ratings was observed especially for short segments of saphenous reflux or stenting for iliac/ inferior vena cava disease, noting that there are multifactorial causes of edema, some of which could coexist with venous disease and possibly impact effectiveness of treatment. Several scenarios were considered never appropriate, including treatment of saphenous veins with no reflux, iliac vein or inferior vena cava stenting for iliac vein compression as an incidental finding by imaging with minimal or no symptoms or signs, and incentivizing sonographers to find reflux.
The AUC statements are intended to serve as a guide to patient care, particularly in areas where high-quality evidence is lacking to aid clinicians in making day-to-day decisions for common venous interventions. This may also prove useful when applied on a population level, such as practice patterns, and not necessarily to dictate decision making for individual cases. As a product of a collaborative effort, it is hoped that this could be utilized by physicians and multiple stakeholders committed toward improving patient care and to identify and stimulate future research priorities.
受发表的潜在不适当静脉治疗应用报告的刺激，美国静脉论坛及其伦理工作组与多个专业学会合作，包括血管外科学会（SVS）、美国静脉与淋巴学会（AVLS）和介入放射学学会（SIR），制定了慢性下肢静脉疾病的适宜性使用标准（AUC），以明确静脉治疗、双功能超声成像、时机和报销的应用。
AUC 使用 RAND/UCLA 适宜性方法制定，这是一种在医疗保健中制定适宜性标准的验证方法。通过进行改良 Delphi 研究，并结合最佳现有证据和专家意见，制定并评分 AUC。
由专家小组在 1 到 9 的范围内对 119 种情况进行了评分，1 表示从不适当，9 表示适当。大多数情况下，症状性指征被认为适合静脉介入治疗。对于解剖学上短段反流和/或无症状的情况，指征的适宜性较低。对于水肿的指征，观察到评分的广泛分散，特别是对于短段隐静脉反流或髂/下腔静脉疾病的支架置入，注意到水肿有多种原因，其中一些可能与静脉疾病并存，并可能影响治疗效果。一些情况被认为从不适当，包括无反流的隐静脉治疗、影像检查中发现髂静脉或下腔静脉狭窄作为偶发发现、有轻微或无症状或体征时进行髂静脉压迫的静脉支架置入，以及激励超声医师寻找反流。
AUC 陈述旨在作为患者护理的指南，特别是在缺乏高质量证据以帮助临床医生做出常见静脉干预日常决策的领域。当应用于人群水平时，如实践模式，而不一定是为了决定个别病例的决策，这也可能是有用的。作为协作努力的产物，希望它能被致力于改善患者护理的医生和多个利益相关者使用，并确定和激发未来的研究重点。
