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     AIUM–ACR--SRU PRACTICE GUIDELINE FOR THE
     PERFORMANCE OF DIAGNOSTIC AND SCREENING
     ULTRASOUND OF THE ABDOMINAL AORTA IN ADULTS

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     Table of Contents
     I. Introduction
     II. Qualifications and Responsibilities of Personnel
     III. Indications/Contraindications
     IV. Written Request for the Examination
     V. Specifications of the Examination
     VI. Documentation
     VII. Equipment Specifications
     VIII. Quality Control and Improvement, Safety, Infection Control, and Patient
             Education



 1   I.     INTRODUCTION
 2
 3   The clinical aspects contained in specific sections of this guideline (Introduction,
 4   Indications, Specifications of the Examination, and Equipment Specifications) were
 5   developed collaboratively by the American Institute of Ultrasound in Medicine (AIUM),
 6   the American College of Radiology (ACR), and the Society of Radiologists in Ultrasound
 7   (SRU). Recommendations for physician requirements, written request for the
 8   examination, procedure documentation, and quality control vary among the three
 9   organizations and are addressed by each separately.
10
11   These guidelines are intended to assist in the performance and interpretation of the
12   dedicated sonographic examination of the abdominal aorta. The examination may be
13   performed as a diagnostic or a screening study. Comprehensive population screening
14   programs have not yet been developed in the United States but do exist elsewhere in the
15   world [1,2]. While it is not possible to detect every abnormality, following this guideline
16   will maximize the detection of abnormalities of the abdominal aorta.
17
18
19   II.    QUALIFICATIONS AND RESPONSIBILITIES OF PERSONNEL
20
21   See the AIUM Official Statement Training Guidelines for Physicians Who Evaluate and
22   Interpret Diagnostic Ultrasound Examinations and the AIUM Standards and Guidelines
23   for the Accreditation of Ultrasound Practices.
24
25


     Abdominal Aorta Ultrasound                             AIUM PRACTICE GUIDELINE
                     NOT FOR PUBLICATION, QUOTATION, OR CITATION

26   III.        INDICATIONS/CONTRAINDICATIONS
27
28   Indications for ultrasound of the abdominal aorta include, but are not limited to:
29
30   A. Diagnostic Evaluation for Abdominal Aortic Aneurysm
31
32          1.   Palpable or pulsatile abdominal mass.
33          2.   Unexplained lower back pain, flank pain, or abdominal pain.
34          3.   Follow-up of a previously demonstrated abdominal aortic aneurysm.
35          4.   Follow-up of patients with an abdominal aortic and/or iliac endoluminal stent
36               graft.
37
38   B. Screening Evaluation for Abdominal Aortic Aneurysm
39
40          1. Men age 65 or older.
41          2. Women age 65 or older with cardiovascular risk factors.
42          3. Patients age 50 or older with a family history of aortic and/or peripheral vascular
43             aneurysmal disease.
44          4. Patients with a personal history of peripheral vascular aneurysmal disease.
45
46   Groups with additional risk include patients with a history of smoking, hypertension, or
47   certain connective tissue diseases (e.g., Marfan’s syndrome).
48
49   There are no absolute contraindications to ultrasound of the aorta. If aortic rupture or
50   dissection is clinically suspected, ultrasound is usually not the examination of choice.
51
52
53   IV.         WRITTEN REQUEST FOR THE EXAMINATION
54
55   The written or electronic request for an ultrasound examination should provide sufficient
56   information to allow for the appropriate performance and interpretation of the
57   examination.
58
59   The request for the examination must be originated by a physician or other appropriately
60   licensed health care provider or under their direction. The accompanying clinical
61   information should be provided by a physician or other appropriate health care provider
62   familiar with the patient’s clinical situation and should be consistent with relevant legal
63   and local health care facility requirements.
64
65
66




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     AIUM PRACTICE GUIDELINE                                      Abdominal Aorta Ultrasound
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 67   V.      SPECIFICATIONS OF THE EXAMINATION
 68
 69   A. Diagnostic Examination
 70
 71   The examination includes the following, when feasible:
 72
 73        1. Abdominal aorta
 74           a. Longitudinal images (along the long axis of the vessel)
 75               i. Proximal
 76               ii. Mid
 77               iii. Distal
 78           b. Transverse images (perpendicular to the long axis of the vessel)
 79               i. Proximal (near diaphragm)
 80               ii. Mid
 81               iii. Distal
 82           c. Measurements
 83             i. Measurements of the proximal, mid, and distal aorta should be obtained.
 84                  Measurements are taken at the greatest diameter of the aorta from outer edge
 85                  to outer edge.
 86               ii. If an aneurysm is present:
 87                     The maximal size and location of the aneurysm should be
 88                        documented and recorded.
 89                     The relationship of the dilated segment to the renal arteries and to
 90                        the aortic bifurcation should be determined if possible.
 91                     A measurement of the length of the aneurysm is not necessary.
 92
 93        2. Common iliac arteries
 94           a. Longitudinal images of the proximal right and left common iliac arteries
 95              (along the long axis of the vessel).
 96           b. Transverse images (perpendicular to the long axis of the vessel) of the
 97              proximal common iliac arteries just below at the bifurcation.
 98           c. Measurement of the widest visualized portion of each common iliac artery
 99              from outer edge to outer edge.
100
101   Color Doppler imaging and/or spectral Doppler with waveform analysis of the aorta
102   and iliac arteries may provide additional information.
103
104   After endoluminal graft placement, color (or power) and spectral Doppler are required to
105   document the presence or absence of endoleaks.
106
107   Interobserver measurements of an aortic aneurysm can vary by as much as 5 mm. This
108   variation makes visual comparison with previous studies is particularly important to
109   determine whether or not a significant change in size has occurred [3].
110
111
112



      Abdominal Aorta Ultrasound                             AIUM PRACTICE GUIDELINE
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113   B. Screening Examination for Abdominal Aortic Aneurysm
114
115         1. Abdominal aorta
116            a. Longitudinal images (along the long axis of the vessel)
117               i. Proximal
118               ii. Mid
119               iii. Distal
120            b. Transverse images (perpendicular to the long axis of the vessel)
121               i. Proximal (near diaphragm)
122               ii. Mid
123               iii. Distal
124
125   C. Interpretation of the screening examination should include at least 3 categories:
126
127         1. Positive –
128               a. Infrarenal abdominal aortic aneurysm greater than or equal to 3 cm in
129                   diameter or
130               b. Greater than or equal to 1.5 times the diameter of the more proximal aorta
131                   [4].
132               c. The latter definition is particularly important in women [5].
133
134         2. Negative – No infrarenal abdominal aortic aneurysm.
135
136         3. Indeterminate – Aneurysmal status not defined because of nonvisualization or
137            only partial visualization of the infrarenal abdominal aorta.
138
139   The report should also state whether or not the suprarenal aorta was seen and, if seen,
140   should reflect whether or not it is normal.
141
142
143   VI.      DOCUMENTATION
144
145   Adequate documentation is essential for high-quality patient care. There should be a
146   permanent record of the ultrasound examination and its interpretation.
147
148        Images of all appropriate areas, both normal and abnormal, should be recorded.
149        Variations from normal size should be accompanied by measurements.
150        Images should be labeled with the
151          patient identification,
152          facility identification,
153          examination date, and the
154          side (right or left) of the anatomic site imaged.
155
156




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      AIUM PRACTICE GUIDELINE                                    Abdominal Aorta Ultrasound
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157   An official interpretation (final report) of the ultrasound findings should be included in
158   the patient’s medical record. Retention of the ultrasound examination should be
159   consistent both with clinical need and with relevant legal and local healthcare facility
160   requirements.
161
162   Reporting should be in accordance with the AIUM Standard for Documentation of an
163   Ultrasound Examination.
164
165
166
167   VII.   EQUIPMENT SPECIFICATIONS
168
169   Abdominal aortic ultrasound should be performed with real-time scanners with
170   transducers that allow for appropriate penetration and resolution, depending on the
171   patient’s body habitus. Diagnostic information should be optimized, while keeping total
172   ultrasound exposure as low as reasonably achievable.
173
174
175   VIII. QUALITY CONTROL AND IMPROVEMENT, SAFETY, INFECTION
176         CONTROL, AND PATIENT EDUCATION
177
178   Policies and procedures related to quality control, patient education, infection control,
179   and safety should be developed and implemented in accordance with the AIUM
180   Standards and Guidelines for the Accreditation of Ultrasound Practices.
181
182   Equipment performance monitoring should be in accordance with the AIUM Standards
183   and Guidelines for the Accreditation of Ultrasound Practices.
184
185
186   IX.    As Low As Reasonably Achievable (ALARA) Principle
187
188   The potential benefits and risks of each examination should be considered. The as low as
189   reasonably achievable (ALARA) principle should be observed when adjusting controls
190   that affect the acoustic output and by considering transducer dwell times. Further details
191   on ALARA may be found in the AIUM publication Medical Ultrasound Safety, Second
192   Edition.
193




      Abdominal Aorta Ultrasound                            AIUM PRACTICE GUIDELINE
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194   ACKNOWLEDGEMENTS
195
196   This guideline was revised by the American Institute of Ultrasound in Medicine (AIUM)
197   in collaboration with the American College of Radiology (ACR) and the Society of
198   Radiologists in Ultrasound (SRU) according to the process described in the AIUM
199   Clinical Standards Committee Manual.
200
201   Collaborative Committee
202
203   ACR                                               AIUM
204   Raymond E. Bertino, MD, FACR                      Lin Diacon, MD
205   Lincoln L. Berland, MD, FACR                      David M. Paushter, MD, FACR
206   Edward I. Bluth, MD, FACR                         Carl C. Reading, MD, FACR
207
208   SRU
209   Mark E. Lockhart, MD, MPH
210   Laurence Needleman, MD, FACR
211   Hisham Tchelepi, MD
212
213   AIUM Clinical Standards Committee
214   David M. Paushter, MD, Chair
215   Leslie Scoutt, MD, Vice Chair
216   Susan Ackerman, MD
217   Lisa Allen, BS, RDMS, RDCS, RVT
218   Mert Ozan Bahtiyar, MD
219   Harris L. Cohen, MD
220   Jude Crino, MD
221   William Lindley Diacon, MD, RDMS
222   Judy Estroff, MD
223   Kimberly Gregory, MD, MPH
224   Charlotte Henningsen, MS, RT, RDMS, RVT
225   Charles Hyde, MD
226   Christopher Moore, MD, RDMS, RDCS
227   Olga Rasmussen, RDMS
228   Carl Reading, MD
229   Daniel Skupski, MD
230   Jay Smith, MD
231   Joseph Wax, MD
232
233




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      AIUM PRACTICE GUIDELINE                                Abdominal Aorta Ultrasound
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234   Comments Reconciliation Committee
235   Beverly G. Coleman, MD, Co-Chair, FACR
236   Richard N. Taxin, MD, Co-Chair, FACR
237   Kimberly E. Applegate, MD, MS, FACR
238   Lincoln L. Berland, MD, FACR
239   Raymond E. Bertino, MD, FACR
240   Edward I. Bluth, MD, FACR
241   Lin Diacon, MD
242   Howard B. Fleishon, MD, MMM, FACR
243   Mary C. Frates, MD, FACR
244   David I. Hammond, MD, FACR
245   Alan D. Kaye, MD, FACR
246   Paul A. Larson, MD, FACR
247   Deborah Levine, MD, FACR
248   Lawrence A. Liebscher, MD, FACR
249   Mark E. Lockhart, MD, MPH
250   Laurence Needleman, MD, FACR
251   David M. Paushter, MD, FACR
252   Carl C. Reading, MD, FACR
253   Hisham Tchelepi, MD
254   E. Kent Yucel, MD, FACR
255




      Abdominal Aorta Ultrasound               AIUM PRACTICE GUIDELINE
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256   REFERENCES
257
258   1. Adams DC, Tulloh BR, Galloway SW, Shaw E, Tulloh AJ, Poskitt KR. Familial
259      abdominal aortic aneurysm: prevalence and implications for screening. Eur J Vasc
260      Surg 1993;7:709-712.
261   2. Ashton HA, Buxton MJ, Day NE, et al. The Multicentre Aneurysm Screening Study
262      (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men:
263      a randomised controlled trial. Lancet 2002;360:1531-1539.
264   3. Comstock CE, Bluth EI, Peattie RA, Schrader T, Leslie BR. Inter-observer variability
265      in ultrasonic evaluation of abdominal aortic aneurysms. J La State Med Soc
266      1994;146:526-530.
267   4. Johnston KW, Rutherford RB, Tilson MD, Shah DM, Hollier L, Stanley JC.
268      Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting
269      Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards,
270      Society for Vascular Surgery and North American Chapter, International Society for
271      Cardiovascular Surgery. J Vasc Surg 1991;13:452-458.
272   5. Isselbacher EM. Thoracic and abdominal aortic aneurysms. Circulation
273      2005;111:816-828.
274
275   Suggested Reading (Additional articles that are not cited in the document but that the
276   committee recommends for further reading on this topic)
277
278   6. Long-term outcomes of immediate repair compared with surveillance of small
279       abdominal aortic aneurysms. N Engl J Med 2002;346:1445-1452.
280   7. Ebaugh JL, Garcia ND, Matsumura JS. Screening and surveillance for abdominal
281       aortic aneurysms: who needs it and when. Semin Vasc Surg 2001;14:193-199.
282   8. Fleming C, Whitlock EP, Beil TL, Lederle FA. Screening for abdominal aortic
283       aneurysm: a best-evidence systematic review for the U.S. Preventive Services Task
284       Force. Ann Intern Med 2005;142:203-211.
285   9. Frame PS, Fryback DG, Patterson C. Screening for abdominal aortic aneurysm in
286       men ages 60 to 80 years. A cost-effectiveness analysis. Ann Intern Med
287       1993;119:411-416.
288   10. Wilmink AB, Quick CR, Hubbard CS, Day NE. Effectiveness and cost of screening
289       for abdominal aortic aneurysm: results of a population screening program. J Vasc
290       Surg 2003;38:72-77.
291




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      AIUM PRACTICE GUIDELINE                                 Abdominal Aorta Ultrasound
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292
      Aorta
      Longitudinal Proximal (like the 2nd image in this group)




                                                                       AOLngProxPP1




                                                                       AOLngProxPP2




                                                                       AOLngProxPP3




                                                                       AOLngProxPP4




      Abdominal Aorta Ultrasound                                 AIUM PRACTICE GUIDELINE
             NOT FOR PUBLICATION, QUOTATION, OR CITATION




                                                                    AOLngProxPP5
Aorta
Longitudinal Mid (like the 2nd and 4th images in this group)




                                                                    AOLngMidPP1




                                                                    AOLngMidPP2




                                                                    AOLngMidPP3




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AIUM PRACTICE GUIDELINE                                        Abdominal Aorta Ultrasound
           NOT FOR PUBLICATION, QUOTATION, OR CITATION

                                             AOLngM idPP4
Aorta #2053 MidDakota
Longitudinal Distal




                                             AOLngDisPP1




                                             AOLngDisPP2




                                             AOLngDisPP3




                                             AOLngDisPP4




Abdominal Aorta Ultrasound            AIUM PRACTICE GUIDELINE
            NOT FOR PUBLICATION, QUOTATION, OR CITATION

Aorta #2053 MidDakota
Transverse Proximal (near diaphragm)




                                               AOTrvProxPP1




                                               AOTrvProxPP2
Aorta #2053 MidDakota
Transverse Mid




                                               AOTrvMidPP1




                                               AOTrvMidPP2




                                               AOTrvMidPP3

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AIUM PRACTICE GUIDELINE                   Abdominal Aorta Ultrasound
                   NOT FOR PUBLICATION, QUOTATION, OR CITATION




                                                                    AOTrvMidPP4
      Aorta #2053 MidDakota
      Transverse Distal




                                                                    AOTrvDisPP1
      Common Iliac Arteries                                         Image
      Longitudinal proximal
      Common Iliac Arteries #2053 MidDakota
      Transverse proximal just below the bifurcation




                                                                    AOIliacPP1




      Color Doppler Imaging and/or Spectral Doppler of the Aorta    Image and/or videoclip
      Color Doppler Imaging and/or Spectral Doppler of the Common   Image and/or videoclip
      Iliac Arteries
293




      Abdominal Aorta Ultrasound                         AIUM PRACTICE GUIDELINE