Vascular Laboratory Education and Training

Vascular Laboratory Education and Training David L. Dawson, MD, RVT, RPVI Vascular laboratory professionals technologists and physicians have specific knowledge and expertise in the use of non- invasive vascular testing. Entering the profession requires relevant education, training, and clinical experience. There are numerous pathways for this. For individuals initially entering the field, a formal training program is the most common. Vascular Technologist Education and Training Training of vascular technologists (sonographers) can follow any of several different paths. While it was common in the early days of vascular laboratories to recruit staff from nursing or other patient care positions, and then to provide on- the- job training, most vascular technologists enter the field after completion of a prescribed course of study, typically in a degree program. Educational standards for curriculum content have been established by consensus of multiple medical organizations, and are outlined in the National Educational Curriculum (NEC) (www.jrcdms.org). These organizations include, but are not limited to, the American Registry for Diagnostic Medical Sonography (ARDMS) (www.ardms.org), Cardiovascular Credentialing International (CCI) (www.cci- online.org), the Commission on Accreditation of Allied Health Education Programs (CAAHEP) (www.caahep.org), the Joint Review Committee on Education in Diagnostic Medical Sonography (JRC- DMS) (www.jrcdms.org), the Joint Review Committee on Education in Cardiovascular Technology (JRC- CVT) (www.jrccvt.org), and several professional specialty societies. Goals and essential elements of undergraduate educational programs have been outlined in a position paper from the Society for Vascular Ultrasound (SVU): Guidelines for Undergraduate Educational Programs in Vascular Ultrasound (www.svunet.org/advocacy/svupositionpapers). Programs need to prepare students with the cognitive, psychomotor, and affective skills and experience necessary to perform patient s, assess information from ultrasound image and related vascular testing, to report summary findings, and to use independent judgment and systematic problem solving. Vascular ultrasound programs may be based in any a hospital or clinic, a community college or junior college, a four- year college or university, or some other type of post- secondary vocational, technical, or proprietary school. Accreditation through CAAHEP is desirable. Vascular ultrasound education takes 18 months or more of full- time study in a program that includes classroom education, student laboratories, and clinical

experience. The curriculum will cover the range of noninvasive vascular s in sufficient detail for graduates to competently and independently perform complete s on a variety of patients, as well as successfully pass their certification s. Twelve months of supervised clinical experience (approximately 1600 hours) performing vascular testing is typical. Clinical sites should be IAC or ACR accredited. Physician Education and Training There are several education and training pathways that physician may follow to become vascular laboratory professionals. In the past, practicing physicians learned about vascular laboratory topics and acquired interpretation experience through a combination of self- directed learning, continuing medical education (CME) programs, and supervised practical and interpretive experience in an established vascular laboratory. As the vascular laboratory has become an integral part of the care of vascular patients, learning about the use and interpretation of non- invasive vascular tests has become a part of the curriculum of graduate medical education (GME) programs, including cardiology, vascular medicine, radiology, and other specialties. For vascular surgery residencies and fellowships in the US and Canada, vascular laboratory training is a curriculum requirement and the Registered Physician in Vascular Interpretation (RPVI) credential is required by the Vascular Surgery Board of the American Board of Surgery (VSB- ABS) before vascular surgeon may be considered for certification. For their graduates to meet the RPVI prerequisites, GME and other training programs must provide didactic instruction and clinical experience with vascular testing. This includes a course of study to provide knowledge of the techniques, limitations, accuracies, and methods of interpretations of noninvasive vascular s that the physician will interpret. The physician must also acquire supervised practical experience for each area of testing area, which includes observing or participating in testing procedures, and the physician must document experience with supervised interpretation of more than 500 studies that include a broad range of tests and pathology. In the early phases of this experience, direct supervision by a clinical educator is needed. Curriculum Outline Some of what a vascular laboratory physician is expected to know is general information learned in medical school, including anatomy, physiology, and pathophysiology of vascular diseases. Much of the knowledge needed, however, is technical or specific to the evaluation of vascular disorders, beyond the level taught in undergraduate medical education. For this, a curriculum covering core vascular laboratory competencies is needed.

Vascular laboratory competence requires physicians to gain specific medical knowledge in three domains: (1) patient and disease states; (2) physics and instrumentation; and (3) protocols and interpretation criteria. (Tables 2 and 3) While medical school curricula may address vascular anatomy, hemodynamic principles, physiology and pathophysiology, and clinical presentations of vascular diseases, a more advanced level of knowledge is required for vascular laboratory physicians. Topics such as ultrasound physics, operation of vascular laboratory equipment, Doppler principles, and use of ultrasound imaging systems are not general knowledge for most physicians, but must be understood to be able to interpret vascular s. In addition, specific knowledge of how vascular laboratory studies are performed and interpreted is needed. With this foundational knowledge, the vascular laboratory physician provides a patient care service by interpreting vascular laboratory studies. In most cases, this professional service requires evaluation of findings, recognition of artifacts, consideration of patient- specific circumstances, and contextual integration of the available data. (Table 4) This patient care service is provided in each of the areas of testing offered by the vascular laboratory (extracranial cerebrovascular, intracranial cerebrovascular, peripheral arterial, venous, and visceral vascular). The physician and vascular technology have a shared responsibility. The physician should understand the technologist s scope of practice and technical expertise. The technologist needs to provide the physician with images and documentation of findings. Ideally, the organization of the vascular laboratory should allow effective information exchange between team members, and subsequent communication of the findings and interpretation to the requesting provider. (Table 5) Quality assurance (QA) and quality improvement (QI) require the participation and commitment of both the vascular laboratory s medical staff and technical personnel. Patient care can be improved by the staff collaboration in performance reviews and outcomes assessments to confirm the quality and accuracy of the reported data. From the results of internal reviews, as well as recognition of scientific evidence and practice standards, vascular laboratories can implement new testing protocols or revise existing ones. This practice- based learning and improvement leads to better patient care. (Table 6) Physicians are expected to learn and practice to professionalism in their vascular laboratory roles, including of protection of private health information (PHI), prompt reporting of critical findings, and compliance with professional behavioral and performance standards. (Table 7) It is important to learn the important role of vascular laboratory in systems- based practice. This can include systems of information management, as well as systems of care. Modern vascular laboratory practices use informatics systems that function

within larger networks and interface with other systems and users. Understanding how to effectively use these data management systems is essential. (Table 8) Also, because vascular laboratories often functions within systems of health care, effective use of non- invasive vascular testing can provide benefits to patient care with concomitant reductions in the costs of care. Instructional Methods Reading, didactic instruction, and use of online courses can provide important background information, but practical experience in the vascular laboratory is essential. The interpreting physician needs to know the details of the laboratory s work flow, how protocols are implemented, how testing equipment is used, and the steps for creating, modifying, and finalizing reports. In addition, participating in the vascular laboratory provides case- based learning opportunities. While vascular laboratory interpreting physicians do not have to be expert in performing diagnostic studies, a structured experience with forty or more hours of time observing and assisting in s can provide a suitable technical introduction. The educational value of this time will be maximized if there are specific expectations established for instructor and student. A curriculum example is provided in Table 9. This curriculum outlines a series of practical experiences in the vascular laboratory that provide the physician with understanding of: vascular laboratory operations, the scope of practice of the technical staff, how commonly requested studies are performed, and an introduction to the techniques used in the conduct of specific s. Educational program directors and vascular laboratories may use this, or a similar curriculum, to specify their goals and objectives for learners, as well as the specific actions expected of the instructor and learner in each session. Educational Milestones for Learners Milestones based on the concepts used by the Accreditation Council for Graduate Medical Education (ACGME) for assessing progression through residency training can be developed to evaluation physician s progression through training in the vascular laboratory. (Table 10) Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies, organized in a developmental framework from less to more advanced. They are descriptors and targets for performance as a trainees move from entry level through completion of their educational program. Tracking from Level 1 to Level 5 is synonymous with moving from novice to expert, though these levels do not correspond with specific periods of education. Milestones for progression for novice (medical school graduate) to advanced vascular laboratory physician (appropriate for medical director of an accredited

vascular laboratory) are listed in Table 11. Table 12 provides summary of milestones specific to vascular laboratory sub- competencies. Table 1 Accreditation Council for Graduate Medical Education (ACGME) Core Competencies Patient Care Medical Knowledge Practice- Based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems- Based Practice Identify, respect, and care about patients differences, values, preferences, and expressed needs; listen to, clearly inform, communicate with and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health. Established and evolving biomedical, clinical, and cognate sciences, and the application of knowledge to patient care. Investigation and evaluation of patient care provided, appraisal and assimilation of scientific evidence, and improvements in patient care. Effective information exchange and teaming with patients, families, and other health professionals. Carrying out professional responsibilities, adherence to ethical principles and sensitivity to a diverse patient population. Awareness of and responsiveness to the larger context and system of health care and the ability to effectively use resources to provide care of optimal value.

Table 2 Medical Knowledge Patient and Disease States Normal anatomy, physiology, and hemodynamics (cerebrovascular, venous, peripheral arterial, abdominal visceral) Vascular pathology and pathophysiology (cerebrovascular, venous, peripheral arterial, abdominal visceral) Ultrasound Physics Continuous wave and pulse wave Doppler Pressure measurements B- mode imaging Color Doppler Instrumentation and Equipment Examination facilities and patient care equipment Duplex ultrasound scanner Continuous wave and pulse wave Doppler Photoplethysmography (PPG) Testing Protocols and Interpretation criteria Transducer selection Patient safety and bioeffects Image assessment of vascular anatomy and pathology Vessel measurement Power Doppler Plethysmography Velocity and velocity ratio criteria Ultrasound contrast agents Laser Doppler Transcutaneous PO 2 Waveform assessment Pressure indices Waveform indices (resistive index, pulsatility index) Provocative maneuvers Volume flow measurements Reflux testing

Table 3 Patient Care (Elements of Interpretation of Vascular Laboratory Examinations) Common Elements Incorporate clinical indications in study interpretation Incorporate physiologic and anatomic findings in interpretation Assess quality, accuracy, and completeness Individual Examination Evaluation Identify and report on incidental findings Incorporate comparison of present study with prior testing Modify interpretation of tests due to anatomic or medical conditions Modify interpretation of tests due to technical limitations (e.g., artifacts)

Table 4 Patient Care (Types of Vascular Laboratory Examinations) Basic Examinations Advanced Diagnostic Examinations Procedure planning, guidance, monitoring and assessment Surveillance and Follow- up Examinations Extracranial carotid and vertebral arteries Transcranial Doppler (TCD) and transcranial duplex Transcranial Doppler monitoring for carotid interventions Carotid endarterectomy and stenting Aortoiliac and lower extremity arterial duplex scanning Mesenteric, portal, and hepatic veins Cardiovascular risk assessment Infrainguinal bypass grafts Lower extremity arteries - indirect physiologic assessment Pelvic venous insufficiency Vascular access Peripheral artery interventions Noninvasive diagnosis of upper extremity arterial disease Trauma Preoperative vein mapping Aortic endografts Aortic and peripheral artery aneurysms Venous ablation Dialysis access Lower extremity venous thrombosis Intraoperative evaluation of arterial repairs Organ transplantation Upper extremity venous thrombosis Intravascular ultrasound and physiologic assessment Chronic venous insufficiency Evaluation and treatment of femoral pseudoaneurysms Mesenteric arteries Dialysis access planning Renal arteries Radial artery evaluation prior to coronary artery bypass grafts Duplex scanning prior to fibula free flap transfers Duplex scanning prior to procedures for breast reconstruction

Table 5 Communication and Reporting Preliminary and final reports Communicate critical findings to referring practitioner Table 6 Practice- Based Learning and Improvement Quality assurance Quality improvement Outcomes reporting Test validation and revision Facility accreditation Credentialing and certification Table 7 Professionalism Compliance with vascular laboratory and institutional policies Protection of protected health information (PHI) Table 8 Systems- Based Practice Evidence- based practice Use of practice guidelines Use of Picture Archiving and Communication System (PACS) Use of electronic health record and reporting

Table 9. Vascular Laboratory Practical Instruction Program for Physician Learner Completion Standards 1. Vascular Laboratory Operations and Instrumentation Learner Identify steps in ordering, conducting, and reporting vascular laboratory s Use appropriate steps to ensure patient and staff safety Become familiar with basic principles and operation of an ultrasound duplex scanner Know required and expected elements and format for vascular laboratory reports Provide orientation to vascular laboratory facilities and equipment Describe vascular laboratory staffing Discuss training and scope of practice of vascular technologists List roles and responsibilities of vascular laboratory technologists and support staff Demonstrate steps in vascular workflow Identify and describe components of duplex scanner, including user interfaces, transducers, and displays Guide learner in set up of duplex scanner, including loading correct patient and from work list, selection of appropriate transducer and presets, and initiation of appropriate protocol (if applicable) Demonstrate professionalism interacting with patients and vascular laboratory staff Use appropriate hand hygiene and Universal Precautions set up duplex scanner and prepare patient for vascular study send images to PACS and create preliminary report Learn the steps required to open preliminary report, add interpretation, finalize, and create addenda Use electronic entry to submit an order for an in the vascular laboratory Demonstrate the steps to created an addendum to a final report Access a preliminary report Demonstrate the steps to add a physician impression to a preliminary report laboratory standards Direct learner through steps required to send images to PACS and create preliminary report Show steps for adding impressions to preliminary reports and adding an addendum to a final report Discuss procedures for final review of reported s used to identify errors or

discrepancies 2. Cerebrovascular: Extracranial Understand steps to evaluate patients referred for cerebrovascular s Learn methods of carotid artery and vertebral artery evaluation with duplex scanning Identify primary adjustments in displayed B- mode images, color Doppler images, and Doppler velocity waveforms Demonstrate duplex scanner set up for cerebrovascular evaluation Discuss patient and examiner positioning for proper ergonomics Demonstrate transducer orientation and use Guide learner in basic system operation to optimize depth, focal zones, gain, and other imaging controls Demonstrate color Doppler and power Doppler use and adjustments Guide learner in adjusting Doppler sample volume positioning, Doppler gain, pulse repetition frequency, baseline position, and other Doppler controls Discuss common imaging artifacts and pitfalls encountered Learner Review history and indications for of patients to be evaluated Measure and record bilateral brachial blood pressures Evaluate for carotid and supraclavicular bruits prepare and position patient for duplex scan Observe basic imaging techniques for cerebrovascular As directed, adjust imaging and Doppler controls With direct guidance, perform unilateral of carotid artery, vertebral, and subclavian arteries send images to PACS and create preliminary report of extracranial cerebrovascular Set up duplex scanner for extracranial cerebrovascular Acquire and record cine loop of sweep of carotid artery in transverse view Acquire and record B- mode images of common, external, and internal carotid arteries, vertebral artery, subclavian artery acquire and record color Doppler images and velocity waveforms from common, external, and internal carotid arteries, vertebral artery, subclavian artery Transmit images from duplex scanner to PACS Generate preliminary report laboratory standards for cerebrovascular testing 3. Peripheral Venous: Deep Vein Thrombosis Identify normal and abnormal venous anatomy Describe venous hemodynamic principles Recognize the clinical Supervise learner s preparation and patient positioning for venous Learner Review history and indications for of patients to be evaluated Evaluate extremities Set up duplex scanner for extremity venous Identify vessels on recorded B- mode

significance of venous thromboembolism (VTE) Understand the role of ultrasound duplex scanning for diagnosis of deep vein thrombosis Guide learner though steps for set up of duplex scanner for venous evaluation Discuss transducer selection for superficial and deep vessel s Demonstrate transducer orientation and use Guide learner in basics system operation, image adjustment, use of color and pulsed Doppler controls Review additional duplex scan controls that alter preset image acquisition and image processing Demonstrate performance of lower extremity venous duplex scan Demonstrate imaging of the inferior vena cava and iliac veins Guide learner in acquisition of venous images for signs of venous disease Prepare and position patient for duplex scan Observe basic imaging techniques for venous duplex scan As directed, adjust imaging and Doppler controls measure vessel diameter using system measurement tools With direct guidance, perform unilateral of femoral and popliteal veins and great saphenous vein send images to PACS and create preliminary report of venous images of iliac veins and the inferior vena cava and use system tools to measure inferior vena cava diameter Acquire and record cine loop images of deep and superficial veins, with and without compression Acquire and record color Doppler images and velocity waveforms from deep and superficial veins without and with augmentation maneuvers Transmit images from duplex scanner to PACS Generate preliminary report laboratory standards for venous testing Discuss pitfalls and technical limitations of venous duplex scanning 4. Peripheral Venous: Evaluation of Venous Insufficiency Characterize chronic venous disease using CEAP reporting criteria Understand the role of venous duplex scanning for the evaluation of venous insufficiency and the testing methods used for assessing competence of venous valves Use standing reflux with automated release of limb cuffs to Assist learner in preparation and positioning of patient for venous reflux Guide learner though steps of positioning, applying, and using pneumatic cuffs Guide learner in basics system operation, image Learner Review history and indications for of patients to be evaluated Evaluate extremities for signs of venous disease Prepare and position patient recumbent and upright for duplex scan to evaluate for venous Acquire and record cine loop and static images of deep and superficial veins, prior to and after cuff release Measure reflux time for each segment evaluated Transmit images from duplex scanner to

evaluated venous segments for valvular competence adjustment, use of color and pulsed Doppler controls Demonstrate performance of lower extremity venous reflux Discuss worksheet use and record preliminary observations and findings Guide learner in recording of venous images Discuss pitfalls and technical limitations of venous reflux reflux Observe basic imaging techniques for venous duplex scan As directed, adjust imaging and Doppler controls measure vein valve closure time (reflux time) using system measurement tools With direct guidance, perform unilateral reflux of femoral and popliteal veins and great saphenous vein at the saphenofemoral junction and in the mid- thigh PACS Generate preliminary report Correctly classify lower extremity venous disease using CEAP classification laboratory standard send images to PACS and create preliminary report of venous 5. Peripheral Arterial: Physiologic Testing Understand physiologic (indirect) testing methods used for evaluation of lower extremity arterial disease Use results of physiologic testing, in combination with history and physical findings, to diagnose and assess the severity of peripheral artery disease (PAD) Recognize artifacts in measured of limb blood pressure that result from medial calcinosis or other test limitations Distinguish ischemic symptoms from non- vascular Review the diagnostic equipment used in the vascular laboratory for arterial testing, including physiologic testing system (segmental pressures), treadmill, and laser Doppler skin perfusion pressure measurement system Demonstrate use of Doppler flow detector (and settings), pneumoplethysmograph, photoplethysmograph, chart recorder, cuff inflator, and remote Learner Review patient history, indications for, and performed complete lower extremity pulse and assess for bruits Measure ankle/brachial indices As directed, apply segmental cuffs to both lower extremities Use CW Doppler probe to obtain Doppler waveforms at each level perform segmental Obtain Doppler signals from lower extremity arteries at multiple levels Measure pressures and calculate ankle/brachial indices Generate preliminary report in RIS laboratory standards for peripheral arterial physiologic testing

causes of lower extremity pain control Supervise learner s preparation and positioning of patient for lower extremity arterial Assist learner in application of cuffs for and demonstrate set up of system Direct learner in acquisition of Doppler waveforms Demonstrate operation of treadmill and instruct patient in conduct of treadmill test Perform treadmill exercise test, with learner assisting Demonstrate, if applicable, use of laser Doppler skin perfusion measurement system Discuss pitfalls and technical limitations of arterial indirect testing pressure measurement acquire segmental pulse volume recordings Measure limb pressures prior to and after exercise on treadmill send study to PACS and create preliminary report of arterial 6. Peripheral Arterial: Native Vessel and Graft Duplex Scanning Understand role of duplex scanning for evaluation of peripheral arteries and grafts Learn the methods of peripheral artery and graft evaluation with duplex scanning Use system controls to adjust displayed B- mode images, color Doppler images, and Doppler velocity waveforms Demonstrate duplex scanner set up for peripheral arterial evaluation Discuss patient and examiner positioning for proper ergonomics Demonstrate transducer orientation and use Provide direction, as required, for learner to operate system controls to optimize depth, focal zones, gain, and other imaging controls Learner Review history and indications for of patients to be evaluated Examine extremity pulses, auscultate for bruits, evaluate extremities for signs of arterial disease and prior operations Prepare and position patient recumbent and upright for arterial duplex scan Observe scanning techniques used for peripheral artery Set up duplex scanner for peripheral arterial Acquire and record images of common femoral, deep femoral, superficial femoral, popliteal, and tibioperoneal arteries If applicable, acquire and record images of graft anastomoses and conduit laboratory standards

Guide learner s adjustments of color Doppler Guide learner in adjusting Doppler sample volume positioning, Doppler gain, pulse repetition frequency, baseline position, and other Doppler controls Discuss common imaging artifacts and pitfalls encountered with peripheral arterial s duplex scan adjust imaging and Doppler controls measure arterial diameters using system measurement tools send images to PACS and create preliminary report of peripheral arterial 7. Abdominal Vascular Evaluation: Aorta and Iliac Testing Understand the relationships between transducer frequency and imaging depth, and the effects of depth on spatial and temporal resolution, imaging frame rate, and ultrasound focus Use ultrasound B- mode imaging to identify abdominal vascular and anatomic landmarks Describe the role of ultrasound screening and techniques used for detection of abdominal aortic aneurysms Use ultrasound duplex scanning to detect and characterized the severity of arterial occlusive disease Understand the role of duplex scanning for follow up after endovascular aortic aneurysm repair (EVAR) Discuss patient and examiner positioning for proper ergonomics Demonstrate duplex scanner set up for abdominal vascular testing Demonstrate transducer selection, orientation and use Compare imaging characteristics of high frequency transducer for imaging of superficial structures and low frequency transducer for deeper structures Guide learner in performing imaging survey of the abdomen Guide learner s adjustments of color Doppler controls Guide learner in adjusting Doppler sample volume positioning, Doppler gain, pulse repetition frequency, baseline Learner Evaluate the patient prior to performing ultrasound Review previous studies, if available to make comparisons to the current study Review patient history, including prior operations or endovascular procedures, arterial disease risk factors, smoking status Review for symptoms of aortoiliac disease, aneurysmal or occlusive disease, including back pain, increased pulsation of abdomen, groin, or popliteal fossa; signs of distal emboli, claudication. Examine extremity pulses, auscultate for bruits, evaluate extremities for signs of arterial disease and Set up duplex scanner for abdominal vascular Acquire and record images of the liver, gall bladder, hepatorenal fossa, spleen, right kidney, and left kidney Acquire and record images of the aorta, including longitudinal view and transverse views at the level of the renal arteries, mid abdominal aorta, and aortic bifurcation As directed, acquire and record color Doppler images and velocity waveforms from representative aortoiliac segments Transmit images from duplex scanner to PACS Generate preliminary report

position, and other pulsed Doppler controls Discuss common imaging artifacts and pitfalls encountered with abdominal arterial s Review protocol for post- EVAR prior operations Measure and record ankle/brachial index (ABI) Verify the requested is appropriate for the patient With guidance, perform imaging survey of the abdomen Image and measure the abdominal aorta Assist technologist s conduct of aortoiliac or post- EVAR, adjusting imaging and Doppler settings, as directed measure aorta and iliac artery diameters using measurement tools laboratory standards for abdominal vascular testing 8. Abdominal Vascular: Renal and Mesenteric Understand the role of the vascular laboratory for diagnosis and follow up of renal and mesenteric artery occlusive disease Use ultrasound duplex scanning to detect and characterized the severity of visceral arterial occlusive disease Understand the role of duplex scanning for follow up after endovascular and surgical treatment of branches of the abdominal aorta Recognize limitations inherent in use of ultrasound for evaluation of visceral vessels Discuss patient and examiner positioning for proper ergonomics Assist in transducer selection and duplex scanner set up for abdominal vascular testing Review protocol for visceral arterial studies Perform renal and mesenteric duplex scan, describing observations features of the and Guide learner in performing imaging survey of the abdomen Learner Evaluate the patient prior to performing ultrasound Verify the requested is appropriate for the patient With guidance, perform imaging survey of the abdomen Image and measure the abdominal aorta Assist technologist s conduct of renal and mesenteric, adjusting imaging and Doppler settings, as directed Set up duplex scanner for visceral vascular Acquire and record images of the renal and mesenteric arteries as the technologist scans As directed, acquire and record color Doppler images and velocity waveforms from representative aortoiliac segments Transmit images from duplex scanner to PACS Generate preliminary report Guide learner s adjustments of image, measure length of

color Doppler, and pulsed Doppler Guide learner in adjusting Doppler sample volume positioning, Doppler gain, pulse repetition frequency, baseline position, and other Doppler controls Discuss common imaging artifacts and pitfalls encountered with visceral arterial s kidneys using measurement tools laboratory standards for visceral artery evaluation 9. Peripheral Vascular Evaluation: Specialized Applications Preoperative Vessel Mapping Understand the role of the vascular laboratory for preoperative assessment and procedure planning Identify superficial and deep vessels for preoperative assessment (vein bypass, dialysis access procedures, radial artery evaluation prior to coronary artery bypass, fibular free flap, or breast reconstruction) Review specialized testing applications offered in the vascular laboratory and discuss importance of communication with the surgeon Discuss techniques for surface marking and documentation of findings in preliminary report Review details of protocol to be used for specific test Assist learner, as needed, in measurement of pressures and recording of plethysmographic waveforms, if these are part of the to be performed Demonstrate imaging components of specialized testing application Learner Evaluate the patient prior to performing ultrasound Confirm that the requested is appropriate for the patient Determine tests needed for patient evaluation and review applicable vascular laboratory policy and procedure documents perform physiologic (indirect) tests, if these are required components of the evaluation to be performed Assist technologist in the conduct and documentation of imaging components of the Set up testing equipment to be used for specified If indicated, complete indirect components of the If indicated, mark surface of skin to localize mapped vascular structures Transmit images from duplex scanner to PACS laboratory standards

10. Vascular Lab Accreditation and Quality Assurance Understand the purpose of vascular laboratory accreditation and the requirements to gain and maintain accreditation Identify methods used to maintain consistency in reporting, identify and correct errors, and confirm accuracy of vascular laboratory exams Use calculations of specificity, sensitivity, predictive value, and accuracy to describe the results of a diagnostic test in comparison with a reference standard Review the vascular laboratory quality control (QC) policies for ultrasound imaging and physiologic testing systems Review the vascular laboratory quality assurance (QA) processes Review the vascular laboratory continuous quality improvement (CQI) processes Learner Perform quality assurance steps on a minimum of ten s Assist in preparation of cases for vascular laboratory CQI meeting Review ARDMS PVI application requirements and content outline laboratory standards Understand the ARDMS certification processes for vascular technologists and interpreting physicians, including prerequisites for RPVI application

Table 10 Milestones for Physician Education in Vascular Laboratory Competencies Level 1: The physician demonstrates milestones expected of medical school graduate with basic knowledge of vascular anatomy and physiology. Level 2: The physician is advancing and demonstrates additional milestones, but with performance less than expected for mid- level trainee. Level 3: The physician continues to advance and demonstrate additional milestones, consistently including the majority of milestones targeted for training. Level 4: The physician has advanced so that he or she now substantially demonstrates the milestones targeted for training. A minimally competent vascular laboratory physician is at this level (e.g. new medical staff of an accredited vascular laboratory). Level 5: The physician has advanced beyond performance targets set for initial vascular laboratory training and is demonstrating aspirational goals, which might describe the performance of someone who has been in practice at an advanced level (medical director of a vascular laboratory). It is expected that only a few exceptional physicians will reach this level during training. Table 11 Vascular Laboratory Milestones