Visceral Vascular Testing Section (Add On)
This form is to be used for add on testing sections for accredited IAC Vascular Testing facilities only. If your facility is not currently accredited or is in the review process, please contact the IAC office before filling out this form.
Please answer all questions. Required attachments will be indicated by the 2 symbol.
Name of institution (as listed in the IAC Accreditation Agreement):
(This institution name will be tracked in the IAC database and will receive all IAC correspondence)
Application #:
Department:
Street address 1:
Street address 2:
City: State: Zip code:
Location of vascular facility:
Hospital
Private office
Free-standing imaging center
Independent facility
Other (please specify):
In the initial evaluation for visceral vascular disease which of the following are routinely performed as your primary examination?
Mesenteric artery duplex
Renal vasculature duplex
Hepatoportal system duplex
Renal transplant duplex
Liver transplant duplex
Indications
Are appropriate indications for the examination documented prior to performing the examination?
Yes No
If no, please explain:
Equipment
Does the equipment used in the performance of visceral vascular duplex examinations include:
1. Color flow Doppler capability?
Yes No
2. A range of imaging frequencies appropriate for the structures to be evaluated?
Yes No
3. Doppler frequencies appropriate for the vessels evaluated?
Yes No
4. Range-gated spectral Doppler with the ability to adjust the depth and position?
Yes No
5. A measureable and adjustable Doppler angle?
Yes No
6. A visual display, audible output, and permanent recording capabilities?
Yes No
Protocols and Diagnostic Criteria
2 Submit a detailed technical protocol and referenced diagnostic criteria for the primary testing.
Protocol: Attached
Criteria: Attached
Visceral Vascular Case Study Instructions
Case study submissions are required in order to assess the interpretative and technical quality of the facility.
· The IAC is HIPAA compliant; do not remove identifying information from the case study materials.
· Cases must represent best work.
· All cases must be selected from within the past 12 months from the date of application filing.
· All cases must be abnormal of varying degrees of pathology.
· The Technical Director and Medical Director must be represented.
· Cases must represent as many staff as possible. When selecting and submitting case studies, do not duplicate staff members (medical and technical) until all staff have been represented at least once.
· All cases must be submitted in digital format (CD, DVD, flash drive) including the embedded image-specific reader (DICOM viewer).
· Label all media with patients’ names or identification, and testing section.
· Submit one copy of the application, all documents, case study images/worksheets and the final reports to the IAC office.
Case Study Submission Requirements
Primary Site Case Study Submission Requirements (if an application includes only one site):
· Primary Examination |Submit a total of three representative patient examinations; all must be abnormal of varying degrees of pathology. If renal artery duplex is primary, case studies must document >60% stenosis.
*Two primary testing case studies must be submitted and if performed, the third case study must be chosen from the list below:
Mesenteric duplex (if not primary)
Hepatoportal duplex (if not primary)
Renal artery duplex (if not primary) (bilateral)
Renal transplant duplex (if not primary)
Liver transplant duplex (if not primary)
Abdominal aorta duplex (Comment: This exam is only an option in one testing area and cannot be submitted if already submitted in the Peripheral Arterial application)
If no additional testing is performed, submit a third primary case study.
Additional Testing: If performed, submit a detailed technical protocol and referenced diagnostic criteria for the third case study chosen above.
Protocol: Attached N/A
Criteria: Attached N/A
Multiple Site Case Study Submission Requirements (if an application includes one or more multiple sites):
· Primary Examination | Submit one abnormal case as noted for primary testing above.
Visceral Vascular Testing Section (Add On) 1
Reviewed 4/2016