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.
If this is a screening service applying in accreditation of medical screening (CAMS), please contact the
IAC office before filling out this form.
Please answer all questions. Required attachments will be indicated by the  symbol.
Name of institution (as listed in the 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):
Which of the following are available to deal with medical emergencies?
Oxygen/airway
Emergency drugs
Defibrillator
Fully-equipped crash cart
Medical physician
Registered nurse
In the initial evaluation for intracranial cerebrovascular 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
Visceral Vascular Testing Section (Add On)
Reviewed 5/2015
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Indications (Applicable Standard – 5.1B)
Are appropriate indications for the examination documented prior to performing the examination
Yes
No
If no, please explain:
Equipment (Applicable Standard – 5.2B)
Visceral vascular duplex – Does the equipment provide:
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 (Applicable Standards – 5.3B/3.4A)
 Mesenteric arterial system duplex examination: If performed submit a detailed technical protocol
and referenced diagnostic criteria.
Protocol:
Criteria:
Attached
Attached
N/A
N/A
 Hepatoportal system duplex examination: If performed submit a detailed technical protocol and
referenced diagnostic criteria.
Protocol:
Criteria:
Attached
Attached
N/A
N/A
 Renal vasculature duplex examination: If performed submit a detailed technical protocol and
referenced diagnostic criteria.
Protocol:
Criteria:
Attached
Attached
Visceral Vascular Testing Section (Add On)
Reviewed 5/2015
N/A
N/A
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 Renal transplant duplex examination: If performed submit a detailed technical protocol and
referenced diagnostic criteria.
Protocol:
Criteria:
Attached
Attached
N/A
N/A
 Liver transplant duplex examination: If performed submit a detailed technical protocol and
referenced diagnostic criteria.
Protocol:
Criteria:
Attached
Attached
N/A
N/A
Quality Improvement (QI) (Applicable Standard – 1.1C)
 QI Policy: Submit a copy of the facility QI policy.
Attached
 QI Log: Submit the QI log including data collected over the past three years documenting a
minimum of 15 patient examinations, demonstrating greater than 70% accuracy.
(Visit intersocietal.org/vascular/seeking/sample_documents.htm to download a sample log.)
Policy:
Attached
Select from the list below what visceral vascular arterial examinations are correlated to:
Contrast angiography
Contrast enhanced computed tomography (CTA)
Magnetic resonance angiography (MRA)
Surgical findings
Enter the overall accuracy percentage of the appropriate validating studies:
Procedure Volumes (Applicable Standard – 5.7B)
Enter the volumes for the examinations performed in the facility within the past 12 operational months.
Include in the total, all volumes from any multi-site and mobile services, if applicable. If the facility has
been in operation less than 12 months, volumes must still be entered.
1. Number of years that the facility has been performing visceral vascular examinations:
2. Mesenteric arterial system annual volumes:
3. Hepatoportal system annual volumes:
4. Renal vasculature annual volumes:
5. Renal transplant annual volumes:
6. Liver transplant duplex annual volumes:
7. Abdominal aortic duplex annual volumes:
Visceral Vascular Testing Section (Add On)
Reviewed 5/2015
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Visceral Vascular Case Study Instructions
Case study submissions are required in order to assess the interpretative and technical quality of the
facility. All of the details of the vascular anatomy should be visualized adequately.
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Cases must represent best work
All cases must be abnormal of varying degrees of pathology
All medical and technical staff must be represented at least once before repeating
The Technical Director and Medical Director must be represented
All cases must be selected from within the past 12 months from the date of application filing
Submit one copy of all case studies/case study materials to the IAC office afterfinal submission.
Label all media with patients’ names or identification, and testing section.
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).
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 Peripheral Arterial)
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:
Criteria:
Attached
Attached
N/A
N/A
Multiple Site Case Study Submission Requirements (if an application includes one or more multiple
sites):

Primary Examination | Submit one abnormal case for each testing section the facility is apply in.
Visceral Vascular Testing Section (Add On)
Reviewed 5/2015
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