Peripheral Arterial 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 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 in the event of medical emergencies?
Oxygen/airway
Emergency drugs
Defibrillator
Fully-equipped crash cart
Medical physician
Registered nurse
In the initial evaluation for lower extremity peripheral arterial disease which of the following are
routinely performed as your primary examination?
Multi-level segmental pressures and multi-level waveforms
CW Doppler waveforms
PVR waveforms
Pulsed wave Doppler waveforms
Ankle brachial index (ABI) with multi-level waveforms
CW Doppler waveforms
PVR waveforms
Pulsed wave Doppler waveforms
Complete Arterial Duplex with ABI
Peripheral Arterial Testing Section (Add On)
Reviewed 5/2015
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Indications (Applicable Standard – 3.1B)
Are appropriate indications for the examination documented prior to performing the examination?
Yes
No
If no, please explain:
Equipment (Applicable Standard – 3.2B)
Extremity segmental pressures:
1. Does the equipment include cuffs of varying width?
Yes
No
2. Does the equipment include directional blood flow meters?
Yes
No
3. Does the equipment include a Doppler transducer frequency of 3 MHz or greater?
Yes
No
4. Does the equipment include a bidirectional Doppler waveform display?
Yes
No
5. Does the equipment include an audible output and permanent recording of the Doppler waveform?
Yes
No
Segmental limb air plethysmography:
1. Is the equipment capable of measuring small segmental volume changes and providing permanent
recordings?
Yes
No
2. Does the equipment supply appropriately sized pneumatic cuffs?
Yes
No
3. Does the equipment provide standardization of inflation pressure?
Yes
No
Duplex examination:
1. Does the equipment provide color Doppler capability?
Yes
No
2. Does the equipment provide a range of imaging frequencies appropriate for the structures evaluated?
Yes
No
Peripheral Arterial Testing Section (Add On)
Reviewed 5/2015
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3. Does the equipment provide Doppler frequencies appropriate for the vessels evaluated?
Yes
No
4. Does the equipment provide range-gated Doppler capability?
Yes
No
5. Does the equipment provide a measureable and adjustable Doppler angle?
Yes
No
6. Does the equipment provide a visual display, audible output, and permanent recording capabilities?
Yes
No
Protocol and Diagnostic Criteria for the Primary examination selected above:
(Applicable Standards – 3.3B/3.4A)
 Lower extremity multi-level segmental pressures and multi-level waveforms:
Protocol:
Criteria:
Attached
Attached
N/A
N/A
 ABI with multi-level waveforms:
Protocol:
Criteria:
Attached
Attached
N/A
N/A
 Complete arterial duplex with ABI:
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 30 extremity correlations, demonstrating greater than 70% accuracy.
(Visit intersocietal.org/vascular/seeking/sample_documents.htm to download a sample log.)
Attached
Select from the list below what arterial examinations are correlated to:
Contrast angiography
Contrast enhanced computed tomography (CTA)
Magnetic resonance angiography (MRA)
Surgical findings
Peripheral Arterial Testing Section (Add On)
Reviewed 5/2015
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Enter the overall accuracy percentage of the appropriate validating studies:
Procedure Volumes (Applicable Standard – 3.9B)
Enter the volumes for the examinations performed in the facility within the past 12 operational months.
Include in the total, all volumes from any multisite 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 peripheral arterial services:
2. Multi-level segmental pressures and multi-level waveforms annual volumes:
3. ABI with multi-level waveforms annual volumes:
4. Lower extremity arterial duplex and ABI annual volumes :
Peripheral Arterial Testing Section (Add On)
Reviewed 5/2015
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Peripheral Arterial 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 bilateral
testing and abnormal of varying degrees of pathology. If duplex testing is submitted, case studies must
demonstrate >50% stenosis. Two primary testing case studies must be submitted and if performed, the
third case study must be chosen from the list below:
Upper extremity arterial duplex (bilateral)
Abdominal aorta duplex
Bypass graft duplex
Lower extremity arterial duplex (if not primary) (bilateral)
Lower extremity physiologic (if not primary) (bilateral)
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.
Peripheral Arterial Testing Section (Add On)
Reviewed 5/2015
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