MRA (Magnetic Resonance Angiogram) Lower Extremity 73725

1 Major Symptom or Complaint presented as primary indication

1.1 Aching pain in extremity, relieved by rest

1.1.1 Suspected Peripheral Arterial Disease

1.2 Bleeding

1.2.1 Suspected AVM

1.3 Claudication

1.3.1 cramping pains caused by poor circulation of the blood to the muscles during exercise. True claudication is relieved with rest from exercise.

1.4 Erectile dysfunction

1.4.1 Peripheral arterial disease suspected

1.5 Leriche syndrome

1.5.1 Leriche syndrome, a clinical triad of intermittent claudication involving the low back, buttocks, hip or thigh, impotency (which occurs in 30 to 50 percent of males with aortoiliac occlusive disease), and “global atrophy” of the lower extremities, reflecting the chronicity of low-grade ischemia.

1.5.1.1 Leriche R, Morel A. The syndrome of thrombotic obliteration of the aortic bifurcation. Ann Surg. 1948;127:193-204.

1.5.2 Peripheral arterial disease suspected

1.9.2.1 Hurst’s The Heart 11th Edition Valentin Fuster, R. Wayne Alexander, and Robert A. O’Rourke, Eds.; Copyright ©2006 The McGraw-Hill Companies. Chapterr 101. Diagnosis and Management of Diseases of the Peripheral Arteries and Veins Paul W. Wennberg, Thom W. Rooke

1.9.2.2 Emile R. Mohler, III; Peripheral Arterial Disease: Identification and Implications; Arch Intern Med 2003 163: 2306-2314

1.9.2.3 White, Robert I., Jr, Pollak, Jeffrey, Persing, John, Henderson, Katharine J., Thomson, J. Grant, Burdge, Catherine M. Long-Term Outcome of Embolotherapy and Surgery for High-Flow Extremity Arteriovenous Malformations J Vasc Interv Radiol 2000 11: 1285-129

1.9.2.4 Schwartz’s Principles of Surgery, 8th Edition F. Charles Brunicardi, et al Copyright © 2005, The McGraw-Hill Companies, Inc.Chapter 15. Skin and Subcutaneous Tissue Scott L. Hansen, Stephen J. Mathes, David M. Young

1.9.2.5 Albrecht, Thomas, Foert, Ellen, Holtkamp, Robin, Kirchin, Miles A., Ribbe, Constanze, Wacker, Frank K., Kruschewski, Martin, Meyer, Bernhard C. 16-MDCT Angiography of Aortoiliac and Lower Extremity Arteries: Comparison with Digital Subtraction Angiography Am. J. Roentgenol. 2007 189: 702-711

2 Working Diagnosis or Rule Out presented as primary indication

2.1 AVM Arteriovenous Malformation Suspected

2.1.1 Bleeding

2.1.2 Localized skin discoloration

2.1.3 Pain

2.1.4 Palpable subcutaneous thrill

2.1.5 Ulceration

2.1.6 References

2.1.6.1 White, Robert I., Jr, Pollak, Jeffrey, Persing, John, Henderson, Katharine J., Thomson, J. Grant, Burdge, Catherine M. Long-Term Outcome of Embolotherapy and Surgery for High-Flow Extremity Arteriovenous Malformations J Vasc Interv Radiol 2000 11: 1285-1295

2.1.6.2 Schwartz’s Principles of Surgery, 8th Edition F. Charles Brunicardi, et al Copyright © 2005, The McGraw-Hill Companies, Inc.Chapter 15. Skin and Subcutaneous Tissue Scott L. Hansen, Stephen J. Mathes, David M. Young

2.2 Peripheral Arterial Disease Suspected

2.2.1.1 ABI<0.9

2.2.2 Risk Factors ONE

2.2.2.1 Diabetes

2.2.2.2 Hypercholesterolemia

2.2.2.3 Smoker

2.2.3 Symptoms or Findings ONE

2.2.3.1 Aching Pain in extremity relieved by rest

2.2.3.2 Asymmetric Blood Pressure in Arms

2.2.3.3 Asymmetric Pulses

2.2.3.4 Bruit

2.2.3.5 Palpable Arterial Thrill

2.2.3.6 Positive or Suspicious Doppler exam

2.2.4 References:

2.2.4.1 Hurst’s The Heart 11th Edition Valentin Fuster, R. Wayne Alexander, and Robert A. O’Rourke, Eds.; Copyright ©2006 The McGraw-Hill Companies. Chapterr 101. Diagnosis and Management of Diseases of the Peripheral Arteries and Veins Paul W. Wennberg, Thom W. Rooke

2.2.4.2 Emile R. Mohler, III; Peripheral Arterial Disease: Identification and Implications; Arch Intern Med 2003 163: 2306-2314

3 Abnormal Physical Exam Finding presented as primary indication

3.1 Absent or diminished peripheral pulses

3.1.1 Suspected Peripheral Arterial Disease

3.2 Ankle-brachial index (ABI) below 0.9

3.2.1 The ankle-brachial index (ABI) is calculated by measuring the systolic blood pressure in the brachial, posterior tibial, and dorsalis pedis arteries. The highest measurement in the ankles and feet is divided by the higher of the brachial measurements:

3.2.1.1 The normal ABI is 1.0 to as high as 1.3

3.2.1.2 An ABI below 0.9 indicates peripheral arterial disease. The lower the index the more severe the changes

3.3 Arterial bruit

3.3.1 Suspected Peripheral Arterial Disease

3.4 Asymmetric blood pressure

3.4.1 Suspected Peripheral Arterial Disease

3.5 Asymmetric pulses

3.5.1 Suspected Peripheral Arterial Disease

3.6 Localized skin discoloration

3.6.1 Suspected AVM

3.7 Palpable subcutaneous thrill

3.7.1 Suspected AVM

3.8 Pulsatile mass

3.8.1 Suspected AVM

3.9 Ulceration

3.9.1 Suspected AVM

3.9.2 References:

3.9.2.1 Hurst’s The Heart 11th Edition Valentin Fuster, R. Wayne Alexander, and Robert A. O’Rourke, Eds.; Copyright ©2006 The McGraw-Hill Companies. Chapterr 101. Diagnosis and Management of Diseases of the Peripheral Arteries and Veins Paul W. Wennberg, Thom W. Rooke

3.9.2.2 Emile R. Mohler, III; Peripheral Arterial Disease: Identification and Implications; Arch Intern Med 2003 163: 2306-2314

3.9.2.3 White, Robert I., Jr, Pollak, Jeffrey, Persing, John, Henderson, Katharine J., Thomson, J. Grant, Burdge, Catherine M. Long-Term Outcome of Embolotherapy and Surgery for High-Flow Extremity Arteriovenous Malformations J Vasc Interv Radiol 2000 11: 1285-129

3.9.2.4 Schwartz’s Principles of Surgery, 8th Edition F. Charles Brunicardi, et al Copyright © 2005, The McGraw-Hill Companies, Inc.Chapter 15. Skin and Subcutaneous Tissue Scott L. Hansen, Stephen J. Mathes, David M. Young

3.9.2.5 Albrecht, Thomas, Foert, Ellen, Holtkamp, Robin, Kirchin, Miles A., Ribbe, Constanze, Wacker, Frank K., Kruschewski, Martin, Meyer, Bernhard C. 16-MDCT Angiography of Aortoiliac and Lower Extremity Arteries: Comparison with Digital Subtraction Angiography Am. J. Roentgenol. 2007 189: 702-711

1.1.1 Suspected Peripheral Arterial Disease

1.2.1 Suspected AVM

1.3.1 cramping pains caused by poor circulation of the blood to the muscles during exercise. True claudication is relieved with rest from exercise.

1.4.1 Peripheral arterial disease suspected

1.5.1.1 Leriche R, Morel A. The syndrome of thrombotic obliteration of the aortic bifurcation. Ann Surg. 1948;127:193-204.

1.5.2 Peripheral arterial disease suspected

1.6 Localized skin discoloration

1.7.1 Suspected AVM

1.8.1 Suspected AVM

1.9.1 Suspected AVM

1.9.2.1 Hurst’s The Heart 11th Edition Valentin Fuster, R. Wayne Alexander, and Robert A. O’Rourke, Eds.; Copyright ©2006 The McGraw-Hill Companies. Chapterr 101. Diagnosis and Management of Diseases of the Peripheral Arteries and Veins Paul W. Wennberg, Thom W. Rooke

1.9.2.2 Emile R. Mohler, III; Peripheral Arterial Disease: Identification and Implications; Arch Intern Med 2003 163: 2306-2314

1.9.2.3 White, Robert I., Jr, Pollak, Jeffrey, Persing, John, Henderson, Katharine J., Thomson, J. Grant, Burdge, Catherine M. Long-Term Outcome of Embolotherapy and Surgery for High-Flow Extremity Arteriovenous Malformations J Vasc Interv Radiol 2000 11: 1285-129

1.9.2.4 Schwartz’s Principles of Surgery, 8th Edition F. Charles Brunicardi, et al Copyright © 2005, The McGraw-Hill Companies, Inc.Chapter 15. Skin and Subcutaneous Tissue Scott L. Hansen, Stephen J. Mathes, David M. Young

2.1.1 Bleeding

2.1.2 Localized skin discoloration

2.1.3 Pain

2.1.4 Palpable subcutaneous thrill

2.1.5 Ulceration

2.1.6.1 White, Robert I., Jr, Pollak, Jeffrey, Persing, John, Henderson, Katharine J., Thomson, J. Grant, Burdge, Catherine M. Long-Term Outcome of Embolotherapy and Surgery for High-Flow Extremity Arteriovenous Malformations J Vasc Interv Radiol 2000 11: 1285-1295

2.1.6.2 Schwartz’s Principles of Surgery, 8th Edition F. Charles Brunicardi, et al Copyright © 2005, The McGraw-Hill Companies, Inc.Chapter 15. Skin and Subcutaneous Tissue Scott L. Hansen, Stephen J. Mathes, David M. Young

2.2.1.1 ABI<0.9

2.2.2.1 Diabetes

2.2.2.2 Hypercholesterolemia

2.2.2.3 Smoker

2.2.3.1 Aching Pain in extremity relieved by rest

2.2.3.2 Asymmetric Blood Pressure in Arms

2.2.3.3 Asymmetric Pulses

2.2.3.4 Bruit

2.2.3.5 Palpable Arterial Thrill

2.2.3.6 Positive or Suspicious Doppler exam

2.2.4.1 Hurst’s The Heart 11th Edition Valentin Fuster, R. Wayne Alexander, and Robert A. O’Rourke, Eds.; Copyright ©2006 The McGraw-Hill Companies. Chapterr 101. Diagnosis and Management of Diseases of the Peripheral Arteries and Veins Paul W. Wennberg, Thom W. Rooke

2.2.4.2 Emile R. Mohler, III; Peripheral Arterial Disease: Identification and Implications; Arch Intern Med 2003 163: 2306-2314

3.1.1 Suspected Peripheral Arterial Disease

3.2.1.1 The normal ABI is 1.0 to as high as 1.3

3.2.1.2 An ABI below 0.9 indicates peripheral arterial disease. The lower the index the more severe the changes

3.3.1 Suspected Peripheral Arterial Disease

3.4.1 Suspected Peripheral Arterial Disease

3.5.1 Suspected Peripheral Arterial Disease

3.6.1 Suspected AVM

3.7.1 Suspected AVM

3.8.1 Suspected AVM

3.9.1 Suspected AVM

3.9.2.1 Hurst’s The Heart 11th Edition Valentin Fuster, R. Wayne Alexander, and Robert A. O’Rourke, Eds.; Copyright ©2006 The McGraw-Hill Companies. Chapterr 101. Diagnosis and Management of Diseases of the Peripheral Arteries and Veins Paul W. Wennberg, Thom W. Rooke

3.9.2.2 Emile R. Mohler, III; Peripheral Arterial Disease: Identification and Implications; Arch Intern Med 2003 163: 2306-2314

3.9.2.3 White, Robert I., Jr, Pollak, Jeffrey, Persing, John, Henderson, Katharine J., Thomson, J. Grant, Burdge, Catherine M. Long-Term Outcome of Embolotherapy and Surgery for High-Flow Extremity Arteriovenous Malformations J Vasc Interv Radiol 2000 11: 1285-129

3.9.2.4 Schwartz’s Principles of Surgery, 8th Edition F. Charles Brunicardi, et al Copyright © 2005, The McGraw-Hill Companies, Inc.Chapter 15. Skin and Subcutaneous Tissue Scott L. Hansen, Stephen J. Mathes, David M. Young

4 Abnormal Lab or Imaging presented as primary indication

5.1 Trauma, vascular injury suspected

5.2.1 Asymptomatic, no more than twice per year

5.2.2 Any change in physical findings

5.3.1 Assessment prior to planned surgery

5.3.2 New or worsening symptoms