IMAGING FOR …MALS (Median Arcuate Ligament Syndrome), SMAS (superior Mesenteric Artery Stenosis), NUTCRACKER, IVCC (Inferior vena Cava Compression), Iliac Vein Compression, Chronic Venous Insufficiency
1. Median arcuate ligament syndrome and superior mesenteric artery stenosis
Order title:
Complete mesenteric arterial duplex ultrasound — fasting — median arcuate ligament syndrome dynamic respiratory protocol and superior mesenteric artery stenosis evaluation
Procedure code:
CPT 93975 — Complete visceral vascular duplex ultrasound
Diagnostic codes:
ICD-10-CM I77.4 — Celiac artery compression syndrome
ICD-10-CM K55.1 — Chronic vascular disorders of intestine / superior mesenteric artery stenosis
Order comments:
Evaluate the celiac artery for median arcuate ligament compression and evaluate the superior mesenteric artery for stenosis.
Obtain angle-corrected peak systolic and end-diastolic velocities at the abdominal aorta, celiac artery origin and proximal celiac artery, and superior mesenteric artery origin, proximal, mid and distal segments.
Record celiac artery velocities during deep inspiration and complete end-expiration, supine and upright. Document respiratory excursion of the celiac artery, focal narrowing, turbulence, deflection or hooking, and post-stenotic dilatation.
Document superior mesenteric artery focal narrowing, elevated velocities, turbulence, post-stenotic changes and velocity ratios relative to the abdominal aorta when technically possible.
Do not substitute a routine abdominal ultrasound.
Female technologist only; no students or observers.
2. Superior mesenteric artery syndrome
Order title:
Limited abdominal ultrasound — fasting — dynamic superior mesenteric artery syndrome protocol
Procedure code:
CPT 76705 — Limited abdominal ultrasound
Diagnostic code:
ICD-10-CM K55.1 — Superior mesenteric artery syndrome
Order comments:
Evaluate for superior mesenteric artery syndrome with compression of the third portion of the duodenum between the superior mesenteric artery and abdominal aorta.
In the sagittal plane, measure and document the aortomesenteric angle and shortest aortomesenteric distance.
Assess the third portion of the duodenum for focal compression and evaluate for proximal duodenal and gastric dilation and impaired passage through the compressed segment.
When technically feasible, dynamically assess duodenal passage and changes in compression in the supine, upright, left-lateral and prone positions.
Use color Doppler as needed to identify the abdominal aorta and superior mesenteric artery. This is an anatomic evaluation for duodenal compression and is separate from the mesenteric arterial duplex evaluation for superior mesenteric artery stenosis.
Female technologist only; no students or observers.
3. Nutcracker syndrome
Order title:
Complete renal venous duplex ultrasound — fasting — Nutcracker syndrome dynamic compression protocol
Procedure code:
CPT 93975 — Complete visceral vascular duplex ultrasound
Diagnostic code:
ICD-10-CM I87.1 — Compression of vein
Order comments:
Evaluate the left renal vein from the renal hilum through the aortomesenteric segment to its junction with the inferior vena cava.
In the sagittal plane, measure and document the aortomesenteric angle and shortest aortomesenteric distance. Correlate these measurements with the location and severity of left renal-vein compression.
Measure left renal-vein diameter and peak velocity at the renal hilum, immediately proximal to compression, within the aortomesenteric compression and distal to compression. Calculate hilar-to-aortomesenteric diameter and velocity ratios.
Perform imaging supine and upright if technically feasible.
Assess for anterior, posterior, retroaortic or circumaortic left renal-vein compression anatomy; reversed or abnormal flow; collateral veins; and left ovarian-vein dilatation or reflux.
Female technologist only; no students or observers.
4. Inferior vena cava compression
Order title:
Complete inferior vena cava venous duplex ultrasound — fasting — dynamic positional and respiratory compression protocol
Procedure code:
CPT 93978 — Complete duplex ultrasound of the aorta, inferior vena cava and/or iliac vasculature
Diagnostic code:
ICD-10-CM I87.1 — Compression of vein / acquired vena cava stenosis
Order comments:
Evaluate the entire visualized inferior vena cava for patency, thrombus, focal stenosis, extrinsic compression, obstruction and collateralization.
Perform imaging supine and upright. If full upright imaging is technically limited, use seated or reverse-Trendelenburg positioning.
Record vessel diameters, flow direction, Doppler waveforms and velocities at the proximal, mid and distal inferior vena cava during quiet respiration, deep inspiration and complete end-expiration.
Assess respiratory phasicity and positional changes. Include Valsalva where technically appropriate.
Document focal narrowing, pre-compression and post-compression velocities, velocity ratios, continuous or nonphasic flow, collateral veins and any segments that cannot be visualized.
Female technologist only; no students or observers.
5. Bilateral iliac-vein compression / non-thrombotic iliac-vein lesion assessment
Order title:
Complete bilateral iliac venous duplex ultrasound — fasting — bilateral iliac-vein compression and non=thrombotic iliac-vein lesion protocol
Procedure code:
CPT 93978 — Complete duplex ultrasound of the aorta, inferior vena cava and/or iliac vasculature
Diagnostic code:
ICD-10-CM I87.1 — Compression of vein / iliac-vein compression syndrome
Order comments:
Evaluate the right and left common iliac veins and external iliac veins for nonthrombotic iliac-vein lesions, focal stenosis, extrinsic arterial compression, obstruction, thrombus and collateralization.
Include the inferior vena cava confluence and bilateral common femoral veins for inflow and outflow comparison.
Specifically evaluate for classic left common iliac-vein compression by the right common iliac artery and for right-sided, bilateral or variant iliac-vein compression anatomy.
Obtain diameter measurements and Doppler velocities proximal to, at and distal to each suspected compression. Calculate diameter-reduction and velocity ratios when technically possible.
Assess respiratory phasicity, flow direction, waveform asymmetry, continuous or nonphasic flow, turbulence and collateral veins.
Perform supine imaging and repeat in upright, seated or reverse-Trendelenburg positioning when technically feasible. Document any segments that cannot be visualized.
Female technologist only; no students or observers.
6. Chronic venous insufficiency
Order title:
Bilateral lower-extremity complete venous reflux duplex ultrasound
Procedure code:
CPT 93970 — Complete bilateral extremity venous duplex ultrasound
Diagnostic code:
ICD-10-CM I87.2 — Venous insufficiency, chronic, peripheral
Order comments:
Perform standing or in a dependent position.
Evaluate the deep, superficial and clinically relevant perforator veins for obstruction and reflux, including the common femoral, femoral, deep femoral, popliteal, great saphenous, small saphenous and accessory saphenous veins.
Use Valsalva and distal augmentation as appropriate. Document the location and duration of reflux and provide bilateral vein mapping.
This is a complete venous reflux study, not a deep-vein-thrombosis-only study.
Female technologist only; no students or observers.
Scheduling and protocoling instructions
Please have the vascular-laboratory medical director or lead vascular technologist review and protocol each examination before scheduling. Do not substitute routine abdominal, renal, aortic or lower-extremity clot protocols.
The inferior vena cava and bilateral iliac-vein compression studies are separate clinical orders. They share CPT 93978 and may be coordinated into one technical appointment or billing line, but both sets of protocol instructions and both separate clinical questions must be addressed in the imaging and final report.
The median arcuate ligament syndrome and superior mesenteric artery stenosis evaluation is a vascular-flow examination. The separate superior mesenteric artery syndrome examination evaluates compression of the duodenum and the aortomesenteric angle and distance. Both clinical questions must be separately addressed.