A narrative review of imaging misallocation in peripheral artery disease - a value-based medicine perspective

Sep 30, 2026

A narrative review examines how imaging for peripheral artery disease (PAD) is frequently misallocated relative to clinical risk. It contrasts guideline-recommended diagnostic sequencing with real-world utilization and cost patterns using sources from PubMed, professional-society guidance, and gray literature (Jan 2015–Feb 2025). The review quantifies underuse of timely CTA/MRA in high-risk CLTI, analyzes drivers including access and supplier-induced demand, and summarizes evidence-based remedies. Strategies include decision support, sequencing guardrails, expedited CLTI workflows, and workforce adjustments to improve equity and outcomes.

LanguageEnglish

CategoryResearch & Report

FormatPDF

Pages12

Reading Time30 min

AccessFree to download

Background and Objective

Methods

Key Content and Findings

Conclusions

Introduction

A narrative review of imaging misallocation in peripheral artery disease: a value-based medicine perspective Daniel Raskin1^, Sasan Partovi1, Abraham Levitin1, Sean P. Lyden2, Levester Kirksey2 1Division of Interventional Radiology, Cleveland Clinic, Cleveland, OH, USA; 2Department of Vascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA Contributions: (I) Conception and design: D Raskin, L Kirksey, A Levitin; (II) Administrative support: S Partovi, SP Lyden; (III) Provision of study materials or patients: SP Lyden, L Kirksey; (IV) Collection and assembly of data: D Raskin, A Levitin; (V) Data analysis and interpretation: D Raskin, A Levitin, S Partovi; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Correspondence to: Daniel Raskin, MD. Division of Interventional Radiology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA. Email: [raskind@ccf.org](raskind@ccf.org). Background and Objective: Imaging for peripheral artery disease (PAD) is frequently misallocated: advanced cross-sectional studies are over-ordered for low-risk claudication, while high-risk chronic limbthreatening ischemia (CLTI) patients often receive no timely anatomic study. This narrative review summarizes current guideline pathways, quantifies real-world deviations, and identifies value-based remedies that better align modality and timing with clinical need. Methods: Data sources were PubMed, professional-society websites [American College of Cardiology/ American Heart Association (ACC/AHA), European Society for Vascular Surgery/European Society of Cardiology (ESVS/ESC), American College of Radiology (ACR)], and gray literature in a timeframe of January 2015–February 2025. Eligible items were English-language PAD imaging guidelines/consensus statements, registry/claims analyses, cohort/comparative studies, and cost/equity evaluations; singlecase reports and non-vascular imaging were excluded. We extracted guideline-recommended diagnostic pathways, compared them with contemporary utilization and cost data, categorized misallocation and operational drivers. Key Content and Findings: Across four contemporary guidelines, the benchmark diagnostic sequence is physiologic testing with the ankle-brachial index or toe-brachial index (ABI/TBI), followed by duplex ultrasonography (DUS); when results would change management, computed tomography angiography (CTA) or magnetic resonance angiography (MRA) should be performed, with catheter-based digital subtraction angiography (DSA) reserved for intervention. Cross-sectional imaging increased three-fold in Medicare from 2011–2021, while first-line physiologic testing declined. Only 54% of CLTI patients receive CTA/MRA within 30 days, and each month of delay raises major amputation risk. Imaging access is poorest among minoritized, socio-economically disadvantaged, and rural groups, whereas supplier-induced demand amplifies scans in affluent settings. Misallocation exposes patients to avoidable radiation and contrast, strains radiology capacity, and contributes >US $4 billion in annual CLTI costs. Evidence shows guidelineaware clinical decision support can cut rarely-appropriate imaging by 10–40%, limb-salvage fast-track pathways reduce major amputations by ~30% and expanding sonographer staffing shifts after-hours demand away from CTA. Conclusions: PAD imaging is misaligned with value-based medicine: over-applied where benefit is marginal and under-applied where it is limb-saving. Implementing sequencing guardrails, decision-support tools, expedited CLTI workflows, and workforce remedies can rebalance utilization, enhance equity, and improve clinical and economic outcomes. Keywords: Peripheral artery disease (PAD); imaging; value-based health care ^ ORCID: 0000-0003-3584-3748. © AME Publishing Company. Cardiovasc Diagn Ther 2025;15(6):1194-1205 | [https://dx.doi.org/10.21037/cdt-2025-426](https://dx.d

FAQs

What is the guideline benchmark diagnostic sequence for PAD imaging in the review?

The review describes physiologic testing first using the ankle-brachial index or toe-brachial index (ABI/TBI), followed by duplex ultrasonography. If results would change management, computed tomography angiography (CTA) or magnetic resonance angiography (MRA) should be performed, while catheter-based digital subtraction angiography (DSA) is reserved for intervention.

How does imaging utilization drift in Medicare according to the review?

Cross-sectional imaging increased three-fold in Medicare from 2011 to 2021, while first-line physiologic testing declined. This indicates a shift away from guideline-aligned sequencing.

What equity and operational issues drive misallocation of PAD imaging?

The review reports poorest imaging access among minoritized, socio-economically disadvantaged, and rural groups. In affluent settings, supplier-induced demand is described as amplifying scan rates, while delays—particularly for CLTI—raise major amputation risk.

Sep 30, 2026

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