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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.",{"@graph":69,"@context":121},[70,84,104],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":40,"@type":76,"position":81},"https://docshare.wps.com/document/research-report/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/a-narrative-review-of-imaging-misallocation-in-peripheral-artery-disease-a-value-based-medicine-perspective/450346/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":98,"encodingFormat":97,"isAccessibleForFree":99,"interactionStatistic":100},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/a-narrative-review-of-imaging-misallocation-in-peripheral-artery-disease-a-value-based-medicine-perspective/450346.png","ImageObject",300,407,{"name":92,"@type":93},"Margaret","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-09-30",true,{"@type":101,"interactionType":102,"userInteractionCount":4},"InteractionCounter",{"@type":103},"ViewAction",{"@type":105,"mainEntity":106},"FAQPage",[107,113,117],{"name":108,"@type":109,"acceptedAnswer":110},"What is the guideline benchmark diagnostic sequence for PAD imaging in the review?","Question",{"text":111,"@type":112},"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.","Answer",{"name":114,"@type":109,"acceptedAnswer":115},"How does imaging utilization drift in Medicare according to the review?",{"text":116,"@type":112},"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.",{"name":118,"@type":109,"acceptedAnswer":119},"What equity and operational issues drive misallocation of PAD imaging?",{"text":120,"@type":112},"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.","https://schema.org",{"og:url":83,"og:type":123,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":125,"canonical":83},"index,follow",{"doc_id":127,"site_id":62},450346,1790732938,{"code":4,"msg":5,"data":130},{"doc_id":127,"user_id":131,"nickname":92,"user_avatar":132,"doc_module":4,"category_id":39,"category_name":40,"doc_title":65,"doc_description":67,"doc_content":133,"file_id":134,"file_url":135,"file_type":136,"file_size":137,"view_count":4,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":138,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":128,"read_time":41},137451207643,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","A narrative review of imaging misallocation in peripheral artery disease: a value-based medicine perspective  \nDaniel Raskin1^, Sasan Partovi1, Abraham Levitin1, Sean P. Lyden2, Levester Kirksey2  \n1Division of Interventional Radiology, Cleveland Clinic, Cleveland, OH, USA; 2Department of Vascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA  \nContributions: (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.  \nCorrespondence to: Daniel Raskin, MD. Division of Interventional Radiology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.  \nEmail: [raskind@ccf.org](raskind@ccf.org).  \nBackground 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  \nthat better align modality and timing with clinical need.  \nMethods: 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  \noperational drivers.  \nKey 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  \naway from CTA.  \nConclusions: 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  \nimprove clinical and economic outcomes.  \nKeywords: Peripheral artery disease (PAD); imaging; value-based health care  \n^ ORCID: 0000-0003-3584-3748.  \n© AME Publishing Company. Cardiovasc Diagn Ther 2025;15(6):1194-1205 | [https://dx.doi.org/10.21037/cdt-2025-426](https://dx.d","cbCaigzGVc6C6Ux7","https://ap.wps.com/l/cbCaigzGVc6C6Ux7","pdf",295969,12,"English","# Background and Objective\n# Methods\n# Key Content and Findings\n# Conclusions\n# Introduction","[{\"question\":\"What is the guideline benchmark diagnostic sequence for PAD imaging in the review?\",\"answer\":\"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.\"},{\"question\":\"How does imaging utilization drift in Medicare according to the review?\",\"answer\":\"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.\"},{\"question\":\"What equity and operational issues drive misallocation of PAD imaging?\",\"answer\":\"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.\"}]","A narrative review of imaging misallocation in peripheral artery disease - a value-based medicine perspective | PDF"]