Who defines the standard in Italy
In Italy there is no single regulatory document imposing a format for the colour duplex report. The standard arises from the convergence of three levels: the operating procedures of the vascular diagnostic societies, the guidelines accredited by the National Guidelines System (SNLG-ISS) and the general legislation on medical acts and data processing.
| Body | Role in the duplex report | Reference document |
|---|---|---|
| SIDV-GIUV Vascular diagnostics |
The only Italian society specifically dedicated to colour duplex ultrasound. It defines the indications, how the examination is performed and the minimum content of the report for each territory. | Operating procedures for vascular diagnostic investigations (2016); supra-aortic trunks update (2025); international version in International Angiology (2012). |
| SICVE Vascular surgery |
It produces the Italian guidelines accredited by SNLG-ISS: they establish when duplex is the first-line test and which diagnostic thresholds must appear in the conclusions. | SNLG guideline on carotid stenosis (2021); SNLG guideline on abdominal aortic aneurysm (2021); SICVE-SIRM guideline on visceral and renal aneurysms (2023); guideline on thoracic aortic disease (2023). |
| SIAPAV Angiology |
Care pathways and intersociety documents, in particular for deep vein thrombosis and the link between the report and the treatment decision. | DVT care pathway (2013); SIAPAV-SISET-SIDV-CIF intersociety documents. |
| SIF and CIF Phlebology |
They define the venous nomenclature and the content of the phlebology report (reflux map, CEAP classification). | SIF-SICVE guidelines on phlebology (2017) and phlebolymphology (2016); CIF guidelines (2013). |
| SIUMB, SIRM, SIECVI | Training and ultrasound image quality standards; certification of operator competence. | Certification pathways and section documents. |
The key point of the Italian model
The report is a single medical act: the person who performs the examination is the same person who interprets and signs it. Unlike in the United States, there is no separation between the technologist who acquires the images and the physician who interprets them. This explains why the Italian report is traditionally more narrative and less tabular than the American one.
The six-block framework
Summarising the SIDV-GIUV operating procedures and the established practice of Italian vascular laboratories, the duplex report is organised into six blocks in a fixed sequence. The order is not arbitrary: it reproduces the logical path from question to judgement, and it is the criterion by which a report is assessed in litigation.
| # | Block | Function | Status |
|---|---|---|---|
| 1 | Header and identification | Who, where, when | Mandatory |
| 2 | Clinical question and targeted history | Why the examination was requested | Mandatory |
| 3 | Method and equipment | How it was performed | Mandatory |
| 4 | Analytical description of the findings | What was seen and measured | Mandatory |
| 5 | Diagnostic conclusions | What it means | Mandatory |
| 6 | Date, signature, attached images | Who takes responsibility | Mandatory |
Tip
The description → conclusion sequence must be kept strictly separate. A common error is to anticipate the judgement in the descriptive body («haemodynamically significant plaque») instead of describing the finding and drawing the consequence in the conclusions. The separation makes the report verifiable and comparable at serial examinations.
Block 1 — Header and identification
| Field | Status | Expected content |
|---|---|---|
| Provider | Mandatory | Name, address, any operating unit and contact details. |
| Patient identification | Mandatory | Surname, first name, date of birth, sex; tax code or internal identifier. |
| Date and time of the examination | Mandatory | Full date. The time is recommended in urgent examinations (suspected DVT, acute ischaemia). |
| Type of examination | Mandatory | Precise name and territory: e.g. «Colour duplex ultrasound of the supra-aortic trunks», not «neck Doppler». |
| Referring physician | Recommended | Name and role; setting (national health service, private, inpatient). |
| Previous comparison examinations | Recommended | Date and place of previous duplex, CT angiography or MR angiography used for comparison. |
Block 2 — Clinical question and targeted history
This is the block that the Italian guidelines have progressively strengthened, because appropriateness of the request depends on making it explicit. The SNLG-SICVE guidelines on carotid stenosis and abdominal aortic aneurysm explicitly link indication, surveillance interval and intervention thresholds: if the question is not recorded, the report loses the ability to demonstrate its own appropriateness.
- Diagnostic question stated explicitly: screening, staging, clinical suspicion, follow-up of a known lesion, post-procedural surveillance, preoperative assessment.
- Relevant symptoms: claudication and walking distance, rest pain, tissue loss, TIA/stroke and side, oedema, vertebrobasilar symptoms.
- Risk factors and comorbidities relevant to the territory: diabetes, smoking, hypertension, dyslipidaemia, renal failure, active cancer, thrombophilia.
- Current therapy that affects interpretation: anticoagulants, antiplatelet agents, compression therapy, vasoactive drugs.
- Previous interventions in the territory: endarterectomy, stent, bypass (site and type of conduit), EVAR, saphenous ablation, creation of an AV fistula.
- Clinical scores when required by the pathway: Wells score for suspected DVT, CEAP classification in chronic venous disease, Rutherford or Fontaine stage in PAD.
Caution
In suspected deep vein thrombosis, the Italian pathway (SIAPAV, SIAPAV-SISET-SIDV-CIF intersociety documents) requires pre-test clinical probability and D-dimer to be an integral part of the reasoning. A negative venous ultrasound report without reference to clinical probability is incomplete: the negative predictive value depends precisely on that information.
Block 3 — Method and equipment
A short block that cannot be omitted: it makes the examination reproducible and justifies any limitations. In Italian practice it takes two or three lines.
| Field | Status | Expected content |
|---|---|---|
| Scanner and probes | Recommended | Scanner model; type and frequency band of the probes (linear 7–12 MHz, convex 2–5 MHz). |
| Modes used | Mandatory | B-mode, colour Doppler, pulsed-wave Doppler; any power Doppler or ultrasound contrast agent. |
| Patient position and manoeuvres | Mandatory | Supine/standing, decubitus; manoeuvres performed (compression, Valsalva, reactive hyperaemia, positional tests). |
| Angle of insonation | Mandatory | ≤ 60°, kept constant at serial examinations. It must be stated because it affects every velocity reported. |
| Nomenclature used | Recommended | For the venous territory, the anatomical nomenclature of the UIP consensus, adopted by the Italian societies. |
| Technical limitations of the examination | Mandatory if present | Bowel gas, obesity, oedema, dressings, calcifications with acoustic shadowing, poor cooperation, high bifurcation. The segment that could not be assessed must be stated. |
Declaring limitations is a requirement, not a precaution
A report that does not mention unexplored segments implies that all were explored and found normal. This is the point on which medico-legal disputes most often focus. Correct wording: «the right external iliac artery could not be assessed because of bowel gas; CT angiography is advised if clinical suspicion persists».
Block 4 — Analytical description of the findings
This is the core of the report. The Italian model proceeds in an anatomical proximal-to-distalorder, side by side, describing for each segment wall morphology, lumen, colour signal and velocity waveform. The implicit rule of the SIDV-GIUV operating procedures is that every segment declared as examined has a written finding, even when normal.
6.1 · The constant grid for each segment
- Wall: intima-media thickness, regularity, echostructure.
- Plaque or thrombus (if present): site, extent, echostructure (hypoechoic, isoechoic, hyperechoic, calcified, heterogeneous), surface (regular, irregular, ulcerated), degree of lumen reduction.
- Lumen and calibre: diameter where relevant (aorta, saphenous veins, veins, conduits).
- Colour signal: present/absent, aliasing, filling defects, direction.
- Velocity waveform: morphology (triphasic, biphasic, monophasic; respiratory phasicity for veins) and values (PSV, EDV, velocity ratios).
- Compressibility in the venous territory: complete, partial, absent.
6.2 · Writing rules
- Always state the side: right and left described separately, never «bilaterally normal» when there are asymmetric findings.
- The velocities in cm/s, i diameters in mm (or cm for the aorta), the reflux times in seconds, the flow volume in mL/min.
- Report the measured value, not just the judgement: «PSV 268 cm/s» and not only «significant acceleration».
- At serial examinations, give the previous value and its date: it is the only way to make progression readable.
Mandatory fields by territory
The following tables turn the SIDV-GIUV operating procedures and the diagnostic chapters of the SNLG-SICVE, SIF-SICVE and CIF guidelines into fields. The numerical reference thresholds are on the technique page for each territory, reachable from Duplex scanning techniques.
7.1 · Supra-aortic trunks
| Field | Status | Content |
|---|---|---|
| Common carotid IMT | Recommended | Measured on the far wall, 1–2 cm proximal to the bulb, in a straight plaque-free segment. |
| Plaque description | Mandatory | Site (CCA, bulb, proximal/mid/distal ICA, ECA), extent, echostructure, surface, calcifications. |
| Degree of stenosis | Mandatory | Expressed in classes (<50%, 50–69%, 70–99%, occlusion) with explicit reference to the NASCET method. |
| PSV and EDV of CCA, ICA, ECA | Mandatory | Bilateral; numerical values in cm/s. |
| ICA/CCA ratio | Mandatory if stenosis | Confirmatory parameter when PSV and EDV are discordant. |
| Vertebral arteries | Mandatory | Patency, calibre, flow direction (antegrade, alternating, retrograde), PSV in the V2 segment. |
| Subclavian arteries and origin of the trunks | Mandatory | Search for subclavian steal; downstream waveform morphology. |
| Course and anomalies | Recommended | Kinking, coiling, high bifurcation, vertebral hypoplasia. |
| Post-endarterectomy / post-stent follow-up | Mandatory at follow-up | In-stent restenosis with dedicated thresholds, patch patency, stent ends. |
7.2 · Lower-limb arteries
| Field | Status | Content |
|---|---|---|
| Segments examined | Mandatory | Common and external iliac, common femoral, superficial femoral (proximal/mid/distal third), profunda, popliteal, anterior tibial, posterior tibial, peroneal. |
| Waveform morphology by segment | Mandatory | Triphasic, biphasic, monophasic; distal damping. |
| PSV and velocity ratio | Mandatory in case of stenosis | PSV in the stenosis and in the healthy proximal segment; ratio (Vr) stated. |
| Site and extent of occlusions | Mandatory | Point of origin and of reconstitution, estimated length, presence of collaterals. |
| ABI (and TBI in diabetes) | Mandatory | Value for each limb; in diabetes and kidney disease non-compressibility (ABI > 1.3–1.4) must be reported and the TBI preferred. |
| Aneurysms | Mandatory if present | Popliteal and femoral: maximum diameter, mural thrombus, lumen patency. |
| Bypass and stent surveillance | Mandatory at follow-up | Proximal and distal anastomoses, body of the conduit, PSV along the whole course, velocity ratio at stenoses. |
| Clinical staging | Recommended | Rutherford or Fontaine, reported in the conclusions. |
7.3 · Upper-limb arteries and thoracic outlet syndrome
| Field | Status | Content |
|---|---|---|
| Segments examined | Mandatory | Subclavian, axillary, brachial, radial, ulnar; palmar arch when relevant. |
| Waveform and PSV by segment | Mandatory | With contralateral comparison. |
| Inter-arm pressure gradient | Recommended | A difference > 15–20 mmHg should be reported. |
| Positional manoeuvres | Mandatory if TOS is suspected | Abduction to 90° and 180°, Adson manoeuvre, hyperabduction: changes in the subclavian/axillary signal. |
| Cold test | Recommended | In suspected Raynaud's phenomenon or digital disease. |
7.4 · Lower-limb veins — suspected DVT
| Field | Status | Content |
|---|---|---|
| Pre-test clinical probability | Mandatory | Wells score and, if available, D-dimer: they determine the value of the result. |
| Segment-by-segment compressibility | Mandatory | Common femoral, femoral and popliteal veins, posterior tibial, peroneal and muscular veins (soleal, gastrocnemius); great and small saphenous veins. |
| Extent of thrombus | Mandatory if present | Proximal and distal limits, occlusive or non-occlusive, appearance (recent/organised), free-floating tip. |
| Iliocaval involvement | Mandatory if suspected | To be assessed when the common femoral vein has continuous, non-phasic flow. |
| Superficial vein thrombosis | Mandatory if present | Vein involved, extent in cm, distance from the saphenofemoral or saphenopopliteal junction: this is the finding that guides the indication for anticoagulation. |
| Differential diagnosis | Recommended | Baker's cyst, haematoma, abscess, lymphadenopathy, subcutaneous oedema. |
| Comparison with the previous examination | Mandatory at follow-up | Recanalisation, reduction in calibre, residual thrombosis: the basis for deciding the duration of anticoagulation. |
7.5 · Lower-limb veins — chronic venous disease and reflux
| Field | Status | Content |
|---|---|---|
| Position for the examination | Mandatory | Standing (or steep reverse Trendelenburg): reflux studied supine is underestimated. |
| Provocation manoeuvre | Mandatory | Distal compression-release or Valsalva manoeuvre for the junctions; which one was used must be stated. |
| Reflux duration | Mandatory | Measured in seconds at each point examined, not just judged «present». |
| Junctions | Mandatory | Saphenofemoral and saphenopopliteal: competence, diameter, presence of accessory veins. |
| Saphenous trunks | Mandatory | Great and small saphenous veins: diameter at standard levels, extent of reflux, escape and re-entry points. |
| Incompetent perforators | Mandatory if present | Site (in cm from the floor or relative to an anatomical landmark), diameter, flow direction. |
| Deep system | Mandatory | Patency, valve competence, post-thrombotic changes. |
| Nomenclature | Mandatory | Anatomical terminology of the UIP consensus adopted by the SIF-SICVE and CIF guidelines. |
| CEAP classification | Mandatory | To be reported in the conclusions; the «E, A, P» component comes directly from duplex ultrasound. |
| Haemodynamic map | Recommended | An attached diagram: the de facto standard of Italian phlebology before treatment. |
7.6 · Abdominal aorta, visceral and renal arteries
| Field | Status | Content |
|---|---|---|
| Maximum aortic diameter | Mandatory | Anteroposterior, measured outer wall to outer wall, on a plane perpendicular to the vessel axis; level of measurement specified. |
| Extent of the aneurysm | Mandatory if present | Relationship with the renal arteries (infrarenal, juxtarenal), neck, iliac involvement, mural thrombus. |
| Comparison with the previous examination | Mandatory during surveillance | Previous diameter and date; growth rate in mm/year. |
| Iliac axes | Mandatory | Calibre, plaques, dilatations. |
| Coeliac trunk and mesenteric arteries | Mandatory for a visceral question | PSV, EDV, waveform morphology; for the coeliac trunk, variation with respiration (median arcuate ligament). |
| Renal arteries | Mandatory for a renal question | PSV at the origin and along the course, RAR (renal-aortic ratio), intraparenchymal indices (RI, acceleration time). |
| Patient preparation | Mandatory | Fasting; any treatment for bowel gas. It must be stated because it affects how well the vessels can be assessed. |
| Post-EVAR surveillance | Mandatory at follow-up | Sac diameter, limb patency, search for endoleak with colour and power Doppler. |
7.7 · Haemodialysis vascular access (AVF and graft)
| Field | Status | Content |
|---|---|---|
| Preoperative mapping | Mandatory before AVF creation | Diameter and patency of the radial and brachial arteries, Allen test, diameter and depth of the cephalic and basilic veins along their whole course; patency of the central veins. |
| Anastomosis | Mandatory | Type, diameter, PSV; presence of juxta-anastomotic stenosis. |
| Flow volume | Mandatory | Measured in the brachial artery; value in mL/min with the measurement site stated. |
| Outflow vein | Mandatory | Calibre, depth from the skin, segment usable for cannulation, stenoses, aneurysms. |
| Complications | Mandatory if present | Thrombosis, stenosis (with velocity ratio), pseudoaneurysm, seroma, steal syndrome, venous hypertension. |
| Central veins | Recommended | Subclavian and jugular signal: loss of phasicity as a sign of central stenosis. |
Block 5 — Diagnostic conclusions
In the conclusions the Italian model calls for a diagnostic synthesis, not a repetition of the findings. This is the part the clinician reads and bases the decision on, and the one on which the SNLG-SICVE guidelines have the most direct impact, because they contain the thresholds that generate a treatment indication.
- Concise judgement for each side and territory, in one or two sentences.
- Classification when one exists: NASCET degree of stenosis, CEAP, Rutherford/Fontaine, aneurysm class by diameter.
- Comparison with the previous examination: stable, progressing, improved — with the numerical value.
- Explicit answer to the clinical question asked at the outset. If the question was «suspected DVT», the conclusion must say whether DVT is present or not.
- Operational recommendations: timing of the next examination, any further imaging (CT angiography, MR angiography), referral to the specialist according to guideline thresholds.
- Limitations affecting the conclusion, summarised again if relevant.
Example · supra-aortic trunks conclusion
Right: fibrocalcific plaque of the bulb and ICA origin, with a regular surface, causing 50–69% stenosis according to NASCET (ICA PSV 186 cm/s, EDV 52 cm/s, ICA/CCA ratio 2.4). Finding substantially stable compared with the examination of 12/03/2025 (PSV 174 cm/s).
Left: diffuse intima-media thickening without haemodynamically significant stenosis.
Vertebral arteries patent, with antegrade flow bilaterally.
A duplex follow-up at 12 months and optimisation of medical therapy of risk factors are advised. If ipsilateral neurological symptoms appear, prompt reassessment.
To avoid
Conclusions limited to «picture as described» or «see the text». They do not answer the question, cannot be compared over time and in litigation are read as a failure to take responsibility for the diagnostic judgement.
Block 6 — Signature, date, images
- Name, surname and qualification of the physician who performed and reported the examination, with a handwritten or qualified digital signature.
- Date of writing of the report, distinct from the date of the examination when they differ.
- Attached images: representative images of the pathological findings and key segments, annotated with side, site and measurement. The images are part of the report and must be stored with it.
- Sequential number or unique identifier of the report, for traceability.
- Delivery method and contact details for questions or clarification.
Images: how much to document
Italian practice does not set a minimum number of images per segment, unlike the American model. The operational criterion is: every pathological finding described must have its own image, plus reference images of the key normal segments. At serial examinations, reproducing the same scan plane as the previous time makes the comparison real rather than assumed.
The language of the Italian report
The Italian report has a descriptive tradition: complete sentences, Italian anatomical terminology, a reasoned judgement. Some writing rules that recur in the operating procedures and in the teaching of the Italian societies:
- Describe first, judge afterwards. «Hypoechoic plaque with an irregular surface in the bulb, with PSV 268 cm/s» → then, in the conclusions, «stenosis > 70% NASCET».
- Avoid unmeasurable adjectives when a measurement exists: «mild acceleration» without the value is neither verifiable nor comparable.
- Distinguish what is seen from what is inferred. «No flow is seen in the lumen» is a finding; «occlusion» is an interpretation, and must be justified (low PRF, increased gain, negative power Doppler).
- Use consistent terminology within the report and between successive reports for the same patient: it is the condition for a readable follow-up.
- Do not introduce elements into the conclusions that were not described in the body of the report.
- Report relevant incidental findings (lymphadenopathy, thyroid nodules, Baker's cysts, effusions) even if unrelated to the question.
Example · venous description
Right lower limb. Common femoral, femoral and popliteal veins fully compressible, with spontaneous flow phasic with respiration and a normal response to distal compression. Posterior tibial and peroneal veins patent and compressible. Soleal and gastrocnemius muscular veins compressible.
Great saphenous vein patent, compressible, with a calibre of 4.2 mm at the thigh; saphenofemoral junction competent (no reflux on Valsalva manoeuvre). Small saphenous vein patent and competent.
No fluid collections or popliteal cysts. Mild perimalleolar subcutaneous oedema.
Medico-legal aspects and data processing
The colour duplex report is a medical act and a health document: clinical rules are overlaid by obligations of a different nature, which the Italian model treats as an integral part of the document's structure.
- Informed consent to the examination: obtained and documented, in particular when an ultrasound contrast agent is used.
- Retention: the report and images must be retained for the periods required for the facility's health records; compliant retention requires the document's integrity and unalterability.
- Data protection (GDPR): identifying data and findings are health data. Local storage, without transmission to external services, is the solution that minimises the risk surface.
- Traceability of changes: a report that has already been delivered is not corrected silently. A corrective report must be issued, stating the change and its date.
- Deferred reporting: if the report is written after the examination, both dates must be given.
- Communication of urgent findings: extensive proximal DVT, free-floating thrombus, acute ischaemia, a rapidly growing or symptomatic aneurysm must be communicated directly to the clinician, and the communication must be noted in the report.
Why it matters for a reporting PWA
Software that generates reports must make it structurally impossible to deliver a document without signature, date, question and conclusions; it must record revisions; and it must keep the data on the device. These are requirements of the document, not optional features.
What distinguishes the Italian model from the American one
| Aspect | Italian model | American model |
|---|---|---|
| Who performs and who signs | The same physician: a single act. | The sonographer/technologist performs; the physician interprets and signs. |
| Intermediate document | Not provided for. | Technologist's preliminary worksheet, distinct from the final report. |
| Prevailing form | Narrative, descriptive, segment by segment. | Tabular and structured, with listed minimum elements. |
| Source of the standard | Societies' operating procedures + SNLG guidelines. | AIUM practice parameter + IAC accreditation (with effects on reimbursement). |
| Image documentation | Recommended, with no prescribed minimum number. | List of mandatory images per protocol. |
| Quality | Operator training and certification (SIUMB, SIECVI, specialty societies). | Laboratory accreditation + individual credential (RVT, RVS, VS) + periodic correlation of results. |
| Velocity criteria | Reference to SRU/international consensus, with adaptations in the SIDV procedures. | Criteria validated internally by the laboratory and checked through correlation. |
The two models are not alternatives: the American structure is stronger on verifiability and reproducibility, the Italian one on continuity between performing the examination and the clinical judgement. A report that adopts the Italian framework while incorporating the minimum elements and image documentation of the American model is the most robust end point. See the structure according to the American guidelines .
Sources
- SIDV-GIUV. Operating procedures for vascular diagnostic investigations — 2016 update (in Italian). Italian Society of Vascular Diagnostics (sidv.net).
- SIDV-GIUV. 2025 guidelines — Assessment of the supra-aortic trunks (in Italian;sidv.net).
- SIDV-GIUV. Guidelines for vascular diagnostic procedures. International Angiology 2012 (international version).
- SICVE (SNLG-ISS). Guideline — Diagnosis and treatment of carotid stenosis, 2021 (in Italian;sicve.it).
- SICVE (SNLG-ISS). Guideline — Prevention, diagnosis and treatment of abdominal aortic aneurysm, 2021 (in Italian).
- SICVE-SIRM. Guideline — Visceral and renal aneurysms, 2023 (in Italian).
- SIF-SICVE. Phlebology guidelines, 2017 (in Italian;societaitalianaflebologia.com); Phlebolymphology guidelines, 2016.
- CIF. Guidelines of the Italian College of Phlebology — Diagnosis and treatment of diseases of the veins and lymphatics, 2013 (collegioitalianoflebologia.it).
- SIAPAV. Care pathway for deep vein thrombosis, 2013 (in Italian;document).
- SIAPAV, SISET, SIDV-GIUV, CIF. Guidelines for the diagnosis and treatment of deep vein thrombosis — Italian intersociety document.
- UIP. Coleridge-Smith P et al. Duplex Ultrasound Investigation of the Veins in Chronic Venous Disease of the Lower Limbs — UIP Consensus Document, 2006; update on post-treatment follow-up, 2011. Anatomical nomenclature adopted by the Italian societies.
- SRU. Grant EG et al. Carotid artery stenosis: gray-scale and Doppler US diagnosis — Society of Radiologists in Ultrasound Consensus Conference. Radiology 2003. Velocity reference also adopted in Italian practice.
This page is an operational summary for healthcare professionals and does not replace consultation of the original documents, which remain the only binding reference. The numerical diagnostic thresholds are on the technique page for each territory, reachable from Duplex scanning techniques.