Variant 1: Nonsmoker, sedentary lifestyle. No symptoms at rest but mild left lower-extremity claudication on walking, asymmetrically diminished left femoral pulse. Next steps on initial physician visit.

Procedure	Appropriateness Category	SOE	Adult RRL	Peds RRL	Rating	Median	Final Tabulations
Procedure	Appropriateness Category	SOE	Adult RRL	Peds RRL	Rating	Median	1	2	3	4	5	6	7	8	9
Best medical management including supervised exercise program only	Usually appropriate		N/A	N/A	9	n/a	0	0	0	0	0	0	0	0	0
Risk factor analysis, lipid profile and ABIs	Usually appropriate		N/A	N/A	9	n/a	0	0	0	0	0	0	0	0	0
US duplex Doppler lower extremity	Usually appropriate		O 0 mSv	O 0 mSv [ped]	8	n/a	0	0	0	0	0	0	0	0	0
Antiplatelet adjunctive therapy	Usually appropriate		N/A	N/A	7	n/a	0	0	0	0	0	0	0	0	0
CTA abdomen and pelvis with bilateral lower extremity runoff with IV contrast	Usually appropriate				7	n/a	0	0	0	0	0	0	0	0	0
MRA abdomen and pelvis with bilateral lower extremity runoff with IV contrast	Usually appropriate		O 0 mSv	O 0 mSv [ped]	7	n/a	0	0	0	0	0	0	0	0	0
Plethysmography and pulse volume recording	May be appropriate		N/A	N/A	6	n/a	0	0	0	0	0	0	0	0	0
Catheter directed angiography	May be appropriate		N/A	N/A	5	n/a	0	0	0	0	0	0	0	0	0
Anticoagulation adjunctive therapy	Usually not appropriate		N/A	N/A	3	n/a	0	0	0	0	0	0	0	0	0
No further treatment or evaluation needed	Usually not appropriate		N/A	N/A	1	n/a	0	0	0	0	0	0	0	0	0

Variant 2: Long history of mild claudication. Acute-onset left lower-extremity pain. Absent left femoral pulse on palpation, faint dorsalis pedis and posterior tibial pulses by Doppler. Next steps.

Procedure	Appropriateness Category	SOE	Adult RRL	Peds RRL	Rating	Median	Final Tabulations
Procedure	Appropriateness Category	SOE	Adult RRL	Peds RRL	Rating	Median	1	2	3	4	5	6	7	8	9
Ankle brachial index	Usually appropriate		N/A	N/A	8	n/a	0	0	0	0	0	0	0	0	0
CTA abdomen and pelvis with bilateral lower extremity runoff with IV contrast	Usually appropriate				8	n/a	0	0	0	0	0	0	0	0	0
US duplex Doppler lower extremity	Usually appropriate		O 0 mSv	O 0 mSv [ped]	8	n/a	0	0	0	0	0	0	0	0	0
MRA abdomen and pelvis with bilateral lower extremity runoff with IV contrast	Usually appropriate		O 0 mSv	O 0 mSv [ped]	7	n/a	0	0	0	0	0	0	0	0	0
Plethysmography and pulse volume recording	May be appropriate		N/A	N/A	5	n/a	0	0	0	0	0	0	0	0	0

Variant 3: Known atrial fibrillation and spine surgery 3 weeks ago. Sudden-onset right lower-extremity pain. Diminished pulses in right lower extremity. CTA demonstrates isolated filling defect in right common iliac artery.

Procedure	Appropriateness Category	SOE	Adult RRL	Peds RRL	Rating	Median	Final Tabulations
Procedure	Appropriateness Category	SOE	Adult RRL	Peds RRL	Rating	Median	1	2	3	4	5	6	7	8	9
Surgical revascularization	Usually appropriate		N/A	N/A	9	n/a	0	0	0	0	0	0	0	0	0
Anticoagulation adjunctive therapy	Usually appropriate		N/A	N/A	7	n/a	0	0	0	0	0	0	0	0	0
Catheter directed mechanical thrombectomy	Usually appropriate		N/A	N/A	7	n/a	0	0	0	0	0	0	0	0	0
Antiplatelet adjunctive therapy	May be appropriate		N/A	N/A	5	n/a	0	0	0	0	0	0	0	0	0
Catheter directed thrombolytic therapy	Usually not appropriate		N/A	N/A	3	n/a	0	0	0	0	0	0	0	0	0

Variant 4: Past medical history of heavy smoking. Severe claudication and no symptoms at rest. Angiogram demonstrates bilateral 90% common iliac artery stenosis (TASC A).

Procedure	Appropriateness Category	SOE	Adult RRL	Peds RRL	Rating	Median	Final Tabulations
Procedure	Appropriateness Category	SOE	Adult RRL	Peds RRL	Rating	Median	1	2	3	4	5	6	7	8	9
Antiplatelet adjunctive therapy	Usually appropriate		N/A	N/A	8	n/a	0	0	0	0	0	0	0	0	0
Bilateral percutaneous transluminal angioplasty only	Usually appropriate		N/A	N/A	8	n/a	0	0	0	0	0	0	0	0	0
Bilateral stent placement	Usually appropriate		N/A	N/A	8	n/a	0	0	0	0	0	0	0	0	0
Best medical management including supervised exercise program only	May be appropriate		N/A	N/A	5	n/a	0	0	0	0	0	0	0	0	0
Surgical revascularization	May be appropriate		N/A	N/A	4	n/a	0	0	0	0	0	0	0	0	0
Anticoagulation adjunctive therapy	Usually not appropriate		N/A	N/A	3	n/a	0	0	0	0	0	0	0	0	0

Variant 5: Past medical history significant for diabetes mellitus, hypertension, and smoking. Increasing claudication of right lower extremity involving right buttock for last 3 months. CTA pelvis with runoff reveals short-segment occlusion of right common iliac artery (TASC B).

Procedure	Appropriateness Category	SOE	Adult RRL	Peds RRL	Rating	Median	Final Tabulations
Procedure	Appropriateness Category	SOE	Adult RRL	Peds RRL	Rating	Median	1	2	3	4	5	6	7	8	9
Antiplatelet adjunctive therapy	Usually appropriate		N/A	N/A	8	n/a	0	0	0	0	0	0	0	0	0
Primary percutaneous transluminal angioplasty alone	Usually appropriate		N/A	N/A	8	n/a	0	0	0	0	0	0	0	0	0
Primary stenting	Usually appropriate		N/A	N/A	8	n/a	0	0	0	0	0	0	0	0	0
Surgical revascularization	May be appropriate		N/A	N/A	4	n/a	0	0	0	0	0	0	0	0	0
Anticoagulation adjunctive therapy	Usually not appropriate		N/A	N/A	2	n/a	0	0	0	0	0	0	0	0	0
Best medical management including supervised exercise program only	Usually not appropriate		N/A	N/A	2	n/a	0	0	0	0	0	0	0	0	0

Variant 6: Past medical history significant for diabetes mellitus, hypertension, and heavy smoking. Gradually increasing claudication of bilateral lower extremities for at least 2 months. CTA pelvis with runoff reveals bilateral common iliac artery occlusion without any involvement of the external or internal iliac artery (TASC C).

Procedure	Appropriateness Category	SOE	Adult RRL	Peds RRL	Rating	Median	Final Tabulations
Procedure	Appropriateness Category	SOE	Adult RRL	Peds RRL	Rating	Median	1	2	3	4	5	6	7	8	9
Antiplatelet adjunctive therapy	Usually appropriate		N/A	N/A	8	n/a	0	0	0	0	0	0	0	0	0
Primary stenting	Usually appropriate		N/A	N/A	8	n/a	0	0	0	0	0	0	0	0	0
Surgical revascularization	Usually appropriate		N/A	N/A	7	n/a	0	0	0	0	0	0	0	0	0
Primary percutaneous transluminal angioplasty alone	May be appropriate		N/A	N/A	6	n/a	0	0	0	0	0	0	0	0	0
Anticoagulation adjunctive therapy	Usually not appropriate		N/A	N/A	3	n/a	0	0	0	0	0	0	0	0	0
Best medical management including supervised exercise program only	Usually not appropriate		N/A	N/A	2	n/a	0	0	0	0	0	0	0	0	0

Variant 7: Worsening claudication and small ischemic ulcers on digits of both feet. Angiogram demonstrates diffuse disease involving distal aorta and both iliac vessels with multiple stenoses >50%, bilateral 75% mid-superficial femoral artery stenoses and 2-vessel tibial runoff bilaterally. (TASC D)

Procedure	Appropriateness Category	SOE	Adult RRL	Peds RRL	Rating	Median	Final Tabulations
Procedure	Appropriateness Category	SOE	Adult RRL	Peds RRL	Rating	Median	1	2	3	4	5	6	7	8	9
Antiplatelet adjunctive therapy	Usually appropriate		N/A	N/A	8	n/a	0	0	0	0	0	0	0	0	0
Catheter directed stent placement (aortoiliac plus femoral angioplasty)	Usually appropriate		N/A	N/A	8	n/a	0	0	0	0	0	0	0	0	0
Catheter directed stent placement (aortoiliac only)	Usually appropriate		N/A	N/A	7	n/a	0	0	0	0	0	0	0	0	0
Percutaneous transluminal angioplasty (aortoiliac only)	May be appropriate		N/A	N/A	6	n/a	0	0	0	0	0	0	0	0	0
Surgical revascularization	May be appropriate		N/A	N/A	6	n/a	0	0	0	0	0	0	0	0	0
Anticoagulation adjunctive therapy	Usually not appropriate		N/A	N/A	3	n/a	0	0	0	0	0	0	0	0	0
Best medical management including supervised exercise program only	Usually not appropriate		N/A	N/A	2	n/a	0	0	0	0	0	0	0	0	0

Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

References: The citation number and PMID for the reference(s) associated with the recommendation.
Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.

Appropriateness Criteria

Variant 1: Nonsmoker, sedentary lifestyle. No symptoms at rest but mild left lower-extremity claudication on walking, asymmetrically diminished left femoral pulse. Next steps on initial physician visit.

Variant 2: Long history of mild claudication. Acute-onset left lower-extremity pain. Absent left femoral pulse on palpation, faint dorsalis pedis and posterior tibial pulses by Doppler. Next steps.

Variant 3: Known atrial fibrillation and spine surgery 3 weeks ago. Sudden-onset right lower-extremity pain. Diminished pulses in right lower extremity. CTA demonstrates isolated filling defect in right common iliac artery.

Variant 4: Past medical history of heavy smoking. Severe claudication and no symptoms at rest. Angiogram demonstrates bilateral 90% common iliac artery stenosis (TASC A).

Variant 5: Past medical history significant for diabetes mellitus, hypertension, and smoking. Increasing claudication of right lower extremity involving right buttock for last 3 months. CTA pelvis with runoff reveals short-segment occlusion of right common iliac artery (TASC B).