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Thoracic Aortic Aneurysm or Dissection-Treatment Planning and Follow-Up
Variant: 1
Adult. Known thoracic aortic aneurysm or dissection without repair. With or without symptoms. Follow-up imaging.
| Procedure | Appropriateness Category | Relative Radiation Level |
| CTA chest abdomen pelvis with IV contrast | Usually Appropriate | ☢☢☢☢☢ |
| CTA chest with IV contrast | Usually Appropriate | ☢☢☢ |
| MRA chest abdomen pelvis with IV contrast | Usually Appropriate | O |
| MRA chest abdomen pelvis without IV contrast | Usually Appropriate | O |
| MRA chest with IV contrast | May Be Appropriate | O |
| MRA chest without IV contrast | May Be Appropriate | O |
| CT chest abdomen pelvis with IV contrast | May Be Appropriate | ☢☢☢☢ |
| CT chest abdomen pelvis without and with IV contrast | May Be Appropriate | ☢☢☢☢ |
| CT chest with IV contrast | May Be Appropriate | ☢☢☢ |
| US echocardiography transesophageal | May Be Appropriate | O |
| US echocardiography transthoracic resting | May Be Appropriate | O |
| CT chest without and with IV contrast | May Be Appropriate | ☢☢☢ |
| CT chest abdomen pelvis without IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| Aortography chest abdomen pelvis | Usually Not Appropriate | ☢☢☢☢ |
| CT chest without IV contrast | Usually Not Appropriate | ☢☢☢ |
| Radiography chest | Usually Not Appropriate | ☢ |
Variant: 2
Adult. Prethoracic endovascular repair or open repair of thoracic aorta aneurysm or dissection. Preprocedure planning.
| Procedure | Appropriateness Category | Relative Radiation Level |
| CTA chest abdomen pelvis with IV contrast | Usually Appropriate | ☢☢☢☢☢ |
| MRA chest abdomen pelvis with IV contrast | Usually Appropriate | O |
| CT chest abdomen pelvis with IV contrast | May Be Appropriate | ☢☢☢☢ |
| CT chest abdomen pelvis without and with IV contrast | May Be Appropriate | ☢☢☢☢ |
| CTA chest with IV contrast | May Be Appropriate | ☢☢☢ |
| CT chest with IV contrast | May Be Appropriate | ☢☢☢ |
| CT chest without and with IV contrast | May Be Appropriate | ☢☢☢ |
| MRA chest abdomen pelvis without IV contrast | May Be Appropriate (Disagreement) | O |
| MRA chest with IV contrast | May Be Appropriate | O |
| MRA chest without IV contrast | May Be Appropriate | O |
| US echocardiography transesophageal | Usually Not Appropriate | O |
| US echocardiography transthoracic resting | Usually Not Appropriate | O |
| Aortography chest abdomen pelvis | Usually Not Appropriate | ☢☢☢☢ |
| CT chest abdomen pelvis without IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT chest without IV contrast | Usually Not Appropriate | ☢☢☢ |
| US duplex Doppler iliofemoral arteries | Usually Not Appropriate | O |
| US duplex Doppler aorta abdomen | Usually Not Appropriate | O |
Variant: 3
Adult. Postthoracic endovascular repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
| Procedure | Appropriateness Category | Relative Radiation Level |
| CTA chest abdomen pelvis with IV contrast | Usually Appropriate | ☢☢☢☢☢ |
| CTA chest with IV contrast | Usually Appropriate | ☢☢☢ |
| MRA chest abdomen pelvis with IV contrast | Usually Appropriate | O |
| CT chest abdomen pelvis with IV contrast | May Be Appropriate | ☢☢☢☢ |
| CT chest abdomen pelvis without and with IV contrast | May Be Appropriate | ☢☢☢☢ |
| CT chest abdomen pelvis without IV contrast | May Be Appropriate | ☢☢☢☢ |
| CT chest with IV contrast | May Be Appropriate | ☢☢☢ |
| CT chest without and with IV contrast | May Be Appropriate | ☢☢☢ |
| MRA chest abdomen pelvis without IV contrast | May Be Appropriate | O |
| MRA chest with IV contrast | May Be Appropriate | O |
| MRA chest without IV contrast | May Be Appropriate | O |
| CT chest without IV contrast | May Be Appropriate | ☢☢☢ |
| Aortography chest abdomen pelvis | Usually Not Appropriate | ☢☢☢☢ |
| Radiography chest | Usually Not Appropriate | ☢ |
| US echocardiography transthoracic resting | Usually Not Appropriate | O |
| US duplex Doppler aorta abdomen | Usually Not Appropriate | O |
| US echocardiography transesophageal | Usually Not Appropriate | O |
Variant: 4
Adult. Postopen repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
| Procedure | Appropriateness Category | Relative Radiation Level |
| CTA chest abdomen pelvis with IV contrast | Usually Appropriate | ☢☢☢☢☢ |
| CTA chest with IV contrast | Usually Appropriate | ☢☢☢ |
| MRA chest abdomen pelvis with IV contrast | Usually Appropriate | O |
| CT chest abdomen pelvis with IV contrast | May Be Appropriate | ☢☢☢☢ |
| MRA chest abdomen pelvis without IV contrast | May Be Appropriate | O |
| MRA chest with IV contrast | May Be Appropriate | O |
| CT chest abdomen pelvis without and with IV contrast | May Be Appropriate | ☢☢☢☢ |
| CT chest with IV contrast | May Be Appropriate | ☢☢☢ |
| CT chest without and with IV contrast | May Be Appropriate | ☢☢☢ |
| MRA chest without IV contrast | May Be Appropriate | O |
| CT chest abdomen pelvis without IV contrast | May Be Appropriate | ☢☢☢☢ |
| CT chest without IV contrast | Usually Not Appropriate | ☢☢☢ |
| Aortography chest abdomen pelvis | Usually Not Appropriate | ☢☢☢☢ |
| Radiography chest | Usually Not Appropriate | ☢ |
| US duplex Doppler aorta abdomen | Usually Not Appropriate | O |
| US echocardiography transesophageal | Usually Not Appropriate | O |
| US echocardiography transthoracic resting | Usually Not Appropriate | O |
Panel Members
Beth Ripley, MD, PhDa; Matthew J. Scheidt, MDb; Ayaz Aghayev, MDc; Charles Y. Kim, MDd; Sandeep S. Hedgire, MDe; Osmanuddin Ahmed, MDf; Sarah Ahmad, MDg; Rachel E. Clough, MD, PhDh; Randall R. DeMartino, MD, MSi; Maros Ferencik, MD, PhD, MCRj; G. Chad Hughes, MDk; Alan K. Klitzke, MDl; Scott D. Steenburg, MDm; Richard Thomas, MD, MBBSn; Bryan J. Wells, MDo; Stephen J. Wolf, MDp; Jason W. Pinchot, MDq; Bill S. Majdalany, MDr.
Summary of Literature Review
Introduction/Background
Medical Management Versus Aortic Repair
Discussion of Procedures by Variant
Variant 1: Adult. Known thoracic aortic aneurysm or dissection without repair. With or without symptoms. Follow-up imaging.
Variant 1: Adult. Known thoracic aortic aneurysm or dissection without repair. With or without symptoms. Follow-up imaging.
A. Aortography chest abdomen pelvis
A. Aortography chest abdomen pelvis
Variant 1: Adult. Known thoracic aortic aneurysm or dissection without repair. With or without symptoms. Follow-up imaging.
B. CT chest abdomen pelvis with IV contrast
B. CT chest abdomen pelvis with IV contrast
Variant 1: Adult. Known thoracic aortic aneurysm or dissection without repair. With or without symptoms. Follow-up imaging.
C. CT chest abdomen pelvis without and with IV contrast
C. CT chest abdomen pelvis without and with IV contrast
Variant 1: Adult. Known thoracic aortic aneurysm or dissection without repair. With or without symptoms. Follow-up imaging.
D. CT chest abdomen pelvis without IV contrast
D. CT chest abdomen pelvis without IV contrast
Variant 1: Adult. Known thoracic aortic aneurysm or dissection without repair. With or without symptoms. Follow-up imaging.
E. CT chest with IV contrast
E. CT chest with IV contrast
Variant 1: Adult. Known thoracic aortic aneurysm or dissection without repair. With or without symptoms. Follow-up imaging.
F. CT chest without and with IV contrast
F. CT chest without and with IV contrast
Variant 1: Adult. Known thoracic aortic aneurysm or dissection without repair. With or without symptoms. Follow-up imaging.
G. CT chest without IV contrast
G. CT chest without IV contrast
Variant 1: Adult. Known thoracic aortic aneurysm or dissection without repair. With or without symptoms. Follow-up imaging.
H. CTA chest abdomen pelvis with IV contrast
H. CTA chest abdomen pelvis with IV contrast
Variant 1: Adult. Known thoracic aortic aneurysm or dissection without repair. With or without symptoms. Follow-up imaging.
I. CTA chest with IV contrast
I. CTA chest with IV contrast
Variant 1: Adult. Known thoracic aortic aneurysm or dissection without repair. With or without symptoms. Follow-up imaging.
J. MRA chest abdomen pelvis with IV contrast
J. MRA chest abdomen pelvis with IV contrast
Variant 1: Adult. Known thoracic aortic aneurysm or dissection without repair. With or without symptoms. Follow-up imaging.
K. MRA chest abdomen pelvis without IV contrast
K. MRA chest abdomen pelvis without IV contrast
Variant 1: Adult. Known thoracic aortic aneurysm or dissection without repair. With or without symptoms. Follow-up imaging.
L. MRA chest with IV contrast
L. MRA chest with IV contrast
Variant 1: Adult. Known thoracic aortic aneurysm or dissection without repair. With or without symptoms. Follow-up imaging.
M. MRA chest without IV contrast
M. MRA chest without IV contrast
Variant 1: Adult. Known thoracic aortic aneurysm or dissection without repair. With or without symptoms. Follow-up imaging.
N. Radiography chest
N. Radiography chest
Variant 1: Adult. Known thoracic aortic aneurysm or dissection without repair. With or without symptoms. Follow-up imaging.
O. US echocardiography transesophageal
O. US echocardiography transesophageal
Variant 1: Adult. Known thoracic aortic aneurysm or dissection without repair. With or without symptoms. Follow-up imaging.
P. US echocardiography transthoracic resting
P. US echocardiography transthoracic resting
Variant 2: Adult. Prethoracic endovascular repair or open repair of thoracic aorta aneurysm or dissection. Preprocedure planning.
Variant 2: Adult. Prethoracic endovascular repair or open repair of thoracic aorta aneurysm or dissection. Preprocedure planning.
A. Aortography chest abdomen pelvis
A. Aortography chest abdomen pelvis
Variant 2: Adult. Prethoracic endovascular repair or open repair of thoracic aorta aneurysm or dissection. Preprocedure planning.
B. CT chest abdomen pelvis with IV contrast
B. CT chest abdomen pelvis with IV contrast
Variant 2: Adult. Prethoracic endovascular repair or open repair of thoracic aorta aneurysm or dissection. Preprocedure planning.
C. CT chest abdomen pelvis without and with IV contrast
C. CT chest abdomen pelvis without and with IV contrast
Variant 2: Adult. Prethoracic endovascular repair or open repair of thoracic aorta aneurysm or dissection. Preprocedure planning.
D. CT chest abdomen pelvis without IV contrast
D. CT chest abdomen pelvis without IV contrast
Variant 2: Adult. Prethoracic endovascular repair or open repair of thoracic aorta aneurysm or dissection. Preprocedure planning.
E. CT chest with IV contrast
E. CT chest with IV contrast
Variant 2: Adult. Prethoracic endovascular repair or open repair of thoracic aorta aneurysm or dissection. Preprocedure planning.
F. CT chest without and with IV contrast
F. CT chest without and with IV contrast
Variant 2: Adult. Prethoracic endovascular repair or open repair of thoracic aorta aneurysm or dissection. Preprocedure planning.
G. CT chest without IV contrast
G. CT chest without IV contrast
Variant 2: Adult. Prethoracic endovascular repair or open repair of thoracic aorta aneurysm or dissection. Preprocedure planning.
H. CTA chest abdomen pelvis with IV contrast
H. CTA chest abdomen pelvis with IV contrast
Variant 2: Adult. Prethoracic endovascular repair or open repair of thoracic aorta aneurysm or dissection. Preprocedure planning.
I. CTA chest with IV contrast
I. CTA chest with IV contrast
Variant 2: Adult. Prethoracic endovascular repair or open repair of thoracic aorta aneurysm or dissection. Preprocedure planning.
J. MRA chest abdomen pelvis with IV contrast
J. MRA chest abdomen pelvis with IV contrast
Variant 2: Adult. Prethoracic endovascular repair or open repair of thoracic aorta aneurysm or dissection. Preprocedure planning.
K. MRA chest abdomen pelvis without IV contrast
K. MRA chest abdomen pelvis without IV contrast
Variant 2: Adult. Prethoracic endovascular repair or open repair of thoracic aorta aneurysm or dissection. Preprocedure planning.
L. MRA chest with IV contrast
L. MRA chest with IV contrast
Variant 2: Adult. Prethoracic endovascular repair or open repair of thoracic aorta aneurysm or dissection. Preprocedure planning.
M. MRA chest without IV contrast
M. MRA chest without IV contrast
Variant 2: Adult. Prethoracic endovascular repair or open repair of thoracic aorta aneurysm or dissection. Preprocedure planning.
N. US duplex Doppler aorta abdomen
N. US duplex Doppler aorta abdomen
Variant 2: Adult. Prethoracic endovascular repair or open repair of thoracic aorta aneurysm or dissection. Preprocedure planning.
O. US duplex Doppler iliofemoral arteries
O. US duplex Doppler iliofemoral arteries
Variant 2: Adult. Prethoracic endovascular repair or open repair of thoracic aorta aneurysm or dissection. Preprocedure planning.
P. US echocardiography transesophageal
P. US echocardiography transesophageal
Variant 2: Adult. Prethoracic endovascular repair or open repair of thoracic aorta aneurysm or dissection. Preprocedure planning.
Q. US echocardiography transthoracic resting
Q. US echocardiography transthoracic resting
Variant 3: Adult. Postthoracic endovascular repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
Variant 3: Adult. Postthoracic endovascular repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
A. Aortography chest abdomen pelvis
A. Aortography chest abdomen pelvis
Variant 3: Adult. Postthoracic endovascular repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
B. CT chest abdomen pelvis with IV contrast
B. CT chest abdomen pelvis with IV contrast
Variant 3: Adult. Postthoracic endovascular repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
C. CT chest abdomen pelvis without and with IV contrast
C. CT chest abdomen pelvis without and with IV contrast
Variant 3: Adult. Postthoracic endovascular repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
D. CT chest abdomen pelvis without IV contrast
D. CT chest abdomen pelvis without IV contrast
Variant 3: Adult. Postthoracic endovascular repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
E. CT chest with IV contrast
E. CT chest with IV contrast
Variant 3: Adult. Postthoracic endovascular repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
F. CT chest without and with IV contrast
F. CT chest without and with IV contrast
Variant 3: Adult. Postthoracic endovascular repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
G. CT chest without IV contrast
G. CT chest without IV contrast
Variant 3: Adult. Postthoracic endovascular repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
H. CTA chest abdomen pelvis with IV contrast
H. CTA chest abdomen pelvis with IV contrast
Variant 3: Adult. Postthoracic endovascular repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
I. CTA chest with IV contrast
I. CTA chest with IV contrast
Variant 3: Adult. Postthoracic endovascular repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
J. MRA chest abdomen pelvis with IV contrast
J. MRA chest abdomen pelvis with IV contrast
Variant 3: Adult. Postthoracic endovascular repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
K. MRA chest abdomen pelvis without IV contrast
K. MRA chest abdomen pelvis without IV contrast
Variant 3: Adult. Postthoracic endovascular repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
L. MRA chest with IV contrast
L. MRA chest with IV contrast
Variant 3: Adult. Postthoracic endovascular repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
M. MRA chest without IV contrast
M. MRA chest without IV contrast
Variant 3: Adult. Postthoracic endovascular repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
N. Radiography chest
N. Radiography chest
Variant 3: Adult. Postthoracic endovascular repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
O. US duplex Doppler aorta abdomen
O. US duplex Doppler aorta abdomen
Variant 3: Adult. Postthoracic endovascular repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
P. US echocardiography transesophageal
P. US echocardiography transesophageal
Variant 3: Adult. Postthoracic endovascular repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
Q. US echocardiography transthoracic resting
Q. US echocardiography transthoracic resting
Variant 4: Adult. Postopen repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
Variant 4: Adult. Postopen repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
A. Aortography chest abdomen pelvis
A. Aortography chest abdomen pelvis
Variant 4: Adult. Postopen repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
B. CT chest abdomen pelvis with IV contrast
B. CT chest abdomen pelvis with IV contrast
Variant 4: Adult. Postopen repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
C. CT chest abdomen pelvis without and with IV contrast
C. CT chest abdomen pelvis without and with IV contrast
Variant 4: Adult. Postopen repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
D. CT chest abdomen pelvis without IV contrast
D. CT chest abdomen pelvis without IV contrast
Variant 4: Adult. Postopen repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
E. CT chest with IV contrast
E. CT chest with IV contrast
Variant 4: Adult. Postopen repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
F. CT chest without and with IV contrast
F. CT chest without and with IV contrast
Variant 4: Adult. Postopen repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
G. CT chest without IV contrast
G. CT chest without IV contrast
Variant 4: Adult. Postopen repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
H. CTA chest abdomen pelvis with IV contrast
H. CTA chest abdomen pelvis with IV contrast
Variant 4: Adult. Postopen repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
I. CTA chest with IV contrast
I. CTA chest with IV contrast
Variant 4: Adult. Postopen repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
J. MRA chest abdomen pelvis with IV contrast
J. MRA chest abdomen pelvis with IV contrast
Variant 4: Adult. Postopen repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
K. MRA chest abdomen pelvis without IV contrast
K. MRA chest abdomen pelvis without IV contrast
Variant 4: Adult. Postopen repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
L. MRA chest with IV contrast
L. MRA chest with IV contrast
Variant 4: Adult. Postopen repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
M. MRA chest without IV contrast
M. MRA chest without IV contrast
Variant 4: Adult. Postopen repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
N. Radiography chest
N. Radiography chest
Variant 4: Adult. Postopen repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
O. US duplex Doppler aorta abdomen
O. US duplex Doppler aorta abdomen
Variant 4: Adult. Postopen repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
P. US echocardiography transesophageal
P. US echocardiography transesophageal
Variant 4: Adult. Postopen repair of thoracic aortic aneurysm or dissection. Follow-up imaging.
Q. US echocardiography transthoracic resting
Q. US echocardiography transthoracic resting
Summary of Highlights
Supporting Documents
The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.
For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.
Gender Equality and Inclusivity Clause
The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.
Appropriateness Category Names and Definitions
|
Appropriateness Category Name |
Appropriateness Rating |
Appropriateness Category Definition |
|
Usually Appropriate |
7, 8, or 9 |
The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients. |
|
May Be Appropriate |
4, 5, or 6 |
The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal. |
|
May Be Appropriate (Disagreement) |
5 |
The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned. |
|
Usually Not Appropriate |
1, 2, or 3 |
The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable. |
Relative Radiation Level Information
Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.
|
Relative Radiation Level Designations |
||
|
Relative Radiation Level* |
Adult Effective Dose Estimate Range |
Pediatric Effective Dose Estimate Range |
|
O |
0 mSv |
0 mSv |
|
☢ |
<0.1 mSv |
<0.03 mSv |
|
☢☢ |
0.1-1 mSv |
0.03-0.3 mSv |
|
☢☢☢ |
1-10 mSv |
0.3-3 mSv |
|
☢☢☢☢ |
10-30 mSv |
3-10 mSv |
|
☢☢☢☢☢ |
30-100 mSv |
10-30 mSv |
|
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.” |
||
References
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Disclaimer
The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.