Suspected and Known Renal or Splanchnic Artery Aneurysm

Variant: 1 Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRA abdomen and pelvis with IV contrast	Usually Appropriate	O
MRA abdomen and pelvis without and with IV contrast	Usually Appropriate	O
MRA abdomen with IV contrast	Usually Appropriate	O
MRA abdomen without and with IV contrast	Usually Appropriate	O
CTA abdomen with IV contrast	Usually Appropriate	☢☢☢
CTA abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢☢
CTA abdomen and pelvis without and with IV contrast	Usually Appropriate	☢☢☢☢
US aorta abdomen with IV contrast	May Be Appropriate	O
US duplex Doppler aorta abdomen	May Be Appropriate	O
MRA abdomen and pelvis without IV contrast	May Be Appropriate	O
MRA abdomen without IV contrast	May Be Appropriate	O
CT abdomen and pelvis with IV contrast	May Be Appropriate	☢☢☢
CT abdomen with IV contrast	May Be Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	May Be Appropriate	☢☢☢☢
CT abdomen without and with IV contrast	May Be Appropriate	☢☢☢☢
Arteriography abdomen	Usually Not Appropriate	☢☢☢
Arteriography abdomen and pelvis	Usually Not Appropriate	☢☢☢☢
MRI abdomen and pelvis without and with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate	O
MRI abdomen without and with IV contrast	Usually Not Appropriate	O
MRI abdomen without IV contrast	Usually Not Appropriate	O
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢
CT abdomen without IV contrast	Usually Not Appropriate	☢☢☢

Variant: 2 Adult. Known splanchnic or renal artery aneurysm. Active surveillance.

Procedure	Appropriateness Category	Relative Radiation Level
MRA abdomen and pelvis with IV contrast	Usually Appropriate	O
MRA abdomen and pelvis without and with IV contrast	Usually Appropriate	O
MRA abdomen with IV contrast	Usually Appropriate	O
MRA abdomen without and with IV contrast	Usually Appropriate	O
CTA abdomen with IV contrast	Usually Appropriate	☢☢☢
CTA abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢☢
US aorta abdomen with IV contrast	May Be Appropriate	O
US duplex Doppler aorta abdomen	May Be Appropriate	O
MRA abdomen and pelvis without IV contrast	May Be Appropriate	O
MRA abdomen without IV contrast	May Be Appropriate	O
CT abdomen and pelvis with IV contrast	May Be Appropriate	☢☢☢
CT abdomen with IV contrast	May Be Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	May Be Appropriate	☢☢☢☢
CT abdomen without and with IV contrast	May Be Appropriate	☢☢☢☢
Arteriography abdomen	Usually Not Appropriate	☢☢☢
Arteriography abdomen and pelvis	Usually Not Appropriate	☢☢☢☢
MRI abdomen and pelvis without and with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate	O
MRI abdomen without and with IV contrast	Usually Not Appropriate	O
MRI abdomen without IV contrast	Usually Not Appropriate	O
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢
CT abdomen without IV contrast	Usually Not Appropriate	☢☢☢

Variant: 3 Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US aorta abdomen with IV contrast	Usually Appropriate	O
US duplex Doppler aorta abdomen	Usually Appropriate	O
MRA abdomen and pelvis without IV contrast	May Be Appropriate	O
MRA abdomen without IV contrast	May Be Appropriate	O
CTA abdomen with IV contrast	May Be Appropriate	☢☢☢
CTA abdomen and pelvis with IV contrast	May Be Appropriate	☢☢☢☢
Arteriography abdomen	Usually Not Appropriate	☢☢☢
Arteriography abdomen and pelvis	Usually Not Appropriate	☢☢☢☢
MRA abdomen and pelvis with IV contrast	Usually Not Appropriate	O
MRA abdomen and pelvis without and with IV contrast	Usually Not Appropriate	O
MRA abdomen with IV contrast	Usually Not Appropriate	O
MRA abdomen without and with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without and with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate	O
MRI abdomen without and with IV contrast	Usually Not Appropriate	O
MRI abdomen without IV contrast	Usually Not Appropriate	O
CT abdomen and pelvis with IV contrast	Usually Not Appropriate	☢☢☢
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢
CT abdomen with IV contrast	Usually Not Appropriate	☢☢☢
CT abdomen without IV contrast	Usually Not Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT abdomen without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 4 Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.

Procedure	Appropriateness Category	Relative Radiation Level
US aorta abdomen with IV contrast	Usually Appropriate	O
US duplex Doppler aorta abdomen	Usually Appropriate	O
MRA abdomen and pelvis without IV contrast	May Be Appropriate	O
MRA abdomen without IV contrast	May Be Appropriate	O
CT abdomen with IV contrast	May Be Appropriate	☢☢☢
CTA abdomen with IV contrast	May Be Appropriate	☢☢☢
CTA abdomen and pelvis with IV contrast	May Be Appropriate	☢☢☢☢
Arteriography abdomen	Usually Not Appropriate	☢☢☢
Arteriography abdomen and pelvis	Usually Not Appropriate	☢☢☢☢
MRA abdomen and pelvis with IV contrast	Usually Not Appropriate	O
MRA abdomen and pelvis without and with IV contrast	Usually Not Appropriate	O
MRA abdomen with IV contrast	Usually Not Appropriate	O
MRA abdomen without and with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without and with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate	O
MRI abdomen without and with IV contrast	Usually Not Appropriate	O
MRI abdomen without IV contrast	Usually Not Appropriate	O
CT abdomen and pelvis with IV contrast	Usually Not Appropriate	☢☢☢
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢
CT abdomen without IV contrast	Usually Not Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT abdomen without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Panel Members

Sasan Partovi, MD^a, Xin Li, MD^b, Ayaz Aghayev, MD^c, Sandeep S. Hedgire, MD^d, Ahmed Sami Abuzaid, MD^e, Sarah Ahmad, MD^f, Aws Hamid, MD^g, Stanislav Henkin, MD, MPH^h, Edward Hulten, MD, MPHⁱ, Prashant Nagpal, MD^j, Anil K. Pillai, MD^k, Margarita V. Revzin, MD, MS^l, Beth Ripley, MD, PhD^m, Sachin S. Saboo, MDⁿ, Richard D. Shih, MD^o, Jeffrey J. Siracuse, MD, MBA^p, Lilja B. Solnes, MD, MBA^q, Richard Thomas, MD^r, Bill S. Majdalany, MD^s

Summary of Literature Review

Introduction/Background

Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

There are procedures that are equivalent alternatives (ie, only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

There are complementary procedures (ie, more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).

Discussion of Procedures by Variant

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
A. Arteriography abdomen

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
B. Arteriography abdomen and pelvis

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
C. CT abdomen and pelvis with IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
D. CT abdomen and pelvis without and with IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
E. CT abdomen and pelvis without IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
F. CT abdomen with IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
G. CT abdomen without and with IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
H. CT abdomen without IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
I. CTA abdomen and pelvis with IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
J. CTA abdomen and pelvis without and with IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
K. CTA abdomen with IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
L. MRA abdomen and pelvis with IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
M. MRA abdomen and pelvis without and with IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
N. MRA abdomen and pelvis without IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
O. MRA abdomen with IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
P. MRA abdomen without and with IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
Q. MRA abdomen without IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
R. MRI abdomen and pelvis without and with IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
S. MRI abdomen and pelvis without IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
T. MRI abdomen without and with IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
U. MRI abdomen without IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
V. US aorta abdomen with IV contrast

Variant 1:Adult. Suspected splanchnic or renal artery aneurysm. Initial imaging.
W. US duplex Doppler aorta abdomen

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
A. Arteriography abdomen

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
B. Arteriography abdomen and pelvis

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
C. CT abdomen and pelvis with IV contrast

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
D. CT abdomen and pelvis without and with IV contrast

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
E. CT abdomen and pelvis without IV contrast

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
F. CT abdomen with IV contrast

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
G. CT abdomen without and with IV contrast

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
H. CT abdomen without IV contrast

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
I. CTA abdomen and pelvis with IV contrast

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
J. CTA abdomen with IV contrast

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
K. MRA abdomen and pelvis with IV contrast

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
L. MRA abdomen and pelvis without and with IV contrast

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
M. MRA abdomen and pelvis without IV contrast

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
N. MRA abdomen with IV contrast

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
O. MRA abdomen without and with IV contrast

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
P. MRA abdomen without IV contrast

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
Q. MRI abdomen and pelvis without and with IV contrast

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
R. MRI abdomen and pelvis without IV contrast

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
S. MRI abdomen without and with IV contrast

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
T. MRI abdomen without IV contrast

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
U. US aorta abdomen with IV contrast

Variant 2:Adult. Known splanchnic or renal artery aneurysm. Active surveillance.
V. US duplex Doppler aorta abdomen

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
A. Arteriography abdomen

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
B. Arteriography abdomen and pelvis

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
C. CT abdomen and pelvis with IV contrast

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
D. CT abdomen and pelvis without and with IV contrast

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
E. CT abdomen and pelvis without IV contrast

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
F. CT abdomen with IV contrast

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
G. CT abdomen without and with IV contrast

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
H. CT abdomen without IV contrast

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
I. CTA abdomen and pelvis with IV contrast

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
J. CTA abdomen with IV contrast

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
K. MRA abdomen and pelvis with IV contrast

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
L. MRA abdomen and pelvis without and with IV contrast

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
M. MRA abdomen and pelvis without IV contrast

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
N. MRA abdomen with IV contrast

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
O. MRA abdomen without and with IV contrast

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
P. MRA abdomen without IV contrast

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
Q. MRI abdomen and pelvis without and with IV contrast

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
R. MRI abdomen and pelvis without IV contrast

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
S. MRI abdomen without and with IV contrast

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
T. MRI abdomen without IV contrast

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
U. US aorta abdomen with IV contrast

Variant 3:Pregnant. Suspected splanchnic or renal artery aneurysm. Initial imaging.
V. US duplex Doppler aorta abdomen

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
A. Arteriography abdomen

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
B. Arteriography abdomen and pelvis

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
C. CT abdomen and pelvis with IV contrast

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
D. CT abdomen and pelvis without and with IV contrast

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
E. CT abdomen and pelvis without IV contrast

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
F. CT abdomen with IV contrast

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
G. CT abdomen without and with IV contrast

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
H. CT abdomen without IV contrast

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
I. CTA abdomen and pelvis with IV contrast

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
J. CTA abdomen with IV contrast

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
K. MRA abdomen and pelvis with IV contrast

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
L. MRA abdomen and pelvis without and with IV contrast

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
M. MRA abdomen and pelvis without IV contrast

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
N. MRA abdomen with IV contrast

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
O. MRA abdomen without and with IV contrast

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
P. MRA abdomen without IV contrast

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
Q. MRI abdomen and pelvis without and with IV contrast

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
R. MRI abdomen and pelvis without IV contrast

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
S. MRI abdomen without and with IV contrast

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
T. MRI abdomen without IV contrast

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
U. US aorta abdomen with IV contrast

Variant 4:Pregnant. Known splanchnic or renal artery aneurysm. Active surveillance.
V. US duplex Doppler aorta abdomen

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.

Safety Considerations in Pregnant Patients

Imaging of the pregnant patient can be challenging, particularly with respect to minimizing radiation exposure and risk. For further information and guidance, see the following ACR documents:

· ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI)

· ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Patients with Ionizing Radiation

· ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical Ultrasound

· ACR Manual on Contrast Media

· ACR Manual on MR Safety

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

1.	Brownstein AJ, Erben Y, Rajaee S, et al. Natural history and management of renal artery aneurysms in a single tertiary referral center. Journal of Vascular Surgery. 68(1):137-144, 2018 07.J Vasc Surg. 68(1):137-144, 2018 07.
2.	Sellier J, Karam C, Beauchet A, et al. Higher prevalence of splenic artery aneurysms in hereditary hemorrhagic telangiectasia: Vascular implications and risk factors. PLoS ONE [Electronic Resource]. 15(1):e0226681, 2020.PLoS ONE. 15(1):e0226681, 2020.
3.	Batagini NC, Constantin BD, Kirksey L, et al. Natural History of Splanchnic Artery Aneurysms. Annals of Vascular Surgery. 73:290-295, 2021 May.Ann Vasc Surg. 73:290-295, 2021 May.
4.	Zhang J, Harish K, Speranza G, et al. Natural history of renal artery aneurysms. Journal of Vascular Surgery. 77(4):1199-1205.e1, 2023 04.J Vasc Surg. 77(4):1199-1205.e1, 2023 04.
5.	Pasha SS, Gloviczki PP, Stanson AA, Kamath PP. Splanchnic artery aneurysms. Mayo Clin Proc 82:472-9, .
6.	Leelaudomlipi S, Bramhall SR, Gunson BK, et al. Hepatic-artery aneurysm in adult liver transplantation. Transpl Int 16:257-61, 2003 Apr.
7.	Heestand G, Sher L, Lightfoote J, et al. Characteristics and management of splenic artery aneurysm in liver transplant candidates and recipients. [Review] [19 refs]. American Surgeon. 69(11):933-40, 2003 Nov.Am Surg. 69(11):933-40, 2003 Nov.
8.	Wayne EJ, Edwards MS, Stafford JM, Hansen KJ, Corriere MA. Anatomic characteristics and natural history of renal artery aneurysms during longitudinal imaging surveillance. J Vasc Surg 60:448-52, 2014 Aug.
9.	Mattar SG, Lumsden AB. The management of splenic artery aneurysms: experience with 23 cases. American Journal of Surgery. 169(6):580-4, 1995 Jun.Am J Surg. 169(6):580-4, 1995 Jun.
10.	Tulsyan N, Kashyap VS, Greenberg RK, et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg. 45(2):276-83; discussion 283, 2007 Feb.
11.	Chaer RA, Abularrage CJ, Coleman DM, et al. The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms. [Review]. Journal of Vascular Surgery. 72(1S):3S-39S, 2020 07.J Vasc Surg. 72(1S):3S-39S, 2020 07.
12.	Rossi M, Krokidis M, Kashef E, Peynircioglu B, Tipaldi MA. CIRSE Standards of Practice for the Endovascular Treatment of Visceral and Renal Artery Aneurysms and Pseudoaneurysms. Cardiovascular & Interventional Radiology. 47(1):26-35, 2024 Jan.Cardiovasc Intervent Radiol. 47(1):26-35, 2024 Jan.
13.	Pratesi C, Esposito D, Martini R, et al. Guidelines on the diagnosis, treatment and management of visceral and renal arteries aneurysms: a joint assessment by the Italian Societies of Vascular and Endovascular Surgery (SICVE) and Medical and Interventional Radiology (SIRM). Journal of Cardiovascular Surgery. 65(1):49-63, 2024 Feb.J Cardiovasc Surg (Torino). 65(1):49-63, 2024 Feb.
14.	Abbas MM, Stone WW, Fowl RR, et al. Splenic artery aneurysms: two decades experience at Mayo clinic. Ann Vasc Surg 16:442-9, .
15.	Scheirey CD, Fowler KJ, Therrien JA, et al. ACR Appropriateness Criteria® Acute Nonlocalized Abdominal Pain. J Am Coll Radiol 2018;15:S217-S31.
16.	Schieda N, Blaichman JI, Costa AF, et al. Gadolinium-Based Contrast Agents in Kidney Disease: A Comprehensive Review and Clinical Practice Guideline Issued by the Canadian Association of Radiologists. Can J Kidney Health Dis. 2018;5():2054358118778573.
17.	Liu Q, Lu JP, Wang F, et al. Visceral artery aneurysms: evaluation using 3D contrast-enhanced MR angiography. AJR Am J Roentgenol. 191(3):826-33, 2008 Sep.
18.	Pilleul F, Beuf O. Diagnosis of splanchnic artery aneurysms and pseudoaneurysms, with special reference to contrast enhanced 3D magnetic resonance angiography: a review. Acta Radiol. 2004 Nov;45(7):702-8.
19.	Hagspiel KD, Flors L, Hanley M, Norton PT. Computed tomography angiography and magnetic resonance angiography imaging of the mesenteric vasculature. [Review]. Tech Vasc Interv Radiol. 18(1):2-13, 2015 Mar.
20.	Meaney JF. Non-invasive evaluation of the visceral arteries with magnetic resonance angiography. [Review] [32 refs]. Eur Radiol. 9(7):1267-76, 1999.
21.	Leiner T. Magnetic resonance angiography of abdominal and lower extremity vasculature. [Review] [237 refs]. Top Magn Reson Imaging. 16(1):21-66, 2005 Feb.
22.	Laissy JP, Trillaud H, Douek P. MR angiography: noninvasive vascular imaging of the abdomen. [Review] [74 refs]. Abdom Imaging. 27(5):488-506, 2002 Sep-Oct.
23.	Barger AV, Block WF, Toropov Y, Grist TM, Mistretta CA. Time-resolved contrast-enhanced imaging with isotropic resolution and broad coverage using an undersampled 3D projection trajectory. Magn Reson Med. 2002 Aug;48(2):297-305.
24.	Ernst O, Asnar V, Sergent G, et al. Comparing contrast-enhanced breath-hold MR angiography and conventional angiography in the evaluation of mesenteric circulation. AJR Am J Roentgenol. 174(2):433-9, 2000 Feb.
25.	Carlos RC, Stanley JC, Stafford-Johnson D, Prince MR. Interobserver variability in the evaluation of chronic mesenteric ischemia with gadolinium-enhanced MR angiography. Acad Radiol. 8(9):879-87, 2001 Sep.
26.	Meaney JF, Prince MR, Nostrant TT, Stanley JC. Gadolinium-enhanced MR angiography of visceral arteries in patients with suspected chronic mesenteric ischemia. J Magn Reson Imaging. 7(1):171-6, 1997 Jan-Feb.
27.	Wasser MN, Geelkerken RH, Kouwenhoven M, et al. Systolically gated 3D phase contrast MRA of mesenteric arteries in suspected mesenteric ischemia. J Comput Assist Tomogr. 20(2):262-8, 1996 Mar-Apr.
28.	Horton KM, Smith C, Fishman EK. MDCT and 3D CT angiography of splanchnic artery aneurysms. [Review] [31 refs]. AJR Am J Roentgenol. 189(3):641-7, 2007 Sep.
29.	Horton KM, Fishman EK. CT angiography of the mesenteric circulation. [Review] [53 refs]. Radiol Clin North Am. 48(2):331-45, viii, 2010 Mar.
30.	Cikrit DF, Harris VJ, Hemmer CG, et al. Comparison of spiral CT scan and arteriography for evaluation of renal and visceral arteries. Ann Vasc Surg. 10(2):109-16, 1996 Mar.
31.	Chappell ET, Moure FC, Good MC. Comparison of computed tomographic angiography with digital subtraction angiography in the diagnosis of cerebral aneurysms: a meta-analysis. Neurosurgery. 2003 Mar;52(3):624-31; discussion 630-1.
32.	McKinney AM, Palmer CS, Truwit CL, Karagulle A, Teksam M. Detection of aneurysms by 64-section multidetector CT angiography in patients acutely suspected of having an intracranial aneurysm and comparison with digital subtraction and 3D rotational angiography. AJNR Am J Neuroradiol. 2008;29(3):594-602.
33.	Jia Z, Huang Y, Shi H, et al. Comparison of CTA and DSA in the diagnosis of superior mesenteric artery dissecting aneurysm. Vascular. 26(4):346-351, 2018 Aug.
34.	Chiesa R, Astore D, Guzzo G, et al. Visceral artery aneurysms. Ann Vasc Surg. 2005 Jan;19(1):42-8.
35.	Chadha M, Ahuja C. Visceral artery aneurysms: diagnosis and percutaneous management. Semin Intervent Radiol. 2009 Sep;26(3):196-206.
36.	Frauenfelder T, Wildermuth S, Marincek B, Boehm T. Nontraumatic emergent abdominal vascular conditions: advantages of multi-detector row CT and three-dimensional imaging. Radiographics. 24(2):481-96, 2004 Mar-Apr.
37.	Zhang LJ, Wu SY, Niu JB, et al. Dual-energy CT angiography in the evaluation of intracranial aneurysms: image quality, radiation dose, and comparison with 3D rotational digital subtraction angiography. AJR Am J Roentgenol. 2010 Jan;194(1):23-30.
38.	Saba L, Anzidei M, Lucatelli P, Mallarini G. The multidetector computed tomography angiography (MDCTA) in the diagnosis of splenic artery aneurysm and pseudoaneurysm. [Review]. Acta Radiol. 52(5):488-98, 2011 Jun 01.
39.	Badea R. Splanchnic artery aneurysms: the diagnostic contribution of ultrasonography in correlation with other imaging methods. J Gastrointestin Liver Dis. 2008 Mar;17(1):101-5.
40.	Ishida H, Konno K, Hamashima Y, et al. Splenic artery aneurysm: value of color Doppler and the limitation of gray-scale ultrasonography. Abdom Imaging. 23(6):627-32, 1998 Nov-Dec.
41.	Li X, Staub D, Rafailidis V, Al-Natour M, Kalva S, Partovi S. Contrast-enhanced ultrasound of the abdominal aorta - current status and future perspectives. Vasa. 48(2):115-125, 2019 Mar.
42.	Li X, Cokkinos D, Gadani S, et al. Advanced ultrasound techniques in arterial diseases. [Review]. Int J Cardiovasc Imaging. 38(8):1711-1721, 2022 Aug.
43.	Pfister K, Kasprzak P, Oikonomou K, et al. [Management of Visceral Artery Aneurysms with Preservation of Organ Perfusion: More Than Twenty Years Experience]. Zentralbl Chir. 2018 Oct;143(5):516-525.
44.	Gunabushanam G, Chaubal R, Scoutt LM. Doppler Ultrasound of the Renal Vasculature. [Review]. J Ultrasound Med. 43(8):1543-1562, 2024 Aug.
45.	Maruno M, Kiyosue H, Tanoue S, Hongo N, Kashiwagi J, Mori H. Unenhanced magnetic resonance angiography with time-spatial labeling inversion pulse for evaluating visceral artery aneurysms after endosaccular packing with detachable coils: preliminary results. J Vasc Interv Radiol. 24(2):289-93, 2013 Feb.
46.	Bultman EM, Klaers J, Johnson KM, et al. Non-contrast enhanced 3D SSFP MRA of the renal allograft vasculature: a comparison between radial linear combination and Cartesian inflow-weighted acquisitions. Magn Reson Imaging. 32(2):190-5, 2014 Feb.
47.	Mori R, Kassai Y, Masuda A, et al. Ultrashort echo time time-spatial labeling inversion pulse magnetic resonance angiography with denoising deep learning reconstruction for the assessment of abdominal visceral arteries. J Magn Reson Imaging. 53(6):1926-1937, 2021 06.
48.	Gietzen C, Janssen JP, Görtz L, et al. Non-contrast-enhanced MR-angiography of the abdominal arteries: intraindividual comparison between relaxation-enhanced angiography without contrast and triggering (REACT) and 4D contrast-enhanced MR-angiography. Abdom Radiol (NY). 2025 Apr;50(4):1887-1898.
49.	Barrionuevo P, Malas MB, Nejim B, et al. A systematic review and meta-analysis of the management of visceral artery aneurysms. J Vasc Surg. 70(5):1694-1699, 2019 11.
50.	Loffroy R, Favelier S, Pottecher P, et al. Endovascular management of visceral artery aneurysms: When to watch, when to intervene?. World J Radiol. 7(7):143-8, 2015 Jul 28.
51.	Hong Z, Chen F, Yang J, Wu Z, Yan Z. Diagnosis and treatment of splanchnic artery aneurysms: a report of 57 cases. Chin Med J. 112(1):29-33, 1999 Jan.
52.	Etezadi V, Gandhi RT, Benenati JF, et al. Endovascular treatment of visceral and renal artery aneurysms. J Vasc Interv Radiol. 22(9):1246-53, 2011 Sep.
53.	Kok HK, Asadi H, Sheehan M, Given MF, Lee MJ. Systematic Review and Single-Center Experience for Endovascular Management of Visceral and Renal Artery Aneurysms. [Review]. J Vasc Interv Radiol. 27(11):1630-1641, 2016 Nov.
54.	Ruhnke H, Kroncke TJ. Visceral Artery Aneurysms and Pseudoaneurysms: Retrospective Analysis of Interventional Endovascular Therapy of 43 Aneurysms. ROFO Fortschr Geb Rontgenstr Nuklearmed. 189(7):632-639, 2017 Jul.
55.	Venturini M, Marra P, Colombo M, et al. Endovascular Repair of 40 Visceral Artery Aneurysms and Pseudoaneurysms with the Viabahn Stent-Graft: Technical Aspects, Clinical Outcome and Mid-Term Patency. Cardiovasc Intervent Radiol. 41(3):385-397, 2018 Mar.
56.	Sheahan KP, Alam I, Pehlivan T, et al. A Qualitative Systematic Review of Endovascular Management of Renal Artery Aneurysms. [Review]. .J Vasc Interv Radiol. 35(8):1127-1138, 2024 Aug.
57.	Shu K, Shao J, Lai Z, et al. Treatment strategy for splenic artery aneurysms and novel classification based on imaging. J Vasc Surg. 80(3):838-846.e1, 2024 Sep.
58.	Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. [Review] [1308 refs]. Circulation. 113(11):e463-654, 2006 Mar 21.Circulation. 113(11):e463-654, 2006 Mar 21.
59.	Tétreau RR, Beji HH, Henry LL, Valette PP, Pilleul FF. Arterial splanchnic aneurysms: Presentation, treatment and outcome in 112 patients. Diagn Interv Imaging 97:81-90, .
60.	Erben YY, Brownstein AA, Rajaee SS, et al. Natural history and management of splanchnic artery aneurysms in a single tertiary referral center. J Vasc Surg 68:1079-1087, .
61.	Gong C, Sun MS, Leng R, et al. Endovascular embolization of visceral artery aneurysm: a retrospective study. Sci Rep. 2023 Apr 28;13(1):6936.
62.	Koganemaru M, Abe T, Uchiyama D, et al. Detection of neck recanalization with follow-up contrast-enhanced MR angiography after renal artery aneurysm coil embolization. J Vasc Interv Radiol. 2010 Feb;21(2):298-300.
63.	Yamada N, Hayashi K, Murao K, Higashi M, Iihara K. Time-of-flight MR angiography targeted to coiled intracranial aneurysms is more sensitive to residual flow than is digital subtraction angiography. AJNR Am J Neuroradiol. 25(7):1154-7, 2004 Aug.
64.	Ferré JC, Carsin-Nicol B, Morandi X, et al. Time-of-flight MR angiography at 3T versus digital subtraction angiography in the imaging follow-up of 51 intracranial aneurysms treated with coils. Eur J Radiol. 2009 Dec;72(3):365-9.
65.	Kaufmann TJ, Huston J 3rd, Cloft HJ, et al. A prospective trial of 3T and 1.5T time-of-flight and contrast-enhanced MR angiography in the follow-up of coiled intracranial aneurysms. AJNR Am J Neuroradiol. 31(5):912-8, 2010 May.
66.	Saltzberg SS, Maldonado TS, Lamparello PJ, et al. Is endovascular therapy the preferred treatment for all visceral artery aneurysms? Ann Vasc Surg. 2005 Jul;19(4):507-15.
67.	Al-Habbal Y, Christophi C, Muralidharan V. Aneurysms of the splenic artery - a review. [Review]. Surgeon Journal of the Royal Colleges of Surgeons of Edinburgh & Ireland. 8(4):223-31, 2010 Aug.Surg.. 8(4):223-31, 2010 Aug.
68.	Corey MR, Ergul EA, Cambria RP, et al. The natural history of splanchnic artery aneurysms and outcomes after operative intervention. J Vasc Surg. 63(4):949-57, 2016 Apr.
69.	Schanzer H, Papa MC, Miller CM. Rupture of surgically thrombosed abdominal aortic aneurysm. J Vasc Surg. 1985 Mar;2(2):278-80.
70.	Guillon R, Garcier JM, Abergel A, et al. Management of splenic artery aneurysms and false aneurysms with endovascular treatment in 12 patients. Cardiovasc Intervent Radiol. 26(3):256-60, 2003 May-Jun.
71.	Berceli SA. Hepatic and splenic artery aneurysms. [Review] [23 refs]. Semin Vasc Surg. 18(4):196-201, 2005 Dec.
72.	Dorigo W, Pulli R, Azas L, et al. Early and Intermediate Results of Elective Endovascular Treatment of True Visceral Artery Aneurysms. Ann Vasc Surg. 2016 Jan;30():S0890-5096(15)00668-8.
73.	Carr SC, Pearce WH, Vogelzang RL, McCarthy WJ, Nemcek AA Jr, Yao JS. Current management of visceral artery aneurysms. Surgery. 120(4):627-33; discussion 633-4, 1996 Oct.
74.	Lakin RO, Bena JF, Sarac TP, et al. The contemporary management of splenic artery aneurysms. J Vasc Surg. 53(4):958-64; discussion 965, 2011 Apr.
75.	Pitton MB, Dappa E, Jungmann F, et al. Visceral artery aneurysms: Incidence, management, and outcome analysis in a tertiary care center over one decade. Eur Radiol. 25(7):2004-14, 2015 Jul.
76.	Sessa C, Tinelli G, Porcu P, Aubert A, Thony F, Magne JL. Treatment of visceral artery aneurysms: description of a retrospective series of 42 aneurysms in 34 patients. Ann Vasc Surg. 18(6):695-703, 2004 Nov.
77.	Hamamoto K, Chiba E, Oyama-Manabe N, et al. Ultra-short Echo-time MR Angiography Combined with a Modified Signal Targeting Alternating Radio Frequency with Asymmetric Inversion Slabs Technique to Assess Visceral Artery Aneurysm after Coil Embolization. Magn Reson Med Sci. 2024 Jan 01;23(1):110-121.
78.	Henke PK, Stanley JC. Renal artery aneurysms: diagnosis, management and outcomes. [Review] [29 refs]. Minerva Chir. 58(3):305-11, 2003 Jun.
79.	Hellmund A, Meyer C, Fingerhut D, Müller SC, Merz WM, Gembruch U. Rupture of renal artery aneurysm during late pregnancy: clinical features and diagnosis. Arch Gynecol Obstet. 2016 Mar;293(3):505-8.
80.	Cohen JR, Shamash FS. Ruptured renal artery aneurysms during pregnancy. J Vasc Surg. 1987 Jul;6(1):51-9.
81.	Suzuki K, Kashimura H, Sato M, et al. Pancreaticoduodenal artery aneurysms associated with celiac axis stenosis due to compression by median arcuate ligament and celiac plexus. J Gastroenterol. 1998 Jun;33(3):434-8.
82.	Chaikof EL, Brewster DC, Dalman RL, et al. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. [Review] [506 refs]. J Vasc Surg. 50(4 Suppl):S2-49, 2009 Oct.
83.	Bjorck M, Koelemay M, Acosta S, et al. Editor's Choice - Management of the Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery (ESVS). [Review]. Eur J Vasc Endovasc Surg. 53(4):460-510, 2017 04.
84.	Pinto F, Miele V, Scaglione M, Pinto A. The use of contrast-enhanced ultrasound in blunt abdominal trauma: advantages and limitations. Acta Radiol. 2014 Sep;55(7):776-84.
85.	Sidhu PS, Cantisani V, Dietrich CF, et al. The EFSUMB Guidelines and Recommendations for the Clinical Practice of Contrast-Enhanced Ultrasound (CEUS) in Non-Hepatic Applications: Update 2017 (Long Version). Ultraschall Med. 2018 Apr;39(2):e2-e44.
86.	Schwarze V, Marschner C, Negrao de Figueiredo G, Rubenthaler J, Clevert DA. Single-Center Study: Evaluating the Diagnostic Performance and Safety of Contrast-Enhanced Ultrasound (CEUS) in Pregnant Women to Assess Hepatic Lesions. Ultraschall in der Medizin. 41(1):29-35, 2020 Feb.Ultraschall Med. 41(1):29-35, 2020 Feb.
87.	Alghamdi SA. Gadolinium-Based Contrast Agents in Pregnant Women: A Literature Review of MRI Safety. Cureus. 2023 May;15(5):e38493.
88.	Starekova J, Nagle SK, Schiebler ML, Reeder SB, Meduri VN. Pulmonary MRA During Pregnancy: Early Experience With Ferumoxytol. J Magn Reson Imaging. 57(6):1815-1818, 2023 06.
89.	Nael K, Villablanca JP, Mossaz L, et al. 3-T contrast-enhanced MR angiography in evaluation of suspected intracranial aneurysm: comparison with MDCT angiography. AJR Am J Roentgenol. 2008 Feb;190(2):389-95.
90.	Lacroix HH, Bernaerts PP, Nevelsteen AA, Hanssens MM. Ruptured renal artery aneurysm during pregnancy: successful ex situ repair and autotransplantation. J Vasc Surg 33:188-90, .
91.	Henke PP, Cardneau JJ, Welling TT, et al. Renal artery aneurysms: a 35-year clinical experience with 252 aneurysms in 168 patients. Ann Surg 234:454-62; discussion 462-3, .
92.	Holdsworth RR, Gunn AA. Ruptured splenic artery aneurysm in pregnancy. A review. Br J Obstet Gynaecol 99:595-7, .
93.	Barrett JJ, Van Hooydonk JJ, Boehm FF. Pregnancy-related rupture of arterial aneurysms. Obstet Gynecol Surv 37:557-66, .
94.	Aung YY, Berry CC, Jayaram PP, Woon EE. Splenic artery aneurysm in pregnancy: A systematic review. Int J Gynaecol Obstet 160:1-11, .
95.	Hamamoto K, Chiba E, Oyama-Manabe N, Shinmoto H. Ultra-short echo time magnetic resonance angiography using a modified signal targeting with alternative radio frequency spin labeling technique for detecting recanalized pulmonary arteriovenous malformation after coil embolization. Acta Radiol Open. 2021 Oct;10(10):20584601211057671.

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.