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Appropriateness Criteria

Variant 1: Varicose veins. Initial diagnosis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler lower extremity Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 0 0 0 4 11
References Study Quality
1 (28447881) 4
9 (23482555) 4
16 (-3194752) 4
15 (28411707) 4
14 (26556703) 4
17 (27430666) 2
Catheter venography iliac veins Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 3 3 1 7 3 2 1 2 0 0 0
Catheter venography lower extremity Usually not appropriate Limited ☢☢ 0.1-1mSv 2 2 2 8 2 2 1 1 0 0 0
References Study Quality
9 (23482555) 4
CTV lower extremity with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 4 5 4 2 0 0 0 1 0
References Study Quality
13 (26946904) 4
12 (25075589) 4
11 (27565630) 4
10 (23929418) 4
9 (23482555) 4
CTV pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 2 2 4 5 5 1 0 0 0 1 0
MRV lower extremity without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 4 6 3 2 0 0 0 1 0
References Study Quality
13 (26946904) 4
12 (25075589) 4
11 (27565630) 4
10 (23929418) 4
9 (23482555) 4
MRV pelvis without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 4 6 5 0 0 0 0 1 0
US intravascular iliac veins Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 3 7 2 2 1 0 0 1 0
Variant 2: Varicose veins. Treatment.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Compression therapy Usually appropriate Strong N/A N/A 9 9 0 0 0 1 0 0 1 6 8
References Study Quality
21 (24974070) 4
20 (28063094) 4
19 (26094638) 4
18 (22819741) 2
15 (28411707) 4
17 (27430666) 2
16 (-3194752) 4
Saphenous vein ablation Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 2 1 7 6
References Study Quality
23 (27180370) 4
22 (25145305) 4
7 (27878794) 4
12 (25075589) 4
31 (28119106) Good
30 (29292115) Good
29 (20638231) 1
28 (29895399) Good
27 (26564912) 4
26 (17600655) 1
25 (27898181) 4
24 (23390218) Inadequate
15 (28411707) 4
Compression sclerotherapy Usually appropriate Strong N/A N/A 7 7 0 0 0 1 0 4 6 4 1
References Study Quality
7 (27878794) 4
14 (26556703) 4
32 (29037363) Good
36 (27561823) 1
35 (26132315) 1
34 (29652081) 1
33 (23769603) 1
Microphlebectomy Usually appropriate Limited N/A N/A 7 7 0 1 0 0 4 1 7 3 0
References Study Quality
2 (24840962) 4
Ligation and stripping May be appropriate Strong N/A N/A 6 6 0 0 0 0 4 8 3 1 0
References Study Quality
40 (23768792) 1
39 (21931012) 1
38 (26319476) 1
37 (20801608) 1
24 (23390218) Inadequate
Variant 3: Venous leg ulcer. Initial diagnosis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler lower extremity Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 2 1 13
References Study Quality
1 (28447881) 4
9 (23482555) 4
14 (26556703) 4
20 (28063094) 4
8 (26358310) 4
19 (26094638) 4
43 (17497654) 3
US duplex Doppler IVC and iliac veins Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 2 1 9 3 1
References Study Quality
46 (26946891) 1
45 (17540535) 2
44 (26992969) 4
CTV abdomen and pelvis with IV contrast May be appropriate Limited ☢☢☢☢ 10-30 mSv 6 6 0 0 4 2 2 8 0 0 0
References Study Quality
13 (26946904) 4
12 (25075589) 4
11 (27565630) 4
10 (23929418) 4
9 (23482555) 4
MRV abdomen and pelvis without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 4 2 2 8 0 0 0
References Study Quality
13 (26946904) 4
12 (25075589) 4
11 (27565630) 4
10 (23929418) 4
9 (23482555) 4
Catheter venography iliac veins May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 0 2 2 3 8 1 0 0 0
References Study Quality
8 (26358310) 4
9 (23482555) 4
41 (28818221) 3
CTV lower extremity with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv 5 5 2 0 5 2 4 3 0 0 0
References Study Quality
13 (26946904) 4
12 (25075589) 4
11 (27565630) 4
10 (23929418) 4
8 (26358310) 4
MRV lower extremity without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 1 5 2 3 2 2 0 0
References Study Quality
9 (23482555) 4
10 (23929418) 4
US intravascular iliac veins May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 1 4 1 1 0 6 3 0
References Study Quality
8 (26358310) 4
42 (29033314) 3
41 (28818221) 3
Catheter venography lower extremity May be appropriate Limited ☢☢ 0.1-1mSv 4 4 0 4 2 5 4 1 0 0 0
References Study Quality
9 (23482555) 4
Variant 4: Venous leg ulcer. Treatment.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Wound care Usually appropriate Limited N/A N/A 9 9 0 0 0 0 1 0 1 2 12
References Study Quality
6 (26358306) 4
21 (24974070) 4
Compression therapy Usually appropriate Strong N/A N/A 8 8 0 0 0 1 0 1 2 6 6
References Study Quality
47 (30554745) 4
21 (24974070) 4
20 (28063094) 4
19 (26094638) 4
18 (22819741) 2
15 (28411707) 4
17 (27430666) 2
16 (-3194752) 4
Saphenous vein ablation Usually appropriate Strong N/A N/A 8 8 0 0 0 0 1 2 3 7 3
References Study Quality
48 (29688123) 1
31 (28119106) Good
30 (29292115) Good
29 (20638231) 1
28 (29895399) Good
27 (26564912) 4
26 (17600655) 1
25 (27898181) 4
24 (23390218) Inadequate
12 (25075589) 4
Compression sclerotherapy Usually appropriate Strong N/A N/A 7 7 0 0 1 0 1 2 10 1 1
References Study Quality
36 (27561823) 1
35 (26132315) 1
34 (29652081) 1
33 (23769603) 1
32 (29037363) Good
14 (26556703) 4
7 (27878794) 4
Iliac vein stenting May be appropriate Limited N/A N/A 6 6 0 0 0 0 6 9 1 0 0
References Study Quality
8 (26358310) 4
15 (28411707) 4
49 (29292114) 1
Ligation and stripping May be appropriate Strong N/A N/A 5 5 0 0 1 2 6 5 2 0 0
References Study Quality
40 (23768792) 1
39 (21931012) 1
38 (26319476) 1
37 (20801608) 1
24 (23390218) Inadequate
Microphlebectomy May be appropriate Expert Consensus N/A N/A 4 4 0 0 8 2 4 1 0 1 0
Variant 5: Suspected pelvic-origin lower extremity varicose veins in females. Initial diagnosis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler lower extremity Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 1 2 8 5
References Study Quality
51 (23019985) 4
20 (28063094) 4
14 (26556703) 4
9 (23482555) 4
1 (28447881) 4
52 (30857986) 4
US duplex Doppler pelvis Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 2 4 9 1
References Study Quality
55 (27688293) 2
54 (25615769) 4
53 (27799418) 4
20 (28063094) 4
14 (26556703) 4
9 (23482555) 4
1 (28447881) 4
CTV abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢☢ 10-30 mSv 7 7 0 0 0 0 1 2 10 3 0
References Study Quality
13 (26946904) 4
12 (25075589) 4
11 (27565630) 4
10 (23929418) 4
9 (23482555) 4
MRV abdomen and pelvis without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 2 7 4 2
References Study Quality
50 (33529720) 4
13 (26946904) 4
12 (25075589) 4
11 (27565630) 4
10 (23929418) 4
9 (23482555) 4
US duplex Doppler IVC and iliac veins Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 1 5 8 1 0
References Study Quality
46 (26946891) 1
45 (17540535) 2
44 (26992969) 4
Catheter venography pelvis May be appropriate Limited ☢☢ 0.1-1mSv 6 6 0 0 1 0 4 8 2 1 0
References Study Quality
9 (23482555) 4
8 (26358310) 4
US intravascular iliac veins May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 0 3 1 2 7 1 0 2
References Study Quality
8 (26358310) 4
42 (29033314) 3
US intravascular renal veins Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 0 0 10 1 3 2 0 0 0
Variant 6: Pelvic-origin lower extremity varicose veins in females. Treatment.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Conservative management Usually appropriate Limited N/A N/A 7 7 0 0 1 1 4 2 4 3 1
References Study Quality
72 (28277860) 4
Compression sclerotherapy May be appropriate Limited N/A N/A 6 6 0 0 1 2 4 6 1 2 0
References Study Quality
60 (25729073) 4
59 (27397619) 4
58 (24190634) 2
57 (26404449) 4
Microphlebectomy May be appropriate Expert Consensus N/A N/A 5 5 0 0 0 4 7 3 0 1 0
Saphenous vein ablation May be appropriate (Disagreement) Expert Opinion N/A N/A 5 5 1 2 0 2 7 4 0 0 0
References Study Quality
56 (25804635) 4
Iliac vein embolization May be appropriate Limited N/A N/A 4 4 0 0 2 7 7 0 0 0 0
References Study Quality
61 (24840963) 4
Iliac vein stenting Usually not appropriate Expert Consensus N/A N/A 3 3 0 4 5 3 3 0 0 1 0
Left renal vein stenting Usually not appropriate Limited N/A N/A 3 3 1 5 3 6 0 1 0 0 0
References Study Quality
62 (22312068) 4
63 (26993690) 4
Left renal vein surgery Usually not appropriate Limited N/A N/A 3 3 0 2 7 1 5 1 0 0 0
References Study Quality
66 (22312071) 4
65 (14738638) 4
64 (6529137) 4
63 (26993690) 4
62 (22312068) 4
Ovarian vein embolization Usually not appropriate Limited N/A N/A 3 3 1 4 4 4 2 0 0 0 0
References Study Quality
71 (26769721) 4
70 (28076514) 3
69 (22727416) 4
68 (28791845) 4
67 (27318059) 4
59 (27397619) 4
57 (26404449) 4
52 (30857986) 4
Iliac vein surgery Usually not appropriate Expert Consensus N/A N/A 2 2 5 5 1 4 1 0 0 0 0
Variant 7: Suspected iliocaval or lower extremity disease with severe post-thrombotic changes. Initial diagnosis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler lower extremity Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 1 12 3
References Study Quality
73 (27260748) 3
20 (28063094) 4
14 (26556703) 4
10 (23929418) 4
9 (23482555) 4
1 (28447881) 4
CTV abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢☢ 10-30 mSv 7 7 0 0 1 0 0 1 9 5 0
References Study Quality
13 (26946904) 4
12 (25075589) 4
11 (27565630) 4
10 (23929418) 4
9 (23482555) 4
MRV abdomen and pelvis without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 1 2 8 4 0
References Study Quality
13 (26946904) 4
12 (25075589) 4
11 (27565630) 4
10 (23929418) 4
9 (23482555) 4
6 (26358306) 4
US duplex Doppler IVC and iliac veins Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 2 7 5 2
References Study Quality
75 (17592051) 3
74 (27247480) 4
Catheter venography iliac veins May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 0 1 0 2 7 5 1 0 0
References Study Quality
6 (26358306) 4
9 (23482555) 4
Catheter venography lower extremity May be appropriate Expert Consensus ☢☢ 0.1-1mSv 5 5 0 1 2 0 10 2 1 0 0
CTV lower extremity with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv 5 5 0 2 1 1 2 5 3 2 0
References Study Quality
13 (26946904) 4
12 (25075589) 4
11 (27565630) 4
10 (23929418) 4
8 (26358310) 4
MRV lower extremity without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 2 1 1 1 6 3 2 0
References Study Quality
13 (26946904) 4
12 (25075589) 4
11 (27565630) 4
9 (23482555) 4
US intravascular iliac veins May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 0 2 0 2 3 6 2 0
References Study Quality
6 (26358306) 4
8 (26358310) 4
Variant 8: Iliocaval or lower extremity disease with severe post-thrombotic changes. Treatment.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Anticoagulation Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 1 5 8 2
References Study Quality
77 (22315268) 4
76 (27618329) 4
Compression therapy Usually appropriate Limited N/A N/A 8 8 0 0 1 0 0 0 6 3 6
References Study Quality
15 (28411707) 4
18 (22819741) 2
21 (24974070) 4
Endovascular stenting Usually appropriate Limited N/A N/A 7 7 0 0 0 0 2 3 6 5 0
References Study Quality
15 (28411707) 4
49 (29292114) 1
Catheter-directed thrombolysis with or without thrombectomy lower extremity May be appropriate Strong N/A N/A 6 6 0 1 1 0 4 8 2 0 0
References Study Quality
79 (31983322) 2
78 (-3194750) 2
Venous angioplasty May be appropriate Limited N/A N/A 6 6 0 0 0 1 3 6 3 3 0
References Study Quality
80 (9129623) 4
81 (3631389) 4
Saphenous vein ablation May be appropriate (Disagreement) Expert Opinion N/A N/A 5 5 0 7 3 1 2 2 0 1 0
Venous bypass procedure May be appropriate Limited N/A N/A 5 5 0 0 1 3 11 1 0 0 0
References Study Quality
82 (26101920) 4
Compression sclerotherapy Usually not appropriate Expert Consensus N/A N/A 3 3 1 3 7 2 3 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.