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Appropriateness Criteria

Variant 1: Cirrhotic patient with active bleeding from large high flow gastric varices, significant portal hypertension,and a MELD score of 14. CT demonstrates a large gastrorenal shunt.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
BRTO Usually appropriate Strong N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
26 (11287510) 2
47 (11959725) 2
18 (15269027) 2
51 (15788621) 2
52 (21353984) 4
56 (19032446) 1
15 (12845306) 1
16 (28246514) 2
20 (24468043) 2
23 (11029085) 4
24 (11283531) 4
25 (15362757) 4
27 (10228513) 4
28 (16714879) 4
29 (16361051) 1
30 (17635469) 4
31 (8661570) 4
32 (16261433) 4
33 (15802443) 4
34 (22942551) 4
35 (18029851) 4
36 (20594229) 2
37 (10086645) 4
38 (12859723) 4
39 (27234486) 2
40 (12853666) 4
41 (26957907) 2
42 (20737152) 4
43 (26316136) 4
44 (23481167) 2
45 (26295655) 2
46 (23323252) 4
48 (28483304) 4
49 (22733913) 2
50 (28180928) 4
53 (18713295) 4
54 (16804972) 2
55 (18647931) 4
57 (10067311) 4
58 (8911204) 4
59 (9473542) 4
60 (25519690) Good
62 (14695698) 4
63 (20172743) 4
64 (15688111) 2
65 (24322305) 2
66 (23939627) 2
61 (19470572) 4
Endoscopic management Usually appropriate Strong N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
6 (15057756) 4
2 (27786365) 4
7 (9260698) 2
8 (26469912) Good
9 (17380280) 3
TIPS Usually appropriate Strong N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
18 (15269027) 2
11 (26517576) 1
12 (24480619) 1
13 (10534333) 4
14 (9558287) 2
15 (12845306) 1
16 (28246514) 2
17 (17661241) 1
19 (10902977) 4
20 (24468043) 2
21 (27106732) 2
22 (27458505) 1
10 (26614596) 4
Partial splenic embolization May be appropriate Strong N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
71 (16534680) 1
55 (18647931) 4
67 (18019732) 3
68 (28494001) 4
69 (25311969) 2
70 (22459878) 3
Surgical management May be appropriate Strong N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
74 (16697728) 1
72 (1735356) 4
73 (25957003) 1
75 (28381381) 2
76 (24960036) 4
77 (16481287) 4
Variant 2: Cirrhotic patient with bleeding from large high flow gastric varices with a MELD score of 20. CT demonstrates a large gastrorenal shunt.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
BRTO Usually appropriate Limited N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
80 (23681780) 2
Endoscopic management Usually appropriate Strong N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
26 (11287510) 2
36 (20594229) 2
39 (27234486) 2
TIPS May be appropriate Limited N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
33 (15802443) 4
79 (29404473) 2
78 (24148622) 4
Partial splenic embolization May be appropriate Limited N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
68 (28494001) 4
69 (25311969) 2
Surgical management May be appropriate Strong N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
26 (11287510) 2
36 (20594229) 2
39 (27234486) 2
Variant 3: Cirrhotic patient bleeding from small, low flow gastric varices and moderate ascites with a MELD score of 18. MRI does not demonstrate a gastrorenal shunt.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic management Usually appropriate Limited N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
6 (15057756) 4
TIPS Usually appropriate Limited N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
81 (28121521) 2
Partial splenic embolization May be appropriate Limited N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
66 (23939627) 2
82 (21618687) 4
Surgical management May be appropriate Strong N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
26 (11287510) 2
36 (20594229) 2
39 (27234486) 2
BRTO Usually not appropriate Limited N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
80 (23681780) 2
Variant 4: Cirrhotic patient bleeding from large, high flow gastric varices with hepatic encephalopathy and a MELD score of 18. MRI demonstrates a large gastrorenal shunt.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
BRTO Usually appropriate Strong N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
26 (11287510) 2
60 (25519690) Good
80 (23681780) 2
Endoscopic management Usually appropriate Limited N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
26 (11287510) 2
Partial splenic embolization May be appropriate Strong N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
66 (23939627) 2
84 (15654779) 2
Surgical management May be appropriate Limited N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
83 (14730033) 4
TIPS May be appropriate Limited N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
83 (14730033) 4
Variant 5: Cirrhotic patient bleeding from esophageal varices and gastric varices not amenable to endoscopic management with a MELD score of 13 and a hepatic wedge pressure of 22 mmHg. CT demonstrates a small gastrorenal shunt.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
TIPS Usually appropriate Strong N/A N/A 9 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
18 (15269027) 2
11 (26517576) 1
13 (10534333) 4
14 (9558287) 2
15 (12845306) 1
16 (28246514) 2
17 (17661241) 1
19 (10902977) 4
20 (24468043) 2
Surgical management May be appropriate Strong N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
73 (25957003) 1
75 (28381381) 2
Partial splenic embolization May be appropriate Limited N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
67 (18019732) 3
BRTO Usually not appropriate Strong N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
26 (11287510) 2
47 (11959725) 2
51 (15788621) 2
24 (11283531) 4
27 (10228513) 4
30 (17635469) 4
35 (18029851) 4
37 (10086645) 4
38 (12859723) 4
53 (18713295) 4
55 (18647931) 4
62 (14695698) 4
63 (20172743) 4
85 (18528292) 2
Variant 6: Cirrhotic patient bleeding from large high flow gastric varices with a MELD score of 12 and a hepatic wedge pressure of 10 mmHg. MRI demonstrates a large gastrorenal shunt.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
BRTO Usually appropriate Limited N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
60 (25519690) Good
Endoscopic management Usually appropriate Limited N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
9 (17380280) 3
TIPS Usually appropriate Limited N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
86 (3391371) 2
Partial splenic embolization May be appropriate Limited N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
67 (18019732) 3
68 (28494001) 4
Surgical management May be appropriate Limited N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
67 (18019732) 3
68 (28494001) 4
87 (15127277) 3
Variant 7: Patient with gastric variceal bleeding, found to have chronic splenic vein occlusion on MRI.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Splenic vein recanalization Usually appropriate Limited N/A N/A 8 8 0 0 0 0 1 1 2 5 2
References Study Quality
93 (23636249) 4
Surgical management Usually appropriate Limited N/A N/A 8 8 0 0 1 0 3 0 1 4 2
References Study Quality
89 (24500452) 4
95 (10773149) 4
96 (8424698) 2
Partial splenic embolization Usually appropriate Limited N/A N/A 7 7 0 0 0 0 1 2 5 3 0
References Study Quality
89 (24500452) 4
94 (26304614) 4
Endoscopic management (sclerosis or cyanoacrylate injection) May be appropriate Limited N/A N/A 5 5 0 1 1 3 2 3 0 1 0
References Study Quality
89 (24500452) 4
90 (18498359) 4
BRTO Usually not appropriate Limited N/A N/A 3 3 2 2 4 3 0 0 0 0 0
References Study Quality
89 (24500452) 4
91 (21479742) 4
92 (23830671) 4
TIPS Usually not appropriate Expert Consensus N/A N/A 3 3 1 2 3 3 1 0 1 0 0
Variant 8: Patient with chronic intrahepatic and extrahepatic portal vein occlusion with cavernous transformation on CT with gastric variceal bleeding.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Portal vein recanalization plus TIPS Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 1 3 5 2
References Study Quality
98 (26997089) 4
102 (16517786) 4
103 (19417681) 4
106 (29113006) 2
105 (22147244) 2
99 (29600476) 2
104 (30503174) 2
101 (19953883) 2
100 (25759969) 1
Endoscopic management (sclerosis or cyanoacrylate injection) May be appropriate Limited N/A N/A 6 6 0 0 0 1 4 1 1 3 1
References Study Quality
1 (28663672) 2
Partial splenic embolization May be appropriate Limited N/A N/A 6 6 0 0 0 1 1 6 3 0 0
References Study Quality
108 (26192300) 4
109 (28643575) 4
110 (15175899) 4
Surgical management May be appropriate Expert Consensus N/A N/A 6 6 0 0 1 0 2 4 3 1 0
BRTO Usually not appropriate Limited N/A N/A 2 2 0 8 2 0 0 0 0 0 0
References Study Quality
107 (24497799) 4
92 (23830671) 4
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.