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Appropriateness Criteria

Variant 1: Adult. Chylothorax of any etiology. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Medical therapy and dietary modification Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 0 3 5 4
References Study Quality
9 (38902767) 4
15 (38391198) 2
13 (31341753) 4
22 (35065672) 4
10 (35738344) 4
23 (38883668) 4
21 (34049583) 4
17 (29132697) 4
18 (29287962) 4
19 (32655864) 3
20 (32773951) 4
14 (33723611) 4
11 (25784759) 4
12 (28719710) 3
16 (24365215) 4
8 (23764409) 4
Thoracic duct embolization May be appropriate Limited N/A N/A 5 5 0 0 1 5 3 2 0 1 0
References Study Quality
26 (38184769) 4
23 (38883668) 4
18 (29287962) 4
25 (32773956) 4
20 (32773951) 4
10 (35738344) 4
24 (29067509) 4
17 (29132697) 4
Surgery May be appropriate Limited N/A N/A 4 4 1 0 3 3 2 2 0 0 1
References Study Quality
29 (39205723) 3
23 (38883668) 4
18 (29287962) 4
20 (32773951) 4
10 (35738344) 4
28 (38351953) 3
17 (29132697) 4
27 (26036222) 3
Pleurodesis Usually not appropriate Limited N/A N/A 3 3 0 0 10 0 2 0 0 0 0
References Study Quality
23 (38883668) 4
10 (35738344) 4
18 (29287962) 4
20 (32773951) 4
Variant 2: Adult. Chylothorax refractory to medical and dietary management. Next therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Thoracic duct embolization Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 0 4 4 4
References Study Quality
26 (38184769) 4
23 (38883668) 4
13 (31341753) 4
20 (32773951) 4
14 (33723611) 4
10 (35738344) 4
24 (29067509) 4
17 (29132697) 4
18 (29287962) 4
Pleurodesis Usually appropriate Limited N/A N/A 7 7 0 1 0 1 2 2 5 1 0
References Study Quality
23 (38883668) 4
10 (35738344) 4
21 (34049583) 4
18 (29287962) 4
20 (32773951) 4
16 (24365215) 4
Surgery May be appropriate Limited N/A N/A 6 6 0 0 1 0 3 6 1 1 0
References Study Quality
29 (39205723) 3
9 (38902767) 4
22 (35065672) 4
10 (35738344) 4
28 (38351953) 3
23 (38883668) 4
17 (29132697) 4
18 (29287962) 4
13 (31341753) 4
20 (32773951) 4
14 (33723611) 4
Variant 3: Adult. Spontaneous chylothorax with concurrent central venous obstruction. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Thoracic duct embolization May be appropriate Limited N/A N/A 6 6 0 0 0 0 4 6 1 0 1
Catheter directed mechanical thrombectomy thoracic central vein May be appropriate Expert Consensus N/A N/A 5 5 0 0 0 2 8 1 1 0 0
Intraabdominal lymphatic embolization May be appropriate Expert Consensus N/A N/A 5 5 0 2 0 2 7 0 1 0 0
Medical therapy and dietary modification May be appropriate (Disagreement) Expert Opinion N/A N/A 5 5 0 1 0 1 2 0 3 4 1
Thoracic central vein recanalization May be appropriate Expert Consensus N/A N/A 5 5 0 0 0 1 7 3 1 0 0
Pleurodesis May be appropriate Limited N/A N/A 4 4 1 1 3 2 5 0 0 0 0
Surgery May be appropriate Limited N/A N/A 4 4 0 0 5 2 4 1 0 0 0
Surgical thrombectomy thoracic central vein May be appropriate Expert Consensus N/A N/A 4 4 0 0 2 7 3 0 0 0 0
Variant 4: Adult. Chylothorax with concurrent chylous ascites. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Medical therapy and dietary modification May be appropriate (Disagreement) Expert Opinion N/A N/A 5 5 0 3 1 0 1 0 2 1 4
Portal vein recanalization May be appropriate Limited N/A N/A 5 5 0 0 0 1 8 3 0 0 0
TIPS May be appropriate Limited N/A N/A 5 5 0 0 0 1 8 3 0 0 0
Surgery May be appropriate Limited N/A N/A 4 4 0 1 5 2 4 0 0 0 0
References Study Quality
38 (38789205) 4
37 (32364837) 2
36 (27993325) 4
Pleurodesis Usually not appropriate Limited N/A N/A 3 3 0 1 7 2 2 0 0 0 0
References Study Quality
39 (20349309) 4
Thoracic duct embolization Usually not appropriate Expert Consensus N/A N/A 3 3 1 3 6 0 1 0 1 0 0
References Study Quality
38 (38789205) 4
24 (29067509) 4
36 (27993325) 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.