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Appropriateness Criteria

Variant 1: Adult. Nonsmoker, sedentary lifestyle. Left lower-extremity claudication on walking, asymmetrically diminished left femoral pulse. No symptoms at rest. Initial management.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Best medical management including supervised exercise program only Usually appropriate Strong N/A N/A 9 9 0 0 0 0 0 0 1 2 8
References Study Quality
9 (31937137) 1
8 (22090168) 1
7 (32888779) 2
6 (22172470) 4
5 (27840332) 4
1 (28886620) 4
Risk factor analysis and lipid profile and ABIs Usually appropriate Limited N/A N/A 9 9 0 0 0 0 0 0 2 3 6
References Study Quality
12 (17140820) 4
Antiplatelet adjunctive therapy Usually appropriate Limited N/A N/A 7 7 0 0 0 0 2 2 3 1 3
References Study Quality
5 (27840332) 4
4 (24196266) 4
3 (24740523) 4
US duplex Doppler lower extremity Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 1 0 0 2 1 4 3 0
References Study Quality
14 (33249132) 1
13 (29571625) 2
CTA abdomen and pelvis with bilateral lower extremity runoff with IV contrast May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 0 0 0 0 6 1 4 0 0
References Study Quality
2 (16990459) 4
MRA abdomen and pelvis with bilateral lower extremity runoff with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 2 5 2 2 0 0
References Study Quality
5 (27840332) 4
10 (20820041) M
Plethysmography and pulse volume recording May be appropriate Moderate N/A N/A 5 5 0 0 0 4 5 1 1 0 0
References Study Quality
11 (26547465) 1
Catheter-directed angiography Usually not appropriate Limited N/A N/A 3 3 2 3 3 1 2 0 0 0 0
References Study Quality
2 (16990459) 4
Anticoagulation adjunctive therapy Usually not appropriate Expert Consensus N/A N/A 2 2 2 5 1 0 2 0 1 0 0
Variant 2: Adult. Long history of claudication. Acute-onset left lower-extremity pain. Absent left femoral pulse by palpation, faint audible DP and PT Doppler signals. Initial management.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Anticoagulation adjunctive therapy Usually appropriate Expert Consensus N/A N/A 8 8 0 0 1 0 1 1 1 4 3
CTA abdomen and pelvis with bilateral lower extremity runoff with IV contrast Usually appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 8 8 0 0 0 0 0 0 4 3 4
Catheter-directed angiography Usually appropriate Moderate N/A N/A 7 7 0 0 0 1 2 2 3 3 0
References Study Quality
15 (30095170) Good
3 (24740523) 4
2 (16990459) 4
1 (28886620) 4
14 (33249132) 1
MRA abdomen and pelvis with bilateral lower extremity runoff with IV contrast Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 0 0 0 2 1 2 6 0 0
US duplex Doppler lower extremity May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 1 1 2 2 4 0 1
Ankle brachial index May be appropriate Expert Consensus N/A N/A 5 5 0 0 0 2 5 3 0 1 0
Risk factor analysis and lipid profile May be appropriate Expert Consensus N/A N/A 5 5 0 0 0 4 3 2 1 1 0
Plethysmography and pulse volume recording Usually not appropriate Moderate N/A N/A 3 3 0 5 4 0 2 0 0 0 0
References Study Quality
11 (26547465) 1
Variant 3: Adult. Known atrial fibrillation and spine surgery performed within the past month. Sudden-onset right lower-extremity pain. Diminished pulses in right lower-extremity. CTA demonstrates isolated filling defect in right common iliac artery. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Anticoagulation adjunctive therapy Usually appropriate Expert Consensus N/A N/A 9 9 0 0 1 0 0 0 2 2 6
Catheter-directed mechanical thrombectomy Usually appropriate Limited N/A N/A 7 7 0 0 0 0 2 1 5 2 1
References Study Quality
5 (27840332) 4
16 (25080883) 2
Surgical revascularization Usually appropriate Limited N/A N/A 7 7 0 0 0 0 1 1 4 3 2
References Study Quality
1 (28886620) 4
5 (27840332) 4
15 (30095170) Good
17 (28567352) Inadequate
Antiplatelet adjunctive therapy May be appropriate Limited N/A N/A 6 6 0 0 1 1 3 2 3 1 0
References Study Quality
5 (27840332) 4
4 (24196266) 4
3 (24740523) 4
Catheter-directed thrombolytic therapy May be appropriate (Disagreement) Expert Opinion N/A N/A 5 5 0 3 4 1 0 1 2 0 0
References Study Quality
15 (30095170) Good
17 (28567352) Inadequate
Percutaneous transluminal angioplasty iliac artery Usually not appropriate Expert Consensus N/A N/A 3 3 2 3 6 0 0 0 0 0 0
Primary stent placement iliac artery Usually not appropriate Expert Consensus N/A N/A 3 3 1 2 3 4 1 0 0 0 0
Variant 4: Adult. Past medical history of heavy smoking. Severe claudication without rest pain. CTA demonstrates bilateral common iliac artery stenosis at or greater than 90% (TASC A). Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Antiplatelet adjunctive therapy Usually appropriate Moderate N/A N/A 7 7 0 0 0 1 0 1 4 2 3
References Study Quality
20 (-3196023) 1
5 (27840332) 4
4 (24196266) 4
3 (24740523) 4
1 (28886620) 4
19 (25477329) 4
Best medical management including supervised exercise program Usually appropriate Strong N/A N/A 7 7 0 0 0 0 0 1 5 3 2
References Study Quality
25 (31103674) 2
24 (28385410) Good
23 (29327569) Inadequate
22 (24342830) Good
9 (31937137) 1
7 (32888779) 2
6 (22172470) 4
5 (27840332) 4
1 (28886620) 4
21 (28711864) 2
Bilateral primary stent placement iliac artery May be appropriate Strong N/A N/A 6 6 0 1 0 0 1 4 1 4 0
References Study Quality
35 (21215582) 2
34 (25733220) 2
33 (26980775) 2
32 (32889158) 2
5 (27840332) 4
4 (24196266) 4
3 (24740523) 4
1 (28886620) 4
31 (25331010) 2
Anticoagulation adjunctive therapy May be appropriate Moderate N/A N/A 5 5 0 0 0 1 5 3 2 0 0
References Study Quality
18 (28844192) 1
Bilateral percutaneous transluminal angioplasty iliac artery Usually not appropriate Strong N/A N/A 3 3 0 3 5 1 1 1 0 0 0
References Study Quality
30 (23842828) 1
29 (21609804) M
28 (33258499) 4
27 (26023746) 4
12 (17140820) 4
26 (33253869) 2
Surgical revascularization Usually not appropriate Expert Consensus N/A N/A 3 3 2 2 4 1 1 1 0 0 0
Variant 5: Adult. Past medical history significant for diabetes mellitus, hypertension, and smoking. Increasing claudication of right lower-extremity involving right buttock for the last 3 months. CTA pelvis with runoff reveals short-segment occlusion of the right common iliac artery (TASC B). Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Antiplatelet adjunctive therapy Usually appropriate Moderate N/A N/A 7 7 0 0 0 0 1 2 3 3 2
References Study Quality
5 (27840332) 4
4 (24196266) 4
3 (24740523) 4
1 (28886620) 4
20 (-3196023) 1
Best medical management including supervised exercise program Usually appropriate Strong N/A N/A 7 7 0 0 0 0 0 1 5 3 2
References Study Quality
25 (31103674) 2
24 (28385410) Good
9 (31937137) 1
8 (22090168) 1
7 (32888779) 2
6 (22172470) 4
5 (27840332) 4
1 (28886620) 4
21 (28711864) 2
23 (29327569) Inadequate
Primary stent placement aortoiliac arterial segment May be appropriate Strong N/A N/A 6 6 0 1 0 0 2 3 1 2 2
References Study Quality
37 (27131926) 1
36 (32360678) 4
35 (21215582) 2
34 (25733220) 2
33 (26980775) 2
32 (32889158) 2
5 (27840332) 4
4 (24196266) 4
3 (24740523) 4
1 (28886620) 4
31 (25331010) 2
Anticoagulation adjunctive therapy May be appropriate Moderate N/A N/A 5 5 0 0 0 1 6 2 2 0 0
References Study Quality
18 (28844192) 1
Percutaneous transluminal angioplasty aortoiliac arterial segment Usually not appropriate Moderate N/A N/A 3 3 0 3 6 0 1 1 0 0 0
References Study Quality
30 (23842828) 1
28 (33258499) 4
27 (26023746) 4
Surgical revascularization Usually not appropriate Expert Consensus N/A N/A 3 3 2 2 3 4 0 0 0 0 0
Variant 6: Adult. Past medical history significant for diabetes mellitus, hypertension, and heavy smoking. Gradually increasing claudication of bilateral lower extremities for at least 2 months. CTA pelvis with runoff reveals bilateral common iliac artery occlusion without any involvement of the external or internal iliac artery (TASC C). Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Antiplatelet adjunctive therapy Usually appropriate Moderate N/A N/A 7 7 0 0 0 0 1 1 6 0 3
References Study Quality
5 (27840332) 4
4 (24196266) 4
3 (24740523) 4
1 (28886620) 4
20 (-3196023) 1
Best medical management including supervised exercise program Usually appropriate Strong N/A N/A 7 7 0 0 0 0 0 0 8 2 1
References Study Quality
25 (31103674) 2
24 (28385410) Good
9 (31937137) 1
8 (22090168) 1
7 (32888779) 2
6 (22172470) 4
5 (27840332) 4
1 (28886620) 4
21 (28711864) 2
23 (29327569) Inadequate
Anticoagulation adjunctive therapy May be appropriate Moderate N/A N/A 6 6 0 0 0 0 4 6 1 0 0
References Study Quality
18 (28844192) 1
Bilateral primary stent placement aortoiliac arterial segment May be appropriate Strong N/A N/A 6 6 0 0 1 0 1 4 2 3 0
References Study Quality
37 (27131926) 1
36 (32360678) 4
35 (21215582) 2
34 (25733220) 2
33 (26980775) 2
32 (32889158) 2
31 (25331010) 2
5 (27840332) 4
4 (24196266) 4
3 (24740523) 4
1 (28886620) 4
Bilateral percutaneous transluminal angioplasty aortoiliac arterial segment Usually not appropriate Moderate N/A N/A 3 3 0 5 5 1 0 0 0 0 0
References Study Quality
30 (23842828) 1
28 (33258499) 4
27 (26023746) 4
Surgical revascularization Usually not appropriate Strong N/A N/A 3 3 0 2 6 1 2 0 0 0 0
References Study Quality
46 (34279686) Inadequate
45 (26362632) 2
44 (31746273) 2
43 (31394230) 2
42 (25529189) 2
41 (31120778) 2
40 (27633164) 2
39 (30850298) 2
38 (32763459) 2
1 (28886620) 4
3 (24740523) 4
4 (24196266) 4
5 (27840332) 4
Variant 7: Adult. Worsening claudication and small ischemic ulcers on digits of both feet. CTA demonstrates diffuse atherosclerosis involving distal aorta and both common and external iliac arteries with multiple stenoses at or greater than 50%, bilateral mid-superficial femoral artery stenoses at or greater than 70% with 2-vessel tibial runoff bilaterally (TASC D). Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Hybrid revascularization with endovascular stenting of aortoiliac disease and infrainguinal bypass Usually appropriate Strong N/A N/A 8 8 0 0 0 0 1 0 4 4 2
References Study Quality
5 (27840332) 4
51 (28822655) 2
50 (27693029) 2
49 (30837177) 3
48 (28189354) 2
47 (27594393) 2
1 (28886620) 4
Percutaneous stent placement aortoiliac arterial segment plus superficial femoral Usually appropriate Moderate N/A N/A 8 8 0 0 1 0 0 0 3 5 2
References Study Quality
37 (27131926) 1
36 (32360678) 4
5 (27840332) 4
4 (24196266) 4
3 (24740523) 4
1 (28886620) 4
29 (21609804) M
Antiplatelet adjunctive therapy Usually appropriate Moderate N/A N/A 7 7 0 0 1 0 1 1 3 2 3
References Study Quality
5 (27840332) 4
4 (24196266) 4
3 (24740523) 4
1 (28886620) 4
20 (-3196023) 1
Surgical revascularization Usually appropriate Strong N/A N/A 7 7 0 0 0 0 0 2 6 3 0
References Study Quality
52 (26115920) 2
45 (26362632) 2
44 (31746273) 2
43 (31394230) 2
42 (25529189) 2
41 (31120778) 2
40 (27633164) 2
39 (30850298) 2
38 (32763459) 2
5 (27840332) 4
4 (24196266) 4
3 (24740523) 4
1 (28886620) 4
Percutaneous stent placement aortoiliac arterial segment May be appropriate Strong N/A N/A 6 6 0 0 0 0 2 5 2 2 0
References Study Quality
51 (28822655) 2
50 (27693029) 2
49 (30837177) 3
48 (28189354) 2
47 (27594393) 2
37 (27131926) 1
36 (32360678) 4
35 (21215582) 2
34 (25733220) 2
5 (27840332) 4
4 (24196266) 4
3 (24740523) 4
1 (28886620) 4
29 (21609804) M
Anticoagulation adjunctive therapy May be appropriate Moderate N/A N/A 5 5 0 0 0 1 5 4 0 1 0
References Study Quality
18 (28844192) 1
Best medical management including supervised exercise program only Usually not appropriate Strong N/A N/A 3 3 0 2 8 0 0 0 0 0 1
References Study Quality
25 (31103674) 2
24 (28385410) Good
9 (31937137) 1
8 (22090168) 1
7 (32888779) 2
6 (22172470) 4
5 (27840332) 4
1 (28886620) 4
21 (28711864) 2
23 (29327569) Inadequate
Percutaneous transluminal angioplasty aortoiliac arterial segment Usually not appropriate Moderate N/A N/A 3 3 0 4 4 2 1 0 0 0 0
References Study Quality
30 (23842828) 1
28 (33258499) 4
27 (26023746) 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.