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Appropriateness Criteria

Variant 1: Adult. Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US echocardiography transthoracic with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 1 1 0 1 0 3 8 6
References Study Quality
46 (19276509) 4
45 (23429940) 3
44 (34322523) 2
43 (17317734) 2
42 (1746435) 3
41 (19091794) 1
1 (24008954) 4
MRA pulmonary arteries without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 2 2 10 2 0
References Study Quality
32 (18356434) 3
33 (33202566) 1
CT chest without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 1 1 5 7 3
References Study Quality
28 (8184042) 4
27 (25032812) 4
10 (19553198) 4
CTA pulmonary arteries with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 0 0 0 1 0 1 4 7 4
References Study Quality
10 (19553198) 4
27 (25032812) 4
31 (32255688) 4
US echocardiography transesophageal with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 0 4 3 6 4 0 0 0 0
References Study Quality
38 (8181373) 4
40 (12848887) 4
Arteriography pulmonary May be appropriate Limited ☢☢☢☢ 10-30 mSv 4 4 0 1 1 11 2 2 0 0 0
References Study Quality
24 (18774307) 2
25 (7956388) 4
MRA chest without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 1 1 2 2 3 8 0 0
CT chest with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 1 0 2 3 7 3 1 0
References Study Quality
10 (19553198) 4
26 (31875234) 4
27 (25032812) 4
CT chest without and with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 3 2 1 8 2 0 0
References Study Quality
10 (19553198) 4
24 (18774307) 2
27 (25032812) 4
CTA chest with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 2 2 2 0 4 5 2
References Study Quality
10 (19553198) 4
27 (25032812) 4
29 (17116729) 3
30 (16484354) 3
US echocardiography transesophageal Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 6 3 5 2 3 0 1 0 0
References Study Quality
39 (2212350) 3
38 (8181373) 4
US echocardiography transthoracic resting Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 5 5 8 0 0 0 1 1 0
References Study Quality
38 (8181373) 4
Radiography chest Usually not appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 2 2 9 3 3 3 1 0 1 0 0
References Study Quality
36 (14742303) 3
37 (29141890) 4
MRA chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 1 4 8 1 3 0 0 0 0
MRA pulmonary arteries without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 2 2 5 3 3 1 1 0 0
Pertechnetate albumin pulmonary scan Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 8 4 2 3 2 0 0 1 0
References Study Quality
34 (3968579) 4
35 (4070672) 4
Variant 2: Adult. Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US echocardiography transthoracic with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 2 0 0 1 2 6 9
References Study Quality
1 (24008954) 4
46 (19276509) 4
45 (23429940) 3
44 (34322523) 2
43 (17317734) 2
42 (1746435) 3
41 (19091794) 1
MRA pulmonary arteries without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 3 3 7 3 0
References Study Quality
32 (18356434) 3
33 (33202566) 1
CT chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 1 0 13 3 0
References Study Quality
10 (19553198) 4
26 (31875234) 4
27 (25032812) 4
CT chest without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 1 2 5 3 4 2
References Study Quality
28 (8184042) 4
27 (25032812) 4
10 (19553198) 4
CTA chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 1 1 3 1 4 7 0
References Study Quality
10 (19553198) 4
27 (25032812) 4
29 (17116729) 3
30 (16484354) 3
CTA pulmonary arteries with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 0 0 0 0 1 1 2 8 5
References Study Quality
10 (19553198) 4
27 (25032812) 4
31 (32255688) 4
Arteriography pulmonary May be appropriate Limited ☢☢☢☢ 10-30 mSv 4 4 0 1 0 9 5 1 0 1 0
References Study Quality
24 (18774307) 2
25 (7956388) 4
MRA chest without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 1 1 4 3 7 1 0
CT chest without and with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 3 2 9 3 0 0 0
References Study Quality
10 (19553198) 4
24 (18774307) 2
27 (25032812) 4
US echocardiography transesophageal Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 5 2 6 5 0 0 1 1 0
References Study Quality
39 (2212350) 3
38 (8181373) 4
US echocardiography transesophageal with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 2 5 3 3 3 1 0 0 0
References Study Quality
38 (8181373) 4
40 (12848887) 4
US echocardiography transthoracic resting Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 5 6 3 1 0 0 1 1
References Study Quality
38 (8181373) 4
Radiography chest Usually not appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 3 3 2 5 4 6 0 0 0 0 0
References Study Quality
36 (14742303) 3
37 (29141890) 4
MRA chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 0 1 12 1 2 1 0 0 0
MRA pulmonary arteries without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 1 5 9 3 1 0 0 0 0
Pertechnetate albumin pulmonary scan Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 9 3 1 5 1 0 0 1 0
References Study Quality
34 (3968579) 4
35 (4070672) 4
Variant 3: Adult. Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US echocardiography transthoracic with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 1 1 0 1 1 5 8 0
References Study Quality
1 (24008954) 4
46 (19276509) 4
45 (23429940) 3
44 (34322523) 2
43 (17317734) 2
42 (1746435) 3
41 (19091794) 1
MRA pulmonary arteries without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 1 2 2 7 4 0
References Study Quality
32 (18356434) 3
33 (33202566) 1
CT chest without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 1 3 2 9 1 1
References Study Quality
10 (19553198) 4
27 (25032812) 4
28 (8184042) 4
CTA chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 1 3 2 10 1 0
References Study Quality
10 (19553198) 4
27 (25032812) 4
29 (17116729) 3
30 (16484354) 3
CTA pulmonary arteries with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv 7 7 0 0 0 0 1 3 5 7 0
References Study Quality
10 (19553198) 4
27 (25032812) 4
31 (32255688) 4
MRA chest without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 1 2 4 3 7 0 0
CT chest with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 0 3 11 2 1 0 0
References Study Quality
10 (19553198) 4
26 (31875234) 4
27 (25032812) 4
CT chest without and with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 0 4 9 3 0 0 0
References Study Quality
10 (19553198) 4
24 (18774307) 2
27 (25032812) 4
US echocardiography transesophageal Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 4 5 3 0 1 0 0 0
References Study Quality
39 (2212350) 3
38 (8181373) 4
US echocardiography transesophageal with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 2 4 4 5 1 1 0 0 0
References Study Quality
38 (8181373) 4
40 (12848887) 4
US echocardiography transthoracic resting Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 2 3 12 0 0 0 0 0 0
References Study Quality
38 (8181373) 4
Radiography chest Usually not appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 3 3 3 3 5 2 3 1 0 0 0
References Study Quality
37 (29141890) 4
36 (14742303) 3
Arteriography pulmonary Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 3 3 2 4 8 1 0 1 0 1 0
References Study Quality
24 (18774307) 2
MRA chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 0 3 8 2 3 0 1 0 0
MRA pulmonary arteries without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 1 7 10 1 0 0 0 0 0
Pertechnetate albumin pulmonary scan Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 9 5 1 4 1 0 0 0 0
References Study Quality
35 (4070672) 4
34 (3968579) 4
Variant 4: Adult. Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US echocardiography transthoracic with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 2 3 9 2
References Study Quality
1 (24008954) 4
46 (19276509) 4
45 (23429940) 3
44 (34322523) 2
43 (17317734) 2
42 (1746435) 3
41 (19091794) 1
MRA pulmonary arteries without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 1 1 2 4 5 4 0
References Study Quality
55 (33449178) 2
56 (25012936) 2
57 (35914744) 2
58 (25851199) 3
CT chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 1 3 12 1 0
References Study Quality
47 (26724660) 2
10 (19553198) 4
29 (17116729) 3
27 (25032812) 4
CT chest without and with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 1 0 1 0 3 3 9 0 0
References Study Quality
10 (19553198) 4
47 (26724660) 2
29 (17116729) 3
27 (25032812) 4
CT chest without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 1 0 0 1 4 4 2 5 3
References Study Quality
52 (33459902) 3
30 (16484354) 3
51 (1535899) 2
50 (14963181) 2
49 (16415131) 4
48 (16371535) 4
47 (26724660) 2
12 (23912618) 3
53 (26560716) 2
27 (25032812) 4
CTA chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 1 1 1 6 8 0
References Study Quality
10 (19553198) 4
47 (26724660) 2
29 (17116729) 3
30 (16484354) 3
27 (25032812) 4
CTA pulmonary arteries with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 0 0 0 0 1 2 4 9 1
References Study Quality
27 (25032812) 4
31 (32255688) 4
54 (35064274) 3
Arteriography pulmonary May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 0 0 0 3 8 5 0 1 0
References Study Quality
10 (19553198) 4
MRA chest without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 0 0 1 3 5 2 5 1 0
US echocardiography transesophageal Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 6 3 9 0 0 1 0 1 0
References Study Quality
39 (2212350) 3
38 (8181373) 4
US echocardiography transesophageal with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 3 3 6 2 0 0 0 0
References Study Quality
38 (8181373) 4
40 (12848887) 4
US echocardiography transthoracic resting Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 5 3 9 1 0 0 1 0 1
References Study Quality
38 (8181373) 4
Radiography chest Usually not appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 3 3 6 3 2 6 1 0 2 0 0
References Study Quality
36 (14742303) 3
37 (29141890) 4
MRA chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 0 2 7 3 5 0 0 0 0
MRA pulmonary arteries without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 1 5 10 3 0 0 0 0 0
Variant 5: Adult. Asymptomatic with abnormal imaging on CT or chest radiography suggestive of PAVM. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US echocardiography transthoracic with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 1 0 0 2 4 7 3
References Study Quality
1 (24008954) 4
46 (19276509) 4
45 (23429940) 3
44 (34322523) 2
43 (17317734) 2
42 (1746435) 3
41 (19091794) 1
MRA pulmonary arteries without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 2 4 1 6 4 0
References Study Quality
32 (18356434) 3
33 (33202566) 1
CTA pulmonary arteries with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 0 0 0 1 2 0 4 9 1
References Study Quality
10 (19553198) 4
27 (25032812) 4
31 (32255688) 4
Arteriography pulmonary May be appropriate Limited ☢☢☢☢ 10-30 mSv 6 6 0 0 0 2 4 9 2 0 0
References Study Quality
24 (18774307) 2
25 (7956388) 4
MRA chest without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 0 1 0 2 6 0 7 1 0
MRA chest without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 0 3 0 7 7 0 0 0 0
CT chest with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 2 4 1 2 0 6 2 0 0
References Study Quality
10 (19553198) 4
26 (31875234) 4
27 (25032812) 4
CT chest without and with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 2 4 2 2 2 5 0 0 0
References Study Quality
10 (19553198) 4
24 (18774307) 2
27 (25032812) 4
CT chest without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 2 4 2 5 2 2 0 0 0
References Study Quality
28 (8184042) 4
27 (25032812) 4
10 (19553198) 4
CTA chest with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 1 0 2 3 0 2 9 0
References Study Quality
10 (19553198) 4
27 (25032812) 4
29 (17116729) 3
US echocardiography transesophageal Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 8 4 4 2 1 1 0 0 0
References Study Quality
38 (8181373) 4
39 (2212350) 3
US echocardiography transesophageal with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 3 3 4 4 0 0 0 0
References Study Quality
38 (8181373) 4
40 (12848887) 4
US echocardiography transthoracic resting Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 6 3 6 2 1 0 2 0 0
References Study Quality
38 (8181373) 4
MRA pulmonary arteries without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 1 6 10 2 0 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.