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Appropriateness Criteria

Variant 1: Known upper extremity arterial occlusion. Suspected embolic etiology. Next imaging study to determine source.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US echocardiography transesophageal Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 3 12 2 0
References Study Quality
2 (25747606) 3
31 (23821020) 2
4 (24523417) 3
50 (31236074) 3
51 (23186295) 4
13 (21529769) 4
10 (19995630) 4
46 (16824834) 3
US echocardiography transthoracic resting Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 0 2 11 3
References Study Quality
49 (26476503) 1
2 (25747606) 3
52 (27256218) 4
46 (16824834) 3
53 (16946152) 3
54 (1987242) 1
MRA chest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 1 3 9 3 0
References Study Quality
43 (20013276) 3
44 (17285264) 2
MRI heart function and morphology without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 0 11 5 0
References Study Quality
45 (29374292) Good
37 (31738598) 4
29 (29961869) Good
39 (10992020) 4
47 (17313647) 4
46 (16824834) 3
48 (23793590) 4
MRI heart function and morphology without IV contrast Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 4 10 2 0
References Study Quality
49 (26476503) 1
45 (29374292) Good
CTA chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 1 1 10 5 0
References Study Quality
12 (29150083) 2
41 (10966185) 4
13 (21529769) 4
CT heart function and morphology with IV contrast Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 0 0 4 13 0
References Study Quality
38 (19179202) 2
36 (29555833) 2
33 (29330651) 3
23 (29218612) 2
32 (25751618) 2
22 (20809409) 2
19 (21757676) 1
20 (22495682) 1
31 (23821020) 2
26 (26341605) 4
24 (28740038) 2
21 (27601228) 2
34 (29374188) 2
25 (30801566) 1
37 (31738598) 4
28 (23406625) Good
30 (26178177) Good
18 (19366905) 1
29 (29961869) Good
39 (10992020) 4
40 (25018846) 4
35 (22342878) 4
27 (19356536) 1
MRA chest without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 1 0 4 7 4 1 0
References Study Quality
43 (20013276) 3
44 (17285264) 2
US duplex Doppler abdomen Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 4 0 1 1 0 0 0 0
Aortography chest Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 2 5 10 0 0 0 0 0 0
References Study Quality
16 (19251175) 4
17 (22723539) 4
11 (21145267) 4
Variant 2: Known arterial occlusion in the mesenteric or renal arterial system or renal infarcts. Suspected embolic etiology. Next imaging study to determine source.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US echocardiography transesophageal Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 3 12 2 0
References Study Quality
2 (25747606) 3
31 (23821020) 2
4 (24523417) 3
50 (31236074) 3
51 (23186295) 4
13 (21529769) 4
10 (19995630) 4
46 (16824834) 3
US echocardiography transthoracic resting Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 1 0 0 4 10 2
References Study Quality
49 (26476503) 1
2 (25747606) 3
52 (27256218) 4
46 (16824834) 3
53 (16946152) 3
54 (1987242) 1
MRA chest and abdomen without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 1 12 4 0
References Study Quality
56 (21482138) 4
58 (24935911) 2
43 (20013276) 3
57 (19770313) 4
44 (17285264) 2
MRI heart function and morphology without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 1 11 5 0
References Study Quality
45 (29374292) Good
37 (31738598) 4
29 (29961869) Good
39 (10992020) 4
47 (17313647) 4
46 (16824834) 3
48 (23793590) 4
MRI heart function and morphology without IV contrast Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 6 8 2 0
References Study Quality
49 (26476503) 1
45 (29374292) Good
CTA chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 0 3 13 0 0
References Study Quality
12 (29150083) 2
41 (10966185) 4
13 (21529769) 4
CT heart function and morphology with IV contrast Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 0 0 10 7 0
References Study Quality
38 (19179202) 2
36 (29555833) 2
33 (29330651) 3
23 (29218612) 2
32 (25751618) 2
22 (20809409) 2
19 (21757676) 1
20 (22495682) 1
31 (23821020) 2
26 (26341605) 4
24 (28740038) 2
21 (27601228) 2
34 (29374188) 2
25 (30801566) 1
37 (31738598) 4
28 (23406625) Good
30 (26178177) Good
18 (19366905) 1
29 (29961869) Good
39 (10992020) 4
40 (25018846) 4
35 (22342878) 4
27 (19356536) 1
CTA chest and abdomen with IV contrast Usually appropriate Limited ☢☢☢☢ 10-30 mSv 7 7 2 0 0 0 0 0 8 7 0
References Study Quality
56 (21482138) 4
57 (19770313) 4
12 (29150083) 2
41 (10966185) 4
13 (21529769) 4
US duplex Doppler abdomen May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 2 1 2 7 4 0 1 0 0
References Study Quality
56 (21482138) 4
MRA chest and abdomen without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 1 11 3 1 0
References Study Quality
56 (21482138) 4
58 (24935911) 2
43 (20013276) 3
57 (19770313) 4
44 (17285264) 2
MRA chest without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 2 7 7 0 0
References Study Quality
43 (20013276) 3
44 (17285264) 2
MRA chest without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 5 5 5 0 0
References Study Quality
43 (20013276) 3
44 (17285264) 2
Aortography chest and abdomen Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 3 3 1 4 9 2 1 0 0 0 0
References Study Quality
16 (19251175) 4
17 (22723539) 4
11 (21145267) 4
Variant 3: Known lower extremity arterial occlusion. Suspected embolic etiology. Next imaging study to determine source.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US echocardiography transesophageal Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 0 3 11 2 0
References Study Quality
2 (25747606) 3
31 (23821020) 2
4 (24523417) 3
50 (31236074) 3
51 (23186295) 4
13 (21529769) 4
10 (19995630) 4
46 (16824834) 3
US echocardiography transthoracic resting Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 0 3 11 2
References Study Quality
49 (26476503) 1
2 (25747606) 3
52 (27256218) 4
46 (16824834) 3
53 (16946152) 3
54 (1987242) 1
MRA chest abdomen pelvis without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 2 12 3 0
References Study Quality
56 (21482138) 4
58 (24935911) 2
43 (20013276) 3
57 (19770313) 4
44 (17285264) 2
MRA chest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 5 11 0 0
References Study Quality
43 (20013276) 3
44 (17285264) 2
MRI heart function and morphology without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 4 12 1
References Study Quality
45 (29374292) Good
37 (31738598) 4
29 (29961869) Good
39 (10992020) 4
47 (17313647) 4
46 (16824834) 3
48 (23793590) 4
MRI heart function and morphology without IV contrast Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 3 11 3 0
References Study Quality
49 (26476503) 1
45 (29374292) Good
CTA chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 0 2 14 0 0
References Study Quality
12 (29150083) 2
41 (10966185) 4
13 (21529769) 4
CT heart function and morphology with IV contrast Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 0 0 10 5 2
References Study Quality
38 (19179202) 2
36 (29555833) 2
33 (29330651) 3
23 (29218612) 2
32 (25751618) 2
22 (20809409) 2
19 (21757676) 1
20 (22495682) 1
31 (23821020) 2
26 (26341605) 4
24 (28740038) 2
21 (27601228) 2
34 (29374188) 2
25 (30801566) 1
37 (31738598) 4
28 (23406625) Good
30 (26178177) Good
18 (19366905) 1
29 (29961869) Good
39 (10992020) 4
40 (25018846) 4
35 (22342878) 4
27 (19356536) 1
CTA chest abdomen pelvis with IV contrast Usually appropriate Limited ☢☢☢☢☢ 30-100 mSv ☢☢☢☢☢ 10-30 mSv [ped] 8 8 0 0 0 0 0 0 6 9 2
References Study Quality
56 (21482138) 4
57 (19770313) 4
12 (29150083) 2
41 (10966185) 4
13 (21529769) 4
MRA chest abdomen pelvis without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 2 10 4 1 0
References Study Quality
56 (21482138) 4
58 (24935911) 2
43 (20013276) 3
57 (19770313) 4
44 (17285264) 2
MRA chest without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 6 4 5 0 0
References Study Quality
43 (20013276) 3
44 (17285264) 2
US duplex Doppler abdomen Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 2 4 2 4 2 0 0 0
References Study Quality
56 (21482138) 4
Aortography chest abdomen pelvis Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 3 3 3 4 6 3 1 0 0 0 0
References Study Quality
16 (19251175) 4
17 (22723539) 4
11 (21145267) 4
Variant 4: Known multiorgan system arterial occlusions. Suspected embolic etiology. Next imaging study to determine source.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US echocardiography transesophageal Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 0 3 12 1 0
References Study Quality
2 (25747606) 3
31 (23821020) 2
4 (24523417) 3
50 (31236074) 3
51 (23186295) 4
13 (21529769) 4
10 (19995630) 4
46 (16824834) 3
US echocardiography transthoracic resting Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 0 3 10 3
References Study Quality
49 (26476503) 1
2 (25747606) 3
52 (27256218) 4
46 (16824834) 3
53 (16946152) 3
54 (1987242) 1
MRA chest abdomen pelvis without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 0 16 0 0
References Study Quality
56 (21482138) 4
58 (24935911) 2
43 (20013276) 3
57 (19770313) 4
44 (17285264) 2
MRA chest abdomen pelvis without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 3 12 0 0
References Study Quality
56 (21482138) 4
58 (24935911) 2
43 (20013276) 3
57 (19770313) 4
44 (17285264) 2
MRA chest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 4 11 2 0
References Study Quality
43 (20013276) 3
44 (17285264) 2
MRI heart function and morphology without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 4 12 1
References Study Quality
45 (29374292) Good
37 (31738598) 4
29 (29961869) Good
39 (10992020) 4
47 (17313647) 4
46 (16824834) 3
48 (23793590) 4
MRI heart function and morphology without IV contrast Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 5 9 3 0
References Study Quality
49 (26476503) 1
45 (29374292) Good
CTA chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 1 3 9 4 0
References Study Quality
12 (29150083) 2
41 (10966185) 4
13 (21529769) 4
CT heart function and morphology with IV contrast Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 0 0 3 11 3
References Study Quality
38 (19179202) 2
36 (29555833) 2
33 (29330651) 3
23 (29218612) 2
32 (25751618) 2
22 (20809409) 2
19 (21757676) 1
20 (22495682) 1
31 (23821020) 2
26 (26341605) 4
24 (28740038) 2
21 (27601228) 2
34 (29374188) 2
25 (30801566) 1
37 (31738598) 4
28 (23406625) Good
30 (26178177) Good
18 (19366905) 1
29 (29961869) Good
39 (10992020) 4
40 (25018846) 4
35 (22342878) 4
27 (19356536) 1
CTA chest abdomen pelvis with IV contrast Usually appropriate Limited ☢☢☢☢☢ 30-100 mSv ☢☢☢☢☢ 10-30 mSv [ped] 7 7 2 0 0 0 0 0 8 6 1
References Study Quality
56 (21482138) 4
57 (19770313) 4
12 (29150083) 2
41 (10966185) 4
13 (21529769) 4
US duplex Doppler abdomen May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 4 2 2 3 6 0 0 0 0
References Study Quality
56 (21482138) 4
MRA chest without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 3 9 4 1 0
References Study Quality
43 (20013276) 3
44 (17285264) 2
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.