ACR logo

Appropriateness Criteria

Variant 1: Adult. Unilateral lower extremity edema. Suspected nonthrombotic iliac vein lesion. Venous etiology. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler lower extremity Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 2 3 6 2 2
References Study Quality
17 (39400315) 1
30 (37196921) 3
22 (33840321) 3
23 (35926801) 2
MRV abdomen and pelvis with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 1 4 5 4
References Study Quality
13 (37542815) 2
12 (36124369) 4
MRV abdomen and pelvis without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 1 3 7 3
References Study Quality
13 (37542815) 2
12 (36124369) 4
MRV abdomen and pelvis without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 3 2 2 8 0 0
References Study Quality
13 (37542815) 2
12 (36124369) 4
CTV abdomen and pelvis with bilateral lower extremity runoff with IV contrast Usually appropriate Limited ☢☢☢☢ 10-30 mSv 8 8 0 0 0 0 1 1 2 7 4
References Study Quality
17 (39400315) 1
30 (37196921) 3
15 (32414674) 4
12 (36124369) 4
14 (32197952) 4
16 (35759778) 4
CTV abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢☢ 10-30 mSv 9 9 0 0 0 0 0 0 3 4 8
References Study Quality
17 (39400315) 1
30 (37196921) 3
15 (32414674) 4
12 (36124369) 4
24 (26885480) 4
16 (35759778) 4
14 (32197952) 4
MRI abdomen and pelvis with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 1 0 1 3 10 0 0 1 0
References Study Quality
13 (37542815) 2
11 (33866382) 3
MRI abdomen and pelvis without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 1 0 0 7 6 1 0 1 0
References Study Quality
13 (37542815) 2
11 (33866382) 3
CT abdomen and pelvis with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 2 10 2 1 0 0
References Study Quality
30 (37196921) 3
CT abdomen and pelvis without and with IV contrast May be appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 5 5 1 0 2 4 6 2 1 0 0
References Study Quality
30 (37196921) 3
US intravascular iliac veins Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 10 0 0 0 0 1 0 0
References Study Quality
17 (39400315) 1
37 (37453549) 3
18 (28818221) 3
22 (33840321) 3
13 (37542815) 2
39 (26993384) 4
15 (32414674) 4
20 (31196766) 0
31 (11932665) 3
14 (32197952) 4
2 (26993015) 4
19 (30926244) 4
US lower extremity Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 2 6 1 2 4 1 0 0 0
References Study Quality
17 (39400315) 1
30 (37196921) 3
22 (33840321) 3
23 (35926801) 2
US lower extremity with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 3 8 0 4 0 0 1 0 0
Radiography abdomen Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 11 0 3 0 1 0 0 0 0
References Study Quality
27 (22835564) 4
Catheter venography pelvis and lower extremity Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 5 8 1 1 1 0 0 0 0
References Study Quality
26 (39138303) 2
34 (36818336) 3
18 (28818221) 3
12 (36124369) 4
24 (26885480) 4
16 (35759778) 4
20 (31196766) 0
11 (33866382) 3
31 (11932665) 3
19 (30926244) 4
MRA abdomen and pelvis with bilateral lower extremity runoff with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 3 12 0 0 0 0 0 1 0
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 3 5 8 0 0 0 0 0 0
References Study Quality
13 (37542815) 2
11 (33866382) 3
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 4 5 0 2 1 0 0 0
References Study Quality
30 (37196921) 3
CTA abdomen and pelvis with bilateral lower extremity runoff with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 2 2 2 8 6 0 0 0 0 0 0
CTA abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 2 6 7 1 0 0 0 0 0
Variant 2: Adult. Asymptomatic. Known left common iliac vein stenosis. Nonthrombotic iliac vein lesion found on US, CT, or MRI. 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 duplex Doppler lower extremity Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 10 2 4 0 0 0 0 0 0
References Study Quality
17 (39400315) 1
23 (35926801) 2
US intravascular iliac veins Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 0 0 1 0 0
References Study Quality
17 (39400315) 1
13 (37542815) 2
15 (32414674) 4
31 (11932665) 3
2 (26993015) 4
US lower extremity Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 5 0 0 0 0 1 0 0
References Study Quality
17 (39400315) 1
23 (35926801) 2
US lower extremity with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 0 0 1 0 0
Radiography abdomen Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 11 0 3 1 0 0 0 0 0
References Study Quality
27 (22835564) 4
Catheter venography pelvis and lower extremity Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 8 4 4 0 0 0 0 0 0
References Study Quality
34 (36818336) 3
12 (36124369) 4
11 (33866382) 3
31 (11932665) 3
33 (30172665) 4
16 (35759778) 4
MRA abdomen and pelvis with bilateral lower extremity runoff with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 0 0 0 1 0
MRI abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 0 0 1 0 0
References Study Quality
13 (37542815) 2
11 (33866382) 3
MRI abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 1 0 0 0 0 0 0
References Study Quality
13 (37542815) 2
11 (33866382) 3
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 1 0 0 0 0 0
References Study Quality
13 (37542815) 2
11 (33866382) 3
MRV abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 4 0 0 1 0 0 0 0
References Study Quality
13 (37542815) 2
12 (36124369) 4
MRV abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 4 0 0 1 0 0 0 0
References Study Quality
13 (37542815) 2
12 (36124369) 4
MRV abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 5 0 0 0 1 0 0 0
References Study Quality
13 (37542815) 2
12 (36124369) 4
CT abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 2 0 0 0 1 0 0 0
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 0 3 1 1 1 1 0 0
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 12 3 0 0 1 0 0 0 0
CTA abdomen and pelvis with bilateral lower extremity runoff with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 13 2 0 0 1 0 0 0 0
CTA abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 13 2 0 0 1 0 0 0 0
CTV abdomen and pelvis with bilateral lower extremity runoff with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 11 4 0 0 1 0 0 0 0
References Study Quality
17 (39400315) 1
12 (36124369) 4
15 (32414674) 4
16 (35759778) 4
CTV abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 10 5 0 0 1 0 0 0 0
References Study Quality
17 (39400315) 1
12 (36124369) 4
15 (32414674) 4
16 (35759778) 4
Variant 3: Adult. Pelvic pain. Suspected nonthrombotic iliac vein lesion. Venous etiology. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US pelvis transabdominal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 1 2 1 5 3 2
MRV abdomen and pelvis with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 1 6 3 4
MRV abdomen and pelvis without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 0 7 4 3
MRV abdomen and pelvis without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 2 2 0 10 0 1
CTV abdomen and pelvis with bilateral lower extremity runoff with IV contrast Usually appropriate Limited ☢☢☢☢ 10-30 mSv 7 7 0 0 0 1 1 1 5 3 4
CTV abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢☢ 10-30 mSv 8 8 0 0 0 0 0 0 2 7 6
US duplex Doppler lower extremity May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 1 0 2 4 2 5 0 1
References Study Quality
36 (39423912) 4
38 (32593634) 4
MRI abdomen and pelvis with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 1 2 0 5 7 1 0 0 0
MRI abdomen and pelvis without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 1 2 0 3 8 2 0 0 0
CT abdomen and pelvis with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 1 1 2 10 0 0 1 0
CT abdomen and pelvis without and with IV contrast May be appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 4 4 1 1 1 6 7 0 0 0 0
US intravascular iliac veins Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 6 2 0 0 0 0 1 0
References Study Quality
36 (39423912) 4
37 (37453549) 3
US lower extremity Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 3 6 2 4 0 0 0 1 0
References Study Quality
36 (39423912) 4
38 (32593634) 4
US lower extremity with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 5 3 0 0 0 1 0 0
Radiography abdomen Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 11 0 2 0 1 1 0 0 0
Catheter venography pelvis and lower extremity Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 3 10 3 0 0 0 0 0 0
MRA abdomen and pelvis with bilateral lower extremity runoff with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 4 8 3 0 0 0 1 0 0
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 5 5 0 0 0 1 0 0
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 1 6 0 3 0 0 0 1
CTA abdomen and pelvis with bilateral lower extremity runoff with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 2 2 5 6 5 0 0 0 0 0 0
CTA abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 4 7 4 0 0 1 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.