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Appropriateness Criteria

Variant 1: Recent onset abdominal pain, no peritoneal signs, and known atrial fibrillation. CTA shows filling defect in proximal SMA consistent with embolus. No intramural or extra-luminal air. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Systemic anticoagulation Usually appropriate Limited N/A N/A 8 8 0 1 0 0 0 1 0 7 5
References Study Quality
1 (30360689) 4
4 (28359440) 4
3 (29757725) 4
Angiography and aspiration embolectomy Usually appropriate Strong N/A N/A 7 7 0 0 1 1 2 0 6 4 1
References Study Quality
9 (22503176) 2
7 (29455017) 3
6 (25737456) 3
1 (30360689) 4
8 (30809084) 2
5 (28121281) Inadequate
4 (28359440) 4
Transcatheter thrombolysis Usually appropriate Strong N/A N/A 7 7 0 0 1 0 1 1 10 1 0
References Study Quality
7 (29455017) 3
8 (30809084) 2
4 (28359440) 4
11 (21889287) 2
12 (23394456) 3
Surgical embolectomy May be appropriate Strong N/A N/A 5 5 0 0 0 2 9 2 0 0 1
References Study Quality
9 (22503176) 2
6 (25737456) 3
8 (30809084) 2
5 (28121281) Inadequate
4 (28359440) 4
10 (31382003) 3
Variant 2: Recent onset abdominal pain, no peritoneal signs, and known atrial fibrillation. CTA shows calcified atherosclerotic plaque involving the aorta and its major branches, as well as proximal short-segment occlusion of the proximal SMA. No intramural or extra-luminal air. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Angiography and endovascular intervention including possible thrombolysis, angioplasty, or stent placement Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 0 2 11 1
References Study Quality
7 (29455017) 3
14 (27178034) 2
6 (25737456) 3
1 (30360689) 4
5 (28121281) Inadequate
13 (33589326) 3
Systemic anticoagulation Usually appropriate Limited N/A N/A 8 8 1 0 1 0 0 1 2 4 6
References Study Quality
1 (30360689) 4
4 (28359440) 4
Surgical endarterectomy or bypass May be appropriate Limited N/A N/A 5 5 0 0 0 2 9 2 0 1 0
References Study Quality
15 (24199769) 3
13 (33589326) 3
Variant 3: Patient with cardiac disease causing low cardiac output who developed abdominal pain but without peritoneal signs. CTA shows patent origins and proximal portions of celiac artery, SMA, and IMA, with diffuse irregular narrowing of SMA branches. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Angiography with infusion of vasodilator Usually appropriate Limited N/A N/A 7 7 0 0 0 0 0 1 8 5 0
References Study Quality
4 (28359440) 4
17 (32444922) 3
19 (28794797) 4
18 (31832858) 3
Systemic anticoagulation Usually appropriate Expert Consensus N/A N/A 7 7 0 0 0 1 3 0 9 1 0
Systemic infusion of prostaglandin E1 May be appropriate Limited N/A N/A 6 6 0 0 1 0 1 8 3 1 0
References Study Quality
20 (30909787) 3
Angiography with percutaneous transluminal angioplasty Usually not appropriate Expert Consensus N/A N/A 3 3 3 2 9 0 0 0 0 0 0
Variant 4: Recent onset abdominal pain, peritoneal signs, and known atrial fibrillation. CTA shows filling defect in the proximal SMA consistent with embolus and evidence of bowel infarction. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Surgical revascularization Usually appropriate Moderate N/A N/A 8 8 0 0 0 0 0 0 0 11 3
References Study Quality
21 (30777691) 2
4 (28359440) 4
Systemic anticoagulation Usually appropriate Limited N/A N/A 8 8 0 1 0 0 0 0 6 4 3
References Study Quality
1 (30360689) 4
4 (28359440) 4
Angiography and aspiration embolectomy May be appropriate Expert Consensus N/A N/A 5 5 0 0 1 1 9 3 0 0 0
Transcatheter thrombolysis Usually not appropriate Expert Consensus N/A N/A 3 3 1 3 7 2 1 0 0 0 0
Variant 5: Abdominal pain after meals and CTA showing widely patent origins of SMA and IMA, with compression of the celiac origin by the median arcuate ligament. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Surgery with median arcuate ligament release Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 0 0 12 2
References Study Quality
31 (3965762) 4
22 (25814203) 4
30 (26365109) 3
28 (25758451) 2
32 (28851450) 2
Mesenteric angiography in lateral projection during both inspiration and expiration Usually appropriate Limited N/A N/A 7 7 0 0 1 0 0 0 8 4 1
References Study Quality
23 (28259570) 2
Supportive measures only May be appropriate Limited N/A N/A 6 6 0 1 0 0 1 11 0 1 0
References Study Quality
29 (28189355) 2
Percutaneous transluminal angioplasty with stent placement May be appropriate Strong N/A N/A 4 4 2 3 2 5 1 2 0 0 0
References Study Quality
22 (25814203) 4
28 (25758451) 2
27 (18375098) 4
26 (11800352) 2
25 (19128929) 4
24 (17903658) 4
Systemic anticoagulation Usually not appropriate Expert Consensus N/A N/A 2 2 4 8 0 1 1 0 0 0 1
Variant 6: History of abdominal pain after meals for the past few months and weight loss. CTA shows aortic atherosclerotic disease and suggests SMA-origin stenosis with occlusion of celiac origin and an occluded IMA. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Angiography with possible percutaneous transluminal angioplasty and stent placement Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 0 1 10 3
References Study Quality
36 (27066948) 2
38 (29217008) 3
33 (29574024) 4
34 (27581131) 2
37 (33171195) 4
35 (31327617) 2
13 (33589326) 3
39 (29571626) Good
40 (19497510) 2
Surgical bypass or endarterectomy May be appropriate Limited N/A N/A 6 6 0 0 0 0 1 9 2 2 0
References Study Quality
38 (29217008) 3
37 (33171195) 4
13 (33589326) 3
Systemic anticoagulation May be appropriate Limited N/A N/A 5 5 1 1 3 2 6 0 1 0 0
References Study Quality
37 (33171195) 4
Variant 7: Previously healthy with worsening diffuse abdominal pain for 2 weeks. CTA shows occlusion of the superior mesenteric vein and its major tributaries. Bowel appears normal. Serum lactate level is normal. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Systemic anticoagulation Usually appropriate Moderate N/A N/A 9 9 0 0 0 0 0 0 0 0 14
References Study Quality
4 (28359440) 4
44 (19821530) 2
Transhepatic superior mesenteric vein catheterization and pharmacomechanical thrombolysis Usually appropriate Moderate N/A N/A 7 7 0 0 0 0 0 3 9 1 1
References Study Quality
47 (15872320) 4
46 (24704749) 4
4 (28359440) 4
48 (26253926) 4
45 (31489698) 2
Transjugular superior mesenteric vein catheterization and pharmacomechanical thrombolysis and TIPS May be appropriate Moderate N/A N/A 6 6 0 0 0 0 3 8 1 2 0
References Study Quality
45 (31489698) 2
SMA angiography followed by thrombolytic infusion May be appropriate Limited N/A N/A 4 4 0 1 0 10 2 1 0 0 0
References Study Quality
42 (19859995) 4
41 (27263813) 3
Surgical thrombectomy Usually not appropriate Limited N/A N/A 3 3 1 1 8 2 1 1 1 0 0
References Study Quality
4 (28359440) 4
43 (30428441) 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.