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Appropriateness Criteria

Variant 1: Device selection: Acutely ill patient requiring infusion of vesicant medication, hemodynamic monitoring, and frequent blood draws for 2 weeks or shorter.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Nontunneled central venous catheter Usually appropriate Moderate N/A N/A 8 8 0 0 0 0 0 3 2 7 4
References Study Quality
15 (20857280) 1
14 (16865322) 4
13 (16100130) M
12 (16970212) M
11 (30095499) Good
PICC Usually appropriate Strong N/A N/A 8 8 0 0 0 0 1 1 4 4 6
References Study Quality
17 (28665469) 4
16 (20574104) 1
15 (20857280) 1
14 (16865322) 4
13 (16100130) M
12 (16970212) M
11 (30095499) Good
Midline catheter May be appropriate Strong N/A N/A 5 5 0 1 1 1 8 4 0 0 0
References Study Quality
10 (34553435) 2
9 (24811603) 1
Tunneled central venous catheter May be appropriate Limited N/A N/A 5 5 0 0 2 1 6 6 0 0 0
References Study Quality
12 (16970212) M
Arm port Usually not appropriate Limited N/A N/A 1 1 11 3 2 0 0 0 0 0 0
References Study Quality
8 (23739070) 2
Chest port Usually not appropriate Limited N/A N/A 1 1 11 3 2 0 0 0 0 0 0
References Study Quality
8 (23739070) 2
Variant 2: Device selection: Patient with acute renal failure requiring central venous access for renal replacement therapy, anticipated duration of therapy for 2 weeks or shorter.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Nontunneled dialysis catheter Usually appropriate Moderate N/A N/A 9 9 0 0 0 0 0 2 0 4 10
References Study Quality
11 (30095499) Good
18 (29202728) 2
Tunneled dialysis catheter Usually appropriate Limited N/A N/A 7 7 0 0 0 2 0 2 8 3 0
References Study Quality
18 (29202728) 2
Arm port Usually not appropriate Expert Consensus N/A N/A 1 1 14 1 0 0 0 0 1 0 0
Chest port Usually not appropriate Expert Consensus N/A N/A 1 1 14 1 0 0 0 0 1 0 0
PICC Usually not appropriate Expert Consensus N/A N/A 1 1 14 1 0 0 0 0 0 1 0
Variant 3: Device selection: Patient with renal failure requiring central venous access for renal replacement therapy, anticipated duration of therapy for more than 2 weeks.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Tunneled dialysis catheter Usually appropriate Limited N/A N/A 9 9 0 0 0 0 0 1 1 2 12
References Study Quality
12 (16970212) M
19 (30345873) 3
Nontunneled dialysis catheter May be appropriate Limited N/A N/A 5 5 0 0 1 5 5 3 1 1 0
References Study Quality
12 (16970212) M
19 (30345873) 3
Arm port Usually not appropriate Expert Consensus N/A N/A 1 1 14 1 0 0 0 0 1 0 0
Chest port Usually not appropriate Expert Consensus N/A N/A 1 1 14 1 0 0 0 0 0 0 1
PICC Usually not appropriate Expert Consensus N/A N/A 1 1 14 1 0 0 0 0 1 0 0
Variant 4: Device selection: Patient with cancer diagnosis requiring central venous access for weekly chemotherapy infusion for more than 2 weeks.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Chest port Usually appropriate Strong N/A N/A 9 9 0 0 0 0 0 0 1 3 12
References Study Quality
24 (33788748) 3
22 (31005243) 1
28 (21652113) 3
27 (24218174) M
26 (31044308) Good
25 (32479699) Inadequate
23 (19179550) 1
21 (31464692) Not Assessed
20 (24005884) 1
Arm port Usually appropriate Strong N/A N/A 7 7 0 0 1 0 0 3 11 1 0
References Study Quality
24 (33788748) 3
22 (31005243) 1
25 (32479699) Inadequate
23 (19179550) 1
21 (31464692) Not Assessed
20 (24005884) 1
PICC May be appropriate Strong N/A N/A 6 6 0 0 1 5 1 4 3 2 0
References Study Quality
22 (31005243) 1
29 (26113804) 2
25 (32479699) Inadequate
21 (31464692) Not Assessed
20 (24005884) 1
12 (16970212) M
Tunneled central venous catheter May be appropriate Strong N/A N/A 6 6 1 0 0 0 6 5 3 1 0
References Study Quality
12 (16970212) M
30 (2666137) 1
29 (26113804) 2
28 (21652113) 3
27 (24218174) M
26 (31044308) Good
Nontunneled central venous catheter Usually not appropriate Limited N/A N/A 3 3 4 4 6 1 1 0 0 0 0
References Study Quality
12 (16970212) M
28 (21652113) 3
27 (24218174) M
26 (31044308) Good
Variant 5: Device selection: Patient requiring continuous or very frequent intravenous administration of intravenous medications (excluding total parenteral nutrition) for more than 2 weeks.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
PICC Usually appropriate Strong N/A N/A 7 7 0 0 0 0 6 0 6 2 2
References Study Quality
12 (16970212) M
25 (32479699) Inadequate
22 (31005243) 1
21 (31464692) Not Assessed
20 (24005884) 1
Tunneled central venous catheter Usually appropriate Moderate N/A N/A 7 7 0 0 0 0 1 2 7 4 2
References Study Quality
12 (16970212) M
28 (21652113) 3
27 (24218174) M
26 (31044308) Good
Chest port May be appropriate Limited N/A N/A 6 6 0 0 0 2 5 8 0 0 0
References Study Quality
8 (23739070) 2
12 (16970212) M
25 (32479699) Inadequate
Arm port May be appropriate Limited N/A N/A 4 4 0 0 1 7 7 0 0 0 0
References Study Quality
8 (23739070) 2
12 (16970212) M
25 (32479699) Inadequate
Nontunneled central venous catheter Usually not appropriate Limited N/A N/A 2 2 2 8 3 1 1 1 0 0 0
References Study Quality
12 (16970212) M
28 (21652113) 3
Variant 6: Device selection: Patient requiring long-term total parenteral nutrition and another indication for central access.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Tunneled central venous catheter double lumen Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 1 1 9 4
References Study Quality
34 (29489708) 4
33 (19464090) 4
32 (28558699) 3
31 (32511768) 2
Double lumen PICC Usually appropriate Strong N/A N/A 7 7 0 0 0 1 2 3 3 3 4
References Study Quality
35 (29148004) 2
34 (29489708) 4
33 (19464090) 4
32 (28558699) 3
31 (32511768) 2
Single lumen PICC May be appropriate Strong N/A N/A 6 6 0 0 0 0 5 4 5 1 0
References Study Quality
35 (29148004) 2
34 (29489708) 4
33 (19464090) 4
32 (28558699) 3
31 (32511768) 2
Tunneled central venous catheter single lumen May be appropriate Limited N/A N/A 6 6 0 0 0 1 2 8 3 1 0
References Study Quality
34 (29489708) 4
33 (19464090) 4
32 (28558699) 3
31 (32511768) 2
Chest port May be appropriate Limited N/A N/A 4 4 1 2 3 5 4 0 0 0 0
References Study Quality
31 (32511768) 2
32 (28558699) 3
Arm port Usually not appropriate Limited N/A N/A 3 3 1 2 7 3 1 1 0 0 0
References Study Quality
31 (32511768) 2
32 (28558699) 3
Variant 7: Device selection: Patient with chronic kidney disease requiring central venous catheter IV infusions for more than 2 weeks.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Tunneled central venous catheter single lumen Usually appropriate Limited N/A N/A 8 8 0 0 1 0 0 0 3 8 3
References Study Quality
46 (27647824) 3
Tunneled central venous catheter double lumen Usually appropriate Limited N/A N/A 7 7 0 0 1 0 3 1 4 6 1
References Study Quality
46 (27647824) 3
Chest port via internal jugular vein May be appropriate Strong N/A N/A 6 6 0 0 1 1 6 2 3 1 2
References Study Quality
38 (2314526) 2
39 (1754109) 2
Chest port via subclavian vein Usually not appropriate Strong N/A N/A 3 3 6 1 3 4 1 0 1 0 0
References Study Quality
38 (2314526) 2
39 (1754109) 2
Arm port Usually not appropriate Limited N/A N/A 2 2 8 3 2 1 1 0 1 0 0
References Study Quality
36 (12616419) 2
37 (33116552) 3
PICC Usually not appropriate Strong N/A N/A 2 2 7 7 1 0 0 0 0 0 0
References Study Quality
45 (-3195138) 4
44 (32778223) 4
43 (22704142) 2
42 (29514546) 3
41 (11099241) 3
40 (15961840) 4
36 (12616419) 2
25 (32479699) Inadequate
22 (31005243) 1
16 (20574104) 1
15 (20857280) 1
Variant 8: Site selection: Patient with acute illness requiring central venous catheter for anticipated therapy for 2 weeks or shorter.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Right or left internal jugular vein Usually appropriate Strong N/A N/A 9 9 0 0 0 0 0 1 2 3 10
References Study Quality
62 (30231668) 3
58 (26398070) 1
56 (16280064) 2
52 (29992634) 3
Right or left subclavian vein Usually appropriate Strong N/A N/A 7 7 1 0 0 0 1 5 4 3 2
References Study Quality
62 (30231668) 3
61 (22419292) M
58 (26398070) 1
57 (11495620) 1
56 (16280064) 2
52 (29992634) 3
Upper extremity vein Usually appropriate Strong N/A N/A 7 7 0 0 0 0 3 3 3 2 5
References Study Quality
15 (20857280) 1
51 (29148000) 2
14 (16865322) 4
13 (16100130) M
12 (16970212) M
11 (30095499) Good
Right or left external jugular vein May be appropriate Limited N/A N/A 6 6 0 0 1 0 1 7 4 2 1
References Study Quality
54 (24306665) 2
53 (25198827) 4
52 (29992634) 3
Right or left femoral vein May be appropriate Strong N/A N/A 5 5 1 0 0 2 6 6 1 0 0
References Study Quality
61 (22419292) M
60 (8001386) 1
59 (29924154) 2
58 (26398070) 1
57 (11495620) 1
56 (16280064) 2
55 (9831940) 2
51 (29148000) 2
Hepatic vein Usually not appropriate Limited N/A N/A 2 2 8 3 4 0 1 0 0 0 0
References Study Quality
47 (14514812) 2
Inferior vena cava Usually not appropriate Limited N/A N/A 2 2 7 3 4 1 1 0 0 0 0
References Study Quality
50 (30281060) 3
49 (7747727) 2
48 (24190069) 4
Variant 9: Site selection: Patient with chronic kidney disease or end-stage renal disease requiring central venous catheter.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Right or left internal jugular vein Usually appropriate Strong N/A N/A 9 9 0 0 0 0 0 2 2 2 10
References Study Quality
38 (2314526) 2
39 (1754109) 2
61 (22419292) M
Right or left external jugular vein May be appropriate Limited N/A N/A 6 6 0 0 0 0 4 9 2 0 0
References Study Quality
53 (25198827) 4
Right or left femoral vein May be appropriate Strong N/A N/A 6 6 0 0 0 0 3 10 2 1 0
References Study Quality
64 (30359982) 1
61 (22419292) M
60 (8001386) 1
58 (26398070) 1
57 (11495620) 1
Inferior vena cava May be appropriate Strong N/A N/A 4 4 0 1 4 5 5 0 0 0 0
References Study Quality
63 (33318464) 2
50 (30281060) 3
49 (7747727) 2
48 (24190069) 4
Right or left subclavian vein May be appropriate Strong N/A N/A 4 4 0 3 1 8 3 0 0 0 0
References Study Quality
38 (2314526) 2
39 (1754109) 2
Hepatic vein Usually not appropriate Limited N/A N/A 3 3 2 4 4 5 0 0 0 0 0
References Study Quality
47 (14514812) 2
Upper extremity vein Usually not appropriate Strong N/A N/A 2 2 7 6 2 0 0 0 0 0 0
References Study Quality
45 (-3195138) 4
44 (32778223) 4
43 (22704142) 2
42 (29514546) 3
41 (11099241) 3
40 (15961840) 4
36 (12616419) 2
16 (20574104) 1
15 (20857280) 1
22 (31005243) 1
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.