American College of Radiology
ACR Appropriateness Criteria®

Nonatherosclerotic Peripheral Arterial Disease

Variant 1: Suspected popliteal entrapment syndrome. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRA lower extremity without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 3 3 2 5
References Study Quality
6 (18553287) 4
7 (19084742) 4
15 (20585781) 4
16 (23352364) 4
8 (18971035) 2
US duplex Doppler lower extremity Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 2 1 3 3 4
References Study Quality
5 (16176228) 4
7 (19084742) 4
8 (18971035) 2
16 (23352364) 4
17 (21944915) 2
18 (22123206) 2
CTA lower extremity with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 0 1 6 5 1
References Study Quality
5 (16176228) 4
15 (20585781) 4
17 (21944915) 2
19 (22109333) 4
MRA lower extremity without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 2 5 7 1 0 0
References Study Quality
6 (18553287) 4
7 (19084742) 4
15 (20585781) 4
16 (23352364) 4
Arteriography lower extremity May be appropriate Limited ☢☢ 0.1-1mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 0 0 0 8 7 0 0 0
References Study Quality
5 (16176228) 4
6 (18553287) 4
7 (19084742) 4
15 (20585781) 4
16 (23352364) 4
US intravascular lower extremity Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 0 2 13 0 0 0 0 0 0
References Study Quality
16 (23352364) 4
Variant 2: Suspected external iliac artery endofibrosis. 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 Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 1 0 0 1 0 4 7
References Study Quality
20 (27209899) 4
21 (23988540) 4
22 (23541546) 4
MRA lower extremity without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 2 0 8 3
References Study Quality
21 (23988540) 4
CTA lower extremity with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 1 0 1 4 2 3 2
References Study Quality
21 (23988540) 4
MRA lower extremity without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 2 5 2 3 1 0
References Study Quality
21 (23988540) 4
Arteriography lower extremity May be appropriate Limited ☢☢ 0.1-1mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 0 0 0 8 2 5 0 0 0
References Study Quality
1 (24758669) 4
32 (24955926) 4
33 (22186674) 4
US intravascular lower extremity Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 4 5 1 0 2 0 1 0 0
Variant 3: Suspected or known lower-extremity inflammatory vasculitides. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Arteriography lower extremity Usually appropriate Limited ☢☢ 0.1-1mSv ☢☢☢ 0.3-3 mSv [ped] 8 8 0 1 0 0 1 0 4 1 6
References Study Quality
2 (22784658) 4
CTA lower extremity with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 1 1 6 3 2
References Study Quality
2 (22784658) 4
34 (21724101) 4
MRA lower extremity without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 6 3 4 0
References Study Quality
2 (22784658) 4
MRA lower extremity without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 1 1 10 3 0 0 0
References Study Quality
2 (22784658) 4
US duplex Doppler lower extremity May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 1 1 7 3 0 3 0
References Study Quality
35 (27013404) 4
US intravascular lower extremity Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 4 6 1 1 1 0 0 0 0
Variant 4: Suspected or known dissection or connective tissue lower-extremity vascular diseases. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CTA lower extremity with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 0 2 11
References Study Quality
1 (24758669) 4
3 (21785848) 4
4 (17715121) 4
MRA lower extremity without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 0 4 7 1
References Study Quality
1 (24758669) 4
2 (22784658) 4
3 (21785848) 4
6 (18553287) 4
MRA lower extremity without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 1 0 4 5 3 0 0
References Study Quality
1 (24758669) 4
2 (22784658) 4
3 (21785848) 4
6 (18553287) 4
Arteriography lower extremity May be appropriate Limited ☢☢ 0.1-1mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 1 3 2 2 4 1 0 0 0
References Study Quality
1 (24758669) 4
4 (17715121) 4
US duplex Doppler lower extremity Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 0 0 9 1 4 1 0 0 0
US intravascular lower extremity Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 4 4 4 1 0 0 0 0 0
Variant 5: Suspected or known other noninflammatory lower-extremity vascular diseases (such as fibromuscular dysplasia, segmental arterial mediolysis). Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CTA lower extremity with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 0 0 1 7 5
References Study Quality
4 (17715121) 4
25 (24768236) 3
27 (21840227) 4
28 (17114538) 4
29 (23988553) 4
31 (22169114) 4
36 (19359118) 4
37 (27665159) 4
MRA lower extremity without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 1 1 8 3
References Study Quality
27 (21840227) 4
31 (22169114) 4
Arteriography lower extremity Usually appropriate Strong ☢☢ 0.1-1mSv ☢☢☢ 0.3-3 mSv [ped] 7 7 0 0 0 0 3 1 4 3 2
References Study Quality
15 (20585781) 4
25 (24768236) 3
26 (17555581) 4
28 (17114538) 4
36 (19359118) 4
38 (20540921) 4
39 (22112553) 2
40 (17097843) 2
MRA lower extremity without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 2 2 5 4 0 0
References Study Quality
27 (21840227) 4
31 (22169114) 4
US duplex Doppler lower extremity May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 2 2 4 2 2 1
References Study Quality
31 (22169114) 4
US intravascular lower extremity May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 2 5 8 0 0 0 0
References Study Quality
31 (22169114) 4
39 (22112553) 2
41 (25220329) 4
Variant 6: Lower-extremity vascular trauma. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CTA lower extremity with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 0 0 13
References Study Quality
34 (21724101) 4
42 (22824572) 4
43 (22190106) 4
Arteriography lower extremity May be appropriate Limited ☢☢ 0.1-1mSv ☢☢☢ 0.3-3 mSv [ped] 6 6 0 0 0 1 1 9 3 1 0
References Study Quality
34 (21724101) 4
43 (22190106) 4
44 (21817992) 4
45 (-3145647) 4
US duplex Doppler lower extremity May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 3 3 6 3 0 0
References Study Quality
43 (22190106) 4
46 (28493614) Good
MRA lower extremity without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 1 5 2 2 1 1 1 0 0
References Study Quality
43 (22190106) 4
MRA lower extremity without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 3 5 3 2 0 0 0 0 0
References Study Quality
43 (22190106) 4
US intravascular lower extremity Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 4 1 1 1 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.