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Appropriateness Criteria

Variant 1: Suspected dysfunction of upper or lower extremity hemodialysis access (ie, arteriovenous fistula or graft) suggested by an abnormal clinical indicator or hemodynamic indicator (ie, reduction in dialysis vascular access blood flow rate or kinetics). Initial imaging to guide interventional radiologic therapy options.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy fistulography hemodialysis access area of interest Usually appropriate Strong ☢☢☢ 1-10 mSv 8 8 0 1 0 0 0 0 1 8 6
References Study Quality
24 (11959724) 3
23 (16344384) 1
22 (1474770) 2
21 (26403274) 3
20 (15286321) 2
19 (17507428) 4
18 (19304717) 2
17 (20829241) 3
16 (20942731) 4
15 (23092640) 4
14 (8000128) 1
13 (24817452) 4
12 (16797391) 2
11 (24194928) Good
7 (27622727) 4
3 (16813991) 4
US duplex Doppler hemodialysis access area of interest Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 0 6 5 4
References Study Quality
33 (11012917) 2
32 (24059390) 4
31 (17928468) 1
30 (27886364) 2
29 (21531585) 2
28 (25368682) 4
27 (23229528) 4
26 (22266595) 2
25 (23641285) 3
MRA extremity area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 3 5 2 2 2 1 0 1 0
CTA extremity area of interest with IV contrast Usually not appropriate Limited Varies Varies 2 2 4 5 4 0 1 0 0 1 0
References Study Quality
18 (19304717) 2
17 (20829241) 3
11 (24194928) Good
CTV extremity area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 2 2 4 7 1 2 1 0 0 0 0
MRA extremity area of interest without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 7 7 1 0 0 0 0 0 0
References Study Quality
11 (24194928) Good
12 (16797391) 2
34 (12500274) 1
MRV extremity area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 5 2 3 0 0 0 0 0
MRV extremity area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 4 3 1 0 1 1 0 0
Variant 2: Suspected dysfunction of the upper or lower extremity hemodialysis access (ie, arteriovenous fistula or graft) suggested by an abnormal clinical indicator or hemodynamic indicator (ie, reduction in dialysis vascular access blood flow rate or kinetics). Treatment and procedures.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy fistulography hemodialysis access with intervention Usually appropriate Strong N/A N/A 9 9 0 0 0 0 0 0 1 5 10
References Study Quality
63 (27388566) 1
62 (27514445) 1
61 (27353358) 1
60 (29622355) 1
59 (26074027) 1
58 (18829240) 1
57 (18256373) 2
56 (9399465) 1
55 (16371528) 2
54 (8850659) 1
53 (-3194801) 4
52 (25575743) 1
51 (24529550) 1
50 (30040057) 1
49 (29471988) 1
48 (24315548) 1
47 (26508448) 1
46 (24794277) 1
45 (14514827) 4
44 (27334570) 2
43 (24587906) 2
42 (26597666) 2
41 (12761309) 2
40 (19028115) 3
39 (21840156) 2
38 (2961397) 3
37 (16557220) 2
36 (21199430) 2
35 (25698092) 2
22 (1474770) 2
7 (27622727) 4
4 (-3194799) 4
3 (16813991) 4
US duplex Doppler hemodialysis access area of interest Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 3 1 5 4 1
References Study Quality
29 (21531585) 2
30 (27886364) 2
80 (23334852) 3
81 (28655388) 2
Surgical consultation May be appropriate Strong N/A N/A 6 6 0 1 0 1 6 2 3 1 2
References Study Quality
75 (26220504) 4
74 (28800839) 2
73 (24190074) 3
72 (26660034) 2
71 (25011092) 3
70 (30055242) 3
69 (23080336) 3
68 (29421426) 3
67 (28218365) 4
66 (22367648) 2
65 (23385224) 3
7 (27622727) 4
Continued hemodialysis access use with surveillance May be appropriate Strong N/A N/A 5 5 0 0 0 2 11 2 0 0 0
References Study Quality
6 (22287223) 3
5 (32778223) 4
4 (-3194799) 4
79 (12324911) 2
78 (25664243) 4
77 (21454718) 1
76 (11932367) 1
73 (24190074) 3
Placement of a new tunneled dialysis catheter May be appropriate Limited N/A N/A 5 5 1 1 2 4 6 0 1 0 1
References Study Quality
5 (32778223) 4
Variant 3: Suspected thrombosis of the upper or lower extremity hemodialysis access, marked by absent pulse and thrill on physical examination. Initial imaging to guide interventional radiologic therapy options.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy fistulography hemodialysis access area of interest Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 0 0 0 0 0 0 4 6 5
References Study Quality
7 (27622727) 4
19 (17507428) 4
US duplex Doppler hemodialysis access area of interest May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 1 1 7 2 0 4 0
References Study Quality
5 (32778223) 4
7 (27622727) 4
83 (27716892) 4
CTA extremity area of interest with IV contrast Usually not appropriate Limited Varies Varies 2 2 5 8 2 0 0 0 0 0 0
References Study Quality
17 (20829241) 3
84 (21969710) 3
85 (28970522) 1
CTV extremity area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 2 2 5 4 4 0 2 0 0 0 1
MRA extremity area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 5 3 1 0 0 0 0 0
MRA extremity area of interest without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 6 3 0 1 0 1 0 0
References Study Quality
86 (25976499) 1
87 (26732890) 3
MRV extremity area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 5 2 2 0 1 1 0 0
MRV extremity area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 4 5 4 1 0 0 1 0 1
Variant 4: Suspected thrombosis of the upper or lower extremity hemodialysis access, marked by absent pulse and thrill on physical examination. Treatment and procedures.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy fistulography hemodialysis access with intervention Usually appropriate Limited N/A N/A 9 9 0 0 1 0 0 0 1 5 9
References Study Quality
4 (-3194799) 4
5 (32778223) 4
7 (27622727) 4
45 (14514827) 4
88 (12085386) 4
Surgical consultation Usually appropriate Strong N/A N/A 7 7 0 1 0 0 3 2 5 3 2
References Study Quality
7 (27622727) 4
89 (8866409) 2
90 (22796333) 1
Placement of a new tunneled dialysis catheter May be appropriate Limited N/A N/A 5 5 0 0 0 0 10 4 1 0 0
References Study Quality
5 (32778223) 4
US duplex Doppler hemodialysis access area of interest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 1 3 5 1 4 1 0 0 1
References Study Quality
80 (23334852) 3
91 (29017808) 3
Variant 5: Failure of an upper or lower extremity arteriovenous fistula to mature within 2 months after creation. Initial imaging to guide interventional radiologic therapy options.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy fistulography hemodialysis access area of interest Usually appropriate Strong ☢☢☢ 1-10 mSv 9 9 0 0 0 0 1 1 2 4 8
References Study Quality
99 (17699217) 2
98 (12969170) 2
97 (11733628) 2
96 (10213648) 2
95 (18503901) 1
94 (22915412) 3
US duplex Doppler hemodialysis access area of interest Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 1 0 0 1 1 5 4 4
References Study Quality
5 (32778223) 4
7 (27622727) 4
32 (24059390) 4
103 (17991787) 3
102 (22164333) 4
101 (25613148) 3
100 (24500848) 1
CTV extremity area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 3 3 5 3 5 0 2 0 0 0 1
MRA extremity area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 6 1 5 1 1 1 1 0 0
MRA extremity area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 7 1 6 0 0 0 1 0 1
MRV extremity area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 7 1 3 3 1 0 1 0 0
CTA extremity area of interest with IV contrast Usually not appropriate Limited Varies Varies 2 2 6 4 4 1 0 0 0 0 0
References Study Quality
17 (20829241) 3
85 (28970522) 1
104 (20173168) 4
MRV extremity area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 8 1 0 0 0 0 0 0
Variant 6: Failure of an upper or lower extremity arteriovenous fistula to mature within 2 months after creation. Treatment and procedures.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy fistulography hemodialysis access with intervention Usually appropriate Strong N/A N/A 9 9 0 0 1 0 0 0 3 3 9
References Study Quality
7 (27622727) 4
105 (14605103) 3
106 (17090715) 3
95 (18503901) 1
99 (17699217) 2
Surgical consultation Usually appropriate Strong N/A N/A 8 8 0 0 0 0 2 1 2 7 4
References Study Quality
5 (32778223) 4
96 (10213648) 2
97 (11733628) 2
101 (25613148) 3
103 (17991787) 3
107 (30309898) 2
US duplex Doppler hemodialysis access area of interest Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 2 1 4 5 3
References Study Quality
107 (30309898) 2
109 (27183858) 2
103 (17991787) 3
102 (22164333) 4
101 (25613148) 3
100 (24500848) 1
Placement of a new tunneled dialysis catheter May be appropriate Moderate N/A N/A 6 6 0 0 0 0 5 4 4 2 1
References Study Quality
5 (32778223) 4
101 (25613148) 3
108 (30244924) 2
Variant 7: Clinical suspicion of central venous stenosis or occlusion suggested by swelling (ie, soft tissue edema) of the extremity ipsilateral to the upper or lower extremity hemodialysis access, with or without the development of venous collaterals. Initial imaging to guide interventional radiologic therapy options.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy fistulography hemodialysis access area of interest Usually appropriate Strong ☢☢☢ 1-10 mSv 8 8 0 0 0 0 0 0 2 7 7
References Study Quality
112 (25890685) 2
111 (23291234) 4
110 (21873620) 2
CTA extremity area of interest with IV contrast Usually not appropriate Strong Varies Varies 2 2 5 7 3 0 0 0 0 0 0
References Study Quality
17 (20829241) 3
18 (19304717) 2
84 (21969710) 3
104 (20173168) 4
114 (16242563) 1
115 (16247148) 3
CTV extremity area of interest with IV contrast Usually not appropriate Limited Varies Varies 2 2 5 6 2 0 0 0 1 1 0
References Study Quality
5 (32778223) 4
MRA extremity area of interest without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 6 2 0 0 0 0 0 0
References Study Quality
11 (24194928) Good
MRA extremity area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 3 4 0 2 0 0 0 0
MRV extremity area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 5 2 0 0 1 0 0 0
MRV extremity area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 5 3 0 0 0 0 0 0
US duplex Doppler hemodialysis access area of interest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 4 5 3 1 1 1 0 0 0
References Study Quality
111 (23291234) 4
113 (17540535) 2
Variant 8: Clinical suspicion of central venous stenosis or occlusion suggested by swelling (ie, soft tissue edema) of the extremity ipsilateral to the upper or lower extremity hemodialysis access, with or without the development of venous collaterals. Treatment and procedures.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy fistulography hemodialysis access with intervention Usually appropriate Strong N/A N/A 9 9 0 0 0 0 0 0 2 5 9
References Study Quality
5 (32778223) 4
7 (27622727) 4
119 (19933663) 2
118 (17398386) 2
117 (16424248) 3
116 (21326501) 4
112 (25890685) 2
110 (21873620) 2
Continued hemodialysis access use with surveillance May be appropriate Limited N/A N/A 4 4 2 1 5 3 3 1 0 1 0
References Study Quality
5 (32778223) 4
110 (21873620) 2
US duplex Doppler hemodialysis access area of interest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 3 7 0 1 1 1 0 0
References Study Quality
17 (20829241) 3
Placement of a new tunneled dialysis catheter Usually not appropriate Limited N/A N/A 2 2 5 3 4 2 0 0 1 0 0
References Study Quality
5 (32778223) 4
111 (23291234) 4
Surgical consultation Usually not appropriate Limited N/A N/A 2 2 3 6 2 1 2 0 1 0 0
References Study Quality
5 (32778223) 4
122 (22633426) 4
121 (24502816) 3
120 (22673549) 4
Variant 9: Abnormal skin changes associated with the upper or lower extremity hemodialysis access cannulation site, including marked thinning, ulceration, eschar formation, spontaneous bleeding, pseudoaneurysm formation, superficial or deep infection. Initial imaging to guide interventional radiologic therapy options.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler hemodialysis access area of interest Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 1 0 0 4 2 5 1 3
References Study Quality
5 (32778223) 4
Fluoroscopy fistulography hemodialysis access area of interest May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 0 1 1 3 6 3 0 0 1
References Study Quality
123 (25154565) 2
CTV extremity area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 3 3 4 4 5 0 2 0 0 0 1
MRA extremity area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 5 3 5 1 1 0 0 1 0
CTA extremity area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 2 2 6 7 2 0 0 0 0 0 0
MRA extremity area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 5 4 0 1 0 0 1 0
MRV extremity area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 4 3 1 1 1 0 1 0
MRV extremity area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 5 3 0 0 0 1 1 0
Variant 10: Abnormal skin changes associated with the upper or lower extremity hemodialysis access cannulation site, including marked thinning, ulceration, eschar formation, spontaneous bleeding, pseudoaneurysm formation, superficial or deep infection. Treatment and procedures.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Surgical consultation Usually appropriate Moderate N/A N/A 8 8 0 0 0 0 1 1 4 4 6
References Study Quality
5 (32778223) 4
132 (28341509) 3
131 (28238919) 2
130 (20175060) 3
129 (21725946) 4
Placement of a new tunneled dialysis catheter Usually appropriate Moderate N/A N/A 7 7 1 0 0 1 4 2 7 0 1
References Study Quality
108 (30244924) 2
Fluoroscopy fistulography hemodialysis access with intervention May be appropriate Strong N/A N/A 5 5 0 0 1 1 8 4 0 0 1
References Study Quality
128 (21840731) 4
127 (23058719) 2
126 (23036977) 2
125 (23934930) 2
124 (22342153) 2
123 (25154565) 2
Continued hemodialysis access use with surveillance Usually not appropriate Limited N/A N/A 2 2 5 5 4 0 2 0 0 0 0
References Study Quality
129 (21725946) 4
130 (20175060) 3
Variant 11: Suspected vascular steal syndrome (upper or lower extremity), suggested by cardiac failure or ischemic symptoms. Initial imaging to guide interventional radiologic therapy options.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy fistulography hemodialysis access area of interest Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 1 0 0 0 1 0 2 7 5
References Study Quality
138 (9783790) 2
137 (14652830) 4
136 (7644631) 4
133 (17699402) 4
US duplex Doppler hemodialysis access area of interest Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 2 5 5 2
References Study Quality
133 (17699402) 4
139 (23581731) 4
CTA extremity area of interest with IV contrast May be appropriate Limited Varies Varies 5 5 0 0 1 0 10 2 2 0 0
References Study Quality
133 (17699402) 4
CTV extremity area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 3 3 5 3 4 2 2 0 0 0 0
MRA extremity area of interest without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 4 5 3 2 1 0 0 0 0
References Study Quality
12 (16797391) 2
MRA extremity area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 5 3 1 0 0 0 0 0
MRV extremity area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 2 5 0 1 0 0 0 0
MRV extremity area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 5 3 0 1 0 0 0 0
Variant 12: Suspected vascular steal syndrome (upper or lower extremity), suggested by cardiac failure or ischemic symptoms. Treatment and procedures.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Surgical consultation Usually appropriate Strong N/A N/A 9 9 0 0 0 0 0 2 2 3 9
References Study Quality
134 (27224985) 3
147 (21276691) 2
146 (26492999) 2
145 (25499703) 2
144 (26349882) 3
143 (26951907) 4
142 (22266588) 2
Continued hemodialysis access use with surveillance May be appropriate Expert Consensus N/A N/A 5 5 0 3 0 2 10 0 0 0 0
Fluoroscopy fistulography hemodialysis access with intervention May be appropriate Limited N/A N/A 5 5 0 0 0 1 7 3 3 0 1
References Study Quality
141 (18379982) 4
140 (27312765) 2
134 (27224985) 3
128 (21840731) 4
Placement of a new tunneled dialysis catheter May be appropriate Moderate N/A N/A 5 5 0 0 0 2 12 0 1 0 0
References Study Quality
108 (30244924) 2
US duplex Doppler hemodialysis access area of interest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 4 5 5 0 0 0 0 1 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.