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Appropriateness Criteria

Variant 1: Adult. Extensive acute bilateral central pulmonary emboli. Sustained hypotension for more than 15 minutes. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Anticoagulation Usually appropriate Limited N/A N/A 9 9 0 0 0 0 1 1 2 2 8
References Study Quality
10 (34352279) 4
Systemic thrombolysis Usually appropriate Limited N/A N/A 8 8 0 0 0 0 1 0 5 4 4
References Study Quality
22 (25631770) 4
21 (24917641) Not Assessed
Catheter-directed therapy pulmonary artery Usually appropriate Strong N/A N/A 7 7 0 0 1 0 1 5 2 2 3
References Study Quality
14 (35588898) 1
13 (36349702) 2
12 (26315743) 2
11 (25856269) 2
Surgical embolectomy pulmonary artery Usually appropriate Strong N/A N/A 7 7 0 0 0 0 1 1 4 3 1
References Study Quality
20 (32199827) 2
19 (35487534) Good
18 (26077690) 2
Extracorporeal membrane oxygenation May be appropriate Strong N/A N/A 6 6 0 0 0 0 5 5 2 1 1
References Study Quality
17 (33974966) 2
16 (32505687) 2
15 (32153003) 4
Variant 2: Adult. Acute bilateral pulmonary emboli. RV/LV ratio greater than 0.9 on CTA. Evidence of right heart strain on echocardiogram. Elevated troponin level. No hypotension. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Anticoagulation Usually appropriate Limited N/A N/A 9 9 0 0 0 0 0 0 2 2 10
References Study Quality
10 (34352279) 4
Catheter-directed therapy pulmonary artery Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 0 3 6 5
References Study Quality
28 (36210021) 2
27 (33454291) 2
26 (31072507) 2
25 (34167677) 1
24 (30025734) 1
23 (24226805) 1
14 (35588898) 1
13 (36349702) 2
12 (26315743) 2
11 (25856269) 2
Surgical embolectomy pulmonary artery May be appropriate (Disagreement) Expert Opinion N/A N/A 5 5 0 0 2 1 5 1 0 1 0
References Study Quality
30 (29659045) 2
29 (26165484) 3
Systemic thrombolysis Usually not appropriate Strong N/A N/A 3 3 0 3 3 0 4 0 0 0 0
References Study Quality
32 (28335835) 1
31 (24716681) 1
22 (25631770) 4
21 (24917641) Not Assessed
Extracorporeal membrane oxygenation Usually not appropriate Expert Consensus N/A N/A 2 2 5 3 5 0 0 1 0 0 0
Variant 3: Adult. Acute bilateral pulmonary emboli. RV/LV ratio less than 0.9 on CTA. No right heart strain on echocardiogram. Normal troponin level. No hypotension. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Anticoagulation Usually appropriate Limited N/A N/A 9 9 0 0 0 0 0 0 0 2 12
References Study Quality
10 (34352279) 4
33 (29498138) Not Assessed
Catheter-directed therapy pulmonary artery Usually not appropriate Expert Consensus N/A N/A 3 3 4 1 6 1 0 2 0 0 0
Extracorporeal membrane oxygenation Usually not appropriate Expert Consensus N/A N/A 1 1 11 3 0 0 0 0 0 0 0
Surgical embolectomy pulmonary artery Usually not appropriate Limited N/A N/A 1 1 10 3 1 0 0 0 0 0 0
References Study Quality
34 (21481423) 2
Systemic thrombolysis Usually not appropriate Expert Consensus N/A N/A 1 1 10 2 0 0 1 0 0 1 0
Variant 4: Adult. Acute saddle pulmonary embolism. Normal RV/LV ratio on CTA. Normal troponin level. No hypotension. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Anticoagulation Usually appropriate Limited N/A N/A 9 9 0 0 0 0 0 0 0 2 12
References Study Quality
10 (34352279) 4
Catheter-directed therapy pulmonary artery Usually not appropriate Expert Consensus N/A N/A 3 3 2 3 4 0 1 0 0 0 0
Systemic thrombolysis Usually not appropriate Expert Consensus N/A N/A 2 2 5 3 2 0 0 0 0 0 0
Extracorporeal membrane oxygenation Usually not appropriate Expert Consensus N/A N/A 1 1 9 3 1 1 0 0 0 0 0
Surgical embolectomy pulmonary artery Usually not appropriate Limited N/A N/A 1 1 8 2 3 0 0 0 0 1 0
References Study Quality
34 (21481423) 2
Variant 5: Adult. Acute bilateral central pulmonary emboli. Evidence of right heart failure on echocardiogram. Sustained a syncopal event with head trauma and acute intracranial hemorrhage. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Catheter-directed therapy pulmonary artery Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 0 4 6 4
References Study Quality
27 (33454291) 2
42 (31634603) 2
43 (28214482) 3
Extracorporeal membrane oxygenation May be appropriate Limited N/A N/A 5 5 3 0 1 3 5 1 1 0 0
References Study Quality
44 (33275707) 4
Surgical embolectomy pulmonary artery May be appropriate (Disagreement) Expert Opinion N/A N/A 5 5 0 5 2 1 0 1 1 0 0
References Study Quality
45 (35574955) Inadequate
Anticoagulation May be appropriate Limited N/A N/A 4 4 1 1 4 2 5 0 0 1 0
References Study Quality
40 (17534695) 4
41 (29642222) 4
Systemic thrombolysis Usually not appropriate Expert Consensus N/A N/A 1 1 13 1 0 0 0 0 0 0 0
Variant 6: Adult. Acute thromboembolism in transit. Thrombus in the right atrium. Sustained hypotension for more than 15 minutes. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Anticoagulation Usually appropriate Strong N/A N/A 9 9 0 0 0 0 0 0 2 0 8
References Study Quality
51 (36384306) 4
50 (30373436) 2
49 (29111332) 4
48 (25832601) 4
47 (28011316) 2
Catheter-directed therapy right heart Usually appropriate Limited N/A N/A 7 7 0 0 0 0 4 1 4 1 0
References Study Quality
52 (35722436) 4
Surgical embolectomy right heart Usually appropriate Limited N/A N/A 7 7 0 0 0 0 0 1 6 2 1
References Study Quality
53 (36661312) 2
Systemic thrombolysis May be appropriate Limited N/A N/A 6 6 0 0 0 0 3 3 2 2 0
References Study Quality
51 (36384306) 4
50 (30373436) 2
49 (29111332) 4
48 (25832601) 4
Extracorporeal membrane oxygenation May be appropriate Expert Consensus N/A N/A 5 5 0 0 0 0 7 3 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.