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Appropriateness Criteria

Variant 1: Adult. Suspected renovascular hypertension. Normal renal function. 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 kidneys retroperitoneal Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 4 2 8
References Study Quality
44 (10742425) 3
48 (17384038) 4
50 (24172238) 4
51 (16301720) 2
49 (12515376) 4
4 (20864945) 4
45 (10957652) 3
46 (22595689) 2
47 (17764871) 4
MRA abdomen without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 1 0 1 1 0 5 3 3
References Study Quality
33 (18372471) 1
35 (21542417) 2
36 (21833688) 4
38 (25204811) 4
70 (11956117) 2
71 (12773688) 2
6 (24245566) 1
37 (23917027) 4
34 (12096862) M
CTA abdomen with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 2 0 0 6 3 3
References Study Quality
28 (9676442) 2
29 (11849401) 3
30 (23885929) 4
31 (18270376) 1
32 (17499952) 1
MRA abdomen without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 1 7 1 1 3 0 0 0
References Study Quality
42 (23096208) 3
41 (21098205) 2
36 (21833688) 4
72 (12704782) 2
40 (18728334) 3
39 (33136181) 4
Arteriography kidney Usually not appropriate Strong ☢☢☢ 1-10 mSv 3 3 3 2 4 3 0 1 0 1 0
References Study Quality
24 (2648471) 2
23 (3526406) 3
21 (6385671) 4
22 (3923557) 4
19 (21078879) 4
20 (7089265) 3
18 (17084261) 4
26 (8686635) 2
27 (8662167) 2
Venography with renal vein sampling Usually not appropriate Limited Varies Varies 2 2 6 3 5 0 0 0 0 0 0
References Study Quality
55 (1994424) 3
14 (14500224) 3
52 (17192278) 4
73 (19233590) 3
74 (24155154) 3
ACE inhibitor renography Usually not appropriate Strong ☢☢☢ 1-10 mSv 2 2 5 5 1 0 0 0 0 0 0
References Study Quality
13 (1831342) 3
9 (11560453) M
12 (12230421) 2
10 (1837991) 4
11 (15728620) 3
14 (14500224) 3
17 (10658939) 3
15 (10816399) 2
16 (12411867) 4
Variant 2: Adult. Suspected renovascular hypertension. Decreased renal function, eGFR less than 30 mL/min/1.73 m2. 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 kidneys retroperitoneal Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 2 2 10
References Study Quality
44 (10742425) 3
45 (10957652) 3
46 (22595689) 2
47 (17764871) 4
48 (17384038) 4
50 (24172238) 4
51 (16301720) 2
43 (25539255) 1
49 (12515376) 4
4 (20864945) 4
MRA abdomen without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 2 0 9 2 1
References Study Quality
33 (18372471) 1
71 (12773688) 2
36 (21833688) 4
38 (25204811) 4
70 (11956117) 2
37 (23917027) 4
35 (21542417) 2
58 (24475854) 4
34 (12096862) M
MRA abdomen without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 0 2 4 1 2 4 0 0
References Study Quality
42 (23096208) 3
41 (21098205) 2
36 (21833688) 4
72 (12704782) 2
40 (18728334) 3
39 (33136181) 4
Arteriography kidney Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 7 4 3 0 0 0 0 0 0
References Study Quality
18 (17084261) 4
27 (8662167) 2
19 (21078879) 4
20 (7089265) 3
Venography with renal vein sampling Usually not appropriate Limited Varies Varies 1 1 8 2 4 0 0 0 0 0 0
References Study Quality
74 (24155154) 3
73 (19233590) 3
52 (17192278) 4
14 (14500224) 3
ACE inhibitor renography Usually not appropriate Strong ☢☢☢ 1-10 mSv 1 1 8 2 3 0 0 1 0 0 0
References Study Quality
6 (24245566) 1
9 (11560453) M
17 (10658939) 3
10 (1837991) 4
11 (15728620) 3
16 (12411867) 4
13 (1831342) 3
12 (12230421) 2
14 (14500224) 3
15 (10816399) 2
CTA abdomen with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 1 9 0 2 0 0 0 0
References Study Quality
58 (24475854) 4
57 (23360737) 4
56 (23579046) 4
74 (24155154) 3
53 (3160766) 4
54 (2944011) 3
55 (1994424) 3
Variant 3: Adult. Suspected renovascular hypertension. Known renal artery stenosis. Normal renal function. Follow-up 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 kidneys retroperitoneal Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 1 4 5 4
References Study Quality
62 (2522152) 4
51 (16301720) 2
47 (17764871) 4
48 (17384038) 4
50 (24172238) 4
49 (12515376) 4
44 (10742425) 3
45 (10957652) 3
46 (22595689) 2
59 (23360742) 4
4 (20864945) 4
MRA abdomen without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 1 2 4 5 1
References Study Quality
6 (24245566) 1
60 (26599922) 4
38 (25204811) 4
70 (11956117) 2
71 (12773688) 2
37 (23917027) 4
35 (21542417) 2
36 (21833688) 4
34 (12096862) M
33 (18372471) 1
CTA abdomen with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 0 1 4 6 3
References Study Quality
30 (23885929) 4
29 (11849401) 3
31 (18270376) 1
32 (17499952) 1
28 (9676442) 2
Arteriography kidney Usually not appropriate Strong ☢☢☢ 1-10 mSv 3 3 2 2 5 2 1 1 0 0 1
References Study Quality
24 (2648471) 2
23 (3526406) 3
21 (6385671) 4
22 (3923557) 4
19 (21078879) 4
20 (7089265) 3
18 (17084261) 4
26 (8686635) 2
Venography with renal vein sampling Usually not appropriate Limited Varies Varies 2 2 5 4 4 0 0 0 1 0 0
References Study Quality
14 (14500224) 3
52 (17192278) 4
73 (19233590) 3
74 (24155154) 3
MRA abdomen without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 1 1 8 1 3 0 0 0 0
References Study Quality
42 (23096208) 3
41 (21098205) 2
38 (25204811) 4
70 (11956117) 2
71 (12773688) 2
40 (18728334) 3
ACE inhibitor renography Usually not appropriate Strong ☢☢☢ 1-10 mSv 3 3 4 0 7 0 3 0 0 0 0
References Study Quality
48 (17384038) 4
47 (17764871) 4
13 (1831342) 3
12 (12230421) 2
11 (15728620) 3
14 (14500224) 3
6 (24245566) 1
9 (11560453) M
10 (1837991) 4
15 (10816399) 2
Variant 4: Adult. Suspected renovascular hypertension. Known renal artery stenosis. Decreased renal function. eGFR less than 30 mL/min/1.73 m2. Follow-up 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 kidneys retroperitoneal Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 2 6 6
References Study Quality
51 (16301720) 2
50 (24172238) 4
46 (22595689) 2
47 (17764871) 4
48 (17384038) 4
49 (12515376) 4
44 (10742425) 3
45 (10957652) 3
43 (25539255) 1
59 (23360742) 4
4 (20864945) 4
MRA abdomen without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 3 3 4 4 0
References Study Quality
60 (26599922) 4
71 (12773688) 2
36 (21833688) 4
38 (25204811) 4
70 (11956117) 2
37 (23917027) 4
35 (21542417) 2
34 (12096862) M
33 (18372471) 1
MRA abdomen without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 4 1 0 6 4 3 0 0 0 0
References Study Quality
42 (23096208) 3
41 (21098205) 2
38 (25204811) 4
70 (11956117) 2
71 (12773688) 2
40 (18728334) 3
Arteriography kidney Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 4 3 5 2 0 0 0 0 0
References Study Quality
64 (10584800) 4
24 (2648471) 2
21 (6385671) 4
22 (3923557) 4
23 (3526406) 3
20 (7089265) 3
18 (17084261) 4
19 (21078879) 4
61 (-3188535) 4
Venography with renal vein sampling Usually not appropriate Limited Varies Varies 1 1 9 2 3 0 0 0 0 0 0
References Study Quality
74 (24155154) 3
52 (17192278) 4
73 (19233590) 3
14 (14500224) 3
ACE inhibitor renography Usually not appropriate Strong ☢☢☢ 1-10 mSv 2 2 6 3 3 1 0 0 1 0 0
References Study Quality
47 (17764871) 4
14 (14500224) 3
13 (1831342) 3
12 (12230421) 2
10 (1837991) 4
11 (15728620) 3
6 (24245566) 1
9 (11560453) M
15 (10816399) 2
CTA abdomen with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 2 6 1 3 0 0 0 0
References Study Quality
30 (23885929) 4
29 (11849401) 3
58 (24475854) 4
31 (18270376) 1
32 (17499952) 1
28 (9676442) 2
Variant 5: Adult. Known renovascular hypertension. Posttreatment evaluation of renal artery stenosis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler kidneys retroperitoneal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 1 3 4 6
References Study Quality
65 (10207465) 4
75 (35286054) 4
69 (19561264) 2
MRA abdomen without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 2 2 1 2 6 1
References Study Quality
71 (12773688) 2
70 (11956117) 2
35 (21542417) 2
36 (21833688) 4
34 (12096862) M
33 (18372471) 1
38 (25204811) 4
42 (23096208) 3
37 (23917027) 4
68 (12490511) 2
67 (12148095) 3
41 (21098205) 2
66 (30898248) 4
CTA abdomen with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 0 1 5 5 3
References Study Quality
69 (19561264) 2
68 (12490511) 2
30 (23885929) 4
28 (9676442) 2
29 (11849401) 3
67 (12148095) 3
58 (24475854) 4
31 (18270376) 1
32 (17499952) 1
63 (33170103) 4
62 (2522152) 4
Arteriography kidney Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 2 2 5 3 0 1 0 1 0
References Study Quality
65 (10207465) 4
24 (2648471) 2
21 (6385671) 4
22 (3923557) 4
23 (3526406) 3
20 (7089265) 3
18 (17084261) 4
19 (21078879) 4
Venography with renal vein sampling Usually not appropriate Limited Varies Varies 2 2 5 5 4 0 0 0 0 0 0
References Study Quality
14 (14500224) 3
52 (17192278) 4
73 (19233590) 3
74 (24155154) 3
MRA abdomen without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 1 1 6 3 3 0 0 0 0
References Study Quality
43 (25539255) 1
42 (23096208) 3
70 (11956117) 2
71 (12773688) 2
72 (12704782) 2
41 (21098205) 2
36 (21833688) 4
38 (25204811) 4
37 (23917027) 4
ACE inhibitor renography Usually not appropriate Strong ☢☢☢ 1-10 mSv 2 2 6 6 2 0 0 0 0 0 0
References Study Quality
48 (17384038) 4
47 (17764871) 4
13 (1831342) 3
12 (12230421) 2
15 (10816399) 2
16 (12411867) 4
46 (22595689) 2
17 (10658939) 3
10 (1837991) 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.