American College of Radiology
ACR Appropriateness Criteria®

Radiologic Management of Iliac Artery Occlusive Disease

Variant 1: Nonsmoker, sedentary lifestyle. No symptoms at rest but mild left lower-extremity claudication on walking, asymmetrically diminished left femoral pulse. Next steps on initial physician visit.
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 O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
Plethysmography and pulse volume recording May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
CTA pelvis with runoff Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
MRA pelvis with runoff Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Catheter directed angiography May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Risk factor analysis, lipid profile and ABIs Usually appropriate N/A N/A 9 n/a 0 0 0 0 0 0 0 0 0
No further treatment or evaluation needed Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Best medical management including supervised exercise program only Usually appropriate N/A N/A 9 n/a 0 0 0 0 0 0 0 0 0
Anticoagulation adjunctive therapy Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Antiplatelet adjunctive therapy Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Long history of mild claudication. Acute-onset left lower-extremity pain. Absent left femoral pulse on palpation, faint dorsalis pedis and posterior tibial pulses by Doppler. Next steps.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Ankle brachial index Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
US duplex Doppler lower extremity Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
Plethysmography and pulse volume recording May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
CTA pelvis with runoff Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
MRA pelvis with runoff Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Known atrial fibrillation and spine surgery 3 weeks ago. Sudden-onset right lower-extremity pain. Diminished pulses in right lower extremity. CTA demonstrates isolated filling defect in right common iliac artery.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Anticoagulation adjunctive therapy Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Antiplatelet adjunctive therapy May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Catheter directed thrombolytic therapy Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Catheter directed mechanical thrombectomy Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Surgical revascularization Usually appropriate N/A N/A 9 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Past medical history of heavy smoking. Severe claudication and no symptoms at rest. Angiogram demonstrates bilateral 90% common iliac artery stenosis (TASC A).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Anticoagulation adjunctive therapy Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Antiplatelet adjunctive therapy Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Best medical management including supervised exercise program only May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Bilateral percutaneous transluminal angioplasty only Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Bilateral stent placement Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Surgical revascularization May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Past medical history significant for diabetes mellitus, hypertension, and smoking. Increasing claudication of right lower extremity involving right buttock for last 3 months. CTA pelvis with runoff reveals short-segment occlusion of right common iliac artery (TASC B).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Best medical management including supervised exercise program only Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Primary percutaneous transluminal angioplasty alone Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Primary stenting Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Surgical revascularization May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Anticoagulation adjunctive therapy Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Antiplatelet adjunctive therapy Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Variant 6: Past medical history significant for diabetes mellitus, hypertension, and heavy smoking. Gradually increasing claudication of bilateral lower extremities for at least 2 months. CTA pelvis with runoff reveals bilateral common iliac artery occlusion without any involvement of the external or internal iliac artery (TASC C).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Best medical management including supervised exercise program only Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Primary percutaneous transluminal angioplasty alone May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Primary stenting Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Surgical revascularization Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Anticoagulation adjunctive therapy Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Antiplatelet adjunctive therapy Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Variant 7: Worsening claudication and small ischemic ulcers on digits of both feet. Angiogram demonstrates diffuse disease involving distal aorta and both iliac vessels with multiple stenoses >50%, bilateral 75% mid-superficial femoral artery stenoses and 2-vessel tibial runoff bilaterally. (TASC D)
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Anticoagulation adjunctive therapy Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Antiplatelet adjunctive therapy Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Best medical management including supervised exercise program only Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Percutaneous transluminal angioplasty (aortoiliac only) May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Catheter directed stent placement (aortoiliac only) Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Catheter directed stent placement (aortoiliac plus femoral angioplasty) Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Surgical revascularization May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.