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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Hawkins BM, Li J, Wilkins LR, et al. SCAI/ACR/APMA/SCVS/SIR/SVM/SVS/VESS position statement on competencies for endovascular specialists providing CLTI care. J Vasc Surg 2022;76:25-34. Review/Other-Dx N/A To develop a position statement outlining competencies for endovascular specialists providing chronic limb-threatening ischemia (CLTI) care. No abstract available 4
2. Menke J, Luthje L, Kastrup A, Larsen J. Thromboembolism in atrial fibrillation. [Review] [72 refs]. Am J Cardiol. 105(4):502-10, 2010 Feb 15. Review/Other-Tx 10 evidence-based practice guideline documents and 61 further sources To present thromboembolic disease as a single entity, ranging from stroke through mesenteric ischemia to acute limb ischemia. In atrial fibrillation, the average annual stroke risk is increased by 2.3% (lethality 30%). The annual incidence of acute mesenteric ischemia is 0.14% (lethality 70%), and that of acute limb ischemia is 0.4% (lethality 16%). In total, approximately 80% of embolism-related deaths are from stroke and 20% from other systemic thromboembolism. The ischemic symptoms generally have an acute onset but may mimic other diseases, particularly in mesenteric ischemia. Early diagnosis and treatment can limit or even prevent tissue infarction. Guideline-recommended therapy with aspirin or warfarin reduces the thromboembolic risk. Suitable patients may optimize their warfarin therapy by self-monitoring of the international normalized ratio (INR). New oral and parenteral anticoagulants with more stable pharmacokinetics are being developed. 4
3. American College of Radiology. ACR Appropriateness Criteria®: Workup of Noncerebral Systemic Arterial Embolic Source. Available at: https://acsearch.acr.org/docs/3158182/Narrative/. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. No abstract available. 4
4. Gale SS, Scissons RP, Salles-Cunha SX, et al. Lower extremity arterial evaluation: are segmental arterial blood pressures worthwhile? J Vasc Surg. 1998; 27(5):831-838; discussion 838-839. Experimental-Dx 81 patients Comparative study to determine whether segmental arterial blood pressures are useful for lower extremity arterial evaluation. Compared with arteriography, the accuracy of waveform analysis was 83% for severe disease at and proximal to the CFA, 79% for SFA disease, 64% for POP disease, and 73% for TIB disease. Adding ABI improved the accuracy significantly (p < 0.01) to 88% (CFA), 86% (SFA), 70% (POP), and 85% (TIB). Accuracy was inferior when SEGP data replaced ABI: 86% (CFA), 85% (SFA), 70% (POP), and 80% (TIB). 2
5. Weinreb JC, Rodby RA, Yee J, et al. Use of Intravenous Gadolinium-based Contrast Media in Patients with Kidney Disease: Consensus Statements from the American College of Radiology and the National Kidney Foundation. Radiology. 298(1):28-35, 2021 01. Review/Other-Dx N/A To improve and standardize the care of patients with kidney disease who have indication(s) to receive ACR designated group II or group III intravenous gadolinium-based contrast media (GBCM). No results in abstract. 4
6. Gulani V, Calamante F, Shellock FG, Kanal E, Reeder SB, International Society for Magnetic Resonance in M. Gadolinium deposition in the brain: summary of evidence and recommendations. Lancet Neurol 2017;16:564-70. Review/Other-Dx N/A To present recommendations for the clinical and research use of gadolinium-based contrast agents. No results stated in summary. 4
7. Rogers S, Carreira J, Phair A, Olech C, Ghosh J, McCollum C. Comparison Between Below Knee Contrast Enhanced Tomographic 3D Ultrasound and CT, MR or Catheter Angiography for Peripheral Artery Imaging. Eur J Vasc Endovasc Surg. 61(3):440-446, 2021 03. Observational-Dx 161 patients To calculate inter- and intra-observer agreement of CEtUS , and compare with below knee angiography. There were 175 comparative patient images split into two groups: 81 had calf imaging and 94 had pedal imaging representing 405 and 198 imaged arteries, respectively. Weighted quadratic kappa/ICC values for intra- and inter-observer agreement were excellent (?/ICC = 0.83 to 0.95) and had narrow confidence intervals in both groups. When comparing angiography and CEtUS, weighted quadratic ?/ICC agreement was moderate with acceptable confidence intervals in both groups (Calf ?/ICC = 0.54; Pedal ?/ICC = 0.53). 2
8. Mougin J, Louis N, Maupas E, Goueffic Y, Fabre D, Haulon S. Fusion imaging guidance for endovascular recanalization of peripheral occlusive disease. Journal of Vascular Surgery. 75(2):610-617, 2022 02.J Vasc Surg. 75(2):610-617, 2022 02. Observational-Dx 179 patients To evaluate the radiation exposure and technical success benefits of fusion imaging guidance in a large cohort of patients treated endovascularly for complex POD. During the study period, 179 patients were treated for iliac (n = 56) or femoropopliteal (n = 123) symptomatic arterial occlusions. Technical success was reported in 171 of 179 procedures (95.5%). The use of a re-entry catheter was required to achieve technical success in 11 patients (6.1%). Mean DAP and CAK were 12.70 Gy·cm2 and 135 mGy, respectively, with a mean fluoroscopy time of 15.26 minutes. DAP and CAK were significantly higher in the iliac group when compared with the femoropopliteal group, although fluoroscopy time was not significantly different. DAP was lower than levels reported in the literature. 4
9. Yoshida T, Nguyen KL, Shahrouki P, Quinones-Baldrich WJ, Lawrence PF, Finn JP. Intermodality feature fusion combining unenhanced computed tomography and ferumoxytol-enhanced magnetic resonance angiography for patient-specific vascular mapping in renal impairment. J Vasc Surg. 71(5):1674-1684, 2020 05. Observational-Dx 15 consecutive patients underwent FE-MRA and unenhanced CT scanning To establish the feasibility of fusing complementary, high-contrast features from unenhanced computed tomography (CT) and ferumoxytol-enhanced magnetic resonance angiography (FE-MRA) for preprocedural vascular mapping in patients with renal impairment. Thirteen patients (aged 76 ± 12 years; seven female) with aortic valve stenosis and chronic kidney disease and two patients with thoracoabdominal vascular aneurysms and chronic kidney disease underwent FE-MRA for preprocedural vascular assessment, and unenhanced CT examinations were available in all patients. No ferumoxytol-related adverse events occurred. There were 247 matched POIs evaluated on the source FE-MRA and fused images. In patients with implantable medical devices, the mean offsets in spatial position were 0.31 ± 0.51 mm (? = 0.99; Cb = 1; 95% confidence interval [CI], 0.99-0.99) for ?x, 0.27 ± 0.69 mm (? = 0.99; Cb = 0.99; 95% CI, 0.99-0.99) for ?y, and 0.20 ± 0.59 mm (? = 1; Cb = 1; 95% CI, 0.99-1.00) for ?z. Interobserver agreement was excellent (intraclass correlation coefficient, >0.99). The mean difference in offset between readers was 1.5 mm. 3
10. American College of Radiology. ACR–NASCI–SIR–SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA).  Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=164+&releaseId=2. Review/Other-Dx N/A Guidance document to promote the safe and effective use of diagnostic and therapeutic radiology by describing specific training, skills and techniques. No abstract available. 4
11. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017;135:e686-e725. Review/Other-Dx N/A To provide a contemporary guideline for diagnosis and management of patients with lower extremity Peripheral Artery Disease (PAD). No results available 4
12. Albrecht T, Foert E, Holtkamp R, et al. 16-MDCT angiography of aortoiliac and lower extremity arteries: comparison with digital subtraction angiography. AJR Am J Roentgenol. 2007; 189(3):702-711. Observational-Dx 50 patients; 2 blinded observers Prospective, blinded study to compare CTA performed on a 16-MDCT scanner and DSA in patients with PAD. No significant differences in diagnostic quality were observed between CTA and DSA above the ankle; both CTA observers noted significantly better visualization of pedal arteries (70 and 72 segments, respectively) than on DSA (57 segments). Of 958 stenoocclusive lesions on DSA, CTA observers 1 and 2 detected 933 and 929 lesions, respectively. Sensitivity and specificity for the detection of hemodynamically relevant (>50%) lesions was 93.3% and 96.5% for observer 1 and 90.1% and 95.6% for observer 2. Collaterals were seen at 150 arterial levels on DSA compared with 97 and 92 levels on CTA (P<0.05, both observers). Patient management decisions based on CTA were equivalent to those based on DSA in 49 of the 50 patients. 1
13. Berg F, Bangard C, Bovenschulte H, et al. Hybrid contrast-enhanced MR angiography of pelvic and lower extremity vasculature at 3.0 T: initial experience. European Journal of Radiology. 70(1):170-6, 2009 Apr.Eur J Radiol. 70(1):170-6, 2009 Apr. Observational-Dx 21 consecutive patients; 2 independent reviewers Prospective, blinded study to evaluate if 3D CE-MRA of the pelvis and lower extremities at 3.0T using a hybrid technique and randomly segmented central k-space ordering is feasible to achieve high spatial resolution images without venous contamination of the aortoiliac, femoropopliteal and calf station. 490 and 488 of 495 arterial segments were visualized with diagnostic image quality by observer 1 and observer 2, respectively. Image quality was excellent in 470 and 457 arterial segments, respectively. Relevant arterial stenoses (50%-99%) were detected in 43 and 47 segments by observer 1 and observer 2, 66 and 65 arterial segments, respectively, were interpreted as occluded. The hybrid MRA protocol at 3.0T offers high diagnostic quality for the whole peripheral arterial tree without venous contamination at high spatial resolution. 1
14. Collins R, Burch J, Cranny G, et al. Duplex ultrasonography, magnetic resonance angiography, and computed tomography angiography for diagnosis and assessment of symptomatic, lower limb peripheral arterial disease: systematic review. BMJ. 2007; 334(7606):1257. Review/Other-Dx 107 studies Systematic review to determine the diagnostic accuracy of duplex US, MRA, and CTA, alone or in combination, for the assessment of lower limb PAD; to evaluate the impact of these assessment methods on management of patients and outcomes; and to evaluate the evidence regarding attitudes of patients to these technologies and summarize available data on adverse events. For the detection of stenosis =50% in a lower limb vessel, CE-MRA had the highest diagnostic accuracy with a median sensitivity of 95% (range 92%-99.5%) and median specificity of 97% (64%-99%). The results were 91% (89%-99%) and 91% (83%-97%) for CTA and 88% (80%-98%) and 96% (89%-99%) for duplex US. CE-MRA might be a viable alternative to contrast angiography where available. 4
15. Heijenbrok-Kal MH, Kock MC, Hunink MG. Lower extremity arterial disease: multidetector CT angiography meta-analysis. Radiology. 2007;245(2):433-439. Meta-analysis 436 patients from 12 studies of 9,541 arterial segments To obtain the best available estimates of the diagnostic performance of MDCTA compared with that of DSA in the assessment of symptomatic lower extremity arterial disease and to identify the most important sources of variation in diagnostic performance between studies. Of the 70 studies initially identified, 12 were included in which multidetector CT angiography was used to evaluate 9541 arterial segments in 436 patients. The pooled sensitivity and specificity for detecting a stenosis of at least 50% per segment were 92% (95% confidence interval: 89%, 95%) and 93% (95% confidence interval: 91%, 95%), respectively. Three studies provided data about the diagnostic performance of multidetector CT angiography in subdivisions of the arterial tract. The diagnostic performance of multidetector CT angiography in the infrapopliteal tract was lower than but not significantly different from that in the aortoiliac (P > .11) and femoropopliteal (P > .40) tracts. Regression analysis showed that diagnostic performance was not significantly influenced by differences in study characteristics. M
16. Iglesias J, Pena C. Computed tomography angiography and magnetic resonance angiography imaging in critical limb ischemia: an overview. [Review]. Tech Vasc Interv Radiol. 17(3):147-54, 2014 Sep. Review/Other-Dx N/A To describe the rise in noninvasive vascular imaging with CTA and MRA in patients with critical limb ischemia (CLI). No results in abstract 4
17. Kreitner KF, Kunz RP, Herber S, Martenstein S, Dorweiler B, Dueber C. MR angiography of the pedal arteries with gadobenate dimeglumine, a contrast agent with increased relaxivity, and comparison with selective intraarterial DSA. J Magn Reson Imaging. 2008; 27(1):78-85. Observational-Dx 22 patients; 2 observers Prospective study to compare Gd-BOPTA-enhanced MRA of the pedal vasculature with selective DSA in patients with PAOD. No differences between contrast enhanced-MRA and DSA in detecting patent vessel segments with a high degree of agreement (kappa = 0.89), and interobserver agreement for MRA was substantial (kappa = 0.89). Good agreement between DSA and CE-MRA for assessment of relevant vessel stenosis (kappa = 0.61); interobserver agreement for MRA was good (kappa = 0.65). CE-MRA detected significantly more patent metatarsal arteries than did DSA (P<0.001). Gd-BOPTA-enhanced MRA is comparable to DSA for assessment of the pedal vasculature, and is able to delineate significantly more patent vessels without segmental occlusions and more metatarsal arteries than selective DSA. 2
18. Met R, Bipat S, Legemate DA, Reekers JA, Koelemay MJ. Diagnostic performance of computed tomography angiography in peripheral arterial disease: a systematic review and meta-analysis. JAMA. 2009; 301(4):415-424. Meta-analysis 20 studies; 957 patients and 2 reviewers Systematic review and meta-analysis to determine the accuracy of CTA compared with intra-arterial DSA in differentiating extent of disease in patients with PAD. Sensitivity of CTA for detecting more than 50% stenosis or occlusion was 95% (95% CI, 92%-97%) and specificity was 96% (95% CI, 93%-97%). CTA correctly identified occlusions in 94% of segments, the presence of more than 50% stenosis in 87% of segments, and absence of significant stenosis in 96% of segments. Overstaging occurred in 8% of segments and understaging in 15%. CTA is an accurate modality to assess presence and extent of PAD in patients with intermittent claudication; however, methodological weaknesses of examined studies prevent definitive conclusions from these data. M
19. Gupta R, Hennebry TA. Percutaneous isolated pharmaco-mechanical thrombolysis-thrombectomy system for the management of acute arterial limb ischemia: 30-day results from a single-center experience. Catheter Cardiovasc Interv. 80(4):636-43, 2012 Oct 01. Observational-Tx 24 patients To study the efficacy of isolated pharmaco-mechanical thrombolysis-thrombectomy (IPMT) by Trellis device (Covidien, Mansfield, MA) in managing acute limb ischemic (ALI). 24 patients constituted 32 arteries; 18 (56.25%) were suprainguinal including 3 grafts (9.4%) and 14 (43.75%) were infrainguinal native arteries. Substantial or complete response was seen in >90% vessels with 87.5% patients revealing TIMI three flow while none demonstrated TIMI 2 or 3 pretreatment. Only three patients required adjunctive post-IPMT thrombolysis. In-hospital and 30-day all cause mortality was 4.16%. One patient died in-hospital and no patient underwent amputation. 3
20. Kuhn JP, Hoene A, Miertsch M, et al. Intraarterial recombinant tissue plasminogen activator thrombolysis of acute and semiacute lower limb arterial occlusion: quality assurance, complication management, and 12-month follow-up reinterventions. AJR Am J Roentgenol 2011;196:1189-93. Observational-Tx 129 patients To assess the efficacy of intraarterial thrombolysis in acute and semiacute occlusions of the lower limb Recanalization was accomplished by rt-PA thrombolysis in 73.6% of all cases. There was no difference in primary therapeutic success between native arteries and bypass grafts (p = 0.601). Thrombolysis was more effective in acute peripheral occlusions, and hospital stays were shorter than those for patients with semiacute occlusion (p = 0.001). The morbidity rate was 31% (minor complications, 20.2%; major complications, 10.9%), and the mortality rate was 2.3%. Within 12 months, radiologic and surgical interventions were necessary for 27 patients. The limb salvage rate after primarily successful recanalization was 89.5%. 2
21. Ofer A, Nitecki SS, Linn S, et al. Multidetector CT angiography of peripheral vascular disease: a prospective comparison with intraarterial digital subtraction angiography. AJR. 2003;180(3):719-724. Observational-Dx 18 patients To determine the accuracy of CTA using a multidetector scanner in the evaluation of patients with PVD when compared with DSA. Authors found agreement for the degree of stenosis in 77.7% of the arteries and discrepancy for 22.3% of the arteries when all categories were considered. Grouping the six categories according to the threshold for treatment (categories 1 and 2 as one group and categories 3, 4, and 5 as the second group) resulted in an agreement of 91.95%. Compared with DSA, CTA yielded a sensitivity of 90.9% and a specificity of 92.4%. MDCTA is an accurate, noninvasive technique for the imaging of PVD. 2
22. Catalano C, Fraioli F, Laghi A, et al. Infrarenal aortic and lower-extremity arterial disease: diagnostic performance of multi-detector row CT angiography. Radiology. 2004;231(2):555-563. Observational-Dx 50 patients To compare MDCTA with DSA in evaluation of the infrarenal aorta and lower-extremity arterial system. Substantial to almost perfect interobserver agreement was achieved in all cases. At DSA, 349 diseased segments were found among the 1,137 segments evaluated. Sensitivity, specificity, and accuracy, based on a consensus reading of MDCTA, were 96%, 93%, and 94%, respectively. A statistically significant difference (P<.05) between DSA and MDCTA was present only in arteries graded 1 or 2. Interobserver agreement was almost perfect among the three readers for treatment recommendations based on findings at CTA and DSA. 2
23. Fine JJ, Hall PA, Richardson JH, Butterfield LO. 64-slice peripheral computed tomography angiography: a clinical accuracy evaluation. J Am Coll Cardiol. 2006;47(7):1495-1496. Observational-Dx 212 patients To determine the accuracy of 64-slice peripheral CTA to determine if improved performance metrics offer a lower risk, more efficient, non-invasive mode of peripheral angiography, which in selected clinical situations may replace the need for catheter angiography. Data from renal, carotid and PAD of 212 patients, 107 had PAD. Vessel to vessel analysis went from sensitivity 86%, specificity 95%, PPV 89%, and NPV 80% in iliac arteries to the popliteal arteries where sensitivity 90%, specificity 96%, PPV 82%, and NPV 98%. 2
24. Addis KA, Hopper KD, Iyriboz TA, et al. CT angiography: in vitro comparison of five reconstruction methods. AJR Am J Roentgenol 2001;177:1171-6. Observational-Dx A 19-vessel phantom containing various grades of concentric stenoses (0-100%) and three lengths (5, 7.5, and 10 mm) of stenoses. To address disagreement in the literature as to the accuracy of five reconstruction methods using a phantom containing stenoses of known diameters. For vessels greater than 4 mm in diameter, axial, MIP, MPR, shaded-surface display, and volume-rendering CT angiography techniques all had a measurement error of less than 2.5%. However, axial, MIP, MPR, and shaded-surface display techniques were less accurate in estimating smaller (<or=4 mm) diameters. Volume rendering tended to be more accurate in the measurement of vessels with a 2.0- to 4.0-mm diameter and was statistically more accurate for diameters of 0.5-1.0 mm (p < 0.001). 1
25. Ouwendijk R, de Vries M, Stijnen T, et al. Multicenter randomized controlled trial of the costs and effects of noninvasive diagnostic imaging in patients with peripheral arterial disease: the DIPAD trial. AJR. 2008;190(5):1349-1357. Experimental-Tx 514 patients randomized to MRA (n=258), DSA (n=177), CTA (n=79) Multicenter randomized trial to evaluate DSA vs CTA vs MRA for accuracy, impact on treatment planning, cost, and quality of life. With adjustment for potentially predictive baseline variables, the learning curve, and hospital setting, a significantly higher confidence and less additional imaging were found for MRA and CTA compared with duplex US. No statistically significant differences were found in improvement in functional patient outcomes and quality of life among the groups. The total costs were significantly higher for MRA and duplex US than for CTA. The results suggest that both CTA and MRA are clinically more useful than duplex US and that CTA leads to cost savings compared with both MRA and duplex US in the initial imaging evaluation of PAD. 1
26. Machida H, Tanaka I, Fukui R, et al. Dual-Energy Spectral CT: Various Clinical Vascular Applications. Radiographics 2016;36:1215-32. Review/Other-Dx N/A To describe basic principles and various techniques of SSDE CT with fast kilovolt-peak switching and offer various vascular applications of SSDE CT with fast kilovolt-peak switching with illustrative clinical data and images to overcome the limitations of SE CT. SSDE CT with fast kilovolt-peak switching allows projection-based reconstruction of DE CT images, which leads to substantial reduction of beam hardening, accurate reconstruction of monochromatic images obtained at 40–140 keV and MDIs that use various basis materials, and detailed analysis of material content by using the spectral Hounsfield unit curve and effective Z histogram. 4
27. Meyer BC, Werncke T, Hopfenmuller W, Raatschen HJ, Wolf KJ, Albrecht T. Dual energy CT of peripheral arteries: effect of automatic bone and plaque removal on image quality and grading of stenoses. Eur J Radiol. 2008; 68(3):414-422. Observational-Dx 50 consecutive patients To evaluate the effect of automatic bone and plaque removal on image quality and grading of steno-occlusive lesions in patients undergoing dual energy CTA of lower extremity. Residual bone fragments (ribs: 46%, patella: 25%, spine: 4%, pelvis: 2%, tibia 2% of patients) were only observed with ABS. The time needed to manually remove these residual bones was 2.1+/-1.1 min and was significantly lower than the duration of manual bone removal (6.8+/-2.0 min, p<0.0001, paired t-test). A total of 1159 arteries were analyzed. Compromising vessel erosions were observed less frequently in the ABS-B dataset (10.6%) than in the MBS dataset (15.2%, p<0.001, wilcoxon's signed rank test). A total of 817 steno-occlusive lesions were assessed. While the agreement of grading of steno-occlusive lesions was good at the levels of the aorta and the pelvic arteries (kappa=0.70 in both, Cohen's kappa statistics), it was moderate at the level of the thigh arteries (kappa=0.57) and poor at the level of the calf (kappa=0.16) 2
28. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease: Executive summary: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Anesth Analg 2010;111:279-315. Review/Other-Dx N/A To assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches for diagnosis, management, and prevention of specific diseases or conditions. Clinicians should consider the quality and availability of expertise in the area where care is provided. No results stated in abstract. 4
29. Kumamaru KK, Hoppel BE, Mather RT, Rybicki FJ. CT angiography: current technology and clinical use. Radiol Clin North Am. 2010;48(2):213-235, vii. Review/Other-Dx N/A To describe CT hardware and associated software for angiography. Recent advances in technology have moved CT to the front line for many vascular diseases, dramatically changing clinical evaluation pathways. Understanding CT technology is critical for optimizing protocols. 4
30. Cambria RP, Kaufman JA, L'Italien GJ, et al. Magnetic resonance angiography in the management of lower extremity arterial occlusive disease: a prospective study. J Vasc Surg. 1997;25(2):380-389. Observational-Dx 79 patients A prospective study to clarify the clinical utility of MRA in the treatment of patients with lower extremity arterial occlusive disease. Precise agreement (%) and the percent of major discrepancies (segment classified as normal/mild stenosis on one study and severe stenosis/occlusion on the other) between MRA and ANGIO for respective arterial segments was as follows: common and external iliacs (n = 256) 77/3.5; superficial femoral and above-knee popliteal (n = 255) 73/6.7; below-knee popliteal (n = 131) 84/3.8; infrapopliteal runoff vessels (n = 864) 74/12.4; pedal vessels (n = 111) 69/19.8 Kappa values indicated moderate agreement (between MRA and angiography) beyond chance for all arterial segments. Treatment plans formulated by the attending surgeon, the MRA surgeon, and the angiography surgeon agreed in more than 85% of cases. 4
31. Jens S, Koelemay MJ, Reekers JA, Bipat S. Diagnostic performance of computed tomography angiography and contrast-enhanced magnetic resonance angiography in patients with critical limb ischaemia and intermittent claudication: systematic review and meta-analysis. Eur Radiol 2013;23:3104-14. Meta-analysis 12 CTA, 30 CE-MRA studies;, 673 and 1,404 participants, respectively To evaluate the diagnostic performance of computed tomography angiography (CTA) and contrast-enhanced magnetic resonance angiography (CE-MRA) in detecting haemodynamically significant arterial stenosis or occlusion in patients with critical limb ischaemia (CLI) or intermittent claudication (IC). Out of 5,693 articles, 12 CTA and 30 CE-MRA studies were included, respectively evaluating 673 and 1,404 participants. Summary estimates of sensitivity and specificity were respectively 96 % (95 % CI, 93-98 %) and 95 % (95 % CI, 92-97 %) for CTA, and 93 % (95 % CI, 91-95 %) and 94 % (95 % CI, 93-96 %) for CE-MRA. Regression analysis showed that the prevalence of CLI in individual studies was not an independent predictor of sensitivity and specificity for either technique. Methodological quality of studies was moderate to good. M
32. Loewe C, Schoder M, Rand T, et al. Peripheral vascular occlusive disease: evaluation with contrast-enhanced moving-bed MR angiography versus digital subtraction angiography in 106 patients. AJR. 2002;179(4):1013-1021. Observational-Dx 106 patients A retrospective analysis to compare contrast-enhanced moving-bed MRA and DSA in the evaluation of PAOD. 2,378 vessel segments were evaluated. In 2,156 segments, MRA and DSA were concordant for stenosis classification; in 188 segments the two modalities differed in one category, and in 24 segments they differed in two categories. MRA sensitivity 96.7%; and specificity 95.8%, for differentiating nonsignificant from hemodynamically significant stenosis (kappa = 0.91). 3
33. Menke J, Larsen J. Meta-analysis: Accuracy of contrast-enhanced magnetic resonance angiography for assessing steno-occlusions in peripheral arterial disease. Ann Intern Med. 2010; 153(5):325-334. Meta-analysis 32 studies; 1,022 patients To summarize evidence of prospective studies about how well MRA identifies or excludes arterial steno-occlusions (50% to 100% lumen reduction) in adults with PAD symptoms. Overall, the pooled sensitivity of MRA was 94.7% (95% CI, 92.1% to 96.4%) and the specificity was 95.6% (CI, 94.0% to 96.8%) for diagnosing segmental steno-occlusions. The pooled positive and negative likelihood ratios were 21.56 (CI, 15.70 to 29.69) and 0.056 (CI, 0.037 to 0.083), respectively. MRA correctly classified 95.3%, overstaged 3.1%, and understaged 1.6% of arterial segments. Similar to most studies of CTA in PAD, the primary studies reported the diagnostic accuracy of MRA on a per-segment basis, not a per-patient basis. This meta-analysis of 32 prospective studies further increases the evidence that CE-MRA has high accuracy for identifying or excluding clinically relevant arterial steno-occlusions in adults with PAD symptoms. M
34. Zhu YQ, Zhao JG, Wang J, et al. Patency of runoff detected by MR angiography at 3.0 T with cuff-compression: a predictor of successful endovascular recanalization below the knee. Eur Radiol. 24(11):2857-65, 2014 Nov. Observational-Dx 63 patients with diabetes (98 limbs) To assess the reliability of detecting distal runoff vessels using contrast-enhanced MR angiography (CE-MRA) that were occult on digital subtraction angiography (DSA) for predicting the outcome of endovascular recanalization (ER). Successful ER was achieved in 85.7 % of limbs, and runoff score was significantly lower than in failure limbs (5.1 ± 1.1 vs. 6.2 ± 1.3; P < 0.05). During follow-up, sustained ankle-brachial index (ABI) improvement was found in 76.6 % claudication patients, and walking distance improvement in 86.5 %; pain was relieved in 70.6 % of critical limb ischemia (CLI) limbs, ulceration healed in 81.3 %, and limb-salvage rate was 100 %. Restenosis/occlusion rate was higher for patients with CLI at 12 months (48.8 % vs. 96.3 % in claudication; P < 0.01). Runoff score was associated with a significantly higher likelihood of ER success (odds ratio = 4.096, 95 % confidence interval: 2.056-8.158; P < 0.001). 3
35. Hodnett PA, Ward EV, Davarpanah AH, et al. Peripheral arterial disease in a symptomatic diabetic population: prospective comparison of rapid unenhanced MR angiography (MRA) with contrast-enhanced MRA. AJR Am J Roentgenol 2011;197:1466-73. Observational-Dx 25 diabetic patients To evaluate the accuracy of the rapid technique of quiescent-interval single-shot (QISS) unenhanced MR angiography (MRA) compared with CEMRA for the diagnosis in diabetic patients referred with symptomatic chronic PAD. For this study, 775 segments were analyzed. On a per-segment basis, the mean values of the diagnostic accuracy of unenhanced MRA compared with reference CEMRA for two reviewers, reviewers 1 and 2, were as follows: sensitivity, 87.4% and 92.1%; specificity, 96.8% and 96.0%; positive predictive value, 90.8% and 94.0%; and negative predictive value, 95.5% and 94.6%. Substantial agreement was found when overall DSA results were compared with QISS unenhanced MRA (kappa = 0.68) and CEMRA (kappa = 0.63) in the subgroup of patients who also underwent DSA. There was almost perfect agreement between the two readers for stenosis scores, with Cohen's kappa values being greater than 0.80 for both MRA techniques. 2
36. Gitsioudis G, Fortner P, Stuber M, et al. Off-resonance magnetic resonance angiography improves visualization of in-stent lumen in peripheral nitinol stents compared to conventional T1-weighted acquisitions: an in vitro comparison study. Int J Cardiovasc Imaging 2016;32:1645-55. Observational-Dx 14 different nitinol vascular stents in vitro To compare the value of inversion recovery with on-resonant water suppression (IRON) to conventional T1-weighted (T1w) MRA and computed tomography angiography (CTA) for visualization of peripheral nitinol stents. X-ray angiography served as gold standard for diameter assessment. Gd-enhanced IRON-MRA exhibited highest in-stent SNR and CNR values compared to conventional T1w MRA (IRON (Gd/USPIO): SNR = 30 ± 3/21 ± 2, CNR = 23 ± 2/14 ± 1; T1w: SNR = 16 ± 1/14 ± 2, CNR = 12 ± 1/10 ± 1, all p < 0.05). Furthermore, IRON-MRA achieved highest relative in-stent signal both using Gd and USPIO (IRON (Gd/USPIO): 121 ± 8 %/103 ± 6 %; T1w: 73 ± 2 %/66 ± 4 %; CTA: 84 ± 6 %, all p < 0.05). However, artificial lumen narrowing appeared similar in all imaging protocols (IRON (Gd/USPIO): 21 ± 3 %/21 ± 2 %; T1w: 16 ± 4 %/17 ± 3 %; CTA: 19 ± 2 %, all p = NS). 1
37. Hood MN, Ho VB, Foo TK, Marcos HB, Hess SL, Choyke PL. High-resolution gadolinium-enhanced 3D MRA of the infrapopliteal arteries. Lessons for improving bolus-chase peripheral MRA. Magn Reson Imaging 2002;20:543-9. Observational-Dx 18 healthy adults To identify imaging factors that can improve arterial visualization in the lower leg using bolus chase peripheral MRA. The calf was imaged using conventional three-station bolus chase three-dimensional (3D) MRA, two dimensional (2D) time-of-flight (TOF) MRA and single-station Gadolinium (Gd)-enhanced 3D MRA. Observer comparisons of vessel visualization, signal to noise ratios (SNR), contrast to noise ratios (CNR) and spatial resolution comparisons were performed. Arterial SNR and CNR were similar for all three techniques. However, arterial visualization was dramatically improved on dedicated, arterial-phase Gd-enhanced 3D MRA compared with the multi-station bolus chase MRA and 2D TOF MRA. This improvement was related to optimization of Gd-enhanced 3D MRA parameters (fast injection rate of 2 mL/sec, high spatial resolution imaging, the use of dedicated phased array coils, elliptical centric k-space sampling and accurate arterial phase timing for image acquisition). The visualization of the infrapopliteal arteries can be substantially improved in bolus chase peripheral MRA if voxel size, contrast delivery, and central k-space data acquisition for arterial enhancement are optimized. 3
38. Low G, Mizzi A, Ong K, Lau PF, McKinstery J. Technical inadequacies of peripheral contrast-enhanced magnetic resonance angiography: incidence, causes and management strategies. Clin Radiol 2006;61:937-45. Review/Other-Dx 249 peripheral CE-MRA examinations To assess the incidence, causes and effects of technical inadequacies in peripheral contrast-enhanced magnetic resonance angiography (CE-MRA) and to discuss relevant management strategies. Of the 249 examinations, 215 (86.3%) were technically satisfactory while 34 (13.7%) were a combination of technical inadequacies [29 cases (11.6%)] and examination failures [five cases (2%)]. The causes of technical inadequacies were: (1) venous contamination (13 cases; 5.2%), (2) motion-induced subtraction artefact (eight cases; 3.2%), (3) stent-induced artefact (four cases; 1.6%), (4) inadequate scan coverage (two cases; 0.8%), and (5) contrast timing error (two cases; 0.8%). The causes of failed examinations were: (1) inability to tolerate lying in the scanner (three cases; 1.2%) and (2) inability to fit into the scanner (two cases; 0.8%). Fifteen (44.1%) of the 34 cases underwent further imaging by CA, and in eight of these there was significant arterial disease that was missed on the MRA. 4
39. Menke J. Improving the image quality of contrast-enhanced MR angiography by automated image registration: a prospective study in peripheral arterial disease of the lower extremities. Eur J Radiol. 2010; 75(3):e1-8. Observational-Dx 404 leg MRAs To prospectively validate the prior findings in patients with peripheral arterial disease of the lower extremities. The prior retrospective study has shown that image registration can improve the MRA image quality especially in the lower legs. All studied image quality parameters showed similar trends. Generally, registration improved the leg MRA quality significantly (P<0.05). The 12% of lower legs with a body shift of 1 mm or more showed the highest gain in image quality when using linear registration instead of no registration, with an average vessel detection probability gain of 20%-49%. Warp registration improved the image quality slightly further. Automated image registration can improve the MRA image quality especially in the lower legs, which is comparable to the effect of pixel shift in DSA. 2
40. Edelman RR, Koktzoglou I. Noncontrast MR angiography: An update. J Magn Reson Imaging 2019;49:355-73. Review/Other-Dx N/A To consider the motivations for using noncontrast MRA, potential contrast mechanisms, imaging techniques, advantages, and drawbacks with respect to CTA and CEMRA, and the level of evidence for using the various MRA techniques. No results stated in abstract. 4
41. Hanrahan CJ, Lindley MD, Mueller M, et al. Diagnostic Accuracy of Noncontrast MR Angiography Protocols at 3T for the Detection and Characterization of Lower Extremity Peripheral Arterial Disease. J Vasc Interv Radiol. 29(11):1585-1594.e2, 2018 11. Observational-Dx 20 patients with PAD and intermittent claudication To compare the diagnostic accuracy of established non-gadolinium (Gd)-enhanced magnetic resonance (MR) angiography protocols with Gd-enhanced MR angiography at 3T for evaluating lower extremity peripheral arterial disease (PAD). Of 573 vascular segments imaged, 16.9% (97/573, 19/20 patients) demonstrated hemodynamically significant abnormalities. Reader confidence was sufficient for diagnosis in 98% of segments with Gd MR angiography, 93% with QIR/ECG-FSE, and 95% with QISS. Overall reader confidence was higher with QISS than QIR/ECG-FSE within all 3 stations combined (P < .05). With lowconfidence segments treated as misdiagnosis, sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and k agreement for all 3 stations combined were 81.4/87.2/57.0/95.8/86.2%/0.578 for QIR/ECG-FSE and 75.0/90.6/61.6/94.7/88.0%/ 0.597 for QISS. Using TASC II criteria to assess severity, QISS and QIR/ECG-FSE had no statistical difference in agreement with Gd MR angiography 1
42. Hodnett PA, Koktzoglou I, Davarpanah AH, et al. Evaluation of Peripheral Arterial Disease with Nonenhanced Quiescent-Interval Single-Shot MR Angiography. Radiology. 2011;260(1):282-293. Observational-Dx 53 patients To assess the diagnostic performance of QISS MRA, a nonenhanced two-dimensional electrocardiographically gated single-shot balanced steady-state free precession examination for the evaluation of symptomatic chronic lower limb ischemia. The sensitivity and specificity of QISS MRA for the determination of nonsignificant (<50%) vs significant (50%-100%) stenosis were compared with the sensitivity and specificity of the reference standard. The diagnostic performance of nonenhanced MRA was found to be nearly equivalent to the diagnostic performances of CE-MRA and DSA. Non-generalized estimating equation segment-based analysis revealed that for the two reviewers, nonenhanced MRA had sensitivities of 89.7% (436/486 segments) and 87.0% (423/486 segments) and specificities of 96.5% (994/1,030 segments) and 94.6% (973/1,028 segments). QISS nonenhanced MRA offers an alternative to currently used imaging tests for symptomatic chronic lower limb ischemia, for which the administration of iodinated or gadolinium-based contrast agents is contraindicated.. 2
43. Krnic A, Vucic N, Sucic Z. Duplex scanning compared with intra-arterial angiography in diagnosing peripheral arterial disease: three analytical approaches. Vasa. 2006; 35(2):86-91. Observational-Dx 30 patients 60 lower limbs To assess the reliability of duplex scanning, as compared with DSA, in diagnosing PAD of the lower limbs. Different duplex reliabilities in detecting significant arterial disease across lower limbs segments. Kappa values (0.35-0.64) shows duplex insufficient accuracy in grading the severity of stenosis. Weighted kappa values (0.45-0.72) confirmed duplex ability to approximate the grade of stenosis. 2
44. Leiner T, Kessels AG, Nelemans PJ, et al. Peripheral arterial disease: comparison of color duplex US and contrast-enhanced MR angiography for diagnosis. Radiology. 2005;235(2):699-708. Observational-Dx 295 patients To prospectively compare the diagnostic accuracies of color duplex US and contrast material-enhanced MRA and to assess interobserver agreement regarding CE-MRA findings in patients suspected of having PAD. 249 patients had at least one hemodynamically significant stenotic lesion at contrast-enhanced MR angiography, duplex US, or both examinations. One hundred fifty-two patients underwent intraarterial DSA. The quadratic weighted kappa for agreement regarding the presence of 50% or greater stenosis at contrast-enhanced MR angiography was 0.89 (95% confidence interval [CI]: 0.87, 0.91). Sensitivity of duplex US was 76% (95% CI: 69%, 82%); specificity, 93% (95% CI: 91%, 95%); and accuracy, 89%. Sensitivity and specificity of contrast-enhanced MR angiography were 84% (95% CI: 78%, 89%) and 97% (95% CI: 95%, 98%), respectively; accuracy was 94%. Sensitivity (P = .002) and specificity (P = .03) of contrast-enhanced MR angiography were significantly higher. 1
45. Kurata N, Iida O, Takahara M, et al. Predictive Factors for Restenosis Following Stent-Supported Endovascular Therapy with Intravascular Ultrasound Evaluation for Femoropopliteal Chronic Total Occlusion. J Vasc Interv Radiol. 32(5):712-720.e1, 2021 05. Observational-Tx 276 lesions in 251 patients To determine the predictive factors for in-stent restenosis (ISR) following stent-supported endovascular therapy (EVT) with intravascular ultrasound (US) evaluation for femoropopliteal chronic total occlusion. The mean follow-up period was 19 months ±16, during which time ISR was observed in 31% of lesions. After multivariate analysis, an increased degree of plaque burden (hazard ratio [HR] = 1.101) and subintimal passage with calcification (HR = 3.408) were associated with an increased risk of ISR; a larger distal external elastic membrane area (HR = 0.898) and use of a stent graft (HR = 0.130) were significantly associated with a reduced risk of ISR. 2
46. Makris GC, Chrysafi P, Little M, et al. The role of intravascular ultrasound in lower limb revascularization in patients with peripheral arterial disease. [Review]. Int Angiol. 36(6):505-516, 2017 Dec. Review/Other-Dx 13 studies with a total number of 2258 patients. To explore the safety and effectiveness of intravascular ultrasound (IVUS) during lower limb endovascular interventions in patients with peripheral arterial disease (PAD). effectiveness of intravascular ultrasound (IVUS) during lower limb endovascular interventions in patients with peripheral arterial disease (PAD). Technical success and patency rates ranged from 90-100% and 45-100%, respectively, with a follow-up that ranged from 4.3-63 months. Three of these studies compared IVUS and non-IVUS guided angioplasty and demonstrated a significant difference in the events of amputations or re-interventions in favor of the IVUS group. Furthermore, five studies evaluated IVUS use in true-lumen re-entry, with the technical success ranging between 97-100%. In one study, where IVUS was used for atherectomy, the technical success was 100% and the long-term patency was 90% during a 12-month follow-up. Overall, no significant peri/postoperative IVUS related complications were reported, whereas, 2 studies suggested an IVUS-associated increase in procedure costs that ranged from $1080-$1333. 4
47. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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