Lower extremity venous insufficiency is a chronic medical condition resulting from primary valvular incompetence or, less commonly, prior deep venous thrombosis or extrinsic venous obstruction. Lower extremity chronic venous disease has a high prevalence with a related socioeconomic burden. In the United States, over 11 million males and 22 million females 40 to 80 years of age have varicose veins, with over 2 million adults having advanced chronic venous disease. The high cost to the health care system is related to the recurrent nature of venous ulcerative disease, with total treatment costs estimated >$2.5 billion per year in the United States, with at least 20,556 individuals with newly diagnosed venous ulcers yearly. Various diagnostic and treatment strategies are in place for lower extremity chronic venous disease and are discussed in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The creation and maintenance of a dialysis access is vital for the reduction of morbidity, mortality, and cost of treatment for end stage renal disease patients. One's longevity on dialysis is directly dependent upon the quality of dialysis. This quality hinges on the integrity and reliability of the access to the patient's vascular system. All methods of dialysis access will eventually result in dialysis dysfunction and failure. Arteriovenous access dysfunction includes 3 distinct classes of events, namely thrombotic flow-related complications or dysfunction, nonthrombotic flow-related complications or dysfunction, and infectious complications. The restoration of any form of arteriovenous access dysfunction may be supported by diagnostic imaging, clinical consultation, percutaneous interventional procedures, surgical management, or a combination of these methods. This document provides a rigorous evaluation of how variants of each form of dysfunction may be appraised and approached systematically. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Noncerebral systemic arterial embolism, which can originate from cardiac and noncardiac sources, is an important cause of patient morbidity and mortality. When an embolic source dislodges, the resulting embolus can occlude a variety of peripheral and visceral arteries causing ischemia. Characteristic locations for noncerebral arterial occlusion include the upper extremities, abdominal viscera, and lower extremities. Ischemia in these regions can progress to tissue infarction resulting in limb amputation, bowel resection, or nephrectomy. Determining the source of arterial embolism is essential in order to direct treatment decisions. This document reviews the appropriateness category of various imaging procedures available to determine the source of the arterial embolism. The variants included in this document are known arterial occlusion in the upper extremity, lower extremity, mesentery, kidneys, and multiorgan distribution that are suspected to be of embolic etiology. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Injuries to the hand and wrist are common reasons for emergency room visits. X-rays are almost always the first imaging test used to evaluate the damage. For blunt or penetrating types of injury, x-rays are usually enough to find any injury to tendons and bone. When injury is suspected but is not seen on the first x-ray, the next imaging tests that are usually appropriate include repeat x-ray in 14 days and CT or MRI without intravenous contrast (dye injected into the vein). For wrist fractures seen on x-ray with suspected tendon or ligament damage, the next appropriate imaging can be MRI, ultrasound (US), MR, or CT arthrography (pictures taken after injection of contrast dye into joint). For hand fractures with suspected tendon or ligament damage, US and MRI without contrast are usually appropriate. When an initial x-ray shows the wrist displaced from normal position without a fracture, CT and MRI of the wrist without contrast and MR arthrography are usually appropriate next imaging tests. CT arthrography may also be appropriate. When the hand is displaced from normal position, MRI without contrast or US is usually appropriate. For penetrating injuries to the soft tissues of the hand or wrist not seen on x-ray, CT without contrast and US are usually appropriate next imaging tests. MRI without contrast may also be appropriate. See the full appropriateness criteria for this topic at https://acsearch.acr.org/docs/69418/Narrative/.

The spondyloarthritides are a cluster of inflammatory rheumatic diseases characterized by different diagnostic entities with heterogeneous phenotypes. The current classification system groups spondyloarthritis patients in two main categories, axial and peripheral spondyloarthritis, providing a framework wherein the clinical picture guides the treatment. However, the heterogeneity of the clinical manifestations of the pathologies, even when residing in the same group, highlights the importance of analyzing the smallest features of each entity to understand how different cellular subsets evolve, what the underlying mechanisms are and what biological markers can be identified and validated to evaluate the stage of disease and the corresponding efficacy of treatments. In this review, we will focus mostly on axial spondyloarthritis, report current knowledge concerning the cellular populations involved in its pathophysiology, and their molecular diversity. We will discuss the implications of such a diversity, and their meaning in terms of patients' stratification.

Nontraumatic aortic disease can be caused by a wide variety of disorders including congenital, inflammatory, infectious, metabolic, neoplastic, and degenerative processes. Imaging examinations such as radiography, ultrasound, echocardiography, catheter-based angiography, CT, MRI, and nuclear medicine examinations are essential for diagnosis, treatment planning, and assessment of therapeutic response. Depending upon the clinical scenario, each of these modalities has strengths and weaknesses. Whenever possible, the selection of a diagnostic imaging examination should be based upon the best available evidence. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. The purpose of this document is to assist physicians select the most appropriate diagnostic imaging examination for nontraumatic aortic diseases.

Cirrhosis is a heterogeneous disease that cannot be studied as a single entity and is classified in two main prognostic stages: compensated and decompensated cirrhosis. Portal hypertension, characterized by a pathological increase of the portal pressure and by the formation of portal-systemic collaterals that bypass the liver, is the initial and main consequence of cirrhosis and is responsible for the majority of its complications. A myriad of treatment options exists for appropriately managing the most common complications of portal hypertension, including acute variceal bleeding and refractory ascites. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

When a woman has an ovarian mass, accurate imaging of it is important so that the correct diagnosis is made. Ultrasound (US) and MRI can be used to find a growth in or around the uterus, ovaries, or fallopian tubes (adnexal mass) and to determine whether or not it is cancerous (malignant) or not (benign). If an adnexal mass is clinically suspected in a woman with no acute symptoms, initial imaging using US duplex Doppler pelvis, US pelvis through the vagina (transvaginal), and US pelvis through the abdomen (transabdominal) are done together. If a likely benign mass is found, US duplex Doppler of pelvis, US pelvis transvaginal, and US pelvis transabdominal are done together as initial follow-up. MRI pelvis without and with intravenous (IV) contrast or MRI pelvis without IV contrast may be appropriate. If it is unclear if the mass is benign, US pelvis transvaginal, US duplex Doppler pelvis, US pelvis transabdominal, and MRI pelvis without and with IV contrast are done together as initial follow-up. In postmenopausal women, CT pelvis without and with IV contrast may be appropriate. If cancer is suspected, CT abdomen and pelvis with IV contrast and MRI pelvis without and with IV contrast are done together as initial follow-up. US pelvis transabdominal or US pelvis transvaginal may be appropriate. In pregnant women, US duplex Doppler pelvis, US pelvis transabdominal, and US pelvis transvaginal are done together for initial imaging and follow-up. MRI pelvis without IV contrast may be appropriate. See the full appropriateness criteria for this topic at https://acsearch.acr.org/docs/69466/Narrative/.

Noncerebral vasculitis is a wide-range noninfectious inflammatory disorder affecting the vessels. Vasculitides have been categorized based on the vessel size, such as large-vessel vasculitis, medium-vessel vasculitis, and small-vessel vasculitis. In this document, we cover large-vessel vasculitis and medium-vessel vasculitis. Due to the challenges of vessel biopsy, imaging plays a crucial role in diagnosing this entity. While CTA and MRA can both provide anatomical details of the vessel wall, including wall thickness and enhancement in large-vessel vasculitis, FDG-PET/CT can show functional assessment based on the glycolytic activity of inflammatory cells in the inflamed vessels. Given the size of the vessel in medium-vessel vasculitis, invasive arteriography is still a choice for imaging. However, high-resolution CTA images can depict small-caliber aneurysms, and thus can be utilized in the diagnosis of medium-vessel vasculitis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The initial diagnosis of retroperitoneal bleeding can be challenging by physical examination and clinical presentation. Prompt imaging can make the diagnosis and be lifesaving. When selecting appropriate imaging for these patient's, consideration must be made for sensitivity and ability to image the retroperitoneum, as well as speed of imaging.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Thoracic outlet syndrome (TOS) is the clinical entity that occurs with compression of the brachial plexus, subclavian artery, and/or subclavian vein at the superior thoracic outlet. Compression of each of these structures results in characteristic symptoms divided into three variants: neurogenic TOS, venous TOS, and arterial TOS, each arising from the specific structure that is compressed. The constellation of symptoms in each patient may vary, and patients may have more than one symptom simultaneously. Understanding the various anatomic spaces, causes of narrowing, and resulting neurovascular changes is important in choosing and interpreting radiological imaging performed to help diagnose TOS and plan for intervention. This publication has separated imaging appropriateness based on neurogenic, venous, or arterial symptoms, acknowledging that some patients may present with combined symptoms that may require more than one study to fully resolve. Additionally, in the postoperative setting, new symptoms may arise altering the need for specific imaging as compared to preoperative evaluation. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

hypertension, refractory hypertension, deterioration of renal function in response to angiotensin-converting enzyme inhibitors, and generalized arteriosclerotic occlusive disease with hypertension.

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.

This publication includes the appropriate imaging modalities to assess suspected deep vein thrombosis in the upper extremities. Ultrasound duplex Doppler is the most appropriate imaging modality to assess upper-extremity deep vein thrombosis. It is a noninvasive test, which can be performed at the bedside and used for serial evaluations. Ultrasound can also directly identify thrombus by visualizing echogenic material in the vein and by lack of compression of the vein walls from manual external pressure. It can indirectly identify thrombus from altered blood-flow patterns. It is most appropriate in the evaluation of veins peripheral to the brachiocephalic vein. CT venography and MR venography are not first-line imaging tests, but are appropriate to assess the central venous structures, or to assess the full range of venous structures from the hand to the right atrium. Catheter venography is appropriate if therapy is required. Radionuclide venography and chest radiography are usually not appropriate to assess upper-extremity deep vein thrombosis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Vascular malformations of the extremities represent a wide spectrum of lesions, broadly divided into high-flow and low-flow categories. High-flow lesions include arteriovenous malformations and arteriovenous fistulas, while the more common low-flow lesions consist of venous and lymphatic malformations. The clinical presentation of vascular malformations is variable and can include extremity pain, discoloration, focal mass, or diffuse extremity enlargement. A vascular murmur can also be present and is more typical of high-flow lesions. While vascular malformations can often be diagnosed or strongly suspected by clinical features alone, imaging is often used to confirm the diagnosis, determine lesion characteristics and extent, and/or plan for treatment. Among the imaging options available, those usually appropriate for initial imaging of suspected vascular malformation are MR angiography without and with intravenous contrast, MRI without and with intravenous contrast, CT angiography with intravenous contrast, or US duplex Doppler. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Venous access is a procedure in which a catheter is placed into a vein for medical diagnosis or therapy. The type of device used depends on the patient and the type of illness being treated. There are two main types of venous access devices: peripheral and central catheters. A peripheral catheter is usually placed into a small vein, often in the arm, and is usually used for up to 96 hours. A central catheter can be placed into a small or large vein in the body, with the tip located in a large vein close to the heart in the chest, and is used for a longer time. There are different types of central venous catheters. These include peripherally inserted central catheters, temporary for short-term use, and tunneled for long-term use. Other devices, like a chest port, may also be put in the body. It is important to use proper hygiene and to monitor for bloodstream infections. If there is an infection, the device may need to be taken out and a new one placed in a different location, and antibiotics may be needed. Monitoring for a blood clot is also important, and anticoagulant medication may be needed if one forms. Typical uses for central venous access include giving nutrition and blood products. Chest ports are used to administer chemotherapy in people with cancer, to treat people having a sickle-cell crisis, or to treat patients with intravenous antibiotics for a blood infection. See the full appropriateness criteria for this topic at https://acsearch.acr.org/docs/3094281/Narrative/

The goal of endovascular angioplasty and of surgical bypass is to restore normal blood flow to the diseased arteries in the legs for individuals with peripheral artery disease. Both procedures need imaging follow-up to check for lesions, typically narrowing of arteries that may come back and cause symptoms. Often, noninvasive testing is done first to help choose the appropriate imaging test. The first test is usually measurement of the ankle-bronchial index (ABI), a noninvasive test in which blood pressure cuffs are placed on the legs to measure local pressures. Other noninvasive tests can also be used. For individuals without symptoms after their procedure, it is appropriate to use a baseline ultrasound (US) examination in addition to ABI and other noninvasive tests. For patients with symptoms such as severe leg cramps during exercise, pain at rest, and wounds that do not heal properly after the procedure, imaging can include CT or MR angiography in addition to US. If the symptoms are more severe, including cold and discolored limbs with a very low pulse, the primary object is to save the leg from amputation. In extremely severe cases, it is appropriate to skip imaging and go directly to surgery. In nonthreatening but severe cases, arteriography (x-rays after a dye is injected into blood vessels through a catheter) is the most appropriate follow-up. Arteriography can provide images of lesions that limit flow and cause drops in leg blood pressure. In less severe cases, both US and CT angiography are appropriate imaging tests. See the full appropriateness criteria for this topic at https://acsearch.acr.org/docs/3102223/Narrative/.