Lower Extremity Chronic Venous Disease

Variant: 1   Varicose veins. Initial diagnosis.
Procedure Appropriateness Category
US duplex Doppler lower extremity Usually Appropriate
Catheter venography iliac veins Usually Not Appropriate
Catheter venography lower extremity Usually Not Appropriate
CTV lower extremity with IV contrast Usually Not Appropriate
CTV pelvis with IV contrast Usually Not Appropriate
MRV lower extremity without and with IV contrast Usually Not Appropriate
MRV pelvis without and with IV contrast Usually Not Appropriate
US intravascular iliac veins Usually Not Appropriate
Variant: 2   Varicose veins. Treatment.
Procedure Appropriateness Category
Compression therapy Usually Appropriate
Saphenous vein ablation Usually Appropriate
Compression sclerotherapy Usually Appropriate
Microphlebectomy Usually Appropriate
Ligation and stripping May Be Appropriate
Variant: 3   Venous leg ulcer. Initial diagnosis.
Procedure Appropriateness Category
US duplex Doppler lower extremity Usually Appropriate
US duplex Doppler IVC and iliac veins Usually Appropriate
CTV abdomen and pelvis with IV contrast May Be Appropriate
MRV abdomen and pelvis without and with IV contrast May Be Appropriate
Catheter venography iliac veins May Be Appropriate
CTV lower extremity with IV contrast May Be Appropriate (Disagreement)
MRV lower extremity without and with IV contrast May Be Appropriate (Disagreement)
US intravascular iliac veins May Be Appropriate (Disagreement)
Catheter venography lower extremity May Be Appropriate
Variant: 4   Venous leg ulcer. Treatment.
Procedure Appropriateness Category
Wound care Usually Appropriate
Compression therapy Usually Appropriate
Saphenous vein ablation Usually Appropriate
Compression sclerotherapy Usually Appropriate
Iliac vein stenting May Be Appropriate
Ligation and stripping May Be Appropriate
Microphlebectomy May Be Appropriate
Variant: 5   Suspected pelvic-origin lower extremity varicose veins in females. Initial diagnosis.
Procedure Appropriateness Category
US duplex Doppler lower extremity Usually Appropriate
US duplex Doppler pelvis Usually Appropriate
CTV abdomen and pelvis with IV contrast Usually Appropriate
MRV abdomen and pelvis without and with IV contrast Usually Appropriate
US duplex Doppler IVC and iliac veins Usually Appropriate
Catheter venography pelvis May Be Appropriate
US intravascular iliac veins May Be Appropriate (Disagreement)
US intravascular renal veins Usually Not Appropriate
Variant: 6   Pelvic-origin lower extremity varicose veins in females. Treatment.
Procedure Appropriateness Category
Conservative management Usually Appropriate
Compression sclerotherapy May Be Appropriate
Microphlebectomy May Be Appropriate
Saphenous vein ablation May Be Appropriate (Disagreement)
Iliac vein embolization May Be Appropriate
Iliac vein stenting Usually Not Appropriate
Left renal vein stenting Usually Not Appropriate
Left renal vein surgery Usually Not Appropriate
Ovarian vein embolization Usually Not Appropriate
Iliac vein surgery Usually Not Appropriate
Variant: 7   Suspected iliocaval or lower extremity disease with severe post-thrombotic changes. Initial diagnosis.
Procedure Appropriateness Category
US duplex Doppler lower extremity Usually Appropriate
CTV abdomen and pelvis with IV contrast Usually Appropriate
MRV abdomen and pelvis without and with IV contrast Usually Appropriate
US duplex Doppler IVC and iliac veins Usually Appropriate
Catheter venography iliac veins May Be Appropriate
Catheter venography lower extremity May Be Appropriate
CTV lower extremity with IV contrast May Be Appropriate (Disagreement)
MRV lower extremity without and with IV contrast May Be Appropriate (Disagreement)
US intravascular iliac veins May Be Appropriate (Disagreement)
Variant: 8   Iliocaval or lower extremity disease with severe post-thrombotic changes. Treatment.
Procedure Appropriateness Category
Anticoagulation Usually Appropriate
Compression therapy Usually Appropriate
Endovascular stenting Usually Appropriate
Catheter-directed thrombolysis with or without thrombectomy lower extremity May Be Appropriate
Venous angioplasty May Be Appropriate
Saphenous vein ablation May Be Appropriate (Disagreement)
Venous bypass procedure May Be Appropriate
Compression sclerotherapy Usually Not Appropriate

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”


















































































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