Central Venous Access Device and Site Selection

Variant: 1   Device selection: Acutely ill patient requiring infusion of vesicant medication, hemodynamic monitoring, and frequent blood draws for 2 weeks or shorter.
Procedure Appropriateness Category
Nontunneled central venous catheter Usually Appropriate
PICC Usually Appropriate
Midline catheter May Be Appropriate
Tunneled central venous catheter May Be Appropriate
Arm port Usually Not Appropriate
Chest port Usually Not Appropriate
Variant: 2   Device selection: Patient with acute renal failure requiring central venous access for renal replacement therapy, anticipated duration of therapy for 2 weeks or shorter.
Procedure Appropriateness Category
Nontunneled dialysis catheter Usually Appropriate
Tunneled dialysis catheter Usually Appropriate
Arm port Usually Not Appropriate
Chest port Usually Not Appropriate
PICC Usually Not Appropriate
Variant: 3   Device selection: Patient with renal failure requiring central venous access for renal replacement therapy, anticipated duration of therapy for more than 2 weeks.
Procedure Appropriateness Category
Tunneled dialysis catheter Usually Appropriate
Nontunneled dialysis catheter May Be Appropriate
Arm port Usually Not Appropriate
Chest port Usually Not Appropriate
PICC Usually Not Appropriate
Variant: 4   Device selection: Patient with cancer diagnosis requiring central venous access for weekly chemotherapy infusion for more than 2 weeks.
Procedure Appropriateness Category
Chest port Usually Appropriate
Arm port Usually Appropriate
PICC May Be Appropriate
Tunneled central venous catheter May Be Appropriate
Nontunneled central venous catheter Usually Not Appropriate
Variant: 5   Device selection: Patient requiring continuous or very frequent intravenous administration of intravenous medications (excluding total parenteral nutrition) for more than 2 weeks.
Procedure Appropriateness Category
PICC Usually Appropriate
Tunneled central venous catheter Usually Appropriate
Chest port May Be Appropriate
Arm port May Be Appropriate
Nontunneled central venous catheter Usually Not Appropriate
Variant: 6   Device selection: Patient requiring long-term total parenteral nutrition and another indication for central access.
Procedure Appropriateness Category
Tunneled central venous catheter double lumen Usually Appropriate
Double lumen PICC Usually Appropriate
Single lumen PICC May Be Appropriate
Tunneled central venous catheter single lumen May Be Appropriate
Chest port May Be Appropriate
Arm port Usually Not Appropriate
Variant: 7   Device selection: Patient with chronic kidney disease requiring central venous catheter IV infusions for more than 2 weeks.
Procedure Appropriateness Category
Tunneled central venous catheter single lumen Usually Appropriate
Tunneled central venous catheter double lumen Usually Appropriate
Chest port via internal jugular vein May Be Appropriate
Chest port via subclavian vein Usually Not Appropriate
Arm port Usually Not Appropriate
PICC Usually Not Appropriate
Variant: 8   Site selection: Patient with acute illness requiring central venous catheter for anticipated therapy for 2 weeks or shorter.
Procedure Appropriateness Category
Right or left internal jugular vein Usually Appropriate
Right or left subclavian vein Usually Appropriate
Upper extremity vein Usually Appropriate
Right or left external jugular vein May Be Appropriate
Right or left femoral vein May Be Appropriate
Hepatic vein Usually Not Appropriate
Inferior vena cava Usually Not Appropriate
Variant: 9   Site selection: Patient with chronic kidney disease or end-stage renal disease requiring central venous catheter.
Procedure Appropriateness Category
Right or left internal jugular vein Usually Appropriate
Right or left external jugular vein May Be Appropriate
Right or left femoral vein May Be Appropriate
Inferior vena cava May Be Appropriate
Right or left subclavian vein May Be Appropriate
Hepatic vein Usually Not Appropriate
Upper extremity vein Usually Not Appropriate
Sharon W. Kwan, MD, MSa; Alan Massouh, MDb; Nicholas Fidelman, MDc; Mikhail C.S.S. Higgins, MD, MPHd; Hani Abujudeh, MD, MBAe; Resmi Charalel, f; Marcelo S. Guimaraes, MDg; Amit Gupta, MDh; Alexander Lam, MDi; Bill S. Majdalany, MDj; Parag J. Patel, MDk; Kevin S. Stadtlander, MDl; Terri Stillwell, MD, MPHm; Elrond Y. L. Teo, MDn; Ricky T. Tong, MD, PhDo; Baljendra S. Kapoor, MDp.

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.

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

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.
































































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