Lower Extremity Chronic Venous Disease

Variant: 1 Varicose veins. Initial diagnosis.

Procedure	Appropriateness Category	Relative Radiation Level
US duplex Doppler lower extremity	Usually Appropriate	O
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	O
MRV pelvis without and with IV contrast	Usually Not Appropriate	O
US intravascular iliac veins	Usually Not Appropriate	O

Variant: 2 Varicose veins. Treatment.

Procedure	Appropriateness Category	Relative Radiation Level
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	Relative Radiation Level
US duplex Doppler lower extremity	Usually Appropriate	O
US duplex Doppler IVC and iliac veins	Usually Appropriate	O
CTV abdomen and pelvis with IV contrast	May Be Appropriate	☢☢☢☢
MRV abdomen and pelvis without and with IV contrast	May Be Appropriate	O
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)	O
US intravascular iliac veins	May Be Appropriate (Disagreement)	O
Catheter venography lower extremity	May Be Appropriate	☢☢

Variant: 4 Venous leg ulcer. Treatment.

Procedure	Appropriateness Category	Relative Radiation Level
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	Relative Radiation Level
US duplex Doppler lower extremity	Usually Appropriate	O
US duplex Doppler pelvis	Usually Appropriate	O
CTV abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢☢
MRV abdomen and pelvis without and with IV contrast	Usually Appropriate	O
US duplex Doppler IVC and iliac veins	Usually Appropriate	O
Catheter venography pelvis	May Be Appropriate	☢☢
US intravascular iliac veins	May Be Appropriate (Disagreement)	O
US intravascular renal veins	Usually Not Appropriate	O

Variant: 6 Pelvic-origin lower extremity varicose veins in females. Treatment.

Procedure	Appropriateness Category	Relative Radiation Level
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	Relative Radiation Level
US duplex Doppler lower extremity	Usually Appropriate	O
CTV abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢☢
MRV abdomen and pelvis without and with IV contrast	Usually Appropriate	O
US duplex Doppler IVC and iliac veins	Usually Appropriate	O
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)	O
US intravascular iliac veins	May Be Appropriate (Disagreement)	O

Variant: 8 Iliocaval or lower extremity disease with severe post-thrombotic changes. Treatment.

Procedure	Appropriateness Category	Relative Radiation Level
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

Panel Members

Summary of Literature Review

Introduction/Background

Discussion of Procedures by Variant

Variant 1: Varicose veins. Initial diagnosis.

Variant 1: Varicose veins. Initial diagnosis.
A. Catheter Venography Iliac Veins

Variant 1: Varicose veins. Initial diagnosis.
B. Catheter Venography Lower Extremity

Variant 1: Varicose veins. Initial diagnosis.
C. CTV Lower Extremity

Variant 1: Varicose veins. Initial diagnosis.
D. CTV Pelvis

Variant 1: Varicose veins. Initial diagnosis.
E. US Intravascular Iliac Veins

Variant 1: Varicose veins. Initial diagnosis.
F. MRV Lower Extremity

Variant 1: Varicose veins. Initial diagnosis.
G. MRV Pelvis

Variant 1: Varicose veins. Initial diagnosis.
H. US Duplex Doppler Lower Extremity

Variant 2: Varicose veins. Treatment.

Variant 2: Varicose veins. Treatment.
A. Compression Therapy

Variant 2: Varicose veins. Treatment.
B. Saphenous Vein Ablation

Variant 2: Varicose veins. Treatment.
C. Compression Sclerotherapy

Variant 2: Varicose veins. Treatment.
D. Ligation and Stripping

Variant 2: Varicose veins. Treatment.
E. Microphlebectomy

Variant 3: Venous leg ulcer. Initial diagnosis.

Variant 3: Venous leg ulcer. Initial diagnosis.
A. Catheter Venography Iliac Veins

Variant 3: Venous leg ulcer. Initial diagnosis.
B. Catheter Venography Lower Extremity

Variant 3: Venous leg ulcer. Initial diagnosis.
C. CTV Lower Extremity

Variant 3: Venous leg ulcer. Initial diagnosis.
D. CTV Abdomen and Pelvis

Variant 3: Venous leg ulcer. Initial diagnosis.
E. US Intravascular Iliac Veins

Variant 3: Venous leg ulcer. Initial diagnosis.
F. MRV Lower Extremity

Variant 3: Venous leg ulcer. Initial diagnosis.
G. MRV Abdomen and Pelvis

Variant 3: Venous leg ulcer. Initial diagnosis.
H. US Duplex Doppler Lower Extremity

Variant 3: Venous leg ulcer. Initial diagnosis.
I. US Duplex Doppler IVC and Iliac Veins

Variant 4: Venous leg ulcer. Treatment.

Variant 4: Venous leg ulcer. Treatment.
A. Compression Therapy

Variant 4: Venous leg ulcer. Treatment.
B. Saphenous Vein Ablation

Variant 4: Venous leg ulcer. Treatment.
C. Compression Sclerotherapy

Variant 4: Venous leg ulcer. Treatment.
D. Iliac Vein Stenting

Variant 4: Venous leg ulcer. Treatment.
E. Microphlebectomy

Variant 4: Venous leg ulcer. Treatment.
F. Ligation and Stripping

Variant 4: Venous leg ulcer. Treatment.
G. Wound Care

Variant 5: Suspected pelvic-origin lower extremity varicose veins in females. Initial diagnosis.

Variant 5: Suspected pelvic-origin lower extremity varicose veins in females. Initial diagnosis.
A. Catheter Venography Pelvis

Variant 5: Suspected pelvic-origin lower extremity varicose veins in females. Initial diagnosis.
B. CTV Abdomen and Pelvis

Variant 5: Suspected pelvic-origin lower extremity varicose veins in females. Initial diagnosis.
C. US Intravascular Iliac Veins

Variant 5: Suspected pelvic-origin lower extremity varicose veins in females. Initial diagnosis.
D. US Intravascular Renal Veins

Variant 5: Suspected pelvic-origin lower extremity varicose veins in females. Initial diagnosis.
E. MRV Abdomen and Pelvis

Variant 5: Suspected pelvic-origin lower extremity varicose veins in females. Initial diagnosis.
F. US Duplex Doppler Lower Extremity

Variant 5: Suspected pelvic-origin lower extremity varicose veins in females. Initial diagnosis.
G. US Duplex Doppler Pelvis

Variant 5: Suspected pelvic-origin lower extremity varicose veins in females. Initial diagnosis.
H. US Duplex Doppler IVC and Iliac Veins

Variant 6: Pelvic-origin lower extremity varicose veins in females. Treatment.

Variant 6: Pelvic-origin lower extremity varicose veins in females. Treatment.
A. Saphenous Vein Ablation

Variant 6: Pelvic-origin lower extremity varicose veins in females. Treatment.
B. Compression Sclerotherapy

Variant 6: Pelvic-origin lower extremity varicose veins in females. Treatment.
C. Iliac Vein Stenting

Variant 6: Pelvic-origin lower extremity varicose veins in females. Treatment.
D. Iliac Vein Embolization

Variant 6: Pelvic-origin lower extremity varicose veins in females. Treatment.
E. Iliac Vein Surgery

Variant 6: Pelvic-origin lower extremity varicose veins in females. Treatment.
F. Left Renal Vein Stenting

Variant 6: Pelvic-origin lower extremity varicose veins in females. Treatment.
G. Left Renal Vein Surgery

Variant 6: Pelvic-origin lower extremity varicose veins in females. Treatment.
H. Microphlebectomy

Variant 6: Pelvic-origin lower extremity varicose veins in females. Treatment.
I. Ovarian Vein Embolization

Variant 6: Pelvic-origin lower extremity varicose veins in females. Treatment.
J. Conservative Management

Variant 7: Suspected iliocaval or lower extremity disease with severe post-thrombotic changes. Initial diagnosis.

Variant 7: Suspected iliocaval or lower extremity disease with severe post-thrombotic changes. Initial diagnosis.
A. Catheter Venography Iliac Veins

Variant 7: Suspected iliocaval or lower extremity disease with severe post-thrombotic changes. Initial diagnosis.
B. Catheter Venography Lower Extremity

Variant 7: Suspected iliocaval or lower extremity disease with severe post-thrombotic changes. Initial diagnosis.
C. CTV Lower Extremity

Variant 7: Suspected iliocaval or lower extremity disease with severe post-thrombotic changes. Initial diagnosis.
D. CTV Abdomen and Pelvis

Variant 7: Suspected iliocaval or lower extremity disease with severe post-thrombotic changes. Initial diagnosis.
E. US Intravascular Iliac Veins

Variant 7: Suspected iliocaval or lower extremity disease with severe post-thrombotic changes. Initial diagnosis.
F. MRV Lower Extremity

Variant 7: Suspected iliocaval or lower extremity disease with severe post-thrombotic changes. Initial diagnosis.
G. MRV Abdomen and Pelvis

Variant 7: Suspected iliocaval or lower extremity disease with severe post-thrombotic changes. Initial diagnosis.
H. US Duplex Doppler Lower Extremity

Variant 7: Suspected iliocaval or lower extremity disease with severe post-thrombotic changes. Initial diagnosis.
I. US Duplex Doppler IVC and Iliac Veins

Variant 8: Iliocaval or lower extremity disease with severe post-thrombotic changes. Treatment.

Variant 8: Iliocaval or lower extremity disease with severe post-thrombotic changes. Treatment.
A. Anticoagulation

Variant 8: Iliocaval or lower extremity disease with severe post-thrombotic changes. Treatment.
B. Catheter-Directed Thrombolysis With or Without Thrombectomy Lower Extremity

Variant 8: Iliocaval or lower extremity disease with severe post-thrombotic changes. Treatment.
C. Compression Therapy

Variant 8: Iliocaval or lower extremity disease with severe post-thrombotic changes. Treatment.
D. Endovascular Stenting

Variant 8: Iliocaval or lower extremity disease with severe post-thrombotic changes. Treatment.
E. Saphenous Vein Ablation

Variant 8: Iliocaval or lower extremity disease with severe post-thrombotic changes. Treatment.
F. Compression Sclerotherapy

Variant 8: Iliocaval or lower extremity disease with severe post-thrombotic changes. Treatment.
G. Venous Angioplasty

Variant 8: Iliocaval or lower extremity disease with severe post-thrombotic changes. Treatment.
H. Venous Bypass Procedure

Summary of Recommendations

Supporting Documents

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 Names and Definitions

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.

Relative Radiation Level Information

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.”

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Disclaimer

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