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Pulmonary Arteriovenous Malformation (PAVM)
Variant: 1
Adult. Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study.
| Procedure | Appropriateness Category | Relative Radiation Level |
| US echocardiography transthoracic with IV contrast | Usually Appropriate | O |
| MRA pulmonary arteries without and with IV contrast | Usually Appropriate | O |
| CT chest without IV contrast | Usually Appropriate | ☢☢☢ |
| CTA pulmonary arteries with IV contrast | Usually Appropriate | ☢☢☢ |
| US echocardiography transesophageal with IV contrast | May Be Appropriate | O |
| Arteriography pulmonary | May Be Appropriate | ☢☢☢☢ |
| MRA chest without and with IV contrast | May Be Appropriate (Disagreement) | O |
| CT chest with IV contrast | May Be Appropriate | ☢☢☢ |
| CT chest without and with IV contrast | May Be Appropriate (Disagreement) | ☢☢☢ |
| CTA chest with IV contrast | May Be Appropriate (Disagreement) | ☢☢☢ |
| US echocardiography transesophageal | Usually Not Appropriate | O |
| US echocardiography transthoracic resting | Usually Not Appropriate | O |
| Radiography chest | Usually Not Appropriate | ☢ |
| MRA chest without IV contrast | Usually Not Appropriate | O |
| MRA pulmonary arteries without IV contrast | Usually Not Appropriate | O |
| Pertechnetate albumin pulmonary scan | Usually Not Appropriate | ☢☢☢ |
Variant: 2
Adult. Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging.
| Procedure | Appropriateness Category | Relative Radiation Level |
| US echocardiography transthoracic with IV contrast | Usually Appropriate | O |
| MRA pulmonary arteries without and with IV contrast | Usually Appropriate | O |
| CT chest with IV contrast | Usually Appropriate | ☢☢☢ |
| CT chest without IV contrast | Usually Appropriate | ☢☢☢ |
| CTA chest with IV contrast | Usually Appropriate | ☢☢☢ |
| CTA pulmonary arteries with IV contrast | Usually Appropriate | ☢☢☢ |
| Arteriography pulmonary | May Be Appropriate | ☢☢☢☢ |
| MRA chest without and with IV contrast | May Be Appropriate | O |
| CT chest without and with IV contrast | May Be Appropriate | ☢☢☢ |
| US echocardiography transesophageal | Usually Not Appropriate | O |
| US echocardiography transesophageal with IV contrast | Usually Not Appropriate | O |
| US echocardiography transthoracic resting | Usually Not Appropriate | O |
| Radiography chest | Usually Not Appropriate | ☢ |
| MRA chest without IV contrast | Usually Not Appropriate | O |
| MRA pulmonary arteries without IV contrast | Usually Not Appropriate | O |
| Pertechnetate albumin pulmonary scan | Usually Not Appropriate | ☢☢☢ |
Variant: 3
Adult. Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging.
| Procedure | Appropriateness Category | Relative Radiation Level |
| US echocardiography transthoracic with IV contrast | Usually Appropriate | O |
| MRA pulmonary arteries without and with IV contrast | Usually Appropriate | O |
| CT chest without IV contrast | Usually Appropriate | ☢☢☢ |
| CTA chest with IV contrast | Usually Appropriate | ☢☢☢ |
| CTA pulmonary arteries with IV contrast | Usually Appropriate | ☢☢☢ |
| MRA chest without and with IV contrast | May Be Appropriate | O |
| CT chest with IV contrast | May Be Appropriate | ☢☢☢ |
| CT chest without and with IV contrast | May Be Appropriate | ☢☢☢ |
| US echocardiography transesophageal | Usually Not Appropriate | O |
| US echocardiography transesophageal with IV contrast | Usually Not Appropriate | O |
| US echocardiography transthoracic resting | Usually Not Appropriate | O |
| Radiography chest | Usually Not Appropriate | ☢ |
| Arteriography pulmonary | Usually Not Appropriate | ☢☢☢☢ |
| MRA chest without IV contrast | Usually Not Appropriate | O |
| MRA pulmonary arteries without IV contrast | Usually Not Appropriate | O |
| Pertechnetate albumin pulmonary scan | Usually Not Appropriate | ☢☢☢ |
Variant: 4
Adult. Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
| Procedure | Appropriateness Category | Relative Radiation Level |
| US echocardiography transthoracic with IV contrast | Usually Appropriate | O |
| MRA pulmonary arteries without and with IV contrast | Usually Appropriate | O |
| CT chest with IV contrast | Usually Appropriate | ☢☢☢ |
| CT chest without and with IV contrast | Usually Appropriate | ☢☢☢ |
| CT chest without IV contrast | Usually Appropriate | ☢☢☢ |
| CTA chest with IV contrast | Usually Appropriate | ☢☢☢ |
| CTA pulmonary arteries with IV contrast | Usually Appropriate | ☢☢☢ |
| Arteriography pulmonary | May Be Appropriate | ☢☢☢☢ |
| MRA chest without and with IV contrast | May Be Appropriate | O |
| US echocardiography transesophageal | Usually Not Appropriate | O |
| US echocardiography transesophageal with IV contrast | Usually Not Appropriate | O |
| US echocardiography transthoracic resting | Usually Not Appropriate | O |
| Radiography chest | Usually Not Appropriate | ☢ |
| MRA chest without IV contrast | Usually Not Appropriate | O |
| MRA pulmonary arteries without IV contrast | Usually Not Appropriate | O |
Variant: 5
Adult. Asymptomatic with abnormal imaging on CT or chest radiography suggestive of PAVM. Next imaging study.
| Procedure | Appropriateness Category | Relative Radiation Level |
| US echocardiography transthoracic with IV contrast | Usually Appropriate | O |
| MRA pulmonary arteries without and with IV contrast | Usually Appropriate | O |
| CTA pulmonary arteries with IV contrast | Usually Appropriate | ☢☢☢ |
| Arteriography pulmonary | May Be Appropriate | ☢☢☢☢ |
| MRA chest without and with IV contrast | May Be Appropriate | O |
| MRA chest without IV contrast | May Be Appropriate | O |
| CT chest with IV contrast | May Be Appropriate (Disagreement) | ☢☢☢ |
| CT chest without and with IV contrast | May Be Appropriate (Disagreement) | ☢☢☢ |
| CT chest without IV contrast | May Be Appropriate | ☢☢☢ |
| CTA chest with IV contrast | May Be Appropriate (Disagreement) | ☢☢☢ |
| US echocardiography transesophageal | Usually Not Appropriate | O |
| US echocardiography transesophageal with IV contrast | Usually Not Appropriate | O |
| US echocardiography transthoracic resting | Usually Not Appropriate | O |
| MRA pulmonary arteries without IV contrast | Usually Not Appropriate | O |
Panel Members
Anil K. Pillai, MDa; Michael L. Steigner, MDb; Ayaz Aghayev, MDc; Sarah Ahmad, MDd; Maros Ferencik, MD, PhD, MCRe; Asha Kandathil, MDf; David S. Kirsch, MDg; Yoo Jin Lee, MDh; Prashant Nagpal, MDi; Kevin O'Neil, MD, MHAj; Sasan Partovi, MDk; Sha'Shonda Revels, MDl; Beth Ripley, MD, PhDm; Raymond R. Russell, MD, PhDn; Sachin S. Saboo, MDo; Andrew Tannenbaum, MDp; Richard Thomas, MD, MBBSq; Bryan J. Wells, MDr; Hei Shun Yu, s; Sanjeeva P. Kalva, t.
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Initial Imaging Definition
Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:
- There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)
OR
- There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).
Discussion of Procedures by Variant
Variant 1: Adult. Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study.
Variant 1: Adult. Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study.
A. Arteriography pulmonary
A. Arteriography pulmonary
Variant 1: Adult. Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study.
B. CT chest with IV contrast
B. CT chest with IV contrast
Variant 1: Adult. Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study.
C. CT chest without and with IV contrast
C. CT chest without and with IV contrast
Variant 1: Adult. Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study.
D. CT chest without IV contrast
D. CT chest without IV contrast
Variant 1: Adult. Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study.
E. CTA chest with IV contrast
E. CTA chest with IV contrast
Variant 1: Adult. Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study.
F. CTA pulmonary arteries with IV contrast
F. CTA pulmonary arteries with IV contrast
Variant 1: Adult. Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study.
G. MRA chest without and with IV contrast
G. MRA chest without and with IV contrast
Variant 1: Adult. Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study.
H. MRA chest without IV contrast
H. MRA chest without IV contrast
Variant 1: Adult. Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study.
I. MRA pulmonary arteries without and with IV contrast
I. MRA pulmonary arteries without and with IV contrast
Variant 1: Adult. Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study.
J. MRA pulmonary arteries without IV contrast
J. MRA pulmonary arteries without IV contrast
Variant 1: Adult. Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study.
K. Pertechnetate albumin pulmonary scan
K. Pertechnetate albumin pulmonary scan
Variant 1: Adult. Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study.
L. Radiography chest
L. Radiography chest
Variant 1: Adult. Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study.
M. US echocardiography transesophageal
M. US echocardiography transesophageal
Variant 1: Adult. Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study.
N. US echocardiography transesophageal with IV contrast
N. US echocardiography transesophageal with IV contrast
Variant 1: Adult. Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study.
O. US echocardiography transthoracic resting
O. US echocardiography transthoracic resting
Variant 1: Adult. Presenting with a transient ischemic attack, or seizures, or brain abscess, or altered sensorium. Chest radiography reveals a lung nodule. Suspected pulmonary arteriovenous malformation (PAVM). Next imaging study.
P. US echocardiography transthoracic with IV contrast
P. US echocardiography transthoracic with IV contrast
Variant 2: Adult. Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging.
Variant 2: Adult. Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging.
A. Arteriography pulmonary
A. Arteriography pulmonary
Variant 2: Adult. Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging.
B. CT chest with IV contrast
B. CT chest with IV contrast
Variant 2: Adult. Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging.
C. CT chest without and with IV contrast
C. CT chest without and with IV contrast
Variant 2: Adult. Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging.
D. CT chest without IV contrast
D. CT chest without IV contrast
Variant 2: Adult. Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging.
E. CTA chest with IV contrast
E. CTA chest with IV contrast
Variant 2: Adult. Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging.
F. CTA pulmonary arteries with IV contrast
F. CTA pulmonary arteries with IV contrast
Variant 2: Adult. Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging.
G. MRA chest without and with IV contrast
G. MRA chest without and with IV contrast
Variant 2: Adult. Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging.
H. MRA chest without IV contrast
H. MRA chest without IV contrast
Variant 2: Adult. Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging.
I. MRA pulmonary arteries without and with IV contrast
I. MRA pulmonary arteries without and with IV contrast
Variant 2: Adult. Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging.
J. MRA pulmonary arteries without IV contrast
J. MRA pulmonary arteries without IV contrast
Variant 2: Adult. Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging.
K. Pertechnetate albumin pulmonary scan
K. Pertechnetate albumin pulmonary scan
Variant 2: Adult. Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging.
L. Radiography chest
L. Radiography chest
Variant 2: Adult. Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging.
M. US echocardiography transesophageal
M. US echocardiography transesophageal
Variant 2: Adult. Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging.
N. US echocardiography transesophageal with IV contrast
N. US echocardiography transesophageal with IV contrast
Variant 2: Adult. Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging.
O. US echocardiography transthoracic resting
O. US echocardiography transthoracic resting
Variant 2: Adult. Presenting with shortness of breath, or hemothorax, or hemoptysis. Patient has history of epistaxis and family history of hereditary hemorrhagic telangiectasia (HHT). Suspected PAVM. Initial imaging.
P. US echocardiography transthoracic with IV contrast
P. US echocardiography transthoracic with IV contrast
Variant 3: Adult. Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging.
Variant 3: Adult. Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging.
A. Arteriography pulmonary
A. Arteriography pulmonary
Variant 3: Adult. Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging.
B. CT chest with IV contrast
B. CT chest with IV contrast
Variant 3: Adult. Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging.
C. CT chest without and with IV contrast
C. CT chest without and with IV contrast
Variant 3: Adult. Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging.
D. CT chest without IV contrast
D. CT chest without IV contrast
Variant 3: Adult. Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging.
E. CTA chest with IV contrast
E. CTA chest with IV contrast
Variant 3: Adult. Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging.
F. CTA pulmonary arteries with IV contrast
F. CTA pulmonary arteries with IV contrast
Variant 3: Adult. Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging.
G. MRA chest without and with IV contrast
G. MRA chest without and with IV contrast
Variant 3: Adult. Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging.
H. MRA chest without IV contrast
H. MRA chest without IV contrast
Variant 3: Adult. Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging.
I. MRA pulmonary arteries without and with IV contrast
I. MRA pulmonary arteries without and with IV contrast
Variant 3: Adult. Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging.
J. MRA pulmonary arteries without IV contrast
J. MRA pulmonary arteries without IV contrast
Variant 3: Adult. Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging.
K. Pertechnetate albumin pulmonary scan
K. Pertechnetate albumin pulmonary scan
Variant 3: Adult. Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging.
L. Radiography chest
L. Radiography chest
Variant 3: Adult. Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging.
M. US echocardiography transesophageal
M. US echocardiography transesophageal
Variant 3: Adult. Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging.
N. US echocardiography transesophageal with IV contrast
N. US echocardiography transesophageal with IV contrast
Variant 3: Adult. Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging.
O. US echocardiography transthoracic resting
O. US echocardiography transthoracic resting
Variant 3: Adult. Asymptomatic with a family history of HHT and suspected PAVM. Initial imaging.
P. US echocardiography transthoracic with IV contrast
P. US echocardiography transthoracic with IV contrast
Variant 4: Adult. Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
Variant 4: Adult. Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
A. Arteriography pulmonary
A. Arteriography pulmonary
Variant 4: Adult. Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
B. CT chest with IV contrast
B. CT chest with IV contrast
Variant 4: Adult. Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
C. CT chest without and with IV contrast
C. CT chest without and with IV contrast
Variant 4: Adult. Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
D. CT chest without IV contrast
D. CT chest without IV contrast
Variant 4: Adult. Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
E. CTA chest with IV contrast
E. CTA chest with IV contrast
Variant 4: Adult. Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
F. CTA pulmonary arteries with IV contrast
F. CTA pulmonary arteries with IV contrast
Variant 4: Adult. Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
G. MRA chest without and with IV contrast
G. MRA chest without and with IV contrast
Variant 4: Adult. Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
H. MRA chest without IV contrast
H. MRA chest without IV contrast
Variant 4: Adult. Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
I. MRA pulmonary arteries without and with IV contrast
I. MRA pulmonary arteries without and with IV contrast
Variant 4: Adult. Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
J. MRA pulmonary arteries without IV contrast
J. MRA pulmonary arteries without IV contrast
Variant 4: Adult. Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
K. Radiography chest
K. Radiography chest
Variant 4: Adult. Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
L. US echocardiography transesophageal
L. US echocardiography transesophageal
Variant 4: Adult. Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
M. US echocardiography transesophageal with IV contrast
M. US echocardiography transesophageal with IV contrast
Variant 4: Adult. Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
N. US echocardiography transthoracic resting
N. US echocardiography transthoracic resting
Variant 4: Adult. Presenting to establish care with a past history of a treated PAVM. Follow-up (surveillance) imaging following embolization of PAVM.
O. US echocardiography transthoracic with IV contrast
O. US echocardiography transthoracic with IV contrast
Variant 5: Adult. Asymptomatic with abnormal imaging on CT or chest radiography suggestive of PAVM. Next imaging study.
Variant 5: Adult. Asymptomatic with abnormal imaging on CT or chest radiography suggestive of PAVM. Next imaging study.
A. Arteriography pulmonary
A. Arteriography pulmonary
Variant 5: Adult. Asymptomatic with abnormal imaging on CT or chest radiography suggestive of PAVM. Next imaging study.
B. CT chest with IV contrast
B. CT chest with IV contrast
Variant 5: Adult. Asymptomatic with abnormal imaging on CT or chest radiography suggestive of PAVM. Next imaging study.
C. CT chest without and with IV contrast
C. CT chest without and with IV contrast
Variant 5: Adult. Asymptomatic with abnormal imaging on CT or chest radiography suggestive of PAVM. Next imaging study.
D. CT chest without IV contrast
D. CT chest without IV contrast
Variant 5: Adult. Asymptomatic with abnormal imaging on CT or chest radiography suggestive of PAVM. Next imaging study.
E. CTA chest with IV contrast
E. CTA chest with IV contrast
Variant 5: Adult. Asymptomatic with abnormal imaging on CT or chest radiography suggestive of PAVM. Next imaging study.
F. CTA pulmonary arteries with IV contrast
F. CTA pulmonary arteries with IV contrast
Variant 5: Adult. Asymptomatic with abnormal imaging on CT or chest radiography suggestive of PAVM. Next imaging study.
G. MRA chest without and with IV contrast
G. MRA chest without and with IV contrast
Variant 5: Adult. Asymptomatic with abnormal imaging on CT or chest radiography suggestive of PAVM. Next imaging study.
H. MRA chest without IV contrast
H. MRA chest without IV contrast
Variant 5: Adult. Asymptomatic with abnormal imaging on CT or chest radiography suggestive of PAVM. Next imaging study.
I. MRA pulmonary arteries without and with IV contrast
I. MRA pulmonary arteries without and with IV contrast
Variant 5: Adult. Asymptomatic with abnormal imaging on CT or chest radiography suggestive of PAVM. Next imaging study.
J. MRA pulmonary arteries without IV contrast
J. MRA pulmonary arteries without IV contrast
Variant 5: Adult. Asymptomatic with abnormal imaging on CT or chest radiography suggestive of PAVM. Next imaging study.
K. US echocardiography transesophageal
K. US echocardiography transesophageal
Variant 5: Adult. Asymptomatic with abnormal imaging on CT or chest radiography suggestive of PAVM. Next imaging study.
L. US echocardiography transesophageal with IV contrast
L. US echocardiography transesophageal with IV contrast
Variant 5: Adult. Asymptomatic with abnormal imaging on CT or chest radiography suggestive of PAVM. Next imaging study.
M. US echocardiography transthoracic resting
M. US echocardiography transthoracic resting
Variant 5: Adult. Asymptomatic with abnormal imaging on CT or chest radiography suggestive of PAVM. Next imaging study.
N. US echocardiography transthoracic with IV contrast
N. US echocardiography transthoracic with IV contrast
Summary of Highlights
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.