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Workup of Noncerebral Systemic Arterial Embolic Source

Variant: 1   Known upper extremity arterial occlusion. Suspected embolic etiology. Next imaging study to determine source.
Procedure Appropriateness Category Relative Radiation Level
US echocardiography transesophageal Usually Appropriate O
US echocardiography transthoracic resting Usually Appropriate O
MRA chest without and with IV contrast Usually Appropriate O
MRI heart function and morphology without and with IV contrast Usually Appropriate O
MRI heart function and morphology without IV contrast Usually Appropriate O
CTA chest with IV contrast Usually Appropriate ☢☢☢
CT heart function and morphology with IV contrast Usually Appropriate ☢☢☢☢
MRA chest without IV contrast May Be Appropriate O
US duplex Doppler abdomen Usually Not Appropriate O
Aortography chest Usually Not Appropriate ☢☢☢

Variant: 2   Known arterial occlusion in the mesenteric or renal arterial system or renal infarcts. Suspected embolic etiology. Next imaging study to determine source.
Procedure Appropriateness Category Relative Radiation Level
US echocardiography transesophageal Usually Appropriate O
US echocardiography transthoracic resting Usually Appropriate O
MRA chest and abdomen without and with IV contrast Usually Appropriate O
MRI heart function and morphology without and with IV contrast Usually Appropriate O
MRI heart function and morphology without IV contrast Usually Appropriate O
CTA chest with IV contrast Usually Appropriate ☢☢☢
CT heart function and morphology with IV contrast Usually Appropriate ☢☢☢☢
CTA chest and abdomen with IV contrast Usually Appropriate ☢☢☢☢
US duplex Doppler abdomen May Be Appropriate O
MRA chest and abdomen without IV contrast May Be Appropriate O
MRA chest without and with IV contrast May Be Appropriate O
MRA chest without IV contrast May Be Appropriate O
Aortography chest and abdomen Usually Not Appropriate ☢☢☢☢

Variant: 3   Known lower extremity arterial occlusion. Suspected embolic etiology. Next imaging study to determine source.
Procedure Appropriateness Category Relative Radiation Level
US echocardiography transesophageal Usually Appropriate O
US echocardiography transthoracic resting Usually Appropriate O
MRA chest abdomen pelvis without and with IV contrast Usually Appropriate O
MRA chest without and with IV contrast Usually Appropriate O
MRI heart function and morphology without and with IV contrast Usually Appropriate O
MRI heart function and morphology without IV contrast Usually Appropriate O
CTA chest with IV contrast Usually Appropriate ☢☢☢
CT heart function and morphology with IV contrast Usually Appropriate ☢☢☢☢
CTA chest abdomen pelvis with IV contrast Usually Appropriate ☢☢☢☢☢
MRA chest abdomen pelvis without IV contrast May Be Appropriate O
MRA chest without IV contrast May Be Appropriate O
US duplex Doppler abdomen Usually Not Appropriate O
Aortography chest abdomen pelvis Usually Not Appropriate ☢☢☢☢

Variant: 4   Known multiorgan system arterial occlusions. Suspected embolic etiology. Next imaging study to determine source.
Procedure Appropriateness Category Relative Radiation Level
US echocardiography transesophageal Usually Appropriate O
US echocardiography transthoracic resting Usually Appropriate O
MRA chest abdomen pelvis without and with IV contrast Usually Appropriate O
MRA chest abdomen pelvis without IV contrast Usually Appropriate O
MRA chest without and with IV contrast Usually Appropriate O
MRI heart function and morphology without and with IV contrast Usually Appropriate O
MRI heart function and morphology without IV contrast Usually Appropriate O
CTA chest with IV contrast Usually Appropriate ☢☢☢
CT heart function and morphology with IV contrast Usually Appropriate ☢☢☢☢
CTA chest abdomen pelvis with IV contrast Usually Appropriate ☢☢☢☢☢
US duplex Doppler abdomen May Be Appropriate O
MRA chest without IV contrast May Be Appropriate O

Panel Members
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Initial Imaging Definition
Discussion of Procedures by Variant
Variant 1: The variant assumes that an upper extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
Variant 1: The variant assumes that an upper extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
A. Aortography Chest
Variant 1: The variant assumes that an upper extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
B. CT Heart Function and Morphology With IV Contrast
Variant 1: The variant assumes that an upper extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
C. CTA Chest With IV Contrast
Variant 1: The variant assumes that an upper extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
D. MRA Chest Without and With IV Contrast
Variant 1: The variant assumes that an upper extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
E. MRA Chest Without IV Contrast
Variant 1: The variant assumes that an upper extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
F. MRI Heart Function and Morphology Without and With IV Contrast
Variant 1: The variant assumes that an upper extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
G. MRI Heart Function and Morphology Without IV Contrast
Variant 1: The variant assumes that an upper extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
H. US Duplex Doppler Abdomen
Variant 1: The variant assumes that an upper extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
I. US Echocardiography Transesophageal
Variant 1: The variant assumes that an upper extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
J. US Echocardiography Transthoracic Resting
Variant 2: The variant assumes that a mesenteric/renal arterial occlusion or renal infarct has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Imaging of Mesenteric Ischemia” [55]).
Variant 2: The variant assumes that a mesenteric/renal arterial occlusion or renal infarct has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Imaging of Mesenteric Ischemia” [55]).
A. Aortography Chest and Abdomen
Variant 2: The variant assumes that a mesenteric/renal arterial occlusion or renal infarct has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Imaging of Mesenteric Ischemia” [55]).
B. CT Heart Function and Morphology With IV Contrast
Variant 2: The variant assumes that a mesenteric/renal arterial occlusion or renal infarct has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Imaging of Mesenteric Ischemia” [55]).
C. CTA Chest With IV Contrast
Variant 2: The variant assumes that a mesenteric/renal arterial occlusion or renal infarct has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Imaging of Mesenteric Ischemia” [55]).
D. CTA Chest and Abdomen With IV Contrast
Variant 2: The variant assumes that a mesenteric/renal arterial occlusion or renal infarct has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Imaging of Mesenteric Ischemia” [55]).
E. MRA Chest Without and With IV Contrast
Variant 2: The variant assumes that a mesenteric/renal arterial occlusion or renal infarct has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Imaging of Mesenteric Ischemia” [55]).
F. MRA Chest Without IV Contrast
Variant 2: The variant assumes that a mesenteric/renal arterial occlusion or renal infarct has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Imaging of Mesenteric Ischemia” [55]).
G. MRA Chest and Abdomen Without and With IV Contrast
Variant 2: The variant assumes that a mesenteric/renal arterial occlusion or renal infarct has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Imaging of Mesenteric Ischemia” [55]).
H. MRA Chest and Abdomen Without IV Contrast
Variant 2: The variant assumes that a mesenteric/renal arterial occlusion or renal infarct has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Imaging of Mesenteric Ischemia” [55]).
I. MRI Heart Function and Morphology Without and With IV Contrast
Variant 2: The variant assumes that a mesenteric/renal arterial occlusion or renal infarct has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Imaging of Mesenteric Ischemia” [55]).
J. MRI Heart Function and Morphology Without IV Contrast
Variant 2: The variant assumes that a mesenteric/renal arterial occlusion or renal infarct has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Imaging of Mesenteric Ischemia” [55]).
K. US Duplex Doppler Abdomen
Variant 2: The variant assumes that a mesenteric/renal arterial occlusion or renal infarct has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Imaging of Mesenteric Ischemia” [55]).
L. US Echocardiography Transesophageal
Variant 2: The variant assumes that a mesenteric/renal arterial occlusion or renal infarct has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Imaging of Mesenteric Ischemia” [55]).
M. US Echocardiography Transthoracic Resting
Variant 3: The variant assumes that a lower extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Sudden Onset of Cold, Painful Leg” [59]).
Variant 3: The variant assumes that a lower extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Sudden Onset of Cold, Painful Leg” [59]).
A. Aortography Chest, Abdomen, and Pelvis
Variant 3: The variant assumes that a lower extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Sudden Onset of Cold, Painful Leg” [59]).
B. CT Heart Function and Morphology With IV Contrast
Variant 3: The variant assumes that a lower extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Sudden Onset of Cold, Painful Leg” [59]).
C. CTA Chest With IV Contrast
Variant 3: The variant assumes that a lower extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Sudden Onset of Cold, Painful Leg” [59]).
D. CTA Chest, Abdomen, and Pelvis With IV Contrast
Variant 3: The variant assumes that a lower extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Sudden Onset of Cold, Painful Leg” [59]).
E. MRA Chest Without and With IV Contrast
Variant 3: The variant assumes that a lower extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Sudden Onset of Cold, Painful Leg” [59]).
F. MRA Chest Without IV Contrast
Variant 3: The variant assumes that a lower extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Sudden Onset of Cold, Painful Leg” [59]).
G. MRA Chest, Abdomen, and Pelvis Without and With IV Contrast
Variant 3: The variant assumes that a lower extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Sudden Onset of Cold, Painful Leg” [59]).
H. MRA Chest, Abdomen, and Pelvis Without IV Contrast
Variant 3: The variant assumes that a lower extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Sudden Onset of Cold, Painful Leg” [59]).
I. MRI Heart Function and Morphology Without and With IV Contrast
Variant 3: The variant assumes that a lower extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Sudden Onset of Cold, Painful Leg” [59]).
J. MRI Heart Function and Morphology Without IV Contrast
Variant 3: The variant assumes that a lower extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Sudden Onset of Cold, Painful Leg” [59]).
K. US Duplex Doppler Abdomen
Variant 3: The variant assumes that a lower extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Sudden Onset of Cold, Painful Leg” [59]).
L. US Echocardiography Transesophageal
Variant 3: The variant assumes that a lower extremity arterial occlusion has already been established. Typically, this diagnosis is made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used (see the ACR Appropriateness Criteria® topic on "Sudden Onset of Cold, Painful Leg” [59]).
M. US Echocardiography Transthoracic Resting
Variant 4: The variant assumes that multiorgan arterial occlusions have already been established. Typically, these diagnoses are made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
Variant 4: The variant assumes that multiorgan arterial occlusions have already been established. Typically, these diagnoses are made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
A. CT Heart Function and Morphology With IV Contrast
Variant 4: The variant assumes that multiorgan arterial occlusions have already been established. Typically, these diagnoses are made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
B. CTA Chest With IV Contrast
Variant 4: The variant assumes that multiorgan arterial occlusions have already been established. Typically, these diagnoses are made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
C. CTA Chest, Abdomen, and Pelvis With IV contrast
Variant 4: The variant assumes that multiorgan arterial occlusions have already been established. Typically, these diagnoses are made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
D. MRA Chest Without and With IV Contrast
Variant 4: The variant assumes that multiorgan arterial occlusions have already been established. Typically, these diagnoses are made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
E. MRA Chest Without IV Contrast
Variant 4: The variant assumes that multiorgan arterial occlusions have already been established. Typically, these diagnoses are made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
F. MRA Chest, Abdomen, and Pelvis Without and With IV Contrast
Variant 4: The variant assumes that multiorgan arterial occlusions have already been established. Typically, these diagnoses are made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
G. MRA Chest, Abdomen, and Pelvis Without IV Contrast
Variant 4: The variant assumes that multiorgan arterial occlusions have already been established. Typically, these diagnoses are made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
H. MRI Heart Function and Morphology Without and With IV Contrast
Variant 4: The variant assumes that multiorgan arterial occlusions have already been established. Typically, these diagnoses are made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
I. MRI Heart Function and Morphology Without IV Contrast
Variant 4: The variant assumes that multiorgan arterial occlusions have already been established. Typically, these diagnoses are made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
J. US Duplex Doppler Abdomen
Variant 4: The variant assumes that multiorgan arterial occlusions have already been established. Typically, these diagnoses are made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
K. US Echocardiography Transesophageal
Variant 4: The variant assumes that multiorgan arterial occlusions have already been established. Typically, these diagnoses are made by CTA, arteriography, or MRA, although the clinical examination or another imaging study could also be used.
L. US Echocardiography Transthoracic Resting
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
References
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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