Soft Tissue Vascular Anomalies: Vascular Malformations and Infantile Vascular Tumors (Non-CNS)-Child

Variant: 1 Infant. Clinical signs or symptoms of infantile hemangioma. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US area of interest	Usually Appropriate	O
US duplex Doppler area of interest	Usually Appropriate	O
MRA and MRV area of interest without and with IV contrast	May Be Appropriate	O
MRI area of interest without and with IV contrast	May Be Appropriate	O
CT area of interest with IV contrast	May Be Appropriate	Varies
US area of interest with IV contrast	Usually Not Appropriate	O
Arteriography area of interest	Usually Not Appropriate	Varies
Radiography area of interest	Usually Not Appropriate	Varies
MRI area of interest without IV contrast	Usually Not Appropriate	O
CT area of interest without and with IV contrast	Usually Not Appropriate	Varies
CT area of interest without IV contrast	Usually Not Appropriate	Varies
CTA and CTV area of interest with IV contrast	Usually Not Appropriate	Varies

Variant: 2 Infant. Multiple cutaneous infantile hemangiomas, screening for infantile hepatic hemangiomas. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US abdomen	Usually Appropriate	O
US duplex Doppler abdomen	Usually Appropriate	O
US abdomen with IV contrast	May Be Appropriate (Disagreement)	O
Radiography abdomen	Usually Not Appropriate	☢☢
Arteriography abdomen	Usually Not Appropriate	☢☢☢☢☢
CTA and CTV abdomen with IV contrast	Usually Not Appropriate	☢☢☢☢☢
MRA and MRV abdomen without and with IV contrast	Usually Not Appropriate	O
MRI abdomen without and with IV contrast	Usually Not Appropriate	O
MRI abdomen without IV contrast	Usually Not Appropriate	O
CT abdomen with IV contrast	Usually Not Appropriate	☢☢☢☢
CT abdomen without IV contrast	Usually Not Appropriate	☢☢☢☢
CT abdomen without and with IV contrast	Usually Not Appropriate	☢☢☢☢☢

Variant: 3 Child. Clinical signs or symptoms of vascular anomaly (tumor or malformation) not suggesting infantile hemangioma. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US area of interest	Usually Appropriate	O
US duplex Doppler area of interest	Usually Appropriate	O
MRA and MRV area of interest without and with IV contrast	Usually Appropriate	O
MRI area of interest without and with IV contrast	Usually Appropriate	O
US area of interest with IV contrast	May Be Appropriate (Disagreement)	O
MRA area of interest without IV contrast	May Be Appropriate (Disagreement)	O
MRI area of interest without IV contrast	May Be Appropriate	O
Arteriography area of interest	Usually Not Appropriate	Varies
Radiography area of interest	Usually Not Appropriate	Varies
CT area of interest with IV contrast	Usually Not Appropriate	Varies
CT area of interest without and with IV contrast	Usually Not Appropriate	Varies
CT area of interest without IV contrast	Usually Not Appropriate	Varies
CTA and CTV area of interest with IV contrast	Usually Not Appropriate	Varies

Variant: 4 Child. Ultrasound features raise suspicion for vascular malformation. Next imaging study.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRA and MRV area of interest without and with IV contrast	Usually Appropriate	O
MRI area of interest without and with IV contrast	Usually Appropriate	O
CT area of interest with IV contrast	May Be Appropriate	Varies
CTA and CTV area of interest with IV contrast	May Be Appropriate	Varies
US area of interest with IV contrast	Usually Not Appropriate	O
Arteriography area of interest	Usually Not Appropriate	Varies
Radiography area of interest	Usually Not Appropriate	Varies
MRI area of interest without IV contrast	Usually Not Appropriate	O
CT area of interest without and with IV contrast	Usually Not Appropriate	Varies
CT area of interest without IV contrast	Usually Not Appropriate	Varies

Variant: 5 Child. Established diagnosis of vascular malformation presenting with new or persistent signs or symptoms. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US duplex Doppler area of interest	Usually Appropriate	O
MRA and MRV area of interest without and with IV contrast	Usually Appropriate	O
MRI area of interest without and with IV contrast	Usually Appropriate	O
US area of interest	May Be Appropriate	O
US area of interest with IV contrast	May Be Appropriate	O
Arteriography area of interest	Usually Not Appropriate	Varies
Radiography area of interest	Usually Not Appropriate	Varies
MRI area of interest without IV contrast	Usually Not Appropriate	O
CT area of interest with IV contrast	Usually Not Appropriate	Varies
CT area of interest without and with IV contrast	Usually Not Appropriate	Varies
CT area of interest without IV contrast	Usually Not Appropriate	Varies
CTA and CTV area of interest with IV contrast	Usually Not Appropriate	Varies

Panel Members

Dianna M. E. Bardo, MD^a; Anne E. Gill, MD^b; Ramesh S. Iyer, MD, MBA^c; Sherwin S. Chan, MD, PhD^d; Matthew L. Cooper, MD^e; Roshni A. Dasgupta, MD^f; Carolina V. Guimaraes, MD^g; Matthew R. Hammer, MD^h; Daniel P. Krowchuk, MDⁱ; Terry L. Levin, MD^j; Marilyn G. Liang, MD^k; Mariana L. Meyers, MD^l; Jonathan D. Samet, MD^m; Marla B.K. Sammer, MD, MHAⁿ; Gary R. Schooler, MD^o; Judy H. Squires, MD^p; Amit S. Sura, MD, MBA^q; Andrew T. Trout, MD^r; Sumit Pruthi, MD, MBBS^s.

Summary of Literature Review

Introduction/Background

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)

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: Infant. Clinical signs or symptoms of infantile hemangioma. Initial imaging.

Variant 1: Infant. Clinical signs or symptoms of infantile hemangioma. Initial imaging.
A. Arteriography area of interest

Variant 1: Infant. Clinical signs or symptoms of infantile hemangioma. Initial imaging.
B. CT area of interest with IV contrast

Variant 1: Infant. Clinical signs or symptoms of infantile hemangioma. Initial imaging.
C. CT area of interest without and with IV contrast

Variant 1: Infant. Clinical signs or symptoms of infantile hemangioma. Initial imaging.
D. CT area of interest without IV contrast

Variant 1: Infant. Clinical signs or symptoms of infantile hemangioma. Initial imaging.
E. CTA and CTV area of interest with IV contrast

Variant 1: Infant. Clinical signs or symptoms of infantile hemangioma. Initial imaging.
F. MRA and MRV area of interest without and with IV contrast

Variant 1: Infant. Clinical signs or symptoms of infantile hemangioma. Initial imaging.
G. MRI area of interest without and with IV contrast

Variant 1: Infant. Clinical signs or symptoms of infantile hemangioma. Initial imaging.
H. MRI area of interest without IV contrast

Variant 1: Infant. Clinical signs or symptoms of infantile hemangioma. Initial imaging.
I. Radiography area of interest

Variant 1: Infant. Clinical signs or symptoms of infantile hemangioma. Initial imaging.
J. US area of interest

Variant 1: Infant. Clinical signs or symptoms of infantile hemangioma. Initial imaging.
K. US area of interest with IV contrast

Variant 1: Infant. Clinical signs or symptoms of infantile hemangioma. Initial imaging.
L. US duplex Doppler area of interest

Variant 2: Infant. Multiple cutaneous infantile hemangiomas, screening for infantile hepatic hemangiomas. Initial imaging.

Variant 2: Infant. Multiple cutaneous infantile hemangiomas, screening for infantile hepatic hemangiomas. Initial imaging.
A. Arteriography abdomen

Variant 2: Infant. Multiple cutaneous infantile hemangiomas, screening for infantile hepatic hemangiomas. Initial imaging.
B. CT abdomen with IV contrast

Variant 2: Infant. Multiple cutaneous infantile hemangiomas, screening for infantile hepatic hemangiomas. Initial imaging.
C. CT abdomen without and with IV contrast

Variant 2: Infant. Multiple cutaneous infantile hemangiomas, screening for infantile hepatic hemangiomas. Initial imaging.
D. CT abdomen without IV contrast

Variant 2: Infant. Multiple cutaneous infantile hemangiomas, screening for infantile hepatic hemangiomas. Initial imaging.
E. CTA and CTV abdomen with IV contrast

Variant 2: Infant. Multiple cutaneous infantile hemangiomas, screening for infantile hepatic hemangiomas. Initial imaging.
F. MRA and MRV abdomen without and with IV contrast

Variant 2: Infant. Multiple cutaneous infantile hemangiomas, screening for infantile hepatic hemangiomas. Initial imaging.
G. MRI abdomen without and with IV contrast

Variant 2: Infant. Multiple cutaneous infantile hemangiomas, screening for infantile hepatic hemangiomas. Initial imaging.
H. MRI abdomen without IV contrast

Variant 2: Infant. Multiple cutaneous infantile hemangiomas, screening for infantile hepatic hemangiomas. Initial imaging.
I. Radiography abdomen

Variant 2: Infant. Multiple cutaneous infantile hemangiomas, screening for infantile hepatic hemangiomas. Initial imaging.
J. US abdomen

Variant 2: Infant. Multiple cutaneous infantile hemangiomas, screening for infantile hepatic hemangiomas. Initial imaging.
K. US abdomen with IV contrast

Variant 2: Infant. Multiple cutaneous infantile hemangiomas, screening for infantile hepatic hemangiomas. Initial imaging.
L. US duplex Doppler abdomen

Variant 3: Child. Clinical signs or symptoms of vascular anomaly (tumor or malformation) not suggesting infantile hemangioma. Initial imaging.

Variant 3: Child. Clinical signs or symptoms of vascular anomaly (tumor or malformation) not suggesting infantile hemangioma. Initial imaging.
A. Arteriography area of interest

Variant 3: Child. Clinical signs or symptoms of vascular anomaly (tumor or malformation) not suggesting infantile hemangioma. Initial imaging.
B. CT area of interest with IV contrast

Variant 3: Child. Clinical signs or symptoms of vascular anomaly (tumor or malformation) not suggesting infantile hemangioma. Initial imaging.
C. CT area of interest without and with IV contrast

Variant 3: Child. Clinical signs or symptoms of vascular anomaly (tumor or malformation) not suggesting infantile hemangioma. Initial imaging.
D. CT area of interest without IV contrast

Variant 3: Child. Clinical signs or symptoms of vascular anomaly (tumor or malformation) not suggesting infantile hemangioma. Initial imaging.
E. CTA and CTV area of interest with IV contrast

Variant 3: Child. Clinical signs or symptoms of vascular anomaly (tumor or malformation) not suggesting infantile hemangioma. Initial imaging.
F. MRA and MRV area of interest without and with IV contrast

Variant 3: Child. Clinical signs or symptoms of vascular anomaly (tumor or malformation) not suggesting infantile hemangioma. Initial imaging.
G. MRA area of interest without IV contrast

Variant 3: Child. Clinical signs or symptoms of vascular anomaly (tumor or malformation) not suggesting infantile hemangioma. Initial imaging.
H. MRI area of interest without and with IV contrast

Variant 3: Child. Clinical signs or symptoms of vascular anomaly (tumor or malformation) not suggesting infantile hemangioma. Initial imaging.
I. MRI area of interest without IV contrast

Variant 3: Child. Clinical signs or symptoms of vascular anomaly (tumor or malformation) not suggesting infantile hemangioma. Initial imaging.
J. Radiography area of interest

Variant 3: Child. Clinical signs or symptoms of vascular anomaly (tumor or malformation) not suggesting infantile hemangioma. Initial imaging.
K. US area of interest

Variant 3: Child. Clinical signs or symptoms of vascular anomaly (tumor or malformation) not suggesting infantile hemangioma. Initial imaging.
L. US area of interest with IV contrast

Variant 3: Child. Clinical signs or symptoms of vascular anomaly (tumor or malformation) not suggesting infantile hemangioma. Initial imaging.
M. US duplex Doppler area of interest

Variant 4: Child. Ultrasound features raise suspicion for vascular malformation. Next imaging study.

Variant 4: Child. Ultrasound features raise suspicion for vascular malformation. Next imaging study.
A. Arteriography area of interest

Variant 4: Child. Ultrasound features raise suspicion for vascular malformation. Next imaging study.
B. CT area of interest with IV contrast

Variant 4: Child. Ultrasound features raise suspicion for vascular malformation. Next imaging study.
C. CT area of interest without and with IV contrast

Variant 4: Child. Ultrasound features raise suspicion for vascular malformation. Next imaging study.
D. CT area of interest without IV contrast

Variant 4: Child. Ultrasound features raise suspicion for vascular malformation. Next imaging study.
E. CTA and CTV area of interest with IV contrast

Variant 4: Child. Ultrasound features raise suspicion for vascular malformation. Next imaging study.
F. MRA and MRV area of interest without and with IV contrast

Variant 4: Child. Ultrasound features raise suspicion for vascular malformation. Next imaging study.
G. MRI area of interest without and with IV contrast

Variant 4: Child. Ultrasound features raise suspicion for vascular malformation. Next imaging study.
H. MRI area of interest without IV contrast

Variant 4: Child. Ultrasound features raise suspicion for vascular malformation. Next imaging study.
I. Radiography area of interest

Variant 4: Child. Ultrasound features raise suspicion for vascular malformation. Next imaging study.
J. US area of interest with IV contrast

Variant 5: Child. Established diagnosis of vascular malformation presenting with new or persistent signs or symptoms. Initial imaging.

Variant 5: Child. Established diagnosis of vascular malformation presenting with new or persistent signs or symptoms. Initial imaging.
A. Arteriography area of interest

Variant 5: Child. Established diagnosis of vascular malformation presenting with new or persistent signs or symptoms. Initial imaging.
B. CT area of interest with IV contrast

Variant 5: Child. Established diagnosis of vascular malformation presenting with new or persistent signs or symptoms. Initial imaging.
C. CT area of interest without and with IV contrast

Variant 5: Child. Established diagnosis of vascular malformation presenting with new or persistent signs or symptoms. Initial imaging.
D. CT area of interest without IV contrast

Variant 5: Child. Established diagnosis of vascular malformation presenting with new or persistent signs or symptoms. Initial imaging.
E. CTA and CTV area of interest with IV contrast

Variant 5: Child. Established diagnosis of vascular malformation presenting with new or persistent signs or symptoms. Initial imaging.
F. MRA and MRV area of interest without and with IV contrast

Variant 5: Child. Established diagnosis of vascular malformation presenting with new or persistent signs or symptoms. Initial imaging.
G. MRI area of interest without and with IV contrast

Variant 5: Child. Established diagnosis of vascular malformation presenting with new or persistent signs or symptoms. Initial imaging.
H. MRI area of interest without IV contrast

Variant 5: Child. Established diagnosis of vascular malformation presenting with new or persistent signs or symptoms. Initial imaging.
I. Radiography area of interest

Variant 5: Child. Established diagnosis of vascular malformation presenting with new or persistent signs or symptoms. Initial imaging.
J. US area of interest

Variant 5: Child. Established diagnosis of vascular malformation presenting with new or persistent signs or symptoms. Initial imaging.
K. US area of interest with IV contrast

Variant 5: Child. Established diagnosis of vascular malformation presenting with new or persistent signs or symptoms. Initial imaging.
L. US duplex Doppler area of interest

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.