Evaluation of Coronary Artery Anomalies

Variant: 1 Adult. Suspected coronary artery anomaly. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRA coronary arteries without and with IV contrast	Usually Appropriate	O
MRA coronary arteries without IV contrast	Usually Appropriate	O
CTA coronary arteries with IV contrast	Usually Appropriate	☢☢☢
US echocardiography transthoracic resting	May Be Appropriate	O
Arteriography coronary	May Be Appropriate	☢☢☢
US echocardiography transesophageal	Usually Not Appropriate	O
US echocardiography transthoracic stress	Usually Not Appropriate	O
MRA chest with IV contrast	Usually Not Appropriate	O
MRA chest without and with IV contrast	Usually Not Appropriate	O
MRA chest without IV contrast	Usually Not Appropriate	O
MRI heart function and morphology without and with IV contrast	Usually Not Appropriate	O
MRI heart function and morphology without IV contrast	Usually Not Appropriate	O
MRI heart function with stress without and with IV contrast	Usually Not Appropriate	O
MRI heart function with stress without IV contrast	Usually Not Appropriate	O
CT chest with IV contrast	Usually Not Appropriate	☢☢☢
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢
CT chest without IV contrast	Usually Not Appropriate	☢☢☢
CT coronary calcium	Usually Not Appropriate	☢☢☢
CTA chest with IV contrast	Usually Not Appropriate	☢☢☢
CTA chest without and with IV contrast	Usually Not Appropriate	☢☢☢
CT heart function and morphology with IV contrast	Usually Not Appropriate	☢☢☢☢
Rb-82 PET/CT MPI rest and stress	Usually Not Appropriate	☢☢☢☢
SPECT or SPECT/CT MPI rest and stress	Usually Not Appropriate	☢☢☢☢

Variant: 2 Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Arteriography coronary	Usually Appropriate	☢☢☢
CTA coronary arteries with IV contrast	Usually Appropriate	☢☢☢
US echocardiography transthoracic resting	May Be Appropriate (Disagreement)	O
US echocardiography transthoracic stress	May Be Appropriate	O
MRA coronary arteries without and with IV contrast	May Be Appropriate	O
MRA coronary arteries without IV contrast	May Be Appropriate	O
MRI heart function and morphology without and with IV contrast	May Be Appropriate	O
MRI heart function and morphology without IV contrast	May Be Appropriate	O
MRI heart function with stress without and with IV contrast	May Be Appropriate	O
MRI heart function with stress without IV contrast	May Be Appropriate	O
CTA chest with IV contrast	May Be Appropriate	☢☢☢
Rb-82 PET/CT MPI rest and stress	May Be Appropriate (Disagreement)	☢☢☢☢
SPECT or SPECT/CT MPI rest and stress	May Be Appropriate	☢☢☢☢
US echocardiography transesophageal	Usually Not Appropriate	O
MRA chest with IV contrast	Usually Not Appropriate	O
MRA chest without and with IV contrast	Usually Not Appropriate	O
MRA chest without IV contrast	Usually Not Appropriate	O
CT chest with IV contrast	Usually Not Appropriate	☢☢☢
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢
CT chest without IV contrast	Usually Not Appropriate	☢☢☢
CT coronary calcium	Usually Not Appropriate	☢☢☢
CTA chest without and with IV contrast	Usually Not Appropriate	☢☢☢
CT heart function and morphology with IV contrast	Usually Not Appropriate	☢☢☢☢

Panel Members

Cristina Fuss, MD^a; Raluca McCallum, MD^b; Brian B. Ghoshhajra, MD, MBA^c; Diana Litmanovich, MD^d; Prachi P. Agarwal, MD^e; Stephen Bloom, MD^f; William M. Brown, MD^g; Anjali Chelliah, MD^h; Carlo N. De Cecco, MD, PhDⁱ; Peter Frommelt, MD^j; Kimberly Kallianos, MD^k; Sachin B. Malik, MD^l; Constantine D. Mavroudis, MD, MSc, MTR^m; Nandini M. Meyersohn, MDⁿ; Sven Plein, MD^o; Tina D. Tailor, MD^p; Chadwick L. Wright, MD, PhD^q; Lynne M. Koweek, MD^r.

Summary of Literature Review

Introduction/Background

Initial Imaging Definition

Discussion of Procedures by Variant

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
A. Arteriography coronary

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
B. CT chest with IV contrast

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
C. CT chest without and with IV contrast

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
D. CT chest without IV contrast

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
E. CT coronary calcium

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
F. CT heart function and morphology with IV contrast

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
G. CTA chest with IV contrast

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
H. CTA chest without and with IV contrast

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
I. CTA coronary arteries with IV contrast

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
J. MRA chest with IV contrast

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
K. MRA chest without and with IV contrast

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
L. MRA chest without IV contrast

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
M. MRA coronary arteries without and with IV contrast

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
N. MRA coronary arteries without IV contrast

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
O. MRI heart function and morphology without and with IV contrast

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
P. MRI heart function and morphology without IV contrast

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
Q. MRI heart function with stress without and with IV contrast

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
R. MRI heart function with stress without IV contrast

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
S. Rb-82 PET/CT MPI rest and stress

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
T. SPECT or SPECT/CT MPI rest and stress

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
U. US echocardiography transesophageal

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
V. US echocardiography transthoracic resting

Variant 1: Adult. Suspected coronary artery anomaly. Initial imaging.
W. US echocardiography transthoracic stress

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
A. Arteriography coronary

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
B. CT chest with IV contrast

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
C. CT chest without and with IV contrast

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
D. CT chest without IV contrast

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
E. CT coronary calcium

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
F. CT heart function and morphology with IV contrast

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
G. CTA chest with IV contrast

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
H. CTA chest without and with IV contrast

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
I. CTA coronary arteries with IV contrast

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
J. MRA chest with IV contrast

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
K. MRA chest without and with IV contrast

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
L. MRA chest without IV contrast

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
M. MRA coronary arteries without and with IV contrast

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
N. MRA coronary arteries without IV contrast

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
O. MRI heart function and morphology without and with IV contrast

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
P. MRI heart function and morphology without IV contrast

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
Q. MRI heart function with stress without and with IV contrast

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
R. MRI heart function with stress without IV contrast

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
S. Rb-82 PET/CT MPI rest and stress

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
T. SPECT or SPECT/CT MPI rest and stress

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
U. US echocardiography transesophageal

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
V. US echocardiography transthoracic resting

Variant 2: Adult. Pretreatment planning for known coronary artery anomaly. Initial Imaging.
W. US echocardiography transthoracic stress

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.

Gender Equality and Inclusivity Clause

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

Appropriateness Category 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.