Practice Guideline

. 2022 Nov;19(11S):S364-S373.

doi: 10.1016/j.jacr.2022.09.002.

ACR Appropriateness Criteria® Lower Extremity Arterial Claudication-Imaging Assessment for Revascularization: 2022 Update

Expert Panel on Vascular Imaging; Ezana M Azene¹, Michael L Steigner², Ayaz Aghayev³, Sarah Ahmad⁴, Rachel E Clough⁵, Maros Ferencik⁶, Sandeep S Hedgire⁷, Caitlin W Hicks⁸, David S Kirsch⁹, Yoo Jin Lee¹⁰, Lee A Myers¹¹, Prashant Nagpal¹², Nicholas Osborne¹³, Anil K Pillai¹⁴, Beth Ripley¹⁵, Nimarta Singh¹⁶, Richard Thomas¹⁷, Sanjeeva P Kalva¹⁸

Affiliations

¹ Director of PERT, Chair Cancer Advisory Council, Medical Governor, Gundersen Health System, La Crosse, Wisconsin. Electronic address: emazene@gundersenhealth.org.
² Panel Chair; Director, Vascular CT/MR, Medical Director 3D Lab, Brigham & Women's Hospital, Boston, Massachusetts.
³ Panel Vice-Chair, Brigham & Women's Hospital, Boston, Massachusetts.
⁴ University of Toronto, Toronto, Ontario, Canada; American College of Physicians.
⁵ St. Thomas' Hospital, King's College, School of Biomedical Engineering and Imaging Science, London, United Kingdom; Society for Cardiovascular Magnetic Resonance.
⁶ Section Head of Cardiovascular Imaging, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Society of Cardiovascular Computed Tomography.
⁷ Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
⁸ Director of Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Maryland; Editor-in-Chief, Seminars in Vascular Surgery; Society for Vascular Surgery.
⁹ Ochsner Hospital, New Orleans, Louisiana.
¹⁰ University of California, San Francisco, San Francisco, California.
¹¹ Keck School of Medicine of USC, Los Angeles, California; Committee on Emergency Radiology-GSER.
¹² Head, Cardiovascular Imaging, University of Wisconsin, Madison, Wisconsin.
¹³ University of Michigan, Ann Arbor, Michigan; Society for Vascular Surgery.
¹⁴ Section Chief, Interventional Radiology, UT Southwestern Medical Center, Dallas, Texas.
¹⁵ VA Puget Sound Health Care System and University of Washington, Seattle, Washington.
¹⁶ Mercyhealth, Rockford, Illinois.
¹⁷ Section Chief of Thoracic Imaging and Cardiac CT and Associate Magnetic Resonance Medical Director, Lahey Hospital and Medical Center, Burlington, Massachusetts.
¹⁸ Specialty Chair; Chief of Interventional Radiology, Massachusetts General Hospital, Boston, Massachusetts.

PMID: 36436963
PMCID: PMC9876734
DOI: 10.1016/j.jacr.2022.09.002

Practice Guideline

ACR Appropriateness Criteria® Lower Extremity Arterial Claudication-Imaging Assessment for Revascularization: 2022 Update

Expert Panel on Vascular Imaging et al. J Am Coll Radiol. 2022 Nov.

. 2022 Nov;19(11S):S364-S373.

doi: 10.1016/j.jacr.2022.09.002.

Authors

Affiliations

¹ Director of PERT, Chair Cancer Advisory Council, Medical Governor, Gundersen Health System, La Crosse, Wisconsin. Electronic address: emazene@gundersenhealth.org.
² Panel Chair; Director, Vascular CT/MR, Medical Director 3D Lab, Brigham & Women's Hospital, Boston, Massachusetts.
³ Panel Vice-Chair, Brigham & Women's Hospital, Boston, Massachusetts.
⁴ University of Toronto, Toronto, Ontario, Canada; American College of Physicians.
⁵ St. Thomas' Hospital, King's College, School of Biomedical Engineering and Imaging Science, London, United Kingdom; Society for Cardiovascular Magnetic Resonance.
⁶ Section Head of Cardiovascular Imaging, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Society of Cardiovascular Computed Tomography.
⁷ Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
⁸ Director of Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Maryland; Editor-in-Chief, Seminars in Vascular Surgery; Society for Vascular Surgery.
⁹ Ochsner Hospital, New Orleans, Louisiana.
¹⁰ University of California, San Francisco, San Francisco, California.
¹¹ Keck School of Medicine of USC, Los Angeles, California; Committee on Emergency Radiology-GSER.
¹² Head, Cardiovascular Imaging, University of Wisconsin, Madison, Wisconsin.
¹³ University of Michigan, Ann Arbor, Michigan; Society for Vascular Surgery.
¹⁴ Section Chief, Interventional Radiology, UT Southwestern Medical Center, Dallas, Texas.
¹⁵ VA Puget Sound Health Care System and University of Washington, Seattle, Washington.
¹⁶ Mercyhealth, Rockford, Illinois.
¹⁷ Section Chief of Thoracic Imaging and Cardiac CT and Associate Magnetic Resonance Medical Director, Lahey Hospital and Medical Center, Burlington, Massachusetts.
¹⁸ Specialty Chair; Chief of Interventional Radiology, Massachusetts General Hospital, Boston, Massachusetts.

PMID: 36436963
PMCID: PMC9876734
DOI: 10.1016/j.jacr.2022.09.002

Abstract

Arterial claudication is a common manifestation of peripheral artery disease. This document focuses on necessary imaging before revascularization for claudication. Appropriate use of ultrasound, invasive arteriography, MR angiography, and CT angiography are discussed. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Keywords: AUC; Angiography; Appropriate Use Criteria; Appropriateness Criteria; CT angiography (CTA); Claudication; MR angiography (MRA); Peripheral artery disease; Ultrasound.

PubMed Disclaimer

Conflict of interest statement

The authors state that they have no conflict of interest related to the material discussed in this article. The authors are non-partner/non-partnership track/employees.

Cited by

Patient-tailored versus fixed post-trigger delay for optimized scan timing: a comparison of image quality and diagnostic confidence in run-off CT angiography.
Qi K, Nie K, Bernhard S, Wang Y, Tian Y, Lyu P, Gao J, Shao B, Li S, Zhang Y, Zhang W, Zhang M, Liu J. Qi K, et al. Eur Radiol. 2025 Jun 7. doi: 10.1007/s00330-025-11731-w. Online ahead of print. Eur Radiol. 2025. PMID: 40481875
Low-iodine 40-keV virtual monoenergetic CT angiography of the lower extremities.
Fahrni G, Mingas T, Deliessche A, Hraichi S, Rotzinger DC, Si-Mohamed SA, Boccalini S, Douek P. Fahrni G, et al. Front Cardiovasc Med. 2023 Oct 23;10:1276738. doi: 10.3389/fcvm.2023.1276738. eCollection 2023. Front Cardiovasc Med. 2023. PMID: 37942065 Free PMC article.

References

1. Leng GC, Lee AJ, Fowkes FG, et al. Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population. Int J Epidemiol 1996;25:1172–81. - PubMed
1. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. J Am Coll Cardiol 2006;47:1239–312. - PubMed
1. Alzamora MT, Fores R, Baena-Diez JM, et al. The peripheral arterial disease study (PERART/ARTPER): prevalence and risk factors in the general population. BMC Public Health 2010;10:38. - PMC - PubMed
1. Muluk SC, Muluk VS, Kelley ME, et al. Outcome events in patients with claudication: a 15-year study in 2777 patients. J Vasc Surg 2001;33:251–7; discussion 57–8. - PubMed
1. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: executive summary. Vasc Med 2017;22:NP1–43. - PubMed

Publication types

Actions

MeSH terms

Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions

Grants and funding

K23 DK124515/DK/NIDDK NIH HHS/United States

LinkOut - more resources

Full Text Sources
Medical
- MedlinePlus Health Information

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

ACR Appropriateness Criteria® Lower Extremity Arterial Claudication-Imaging Assessment for Revascularization: 2022 Update

Affiliations

ACR Appropriateness Criteria® Lower Extremity Arterial Claudication-Imaging Assessment for Revascularization: 2022 Update

Authors

Affiliations

Abstract

Conflict of interest statement

Similar articles

Cited by

References

Publication types

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources

Medical

Abstract

Conflict of interest statement

Similar articles

Cited by

References

Publication types

MeSH terms

Related information

Grants and funding

LinkOut - more resources

Full Text Sources

Medical