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## Complete Summary

#### GUIDELINE TITLE

Claudication.

#### BIBLIOGRAPHIC SOURCE(S)

Sacks D, Bettmann MA, Casciani T, Gomes AS, Grollman J, Holtzman SR,
Polak JF, Stanford W, Jaff M, Moneta GL, Expert Panel on Cardiovascular
Imaging. Claudication. \[online publication\]. Reston (VA): American
College of Radiology (ACR); 2005. 6 p. \[56 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

It updates a previously published version: Bettmann MA, Boxt LM, Gomes
AS, Grollman J, Henkin RE, Higgins CB, Kelley MJ, Needleman L,
Pagan-Marin H, Polak JF, Stanford W, Levin DC, Gardiner GA. Diagnostic
imaging in patients with claudication. American College of Radiology.
ACR Appropriateness Criteria. Radiology 2000 Jun;215(Suppl):61-5. \[44
references\]

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [May 23, 2007, Gadolinium-based Contrast
    Agents](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Gadolinium):
    The addition of a boxed warning and new warnings about the risk of
    nephrogenic systemic fibrosis (NSF) to the full prescribing
    information for all gadolinium-based contrast agents (GBCAs).

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Claudication

#### GUIDELINE CATEGORY

Diagnosis

#### CLINICAL SPECIALTY

Cardiology\
Family Practice\
Internal Medicine\
Radiology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of initial radiologic examinations for
patients with claudication

#### TARGET POPULATION

Patients with claudication

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Physiological noninvasive tests

2.  Invasive (INV) tests

    -   Lower extremity angiography

    -   Cine angiography

3.  Lower extremity magnetic resonance angiography (MRA)

4.  Lower extremity computed tomography angiography (CTA)

5.  Ultrasound (US)

    -   Lower extremity, Duplex, spectral and color

    -   Lower extremity, Doppler, spectral only

    -   Lower extremity, venous, duplex

    -   Heart, echocardiography

6.  X-ray, lumbosacral spine

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in differential diagnosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals, and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed for reaching agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1-9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by the Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Diagnostic Imaging in Patients with Claudication**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  Physiological        9                    
  noninvasive tests                        

  INV, lower           8                   If noninvasive tests are abnormal.
  extremity,                               
  angiography                              

  MRA, lower extremity 8                    

  CTA, lower extremity 6                    

  US, lower extremity, 6                    
  Duplex, spectral and                     
  color                                    

  US, lower extremity, 5                    
  Doppler, spectral                        
  only                                     

  X-ray, lumbosacral   3                    
  spine                                    

  US, heart,           2                    
  echocardiography                         

  US, lower extremity, 2                    
  venous, duplex                           

  INV, Cine            1                    
  angiography                              

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the table are listed at the end of the
\"Major Recommendations\" field.

Claudication is a symptom complex characterized by pain and weakness in
an active muscle group, reproducibly precipitated by similar amounts of
exercise and promptly relieved by rest. Claudication is the most common
manifestation of peripheral arterial disease, but other disease entities
can cause a similar clinical picture. Non-arterial etiologies have been
reported as the cause of symptoms in 20-38% of patients being evaluated
for claudication. The most common non-arterial cause is neurogenic
disease (especially spinal stenosis), but other diseases such as
compartment syndromes, pelvic tumors, and chronic venous occlusion have
also been associated with symptoms similar to claudication. In addition,
most patients with peripheral arterial occlusive disease are
asymptomatic; as few as 6-20% of such patients will have symptoms of
claudication.

Estimates of the prevalence of claudication in the general population
range from less than 1% to almost 8% depending on the age, gender,
geographic location of the population and the diagnostic criteria used.
The presence of vascular disease in patients with symptoms of
claudication is reliably established by a variety of noninvasive
hemodynamic tests. In patients who do not have demonstrable arterial
disease, imaging studies of other systems such as the lumbar spine or
soft tissues of the pelvis may be indicated. If the presence of
peripheral vascular disease is confirmed, additional studies may be
indicated to screen for other commonly associated diseases that may have
an important impact on patient survival, such as coronary artery
disease.

Since the presence and severity of arterial obstructions are reliably
established using noninvasive hemodynamic tests such as the ankle
brachial index (ABI), toe brachial index (TBI), segmental pressures, or
pulse volume recordings (PVR), imaging studies are reserved for
circumstances that warrant consideration for invasive therapy. The
indications for surgical or interventional procedures in patients with
claudication are controversial, and thus specific indications for
imaging studies remain ill-defined. Some factors that influence this
decision include 1) the natural history of limb and patient survival, 2)
the patient\'s tolerance of symptoms and resulting changes in lifestyle,
3) the effectiveness of medical or exercise therapy, 4) the potential
risks of invasive tests and treatments, and 5) the short-term and
long-term outcomes of surgery or interventional procedures. Based on
natural history studies, the risk of amputation in patients suffering
from claudication is approximately 1% per year. Since most of these
studies were performed before the era of noninvasive testing, many
patients who did not actually have vascular disease were probably
included, thereby possibly underestimating the frequency of serious
complications. Modern natural history studies, using noninvasive
hemodynamic tests to confirm the presence of vascular disease, show that
progression of symptoms occurs in 25-60% of surviving patients within 5
years of presentation. Because the risks associated with interventional
procedures are low compared with surgery, image-guided interventional
studies may be indicated for less severe disease than if surgery were
the only option for treatment.

**Noninvasive Hemodynamic Studies**

In combination with the history and physical examination of patients,
noninvasive hemodynamic studies have become an important tool for the
evaluation of peripheral vascular disease. Their importance is related
to their ability to provide an objective test for the presence or
absence of peripheral vascular disease. They also provide a valuable
means of quantifying the severity of vascular disease and are useful in
documenting the functional significance of arterial lesions demonstrated
by angiography.

There is no consensus regarding which test is most valuable or accurate,
because there may be considerable variability depending on clinical
circumstances. For instance, patients with stiff, noncompliant arteries
(often associated with diabetes) are difficult to study using tests such
as the ABI or segmental pressures that depend on measurements of
arterial pressure. In these patients the TBI or PVR may be more helpful.
Most laboratories use a combination of tests that increases overall
sensitivity and accuracy. The simplicity, reliability, and noninvasive
nature of these tests have led to their routine use in screening
patients with appropriate symptoms and physical findings. The presence
of a normal ABI both at rest and following exercise in a patient with
compressible vessels effectively excludes atherosclerotic occlusive
disease as a cause of leg claudication and obviates the need for
additional arterial imaging. However, the ABI will not evaluate for
hypogastric arterial occlusions that may produce buttock claudication.
The main limitation of noninvasive testing is that proving the presence
of vascular disease does not necessarily exclude the possibility that
symptoms are nonetheless caused by neurologic disease. Careful
correlation with clinical evaluation is necessary and, in certain cases,
tests to rule out neurologic disease (e.g., spine or pelvic MRI) may be
indicated.

*Contrast Angiography*

Once the decision has been made that invasive therapy is indicated, an
accurate and complete assessment of the peripheral arteries is essential
for adequate planning of the procedure. In most circumstances a complete
survey of the arterial system from the abdominal aorta to the pedal arch
is helpful. The gold standard for imaging the peripheral arteries is
multiprojection contrast angiography. Oblique views are usually
necessary for a complete study because of the overlapping of branching
vessels, the anteroposterior course of the pelvic vessels, and the
tendency of atherosclerotic plaque to develop on the posterior arterial
wall. The development of digital subtraction has enhanced the ability of
contrast angiography to visualize poorly opacifying distal vessels, and
permits multiple views while minimizing the amount of contrast injected.

Although contrast angiography remains the diagnostic standard for
peripheral vascular disease, it does have shortcomings that limit its
usefulness. The main diagnostic limitation of angiography is
inconsistent correlation between the hemodynamic or functional effects
and the morphology of the arterial lesions. Several studies have
reported this poor correlation, but in some of these studies the problem
may be accentuated by less than optimal angiographic technique (e.g.,
single projection, nonselective injections). Other factors are also
involved, however, such as diffusely diseased arteries that make it
difficult to estimate stenosis severity (no normal arterial segments are
available for comparison). In addition, serial lesions, luminal
irregularity, and the degree of collateral development may produce
effects on the blood flow that are difficult to quantify
angiographically. The other main drawback of contrast angiography is the
low but not insignificant incidence of complications, due to arterial
catheterization or injection of contrast material. Currently, with
improved noninvasive imaging, contrast angiography´s role in patients
with claudication is limited to situations in which a therapeutic
intervention is expected to be undertaken.

**Noninvasive Imaging**

*Duplex Ultrasound*

Duplex US of the extremities can be used to diagnose the anatomic
location and degree of stenosis. Although duplex US includes images, in
either black and white or color format, the primary clinically relevant
information derived from duplex studies has been validated from analysis
of the velocity of blood flow.

The sensitivity and specificity for the diagnosis of stenoses greater
than 50% diameter from the iliac arteries to the popliteal arteries are
each approximately 90-95%. Accuracy of the duplex exam depends on the
ability of the technique to visualize the vessel adequately. The use of
color improves accuracy. Accuracy is diminished in examinations of the
iliac arteries if bowel gas or tortuosity obscures the iliac vessels.
Dense calcification can also obscure flow, particularly if flow is slow.
The examination requires a highly skilled sonographer and can require
over an hour to perform.

Duplex US can be used for pre-intervention decision making, although
duplex may be inferior to angiography for evaluation of tibial arteries
for distal bypass. It is the standard technique for
post-revascularization surveillance of vein graft patency leading to
improved long-term graft patency. Duplex US surveillance of synthetic
grafts is of questionable value. Duplex US following angioplasty is
widely performed to detect recurrent stenoses but has not yet been
demonstrated to improve patient outcomes.

*Magnetic Resonance Angiography*

MRA techniques continue to evolve and improve. Techniques employed
include two-dimensional time of flight, three-dimensional imaging,
contrast enhancement with gadolinium, subtraction, cardiac gating, and
bolus chase. These techniques may be used in combination, as each has
advantages and disadvantages. The clinical use of these techniques for
peripheral vascular disease has met with considerable success. The
sensitivity and specificity for detection of stenoses \>50% diameter
compared to catheter angiography is 90-100%. Compared to color duplex
US, MRA is more accurate for detecting significant stenoses and for
preoperative planning. Studies have demonstrated that MRA can be
effectively used to plan interventional or surgical procedures,
eliminating the necessity for conventional angiography. For
post-operative and post-angioplasty surveillance, small studies have
shown MRA to be helpful in detecting recurrent disease, but improved
outcomes for such surveillance have not been documented.

Some technical problems persist regarding the use of MRA for peripheral
vascular disease. These may include marginal image quality related to
low signal/noise ratio, limited spatial resolution, motion artifacts,
long acquisition times, unreliable visualization of lesions with high
flow and turbulence (excessive signal loss at regions of high-grade
stenoses), nonvisualization of patent vessel segments with reversed
blood flow, the need to exclude patients with pacemakers or other
metallic implants, and loss of signal in arterial segments within metal
stents or adjacent to metallic clips or prosthetic joints. Some of these
problems have been addressed successfully with the use of newer imaging
sequences and the addition of MR contrast agents.

MRA has not yet replaced catheter angiography as the gold standard, but
it has replaced angiography in some institutions as a pre-intervention
planning study. As contrast agents and MR imaging sequences improve, MRA
is likely to entirely supplant catheter angiography as a pure diagnostic
tool.

*Computed Tomography Angiography*

Spiral or helical CTA is increasingly used for peripheral vascular
disease. Multidetector CT scanners with up to 64 slices obtained
simultaneously allows scanning from the aorta to the feet in less than 1
minute. CTA has the advantage of offering three-dimensional images with
lower radiation dose than catheter angiography and with no need for an
arterial puncture. Iodinated contrast material is necessary, but in
doses comparable to or less than contrast angiography. The intravenous
injection of contrast during CTA fills all collateral vessels and
opacifies arteries distal to occlusions that may be occult by catheter
angiography. CTA images tissues surrounding the opacified lumen of the
artery and has demonstrated that some popliteal stenoses and occlusions
are due to aneurysms, popliteal entrapment, and cystic adventitial
disease that are not detected with catheter angiography. Spatial
resolution, although excellent overall, is lower than that of catheter
angiography. In general, however, this is not an important clinical
consideration.

Results of relatively small series of patients studied with CTA have
been excellent. Compared to catheter angiography the sensitivity and
specifity of CTA for detection of stenoses \>50% diameter is 90-100%.
However, diagnostic certainty is lower with CTA compared to catheter
angiography, leading to more recommendations for additional imaging.
Accuracy in patients with bypass grafts is excellent compared to duplex
ultrasound.

At this time, studies of CTA are fewer and smaller than those of MRA in
evaluating peripheral arteries. However, CTA has potential advantages
compared to MRA. Patients with pacemakers or defibrillators, who are
excluded from MRI, may be safely imaged with CTA. Metal clips, stents,
and prostheses usually do not cause significant CTA artifacts. CTA has
higher resolution and can provide images of calcification in the vessel
wall. As with MRA, extensive calcification may obscure the opacified
lumen with CTA. Scan times are significantly faster with CTA than MRA.
Claustrophobia is far less of a problem.

**Summary**

Multiple clinical and technical factors are involved in determining the
proper timing and technique for imaging the lower extremity arterial
system in patients with claudication. The purpose of imaging studies is
to define the location and extent of vascular lesions before a
percutaneous or surgical revascularization procedure. The clinical
success of these vascular procedures depends to a large extent on
accurate and complete visualization of the entire lower extremity
arterial system, or at least of the entire symptomatic extremity and the
pelvic vasculature.

Several noninvasive vascular imaging methods have been shown to be
useful in certain clinical situations. All, however, currently have
important practical limitations. Although the role of these techniques
in evaluating patients with peripheral vascular disease continues to
evolve, contrast angiography must still be considered the gold standard
even though it is rarely necessary for diagnosing claudication or
assessing the severity of arterial obstruction causing claudication. The
noninvasive imaging modalities, supplemented by physical examination and
history, usually provide all the information needed to confirm or
exclude the presence of peripheral vascular disease as the cause of
claudication. Further, they can provide sufficient information to
accurately plan medical, surgical, or catheter-directed treatment. The
choice of noninvasive imaging modality will depend on local expertise
and experience.

**Abbreviations**

-   CTA, computed tomography angiography

-   INV, invasive

-   MRA, magnetic resonance angiography

-   US, ultrasound

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate radiologic imaging procedures for evaluation of
patients with claudication

#### POTENTIAL HARMS

Although contrast angiography remains the diagnostic standard for
peripheral vascular disease, it does have shortcomings that limit its
usefulness. The main diagnostic limitation of angiography is
inconsistent correlation between the hemodynamic or functional effects
and the morphology of the arterial lesions. The other main drawback of
contrast angiography is the low but not insignificant incidence of
complications, due to arterial catheterization or injection of contrast
material.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (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 exams 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
U.S. Food and Drug Administration (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.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Sacks D, Bettmann MA, Casciani T, Gomes AS, Grollman J, Holtzman SR,
Polak JF, Stanford W, Jaff M, Moneta GL, Expert Panel on Cardiovascular
Imaging. Claudication. \[online publication\]. Reston (VA): American
College of Radiology (ACR); 2005. 6 p. \[56 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1995 (revised 2005)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Cardiovascular
Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Names of Panel Members*: David Sacks, MD (*Principal Author*); Michael
A. Bettmann, MD (*Panel Chair*); Thomas Casciani, MD; Antoinette S.
Gomes, MD; Julius Grollman, MD; Stephen R. Holtzman, MD; Joseph F.
Polak, MD, MPH; William Stanford, MD; Michael Jaff, MD; Gregory L.
Moneta, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

It updates a previously published version: Bettmann MA, Boxt LM, Gomes
AS, Grollman J, Henkin RE, Higgins CB, Kelley MJ, Needleman L,
Pagan-Marin H, Polak JF, Stanford W, Levin DC, Gardiner GA. Diagnostic
imaging in patients with claudication. American College of Radiology.
ACR Appropriateness Criteria. Radiology 2000 Jun;215(Suppl):61-5. \[44
references\]

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/Vascular/ClaudicationDoc9.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on February 20, 2001. The information
was verified by the guideline developer on March 14, 2001. This summary
was updated by ECRI on March 6, 2006. This summary was updated by ECRI
Institute on May 17, 2007 following the U.S. Food and Drug
Administration (FDA) advisory on Gadolinium-based contrast agents. This
summary was updated by ECRI Institute on June 20, 2007 following the
U.S. Food and Drug Administration (FDA) advisory on gadolinium-based
contrast agents.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008