Dizziness and Ataxia

Dizziness and Ataxia. Atrophy of the cervical spinal cord has been reported in several forms of degenerative ataxia, which may be a helpful diagnostic finding in patients presenting with disequilibrium [78-80]. In patients with chronic disequilibrium due to sensory ataxia and loss of proprioception that is out of proportion to other sensory modalities and motor function, spine MRI is useful to evaluate the dorsal columns of the spinal cord (eg, compressive myelopathy, B12/copper deficiency, or tabes dorsalis neurosyphilis). MRI Head and Internal Auditory Canal With IV Contrast There is no relevant literature regarding the use of MRI head and IAC with IV contrast in the evaluation of sensory ataxia. MRI Head and Internal Auditory Canal Without and With IV Contrast There is no relevant literature regarding the use of MRI head and IAC without and with IV contrast in the evaluation of sensory ataxia. MRI Head and Internal Auditory Canal Without IV Contrast There is no relevant literature regarding the use of MRI head and IAC without IV contrast in the evaluation of sensory ataxia. MRI Head With IV Contrast There is no relevant literature regarding the use of MRI head with IV contrast in the evaluation of sensory ataxia. MRI Head Without and With IV Contrast There is no relevant literature regarding the use of MRI head without and with IV contrast in the evaluation of sensory ataxia. MRI Head Without IV Contrast There is no relevant literature regarding the use of MRI head without IV contrast in the evaluation of sensory ataxia. CT Head With IV Contrast There is no relevant literature regarding the use of CT head with IV contrast in the evaluation of isolated dizziness. CT Head Without and With IV Contrast There is no relevant literature regarding the use of CT head without and with IV contrast in the evaluation of isolated dizziness. Dizziness and Ataxia CT Head Without IV Contrast Head CT allows for evaluation of the intracranial structures; however, soft tissue contrast is inferior to MRI.


Dizziness and Ataxia

Dizziness and Ataxia. This is especially true of lesions in the posterior cranial fossa, which are more likely to cause dizziness [2]. In 29,510 patients with isolated dizziness presenting to a large academic emergency department, the overall diagnostic yield of CT is very low (<1%) [4]. In multiple studies, CT has demonstrated a high negative predictive value of approximately 90% but a low sensitivity (20%-40%) for detecting a causative etiology [2,3]. CT Temporal Bone With IV Contrast There is no relevant literature regarding the use of CT temporal bone with IV contrast in the evaluation of isolated dizziness. CT Temporal Bone Without and With IV Contrast There is no relevant literature regarding the use of CT temporal bone without and with IV contrast in the evaluation of isolated dizziness. CT Temporal Bone Without IV Contrast There is no relevant literature regarding the use of CT temporal bone without IV contrast in the evaluation of isolated dizziness. CTA Head and Neck With IV Contrast CTA allows for evaluation of the course and luminal caliber of the studied arteries. CTA can also detect luminal filling defects, which may include thrombus, embolus, atherosclerotic plaque, dissection flap, or vascular web. CTA of the head and neck has been shown to have a low overall diagnostic yield of approximately 3% in the setting of isolated dizziness. CTA also did not contribute any additional information over noncontrast head CT in this clinical setting. Overall, CTA in isolated dizziness was shown to have a sensitivity of 14%, specificity of 98%, positive predicative value of 40% and negative predicative value of 92% [3]. MRA Head and Neck With IV Contrast There is no relevant literature regarding the use of MRA head and neck with IV contrast in the evaluation of isolated dizziness. MRA Head and Neck Without and With IV Contrast There is no relevant literature regarding the use of MRA head and neck without and with IV contrast in the evaluation of isolated dizziness.


Dizziness and Ataxia

Dizziness and Ataxia. MRA Head and Neck Without IV Contrast There is no relevant literature regarding the use of MRA head and neck without IV contrast in the evaluation of isolated dizziness. MRI Cervical and Thoracic Spine With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine with IV contrast in the evaluation of isolated dizziness. MRI Cervical and Thoracic Spine Without and With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without and with IV contrast in the evaluation of isolated dizziness. MRI Cervical and Thoracic Spine Without IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without IV contrast in the evaluation of isolated dizziness. MRI Head and Internal Auditory Canal With IV Contrast There is no relevant literature regarding the use of MRI head and IAC with IV contrast in the evaluation of isolated dizziness. MRI Head and Internal Auditory Canal Without and With IV Contrast There is no relevant literature regarding the use of MRI head and IAC without and with IV contrast in the evaluation of isolated dizziness. MRI Head and Internal Auditory Canal Without IV Contrast There is no relevant literature regarding the use of MRI head and IAC without IV contrast in the evaluation of isolated dizziness. Dizziness and Ataxia MRI Head With IV Contrast There is no relevant literature regarding the use of MRI head with IV contrast in the evaluation of isolated dizziness. MRI Head Without and With IV Contrast There is no relevant literature regarding the use of MRI head without and with IV contrast in the evaluation of isolated dizziness. MRI Head Without IV Contrast MRI allows for detailed evaluation of the intracranial structures with improved soft tissue resolution when compared with CT. Despite this, the diagnostic yield of noncontrast MRI head in patients presenting to the emergency department with isolated dizziness is low (~4%).


Acute Respiratory Illness in Immunocompetent Patients.  Introduction/Background Acute respiratory illness (ARI) is defined as one or more of the following symptoms: cough, sputum production, chest pain, or dyspnea (with or without fever), usually in the setting of suspected respiratory infection. ARI is a major public health issue, being one of the most common reasons for doctor office or emergency department (ED) visits. Cough, chest pain, and dyspnea account for 3 of the top 10 presenting symptoms during ED visits [1]. Most cases of ARI are attributable to infection, and the major diagnostic dilemma for patients with ARI is distinguishing patients with self-limited viral infection from those with a bacterial pneumonia (PNA), such as community-acquired PNA. In 2014, PNA (combined with influenza) accounted for the eighth most common cause of death in the United States [2]. The primary role of imaging in patients with ARI is to aid in the diagnosis or exclusion of PNA. By helping to identify the subset of ARI patients with PNA, imaging helps separate patients who would benefit from antibiotic therapy from those who would not. This increases the chance that patients with PNA receive appropriate therapy and reduces the risks associated with inappropriate use of antibiotics in patients with viral causes of ARI. The need for imaging in the ARI patient may depend on a number of factors, which can include severity of illness; presence of fever, leukocytosis, or hypoxemia; clinical history; physical examination findings; patient age; and the presence of other risk factors. Not all studies concur as to which patients with ARI should have an initial imaging study. While chest radiographs have a long track record, they do have lower sensitivity for PNA relative to other imaging modalities such as CT. Self et al [5] performed an observational cross-sectional multicenter study that enrolled 3,423 ED patients presenting with ARI. This is one of the largest studies comparing chest radiographs and CT in the ED setting.


Acute Respiratory Illness in Immunocompetent Patients. Using CT as a gold standard, chest radiograph test characteristics for detection of pulmonary opacities included: sensitivity of 43.5%, specificity of 93.0%, positive predictive value of 26.9%, and negative predictive value of 96.5%. Conversely, other studies, such as Haga et al [6], demonstrate sensitivities as high as 91% for chest radiographs relative to CT for diagnosing PNA. Despite inconsistent data regarding the aMayo Clinic, Phoenix, Arizona. bPanel Chair, National Jewish Health, Denver, Colorado. cMassachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. dThe University of Texas MD Anderson Cancer Center, Houston, Texas. eUniversity of Southern California, Los Angeles, California. fSouthern Illinois University School of Medicine, Springfield, Illinois; The Society of Thoracic Surgeons. gThe University of Texas MD Anderson Cancer Center, Houston, Texas. hUniversity of Iowa, Iowa City, Iowa; The Society of Thoracic Surgeons. iVanderbilt University Medical Center, Nashville, Tennessee; American College of Chest Physicians. jMayo Clinic, Jacksonville, Florida. kColumbia University Medical Center New York and Temple University Health System, Philadelphia, Pennsylvania. lSpecialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: publications@acr.org sensitivity of chest radiographs for PNA, it still plays a role as the primary modality for making or excluding the diagnosis of PNA in patients presenting with ARI.


Acute Respiratory Illness in Immunocompetent Patients. CT Chest The major advantage of CT in the setting of ARI is its increased sensitivity relative to chest radiographs for the diagnosis of PNA. In comparative studies in which patients with PNA received both CT and chest radiograph, the rate of PNA missed by chest radiographs but detected by CT has been highly variable, ranging from 9.4% [6] to 56.5% [5]. CT has also been shown to be more specific than chest radiographs for the diagnosis of PNA [5,7]. US Chest There is a growing body of literature suggesting that bedside lung ultrasound (US) can be a useful tool in the diagnosis and management of PNA [8-12]. Nazerian et al [10] evaluated the accuracy of US relative to CT on 285 patients who had at least one respiratory complaint for which the ED physician ordered a CT. CT was considered positive if at least one typical consolidation was detected. US identified at least one consolidation in 81 patients versus 87 for CT. Relative to CT; US had a sensitivity of 82.8% and a specificity of 95.5%. While this study demonstrates impressive performance of US for detecting pulmonary consolidation, the study was limited by the fact that patients were enrolled based on whether or not they had a CT ordered rather than clinical suspicion of PNA. US is of limited value in patients with subcutaneous emphysema, in the setting of obesity/thick chest wall, and in patients with limited chest wall access related to bandages, prosthetic material, and skin disorders [13]. In addition, US has difficulty identifying PNAs that are not adjacent to the pleura. This limits its effectiveness for detecting more central infections, especially when there is aerated lung intervening between the transducer and the PNA [8,10,11]. MRI Chest Our literature search identified one recently published article evaluating the use of MRI in the setting of ARI in immunocompetent adult patients [14]. The study suggests a sensitivity for PNA that approaches that of CT.


Acute Respiratory Illness in Immunocompetent Patients. Over the past 10 years, the utility of MRI for detecting PNA has been studied more extensively in pediatric and immunocompromised patient populations; these studies demonstrated a similar favorable sensitivity of MRI for detecting PNA [15-20]. PET/CT Our literature search failed to identify any articles published within the past 10 years that justify the use of PET/CT in the initial workup of ARI in the immunocompetent patient. The usefulness of this imaging modality is not discussed in any of the clinical variants because of lack of evidence. CT Chest Our literature search failed to identify any data that suggest that CT serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA. US Chest Many of the studies evaluating the potential of US to diagnose PNA in the ED are aimed at assessing the diagnostic accuracy of US for PNA using either CT or discharge diagnosis as the gold standard [8-11]. Many of these patients were sick enough to warrant CT or admission, representing a subset of patients with a relatively high pretest probability of PNA. The current literature does not suggest a routine role for initial imaging with US in a clinical variant with a low pretest probability of PNA. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA. Variant 2: Acute respiratory illnesses in immunocompetent patients with positive physical examination, abnormal vital signs, organic brain disease, or other risk factors. Initial imaging. Radiography Chest In a series of 300 patients with acute cough illness, Aagaard et al [29] found that a chest radiograph was not always obtained for patients with a high pretest probability of PNA; they infer that when the clinical probability of PNA exceeds a certain level, a negative radiograph would not alter treatment decisions.


Acute Respiratory Illness in Immunocompetent Patients. A series by Basi et al [30] that included 2,706 patients hospitalized with community-acquired PNA similarly showed that about one- third had radiographs initially interpreted as negative for PNA, with minimal change in this interpretation on retrospective review of a random subgroup. These two studies call into question the usefulness of radiographs in patients with a high pretest probability of PNA. That being said, data from many of the studies that suggested the low utility of chest radiographs in Variant 1 also demonstrate a relatively high incidence of PNA on chest radiographs in patients with physical examination findings, abnormal vital signs, leukocytosis, or other risk factors, such as advanced age [21-25]. For example, Benacerraf et al [21] reported that a subgroup of patients <40 years of age with an abnormal physical examination were about six times more likely to have an acute finding on their chest radiograph. Speets et al [31] evaluated 192 patients with a clinical suspicion of PNA by general practitioners and found that the post- test probability of PNA was changed by chest radiographic results in 53% of patients, with a 47% decrease in probability and a 6% increase in probability. Patient management changed following a chest radiograph in 69% of patients. These data would seem to support the routine use of chest radiographs to confirm the diagnosis of PNA in this clinical variant. Current IDSA/ATS guidelines also support this approach [4]. In a population of ED patients who received a chest radiograph for respiratory complaints, Heckerling [22] found that over 75% of the patients with dementia had PNA on their chest radiograph regardless of physical examination findings. The authors postulate that aspiration related to altered level of consciousness and compromised epiglottic closure could account for the high prevalence of PNA amongst these patients.


Acute Respiratory Illness in Immunocompetent Patients. Although there is a paucity of data to support this, it would be logical to include other patients with organic brain disease, such as Acute Respiratory Illness in Immunocompetent Patients stroke and delirium, in addition to dementia, as also having a high pretest probability of PNA despite otherwise negative physical examination findings and normal vital signs. CT Chest Our literature search failed to identify any data that suggest that CT serves any significant role in the initial imaging of immunocompetent patients with a high pretest probability of PNA. The role of CT for patients with a negative or equivocal initial chest radiograph is discussed in Variant 3. US Chest One prospective multicenter study performed by Reissig et al [11] enrolled 362 patients with abnormal vital signs or physical examination findings in addition to ARI symptoms. Patients received a two-view chest radiograph and a US. In cases in which the chest radiograph was negative or inconclusive and the US was positive, a chest CT was performed. This study demonstrated US sensitivity and specificity of 93.4% and 97.7%, respectively; however, these values are almost certainly overestimated because of the fact that a chest radiograph, rather than CT, was used as the reference standard in all cases except those in which there was discordance between an inconclusive or negative chest radiograph and a positive US. Bourcier et al [8] studied US and chest radiographs in a similar patient population. The final diagnosis was based on a chart review made by an independent expert and included clinical findings, labs, chest radiographs, and CT, if available. US in this study again demonstrated superior sensitivity for PNA relative to chest radiographs. Like Reissig et al, this study was limited by the lack of a consistent end point. Even with these limitations, the results of these studies suggest bedside US can be a useful tool for evaluating certain patients with a high pretest probability of PNA.


Acute Respiratory Illness in Immunocompetent Patients. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a high pretest probability of PNA. The role of MRI for patients with a negative or equivocal initial chest radiograph is discussed in Variant 3. Variant 3: Acute respiratory illness in immunocompetent patients with positive physical examination, abnormal vital signs, organic brain disease, or other risk factors and negative or equivocal initial chest radiograph. Next imaging study. Radiography Chest There is no indication in the literature to suggest that repeat chest radiograph serves any significant role in imaging patients with a high pretest probability of PNA and a negative or equivocal initial chest radiograph. CT Chest There are several studies that assess the use of CT as a subsequent study in patients who have already had a chest radiograph. One of the larger reviews by Hayden et al [32] identified 97 of 1,057 ED patients with a diagnosis of PNA who had both a chest radiograph and CT. Within this selected group, 26 patients (27%) had PNA that was not detected with chest radiograph but was subsequently detected with CT. Maughan et al [33], in a retrospective review designed to evaluate the false-negative rate of chest radiographs in ED patients with PNA, identified 49 cases (11.4%) where PNA was diagnosed with CT, despite a normal chest radiograph. Haga et al [6] also demonstrated the improved ability of CT to assess the severity of PNA relative to chest radiographs. Bilateral PNA, as detected by CT, was associated with a higher degree of mortality. The presence of multilobar opacities, which is a minor criterion in the IDSA/ATS guidelines for intensive care unit admission, is best assessed with CT [4]. One of the more recent studies assessing the use of CT for ED patients with suspected PNA is Claessens et al [7], a prospective multicenter study that enrolled 319 patients.


Acute Respiratory Illness in Immunocompetent Patients. The inclusion criteria included a mix of ARI symptoms and abnormal vital signs or physical examination findings. All patients received a chest radiograph and a CT within 4 hours of presentation. Chest radiographs identified opacities consistent with PNA in 188 of 319 (59%) patients. CT revealed PNA in 40 (33%) of the 131 patients without opacity on chest radiographs and excluded PNA in 56 (29.8%) of the 188 patients with opacities on chest radiographs. Because of CT, antibiotics were initiated in 51 (16%) patients and discontinued in 29 (9%) patients. CT findings also resulted in 22 additional hospitalizations and 23 discharges. The available data clearly show that CT is more accurate than chest radiographs for the diagnosis of PNA. In most cases a combination of vital signs and physical examination findings, along with judicious use of chest radiographs, is deemed sufficient for diagnosing or excluding PNA. However, in certain patients, such as those who cannot reliably follow-up or for whom any delay in diagnosis of PNA could be life-threatening (such as patients with advanced age, unreliable follow-up, or significant comorbidities), chest CT may be warranted when initial chest radiograph is negative or equivocal [24,32,34]. The IDSA/ATS consensus guidelines consider CT a reasonable alternative to empiric antibiotic therapy with follow-up chest radiographs when there is a high clinical suspicion of PNA [4]. Given the difficulty of obtaining an accurate history and physical examination and the high incidence of PNA in patients with organic brain disease, CT is a reasonable alternative to empiric treatment antibiotics in the setting of a negative or equivocal initial chest radiograph. US Chest Studies performed by Reissig et al [11] and Bourcier et al [8] suggest that US has a higher sensitivity than radiographs for PNA, implying that US may add value in cases in which PNA is suspected but initial chest radiographs are negative or equivocal.


Acute Respiratory Illness in Immunocompetent Patients. Nazerian et al [10] evaluated the accuracy of US relative to CT on 285 patients who had at least one respiratory complaint for which the ED physician ordered a CT. In the subgroup of patients who also had a chest radiograph, US demonstrated sensitivity and specificity of 81.4% and 94.2%, respectively, versus 64.3% and 90% for chest radiographs. The increased sensitivity of US implies additional value of US in cases in which the initial chest radiograph is discordant with clinical suspicion; however, the study was limited by the fact that patients were enrolled based on whether or not they had a CT ordered, rather than clinical suspicion of PNA. Given the difficulty of obtaining an accurate history and physical examination as well as the high incidence of PNA in patients with organic brain disease, US is a reasonable alternative to empiric treatment with antibiotics in the setting of a negative or equivocal initial chest radiograph. The ability of the patient to tolerate an US examination, presence of an adequate acoustic window, and the limited ability of US to detect all but peripheral PNAs would be additional considerations. MRI Chest Syrjala et al [14] compared the sensitivity and specificity of noncontrast MRI (respiratory-triggered T2 fast spin- echo) to chest radiographs using CT as a gold standard. The patient population consisted of immunocompetent adult ambulatory outpatients with ARI who were febrile and symptomatic for <7 days. CT detected 32 cases of PNA out of 77 prospectively enrolled patients. MRI detected 30/32 cases (sensitivity 94%) with no false-positives (specificity 98%), whereas chest radiographs only detected 23 cases (sensitivity 72%) and gave 4 false-positive results (specificity 91%). These data suggest a potential role for MRI in detecting PNA in situations where initial chest radiographs findings are negative or equivocal; however, the sensitivity of CT appears to be slightly superior to that of MRI.


Acute Respiratory Illness in Immunocompetent Patients. Variant 4: Acute respiratory illnesses in immunocompetent patients with pneumonia complicated by suspected parapneumonic effusion or abscess on initial chest radiograph. Next imaging study. Radiography Chest Chest radiographs are a useful initial imaging modality for complicated PNA, but they are inferior to other modalities for evaluating the pleura, for guiding interventions, or for assessing an opacity that has been refractory to therapy. CT Chest In severe cases of PNA, CT can demonstrate the overall extent of disease, which may provide important prognostic information [6]. CT can also demonstrate necrotizing PNA and abscess formation long before the findings become visible on a chest radiograph. The use of intravenous contrast can increase the conspicuity of empyemas and other pleural complications. CT can also serve as a guide for pleural drainage or localization of an appropriate site for biopsy [35]. CT is the modality of choice for evaluating a persistent opacity. Its superior contrast resolution allows it to detect obstructing masses, delineate lesions, such as sequestrations, and even characterize patterns of parenchymal disease, such that a particular etiology, such as organizing PNA or mycobacterial infection, can sometimes be suggested. US Chest US may be a useful adjunct for the evaluation of parapneumonic effusions as it is superior to chest radiographs for demonstrating pleural thickening and adhesions. US is superior to noncontrast CT for detecting septations in Acute Respiratory Illness in Immunocompetent Patients complex effusions. US can also be used to guide PNA-related interventions, such as biopsy, thoracentesis, and thoracostomy tube placement [36]. MRI Chest Our search failed to identify any studies evaluating the role of MRI in this clinical scenario. The study population examined by Syrjala et al [14] did not include any patients with parapneumonic effusion or empyema.


Acute Respiratory Illness in Immunocompetent Patients. However, MRI has been shown to be at least as sensitive as CT for detecting pleural effusions in immunocompromised patients and is superior to CT for detecting pleural adhesions/loculations [16]. Variant 5: Acute asthma exacerbation in immunocompetent patients, uncomplicated (no suspicion of pneumonia or pneumothorax). Initial imaging. Radiography Chest The incidence of PNA is exceedingly low in patients presenting with an uncomplicated asthma exacerbation. Heckerling [22] reported <2% of asthmatic patients as having pneumonic opacities. Findley and Sahn [37] observed that 99% of their patients either had normal chest radiograph examinations or showed only slightly prominent markings or hyperinflation. CT Chest Our literature search failed to identify any data that suggest that CT serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with an acute asthma exacerbation. US Chest Our literature search failed to identify any data that suggest that US serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with an acute asthma exacerbation. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with an acute asthma exacerbation. Variant 6: Acute asthma exacerbation in immunocompetent patients, complicated (suspected pneumonia or pneumothorax). Initial imaging. Radiography Chest Use of chest radiographs in patients with asthma exacerbation is controversial. Petheram et al [38] found clinically important radiographic findings in 9% of their patients and concluded that a chest radiograph is indicated. However, the incidence of PNA in patients presenting with an asthma exacerbation is low [22,37].


Acute Respiratory Illness in Immunocompetent Patients. Findley and Sahn [37] recommended chest radiographs only when PNA or pneumothorax is suspected. White et al [39] found significant chest radiograph abnormalities in 34% of adults whose asthma exacerbation warranted hospital admission. CT Chest Although our literature search failed to identify any data that suggest that CT serves any significant role in the initial imaging of patients with a high pretest probability of PNA presenting with an acute asthma exacerbation, patients who cannot reliably follow-up or for whom any delay in diagnosis of PNA could be life-threatening may warrant a CT if the chest radiograph is negative or equivocal. Chest radiographs are usually sufficient to diagnose pneumothorax. CT should be reserved for patients who require additional evaluation of their pneumothorax to look for an underlying cause. US Chest US may be a reasonable alternative to chest radiographs to identify PNA [8-12] and pneumothorax [13]. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a high pretest probability of PNA presenting with an acute asthma exacerbation. Acute Respiratory Illness in Immunocompetent Patients Variant 7: Acute COPD exacerbation in immunocompetent patients, uncomplicated (no chest pain, fever, or leukocytosis, no history of coronary artery disease, or heart failure). Initial imaging. Radiography Chest The ATS defines a chronic obstructive pulmonary disease (COPD) flare as an acute worsening of COPD symptoms. Sherman et al [40] studied the usefulness of chest radiographs in 242 patients with acute exacerbations of COPD. Of this group, 135 patients (56%) had asthma, and 107 (44%) had emphysema and chronic bronchitis. Chest radiographs were abnormal in 14% but resulted in significant change in management in only 4.5%.


Acute Respiratory Illness in Immunocompetent Patients. CT Chest Our literature search failed to identify any data that suggest that CT serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with a COPD exacerbation. US Chest Our literature search failed to identify any data that suggest that US serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with a COPD exacerbation. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with a COPD exacerbation. Variant 8: Acute COPD exacerbation in immunocompetent patients with accompanying chest pain, fever, or leukocytosis, or a history of coronary artery disease, or heart failure. Initial imaging. Radiography Chest Chest radiographs seem warranted in COPD patients with significant comorbidities or a higher pretest probability of PNA (such as those who are elderly or who have abnormal vital signs or physical examination findings). Sherman et al [40] suggested that a chest radiograph is indicated if a COPD exacerbation is accompanied by leukocytosis, chest pain, or edema, or by a history of coronary artery disease or congestive heart failure. US Chest Studies by Reissig et al [11] and Nazerian et al [10] included patients with COPD. There was no mention of how the presence of COPD might affect the ability of US to diagnose PNA. The presence of COPD did not appear to be a contraindication to US. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a high pretest probability of PNA presenting with a COPD exacerbation.


Acute Respiratory Illness in Immunocompetent Patients. Summary of Recommendations Variant 1: A chest radiograph is usually appropriate for the initial imaging of immunocompetent patients presenting with ARI and a negative physical examination, normal vital signs, and no other risk factors. Variant 2: A chest radiograph is usually appropriate for the initial imaging of immunocompetent patients presenting with ARI and positive physical examination, abnormal vital signs, organic brain disease, or other risk factors. Variant 3: Chest CT without IV contrast is usually appropriate for imaging immunocompetent patients with ARI and positive physical examination, abnormal vital signs, organic brain disease or other risk factors and a negative or equivocal initial chest radiograph. 10 Variant 4: Chest CT, with or without IV contrast, is usually appropriate for imaging immunocompetent patients with PNA complicated by suspected parapneumonic effusion or abscess on initial chest radiograph and MRI may be appropriate in this scenario. Variant 5: Imaging is usually not appropriate for the initial workup of immunocompetent patients presenting with an uncomplicated acute asthma exacerbation (no suspicion of PNA or pneumothorax) but a chest radiograph may be appropriate. Variant 6: A chest radiograph is usually appropriate for the initial imaging of immunocompetent patients presenting with a complicated acute asthma exacerbation (suspected PNA or pneumothorax). Variant 7: A chest radiograph is usually appropriate for the initial imaging of an uncomplicated acute COPD exacerbation in immunocompetent patients (no chest pain, fever, or leukocytosis, no history of coronary artery disease, or heart failure). Variant 8: A chest radiograph is usually appropriate for the initial imaging of complicated acute COPD exacerbation in immunocompetent patients (chest pain, fever, leukocytosis, or a history of coronary artery disease, or heart failure).


Acute Trauma to the Ankle

Acute Trauma to the Ankle.  Introduction/Background Ankle injuries are the most common injury presenting to primary care and emergency rooms [1,2], accounting for 4.4% of United States emergency room visits [3]. Acute ankle sprains (pain, swelling, limited mobility) make up the majority of these injuries, with an estimated incidence of 2 million per year [4]. Diagnosis of presence and degree of sprain, fracture, subluxation, dislocation, cartilage abnormalities, foreign bodies, or neurovascular involvement are critical in determining appropriate and timely orthopedic fixation/treatment planning [1,5] and to avoid chronic pain and immobility. Appropriate use of ankle imaging guidelines and clinical decision support mechanisms is paramount [6,7]. The current standard clinical imaging guidelines to determine if radiographs are necessary are the Ottawa Ankle Rules (OAR), instituted in 1992. The OAR have been validated for adults and children >5 years of age [8] and recommend ankle radiographs in patients with the following clinical criteria in the acute setting: 1) inability to bear weight, 2) point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, or 3) inability to ambulate for 4 steps. For the purposes of this paper, the OAR will still apply during the first 1- to 3-week interval following initial injury. Multiple validation studies have confirmed OAR effectiveness and utility in obtaining appropriate imaging, reducing unnecessary radiographs and costs, and improving clinical outcomes [8-13]. Exclusionary Criteria OAR should not be used in children <5 years of age or in those patients with a neurologic abnormality affecting the lower leg with decreased sensation (eg, diabetic), altered sensorium, or inability to communicate [8,25,26]. Other The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: publications@acr.org Acute Trauma to the Ankle possible cautionary or exclusionary scenarios include pregnancy, penetrating trauma, or presence of prior recent outside radiographs on transfer. Special Imaging Considerations Avoidance of manipulation of the ankle prior to radiographs in the absence of neurovascular deficit or critical skin injury is recommended in order to avoid remanipulation or complication in this setting [27]. Advances in MRI technology have facilitated short dedicated extremity MRI protocols in some centers that may be used as an emergent adjunct to radiographs [28]. OR Discussion of Procedures by Variant Variant 1: Adult or child 5 years of age or older. Acute trauma to the ankle or acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial imaging. Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are positive: 1. Inability to bear weight immediately after the injury, OR 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, OR 3. Inability to ambulate for 4 steps in the emergency department. Bone Scan Ankle Bone scan is not routinely used as the first imaging study for the evaluation of acute trauma to the ankle with positive OAR. talus, or calcaneus, OR CT Ankle Although CT may be used in polytrauma patients to determine the extent of injury in complex fractures, CT is not routinely used as the first imaging study of acute trauma to the ankle with positive OAR when exclusionary criteria do not apply.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. MRI Ankle Although MRI may be used for occult injuries or suspicion for ligamentous tears in inversion injuries [29], it is not the first imaging study for the evaluation of acute trauma to the ankle with positive OAR. Radiography Ankle Radiographs are indicated in patients who meet OAR criteria as the initial imaging study. Studies demonstrate between 92% and 99% sensitivity for detecting ankle fracture using these guidelines, with <2% of those who are negative for fracture using the OAR actually having a fracture [13-15,30]. The OAR are validated in children >5 years of age and should not be used in patients meeting the exclusionary criteria listed above [8]. Typical radiographic protocols should include 3 standard views: anteroposterior, lateral, and mortise views to include the base of the fifth metatarsal bone distal to the tuberosity [31]. Although foot and ankle radiographs have been performed together in clinical settings in the past, in a retrospective study of 243 patients with both radiographs performed, no foot fractures other than the base of the fifth metatarsal were noted. In the presence of inversion injury or fracture of the ankle, foot or knee radiographs should not be performed owing to low yield [32,33]. Weight-bearing radiographs, if possible, provide important information, particularly with fractures of uncertain stability, because the most important criterion in treatment of malleolar fractures is stability. A medial clear space of <4 mm should confirm stability. Increased incidence of fracture and instability is noted with medial tenderness, bruising or swelling, fibular fracture above the syndesmosis, bi- or trimalleolar fractures, open fracture, or high- energy fracture injury [34]. Special scenarios that warrant special mention and additional views include: Acute Trauma to the Ankle US Ankle Ultrasound (US) may be useful but is not typically considered the first line of imaging for the evaluation of acute trauma to the ankle with positive OAR [41].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Variant 2: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present (eg, neurologically intact (including no peripheral neuropathy)). Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are negative: No point tenderness over the malleoli, talus, or calcaneus on physical examination. Able to walk. Initial imaging. Bone Scan Ankle Bone scan is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario. CT Ankle CT is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario. MRI Ankle MRI is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario. Radiography Ankle Radiography is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario. US Ankle US is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario. Variant 3: Adult or child 5 years of age or older. Acute trauma to the ankle. Exclusionary criteria are present (eg, neurologic disorder, neuropathy, or other). Patient does not meet requirements for evaluation by the Ottawa Ankle Rules. Initial imaging. OAR should not be used in patients with neurologic abnormality involving the lower leg or those with decreased sensation (eg, diabetics), altered sensorium, or inability to communicate [25,26]. Other possible cautionary or exclusionary scenarios include pregnancy, penetrating trauma, or presence of prior recent outside radiographs on transfer. Acute Trauma to the Ankle Bone Scan Ankle Bone scan is not routinely used as the first imaging study for the evaluation of acute trauma to the ankle in the setting of peripheral neuropathy or other exclusionary criteria.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. CT Ankle The imaging pathway is dependent on the severity of the trauma in patients within this particular clinical scenario. In the high-energy trauma patient or polytrauma patient, fractures and dislocations may be more difficult to identify clinically in the neurologically impaired or neuropathy patient. Occasionally, multidetector CT can be useful as first-line imaging study, particularly for complex injuries such as posterior malleolar fracture and posterior pilon variant fractures, which fall outside the typical classification systems. In a study of 270 patients by Switaj et al [41], the frequency of posterior malleolus fractures and posterior pilon variants was 50% and 20%, respectively; both were found more commonly in older females and diabetic patients. Recent studies of use and implementation of low-dose weight-bearing cone beam CT, particularly in the pediatric population, may be a viable alternative to standard CT studies [42]. MRI Ankle MRI is not routinely used as the first imaging study for the evaluation of acute trauma to the ankle in the setting of peripheral neuropathy or neurological disorder or other exclusionary criteria. Radiography Ankle In patients with diabetic neuropathy, neurologic compromise of the lower leg, or other exclusionary criteria in which application of the OAR is not possible and fracture is suspected, ankle radiographs are considered the initial imaging study. These patients may have no pain or point tenderness and may walk without discomfort despite fracture because of poor pain proprioception [25]. If there is high suspicion for foreign body, radiographs may also be useful for identification if the foreign body is radiopaque in nature. Radiography Ankle Stress Views Ankle stress views are not the first imaging study for the evaluation of acute trauma to the ankle in the setting of peripheral neuropathy or other exclusionary criteria.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. US Ankle US is not routinely used as the first imaging study for the evaluation of acute trauma to the ankle in the setting of peripheral neuropathy or other exclusionary criteria. US may be useful as a secondary step in evaluation of foreign bodies or focal fluid collections. Variant 4: Adult or child 5 years of age or older. Acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial radiographs negative. Next study. Acute trauma includes immediate time of injury to <3 weeks, whereas subacute trauma includes 3 weeks to <6 months. The timeframe of this clinical scenario is at the intersection of the late acute and subacute phases, and the OAR criteria can still apply for acute ankle trauma in this setting. Persistent pain may be associated with a radiographically occult fracture, bone contusion, subtle cartilage injury, soft-tissue injury, or foreign body not visible on radiographic examination. Diagnosis is critical in determining appropriate and timely orthopedic fixation/treatment planning [1,5]. Bone Scan Ankle Bone scan is typically not used as the next step in this clinical scenario. CT Ankle CT of the ankle without intravenous (IV) contrast is useful in the trauma setting as the next study to evaluate for radiographically occult fractures and soft-tissue abnormalities. It is rare (<1%) for patients with a large joint effusion but no discernible fracture on radiographic examination, however, CT proved useful in demonstrating a fracture in one-third of cases in one large study [43,44]. Talar fractures (lateral process or comminuted talar body/dome fractures) and fractures associated with the subtalar joint can be difficult to detect on radiographs but are well identified on CT [45,46]. In patients with spiral fractures of the tibia, there is a higher incidence of nondisplaced posterior malleolar fractures that may be missed on radiographic examination [47].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. A comparison of multidetector CT versus radiography for ankle fracture detection demonstrated only 87% and 78% sensitivity, respectively, for calcaneal fracture and talar fractures by radiography as compared with CT [48]. Occult osteochondral fractures of the subtalar joint may only be visualized on CT, particularly in patients without Acute Trauma to the Ankle dislocation, with fractures involving the posterior facet, with associated massive swelling, or with failure to regain subtalar motion after a period of immobilization [49]. CT with IV contrast is not indicated in this scenario because soft-tissue abnormalities and fluid collections can be identified on noncontrast high-resolution CT studies. MRI Ankle MRI of the ankle without IV contrast is most sensitive for evaluation of occult fractures with associated bone marrow edema patterns, particularly in inversion injuries and persistent lateral ankle pain, as well as presence and extent of soft-tissue injuries [29]. Stress injuries of bone, including those of the weekend warrior, are best depicted by MRI [50]. MRI is the reference standard for ligamentous injury and assessment of stability, which is particularly important in athletes, in whom determination of grade (1, 2, or 3) of syndesmotic ligament, anterior tibiofibular ligament, and deltoid injuries is critical for treatment planning and return to sport assessment [51]. High-resolution evaluation of the tendons and ligaments allows distinction between tendinopathy, sprain, and partial or complete tears. Ligament and tendon injuries can occur without fracture on radiography. Grossterlinden et al [52] compared MRI and radiography and showed that 15% of ligamentous injuries (including sprains, partial tears, and complete tears) at the syndesmosis in acute ankle injuries on MRI demonstrated no fracture on radiography.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Presence of bone bruise and adjacent soft-tissue edema have shown a higher association with acute ligamentous injuries (anterior talofibular ligament most common) and tendon abnormalities [53,54] in patients with negative radiographs. MRI can also help exclude Salter 1 fractures in the pediatric population [55]. Radiography Ankle Repeat radiographs are not typically the next study but may be of use to identify early callous formation at an occult fracture line or possible mineralization at a site of intramuscular hematoma if contusion occurred during trauma. Radiographs with better technique may assist in diagnosis of subtle injuries such as the lateral talar process avulsion, which may erroneously be diagnosed as a lateral ankle sprain [37]. Radiography Ankle Stress Views Although ankle stress views are not the typical next best study for this patient group, if there is clinical evidence of instability on physician maneuvers, ankle stress views may be of benefit for identification of occult avulsion injury at ligamentous attachments that may contribute to widening of the joint space on radiographic stress views. US Ankle US is not typically the next imaging study. US may be useful as a secondary evaluation modality for focused evaluation of underlying soft-tissue injuries and ligaments, with the added benefit of dynamic imaging. This includes focused high-resolution US of the peroneal tendons and the superior peroneal retinaculum [56], stress US (during anterior drawer) to assess joint laxity or chondral avulsion fractures associated with lateral ligament injury in children with negative radiographs [57,58], and potential detection of superficial occult fractures at the base of the fifth metatarsal, lateral malleolus, and malleolus [41]. Variant 5: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present. Radiographs demonstrate fracture or potential osteochondral injury. Next study.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Bone Scan Ankle Osteochondral lesions Bone scan is not the next imaging study in this clinical scenario. Fractures Bone scan is not the next imaging study in this clinical scenario. Bone scan may be used in rare setting in polytrauma cases for evaluation of multiple fractures. CT Ankle Osteochondral lesions Although MRI is the reference standard, CT is also of utility to identify, locate, and quantify cortical and subcortical involvement or loss as well as presence of intra-articular ossific bodies or associated fractures. In a prospective study of 399 patients, uncontained osteochondral lesion of the talus shoulder, as determined arthroscopically, had a more complicated clinical outcome than those with nonshoulder lesions, confirming the importance of imaging localization for clinical outcome [59]. An inverted osteochondral fracture of the lateral talus (lateral, inverted, Acute Trauma to the Ankle fracture talus, also known as the LIFT lesion) can occur after twisting injury to the ankle. Initial radiographs should be followed by CT and MRI [60,61]. These lesions are treated successfully with combined open approach and arthroscopy. Fractures CT is the first-line imaging study after radiographs to determine extent, displacement, comminution, intra-articular extension, associated injuries, and potential classification of fractures [48]. This is particularly important in subtalar, calcaneal, and talar fractures because of the complex anatomy and in high-impact polytrauma or complex comminuted injuries in which multiplanar CT imaging is recommended to help direct the preoperative planning evaluation process [62]. MRI Ankle Osteochondral lesions MRI without IV contrast is considered the study of choice for assessment of cartilage abnormalities and bone contusions related to acquired osteochondral lesion, particularly in patients with symptoms of persistent pain, stiffness, locking, clicking, and ankle swelling [22,55-57,63].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Although radiographs and CT depict ossific fragments and fracture lines, cartilage abnormalities and bone contusions related to osteochondral lesion are best seen on MRI. Seventy percent of ankle fractures and 50% of ankle sprains have been shown to result in some variation of cartilage injury [57,58,61,64]. Fractures Although CT is more commonly used as the next step in fracture assessment in known fractures, MRI can be useful as a follow-up imaging modality for assessment of associated bone marrow contusions, stress injuries, or fractures [65]. MRI is especially important in fracture sites such as the talus, which are at higher risk for osteonecrosis. MRI is highly accurate for associated soft-tissue abnormalities including tendon entrapment/dislocation and for ligamentous injuries [66]. US Ankle Osteochondral lesion US is not the next step in this clinical scenario. Fractures US has been shown to be useful for identification of lateral malleolar, medial malleolar, and fifth metatarsal fractures [41] but is not considered a first-line assessment tool or next imaging study in this clinical scenario. Variant 6: Adult or child 5 years of age or older. Acute trauma to the ankle. Radiographs negative for osseous injury and physical examination or radiographs demonstrate alignment abnormality suggesting syndesmotic/ligamentous injury or dislocation. Next study. Lateral sprain is more common than medial strain, with the anterior talofibular ligament most commonly torn. High sprain and fractures are more common in high-collision sport injuries [60], with higher incidence of ankle injuries during winter months [67] and increased incidence in military recruits [68]. Inversion injuries of the ankle account for 25% of musculoskeletal system injuries and 50% of all sports-related injuries [1]. Bone Scan Ankle Bone scan is not routinely the next line of imaging in this clinical scenario. Acute Trauma to the Ankle


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Rare pantalar dislocations without associated talar or other fracture can be assessed on CT or MRI and have high rates of osteonecrosis, osteoarthritis, and infection [71]. MRI Ankle MRI is the reference standard for ligamentous injury and assessment of stability, which is particularly important in athletes, in whom determination of grade (1, 2, or 3) of syndesmotic ligament, anterior tibiofibular ligament, and deltoid injuries is critical for treatment planning and return to sport assessment [51]. Ligamentous injuries can occur without fracture on radiography. Grossterlinden et al [52] compared MRI and radiography and showed that 15% of ligamentous injuries (including sprains, partial tears, and complete tears) at the syndesmosis in acute ankle injuries on MRI demonstrated no fracture on radiography. Rare pantalar dislocations without associated talar or other fracture can be assessed on CT or MRI and have high rates of osteonecrosis, osteoarthritis, and infection [71]. Radiography Ankle Stress Views Stress radiographs may be useful in assessing syndesmotic instability, particularly in supination external rotation ankle injuries according to the Lauge-Hansen classification. Lee et al [72] noted that tibiotalar tilt angle and anterior tibiofibular space measurements were affected when the anterior tibiofibular and posterior talofibular ligaments were injured (confirmed on MRI) in 299 patients. Lateral stress testing with widening of the tibiofibular clear space has been shown to be an indicator of syndesmotic injury, with the traditional external rotation stress test shown to be a poor indicator when the deltoid ligament is injured [73]. Radiography Leg Maisonneuve fracture (syndesmotic injury of the ankle in combination with a proximal fibular fracture) may be overlooked as a result of lack of pain at the fibula. Careful palpation of the proximal fibula should be performed with radiographic evaluation of the entire tibia and fibular if focal tenderness is present [74].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. US Ankle US is not typically the next line of evaluation of syndesmotic injuries. Although some studies have suggested focused US could be beneficial for ligamentous evaluation, others have shown limited utility in lateral ankle ligament sprains [75]. Summary of Recommendations Variant 1: Ankle radiographs are usually appropriate for the initial imaging of patients 5 years of age or older with acute trauma to the ankle or acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks with no exclusionary criteria present and the OAR are positive: 1. Inability to bear weight immediately after the injury, OR 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, OR 3. Inability to ambulate for 4 steps in the emergency department. Variant 2: Imaging is usually not appropriate for patients 5 years of age or older with acute trauma to the ankle when the patient is able to walk and there are no exclusionary criteria present (eg, neurologically intact (including no peripheral neuropathy)) and the OAR are negative: No point tenderness over the malleoli, talus, or calcaneus on physical examination. Variant 3: Ankle radiographs are usually appropriate for the initial imaging of patients 5 years of age or older with acute trauma to the ankle when exclusionary criteria are present (eg, neurologic disorder, neuropathy, or other) and the patient does not meet requirements for evaluation by the OAR. Acute Trauma to the Ankle ankle without IV contrast is more likely to be performed for known fracture evaluation with MRI ankle without IV contrast more likely to be performed for potential osteochondral injury evaluation. 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.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease.  Introduction/Background Lower extremity venous insufficiency is a common chronic medical condition resulting from primary valvular incompetence or, less commonly, prior deep venous thrombosis (DVT) or extrinsic venous obstruction. Venous insufficiency may cause varicosities that vary in presentation from cosmetic concern to chronic lower extremity discomfort, swelling, induration, dermatitis, and ulceration [1]. Varicose veins are dilated and usually tortuous subcutaneous veins measuring at least 3 mm in diameter in an upright position, larger than reticular veins (subdermal veins, 1-3 mm in diameter) and telangiectasia (intradermal veins, <1 mm in diameter) [1]. Venous disease of the legs can be categorized according to the severity, cause, site, and specific abnormality using the Clinical Etiologic Anatomic Pathophysiologic (CEAP) classification system [1,2]. The elements of the CEAP classification include, 1) Clinical severity (grade 0-6, asymptomatic, symptomatic), 2) Etiology (congenital, primary, secondary), 3) Anatomical distribution (superficial, deep, perforator veins), and 4) Pathophysiological dysfunction (reflux, obstruction). Lower extremity chronic venous disease has a high prevalence with a related socioeconomic burden. In the United States, over 11 million men and 22 million women 40 to 80 years of age have varicose veins, with over 2 million adults having advanced chronic venous disease [3]. Approximate total prevalence of C2 to C3 disease is 25% and 5% for stages C4 to C6 [1,3]. Additionally, most chronic leg ulcers are venous in origin, with prevalence of nearly 1% [4,5]. The high cost to the health care system is related to the recurrent nature of venous ulcerative disease, with total treatment costs estimated >$2.5 billion per year in the United States, with at least 20,556 individuals with newly diagnosed venous ulcers yearly [4]. Treatment of superficial venous insufficiency is intended to alleviate symptoms and reduce the risk of complications.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Conventional management targeted at reducing reflux has been surgical removal of the great saphenous vein (GSV) from the level of the saphenofemoral junction to the level of the knee or ankle (along with saphenous vein branch ligation in the groin). Alternatives to saphenous vein stripping and ligation include vein ablation using laser energy, radiofrequency-generated thermal energy, or chemical sclerosing agents [6-8]. Discussion of Procedures by Variant Variant 1: Varicose veins. Initial diagnosis. Catheter Venography Iliac Veins Catheter venography of the iliac veins can aid in evaluating proximal occlusions or significant stenosis when proximal varicosities are present. Adjunctive usage of intravascular ultrasound (IVUS) can improve the specificity aModern Vascular of Denver, Thornton, Colorado. bResearch Author, University of Colorado Denver, Denver, Colorado. cPanel Chair, University of Michigan, Ann Arbor, Michigan. dPanel Chair, Massachusetts General Hospital, Boston, Massachusetts. ePanel Vice-Chair, University of California San Francisco, San Francisco, California. fPanel Vice-Chair, University of Vermont Medical Center, Burlington, Vermont. gDetroit Medical Center, Tenet Healthcare and Envision Radiology Physician Services, Detroit, Michigan. hZucker School of Medicine at Hofstra Northwell, Hempstead, New York. iTufts University School of Medicine, Boston, Massachusetts; Society for Vascular Surgery. jOregon Health and Science University, Portland, Oregon. kMedical University of South Carolina, Charleston, South Carolina. lRenaissance School of Medicine at Stony Brook University, Stony Brook, New York. mBoston University School of Medicine, Boston, Massachusetts. nMayo Clinic, Rochester, Minnesota; Commission on Nuclear Medicine and Molecular Imaging. oWeill Cornell Medicine- New York Presbyterian Hospital, New York, New York; American Vein & Lymphatic Society. pFroedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. qSpecialty Chair, Emory University Hospital, Atlanta, Georgia. rSpecialty Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: publications@acr.org Lower Extremity Chronic Venous Disease of such lesions. However, there is no relevant literature regarding the use of catheter-directed venography of the iliac veins when evaluating for varicose veins. Catheter Venography Lower Extremity Catheter venography is ideal in performing descending venography of the lower extremity to evaluate for deep vein reflux [9]. However, there is no relevant literature regarding the use of catheter-directed lower extremity venography in the evaluation of bilateral GSV insufficiency with visible varicose veins. CTV Lower Extremity CT venography (CTV) of the lower extremity has not been cited as a first-line examination. However, given the high rate of recurrence 2 years postintervention (15%-35%), it has been suggested that further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Understanding the anatomy could aid in the appropriate selection of treatment, plan interventions, reduce recurrence, and decrease complication rates. In a study, a retrospective evaluation of a prospectively acquired database, out of 810 studied limbs, there were numerous anatomic variations, including 1 anatomic variant that had not been described in the literature [11]. Limitations of this study include retrospective nature and possible selection bias given that it was a single center and consecutively acquired data. US has been championed as a best initial test.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. However, there are rare cases in which US imaging is limited, such as obesity. In these cases, where characterization of lower extremity veins is suboptimal, CTV can be used adjunctively [9]. CTV Pelvis There is no relevant literature regarding the use of CTV of the pelvis in the evaluation of bilateral GSV insufficiency with visible varicose veins. However, a comprehensive understanding of the anatomy could aid in the appropriate selection of treatment, planning interventions, and decreasing complication rates. US Intravascular Iliac Veins There is no relevant literature regarding the use of iliac vein IVUS in the evaluation of bilateral GSV insufficiency with visible varicose veins. MRV Lower Extremity MR venography (MRV) of the lower extremity has not been cited as a first-line examination. However, given the high rate of recurrence 2 years postintervention (15%-35%), it has been suggested that further anatomic characterization before therapy may be useful and could result in selecting more effective treatment [10-13]. In rare cases in which US imaging is limited, characterization of lower extremity veins is suboptimal, or the goal is to avoid iodinated contrast, MRV can be used adjunctively [9]. MRV Pelvis There is no relevant literature regarding the use of MRV of the pelvis in the evaluation of asymptomatic bilateral GSV insufficiency with visible varicose veins. However, a comprehensive understanding of the anatomy could aid in the appropriate selection of treatment, planning interventions, and decreasing complication rates. US Duplex Doppler Lower Extremity It is widely agreed upon that duplex US should be the first assessment of the lower extremity venous system [1,9,14]. Duplex US evaluation should include condition of the deep venous system, GSV, small saphenous vein (SSV), and accessory saphenous veins.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Presence and location of clinically relevant perforating veins and extent of possible alternative refluxing superficial venous pathways should also be included in any duplex US evaluation. Evaluation of venous structures should be accomplished via both transverse and longitudinal planes. Respiratory variation and cardiac pulsations are normally present and indicate a patent pathway to the heart [1]. The association between reflux and clinical manifestations of chronic venous disease is well established. Reflux, defined as retrograde venous flow >500 ms is almost always the result of primary degenerative changes within the venous wall and valves or as sequela of acute DVT causing destruction of venous valves [15]. Duplex Doppler US recordings should thus document presence, absence, and location of reflux. At a base level, abnormal reflux times should be measured and reported [16]. Variant 2: Varicose veins. Treatment. Compression Therapy Compression therapy has been widely described as the best initial treatment for varicose veins [18-20]. Compression therapy involves the use of a wide varying degree of devices to provide extrinsic compression on the lower extremity. As a group, they reduce venous stasis in various ways. Edema is contained by reduction of capillary filtration, fluid shift into noncompressed regions, and improved lymphatic drainage. Veins are directly affected by increasing venous blood flow velocity, reducing blood pooling, and improving venous pumping function. Lastly, microcirculation is influenced by transient increases in sheer stress, which in turn causes the release of anti- inflammatory, vasodilating, and antithrombotic mediators [19,21]. When using compression therapy, a minimum pressure of 20 to 30 mm Hg is recommended. Pressures of 30 to 40 mm Hg are advised for more severe disease [20].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Of note, improved ejection fraction in refluxing vessels and higher extrinsic pressures were achieved when higher pressures were exerted at the calf over the distal ankle (negative graduated compression bandage). Improved pressures and ejection fractions were also observed when placing the compression bandage over the calf versus the distal leg [18]. Until recently, it had been widely accepted that treatment failure typically results from noncompliance [16,17]. However, 2 high-quality systematic reviews have concluded that the current published data are inadequate. The weakness in the data relates to the reliance on surrogate outcomes and subjective clinical improvement. Though present, few data demonstrate correlation with quality of life (QoL) improvement with routine use of compression alone [15]. Adherence should nonetheless be encouraged with proper fitting, education, and detailed instructions [19,20]. Despite the minimal evidence regarding C2 to C4 disease, there is evidence that compression therapy has value in C5 (preventing ulcer recurrence) and C6 disease (healing ulcers) [15]. Mosti and Partsch [18] demonstrated that 30 to 40 mm Hg inelastic compression is better than elastic bandaging for wound healing. They also showed that for ankle-brachial indices between 0.9 and 0.6, reduced compression to 20 to 30 mm Hg is successful and safe for venous leg ulcers (VLU) healing. Velcro inelastic compression was noted to be as good as 3- or 4-layer inelastic bandages. Caution is advised, however, when the ankle-brachial index is <0.6 because it indicates an arterial anomaly needing revascularization [21]. Saphenous Vein Ablation Endovenous ablation has largely supplanted surgical ligation and stripping as the main invasive method to treat varicose veins with similar efficacy, improved early QoL, and reduced hospital recovery [7,22,23]. The 2 types of endovenous ablation are radiofrequency ablation (RFA) and endovenous laser ablation (EVLA).


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. RFA is a minimally invasive procedure in which a catheter is inserted into a target vein lumen. Intense, local heat- based energy through the catheter then obliterates the vein lumen and destroys the wall. EVLA uses laser energy that is absorbed by the target tissue and converted to heat. Both treatments use tumescent anesthesia, a method by which diluted local anesthetic with or without epinephrine and/or sodium bicarbonate are injected around the target vessel. This adjuvant protects the surrounding tissue and collapses the vein wall extrinsically to further ensure the target tissue is ablated in its entirety [7]. By 3 months post-treatment, endothelium is absent and organized thrombus is formed. Occlusion rates for these types of endovenous ablation vary from 91% to 100% within 1-year post- treatment [7,22]. Multiple recent meta-analyses confirm that EVLA and RFA are at least as efficacious, if not slightly more so, than surgery [12,24-26]. When compared to surgery, EVLA had fewer rates of bleeding, hematoma, and wound infection [24]. EVLA and RFA were also noted to have reduced rates of paresthesia compared to surgery [27]. A meta- analysis pooling 52 studies of both RFA and EVLA demonstrated postprocedural thrombotic events infrequently; DVT occurred in 0.3% of cases, and pulmonary embolism occurred in 0.1% of cases [28]. Rates of recurrence between surgery and EVLA had conflicting data, with Paravastu et al [25] noting improved recurrence rates with EVLA at 6 weeks and 1 year and Pan et al [24] noting no significant difference. So far, little difference is seen when comparing the various endovenous treatments in terms of QoL, benefit, and durability [15]. Current data on RFA versus EVLA is rather limited, although there have been some recent Lower Extremity Chronic Venous Disease developments. Gale et al [29] randomized 48 patients into EVLA and 46 patients into RFA, with 11 RFA patients demonstrating recurrence compared with 2 cases of recurrence in the EVLA arm.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. A meta-analysis showed not only no statistically significant difference in long-term outcomes between conventional surgery and endovenous therapy but also no statistically significant difference in long-term outcomes between RFA and EVLA or conventional surgery [30]. An additional meta-analysis including 792 EVLA-treated and 785 RFA-treated patients demonstrated the same safety and efficacy between the 2 treatment cohorts. Outcomes included 3-day and 10-day pain scores, 1 month and 1 year QoL, occlusion, thrombophlebitis, hematoma, and recanalization. Though limited, data from this meta-analysis suggest RFA seems to have a lower overall risk of complication when compared to EVLA [31]. We can conclude that the aggregate of evidence supports that ablation of saphenous veins provides significant benefits compared with compression [15]. Compression Sclerotherapy Compression sclerotherapy has been used effectively in the treatment of varicose veins, reticular veins, and telangiectasias [7,14]. In sclerotherapy, a liquid or foamed sclerosing drug is injected into the lumen of the varicose vein. This sclerosant is a chemical that damages the vein wall and ultimately occludes it secondary to fibrotic transformation of the vessel. Foamed sclerosant is used to increase the surface area by which the luminal wall can be treated. Doppler US of the GSV ablated with foam at 1-year post-treatment demonstrated occlusion rates vary from 72% to 89%, which is lower compared to EVLA at 1 year [7,32]. Sclerosant can also be administered over a rotating wire, which causes local trauma to the vessel. This form of mechanochemical ablation has closure rates that vary from 88% to 94% in the literature [7]. Advantages of these chemical ablative techniques include a lack of potential thermal injury that could injure the skin, nerves, muscles, and nontarget blood vessels, which is rarely seen with endovenous ablation. Additionally, because of a lack of thermal energy, tumescent anesthesia is not needed.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Potential complications include phlebitis, new telangiectasias, and residual pigmentations. Exceedingly rare complications include DVT [7]. Other nontumescent techniques that are used are cyanoacrylate glue. Risk factors would be allergies to adhesives. Multiple studies have shown that, compared with conventional open surgery and EVLA, chemical sclerotherapy has worse outcomes at 1-, 5-, and 8-year follow-ups, with higher rates of recurrent GSV reflux and saphenofemoral junction failure [33-36]. There are conflicting data on QoL, however, with equivalent improvement reported per the Aberdeen Varicose Vein Severity Score [36] and inferior improvement reported per the Chronic Venous Insufficiency Quality of Life Questionnaire [35]. Ligation and Stripping Higher rates of GSV reflux recurrence are identified with EVLA compared with high ligation and stripping. Both EVLA and high ligation and stripping, however, were noted to have similar metrics on disease specific QoL [37- 39]. Another study comparing high ligation and stripping versus EVLA in patients with GSV incompetence showed no significant difference between the 2 groups in recurrent GSV reflux, recurrent varicose veins, frequency of reoperations, Venous Clinical Severity Score, and QoL scores in a 5-year follow-up [40]. The RELACS study demonstrated, specifically, that high ligation and stripping was superior to EVLA in recurrence rates 5 years post- treatment [38]. There are conflicting data regarding procedural complications. Pan et al [24] affirms that there is no significant difference in postprocedural phlebitis and bruising and concludes that there are fewer complications regarding bleeding, hematoma, wound infection, and paresthesia with EVLA. Rass et al [39], on the other hand, affirms that higher rates of phlebitis, tightness, and dyspigmentation were noted with EVLA. Microphlebectomy Microphlebectomy involves the surgical excision of pathologic vessels.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. This method is used in combination with sclerotherapy ablation for best results. The most common complication involves skin blistering from dressing abrasions and adhesive tape. Wound infections may occur. Less commonly, small sensory nerves can be injured leading to areas of anesthesia and less commonly hyperesthesia. A rare injury could result from common peroneal nerve injury. The common peroneal nerve is commonly located just medial to the biceps femoris tendon and near the fibular head. Injury to this nerve can cause sensory loss or foot drop. When planning microphlebectomy, care or avoidance of this region is recommended [2]. Lower Extremity Chronic Venous Disease Variant 3: Venous leg ulcer. Initial diagnosis. Catheter Venography Iliac Veins Catheter-directed venography of the iliac veins has been described as the next step in diagnosis after CTV/MRV has characterized an occlusion or stenosis [9]. Venography has been criticized for low sensitivity for identifying critical lesions in the iliac vein [41]. Venographic findings can be grouped into normal, stenosis, and occlusion [8]. Catheter Venography Lower Extremity Digital subtraction ascending venography has been described as the next step in diagnosis after CTV or MRV has characterized an occlusion or stenosis [9]. Catheter-directed venography of the lower extremity is used mainly as part of a procedure in which treatment is planned for post-thrombotic and nonthrombotic obstruction of the iliac veins and much less often for post-thrombotic femoral veins. CTV Lower Extremity CTV of the lower extremity has not been cited as a first-line examination. However, it is helpful after duplex US in evaluation for occlusion, stenosis, collaterals, post-thrombotic changes, and axial transformation of the profunda vein [8]. Further highlighting the importance of CTV before intervention is the high rate of recurrence 2 years postintervention (15%-35%).


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Understanding the anatomy could aid in the appropriate selection of treatment and reduce recurrence and complication rates. CTV Abdomen and Pelvis CTV of the abdomen and pelvis has been suggested in the literature in cases with signs of iliac or inferior vena cava (IVC) involvement [9]. Further anatomic characterization before therapy can ensure appropriate and effective treatment, thus reducing the frequency for reintervention [10-13]. Understanding the anatomy could aid in the selection of an appropriate treatment modality and reduce recurrence and complication rates. US Intravascular Iliac Veins IVUS has been cited as the most sensitive and specific imaging modality for detecting deep vein obstructive disease. Compared to multiplanar venography, IVUS has been found to be more sensitive for detecting significant stenosis. One study found that, in 26.3% of patients, significant lesions were detected with IVUS not initially seen with 3- view venography [42]. Up to 10% of significant stenotic lesions, however, could not be seen via IVUS and required trial balloon angioplasty to unmask stenosis [8]. IVUS has also shown utility at predicting when stenting for iliofemoral vein stenosis will result in symptomatic improvement. One study involving CEAP C4 to C6 study population has shown significant improvement symptomatology in stenting >50% iliofemoral vein stenosis (50% area reduction chosen by authors) [41]. MRV Lower Extremity MRV of the lower extremity has not been cited as a first-line examination. As with CTV, MRV identifies stenosis, occlusion, venous atresia, collaterals, and edema. In addition, MRV can show webs, trabeculations, and vein wall thickening [9]. Furthermore, understanding unique patient anatomy [10] could aid in the selection of the appropriate treatment modality and reduce recurrence and complication rates.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. In cases in which characterization of lower extremity veins is suboptimal, MRV can be used adjunctively [9]. MRV Abdomen and Pelvis MRV of the abdomen and pelvis has not been cited as a first-line examination. As with CTV, MRV identifies stenosis, occlusion, venous atresia, collaterals, and edema. In addition, MRV can show webs, trabeculations, and vein wall thickening [9]. Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Characterization of these potential variants is important for treatment planning purposes. US Duplex Doppler Lower Extremity It is widely agreed upon that duplex US should be the first assessment of the lower extremity venous system [1,9,14]. Duplex US is currently the most common imaging technique because it is noninvasive. Evaluation should include direction of blood flow, assessment for venous reflux, and venous obstruction [20]. Additionally, duplex US evaluation should include the condition of the deep venous system, GSV, SSV and its thigh extension (Giacomini Vein), and accessory saphenous veins. Presence and location of perforating veins near a VLU should also be included in any duplex US evaluation [1]. Lower Extremity Chronic Venous Disease If after treatment an ulcer recurs, repeat duplex US should assess for recanalization of treated GSV or reflux into the Giacomini vein, transmitting to the short saphenous vein [8]. Arterial vascular characterization may also prove useful because it has been noted that 16% of patients with VLU have concomitant arterial occlusive disease, which is frequently not recognized [19,43]. US Duplex Doppler IVC and Iliac Veins As in arterial vasculature, critical stenosis is defined by a sharp reduction in forward flow; in venous vasculature, critical stenosis is related to venous hypertension. In fact, the beneficial effects of venous stenting are related to peripheral venous decompression [44].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. This is an important distinction to make because Doppler US can be used to evaluate for this metric via peak systolic velocities. Labropoulos et al [45] and Metzger et al [46] agree that a peak systolic velocity ratio >2.5 across the stenosis (poststenotic velocity to prestenotic velocity) as an accurate criterion to use for the presence of a pressure gradient of 3 mm Hg. Doppler US can thus be used to determine candidacy for intervention and also monitor success of treatment on follow-up. Variant 4: Venous leg ulcer. Treatment. Compression Therapy Compression therapy has been widely described as a helpful initial treatment for VLU [18-20]. Compression therapy involves the use of a wide varying degree of devices to provide extrinsic compression on the lower extremity. As a group, they reduce venous stasis in various ways. Edema is contained by reduction of capillary filtration, fluid shift into noncompressed regions, and improved lymphatic drainage. Veins are directly affected by increasing venous blood flow velocity, reducing blood pooling, and improving venous pumping function. Lastly, microcirculation is influenced by transient increases in sheer stress, which in turn causes the release of anti- inflammatory, vasodilating, and antithrombotic mediators [19,47]. When using compression therapy, a minimum pressure of 20 to 30 mm Hg is recommended. Pressures of 30 to 40 mm Hg are advised for more severe disease [20]. Of note, improved ejection fraction in refluxing vessels and higher extrinsic pressures were achieved when higher pressures were exerted at the calf over the distal ankle (negative graduated compression bandage). The alternative, graduated compression bandage, in which more force is generated at the distal ankle over the calf, demonstrated inferior ejection fraction in refluxing vessels and lower extrinsic pressures compared with their negative graduated compression bandage counterparts.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Improved pressures and ejection fractions were also observed when placing the compression bandage over the calf versus the distal leg [18]. Until recently, it had been widely accepted that treatment failure typically results from noncompliance [16,17]. However, 2 high-quality systematic reviews have concluded that the current published data are inadequate. The weakness in the data relates to the reliance on surrogate outcomes and subjective clinical improvement. Though present, few data demonstrate correlation with QoL improvement with routine use of compression alone [15]. Adherence should nonetheless be encouraged with proper fitting, education, and detailed instructions [19,20]. Despite the minimal evidence regarding C2 to C4 disease, there is evidence that compression therapy has value in C5 (preventing ulcer recurrence) and C6 disease (healing ulcers) [15]. Mosti and Partsch [18] demonstrated that 30 to 40 mm Hg inelastic compression is better than elastic bandaging for wound healing. They also showed that for ankle-brachial indices between 0.9 to 0.6, reduced compression to 20 to 30 mm Hg is successful and safe for VLU healing. Velcro inelastic compression was noted to be as good as 3- or 4-layer inelastic bandages. Caution is advised, however, when the ankle-brachial index is <0.6 because it indicates an arterial anomaly needing revascularization [21]. Saphenous Vein Ablation Multiple recent meta-analyses confirm that EVLA and RFA are at least as efficacious, if not slightly more so, than surgery [12,24-26]. When compared to surgery, EVLA had fewer rates of bleeding, hematoma, and wound infection [24]. EVLA and RFA were also noted to have reduced rates of paresthesia compared to surgery [27]. A meta- analysis pooling 52 studies of both RFA and EVLA demonstrated postprocedural thrombotic events infrequently; DVT occurred in 0.3% of cases, and pulmonary embolism occurred in 0.1% of cases [28].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Rates of recurrence between surgery and EVLA had conflicting data, with Paravastu et al [25] noting improved recurrence rates with EVLA at 6 weeks and 1 year and Pan et al [24] noting no significant difference. Lower Extremity Chronic Venous Disease Gohel et al [48] compared timing of EVLA, either immediately (within 2 weeks) or deferred (after 6 months or resolution of ulcer) and determined that early EVLA resulted in faster healing of venous ulcers and more ulcer-free time. Current data on RFA versus EVLA is rather limited, although there have been some recent developments. Gale et al [29] randomized 48 patients into EVLA and 46 patients into RFA, with 11 RFA patients demonstrating recurrence compared with 2 cases of recurrence in the EVLA arm. A meta-analysis showed not only no statistically significant difference in long-term outcomes between conventional surgery and endovenous therapy but also no statistically significant difference in long-term outcomes between RFA and EVLA or conventional surgery [30]. An additional meta-analysis including 792 EVLA-treated and 785 RFA-treated patients demonstrated the same safety and efficacy between the 2 treatment cohorts. Outcomes included 3-day and 10-day pain scores, 1-month and 1-year QoL, occlusion, thrombophlebitis, hematoma, and recanalization. Although limited, data from this meta-analysis suggest RFA seems to have a lower overall risk of complication compared to EVLA [31]. Compression Sclerotherapy Compression sclerotherapy has been used effectively in the treatment of varicose veins, reticular veins, and telangiectasias [7,14]. In foam sclerotherapy, a liquid or foamed sclerosing drug is injected into the lumen of the varicose vein. This sclerosant is a chemical that damages the vessel wall and occludes the affecting vasculature secondary to fibrotic transformation of the vessel. Foamed sclerosant is used to increase the surface area by which the luminal wall can be treated.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. At 1-year post-treatment, occlusion rates vary from 72% to 89%, which is lower when compared to EVLA at 1 year [7,32]. Sclerosant can also be administered over a rotating wire, which causes local trauma to the vessel. This form of mechanochemical ablation has closure rates that vary from 88% to 94% in the literature [7]. Advantages of these chemical ablative techniques include a lack of potential thermal injury that could injure the skin, nerves, muscles, and nontarget blood vessels, which is rarely seen with endovenous ablation. Additionally, because of a lack of thermal energy, tumescent anesthesia is not needed. Potential complications include phlebitis, new telangiectasias, and residual pigmentations. Exceedingly rare complications include DVT [7]. Other nontumescent techniques that are used are cyanoacrylate glue. Risk factors would be allergies to adhesives. Multiple studies have shown that, compared with conventional open surgery and EVLA, chemical sclerotherapy has worse outcomes at 1-, 5-, and 8-year follow-ups, with higher rates of recurrent GSV reflux and saphenofemoral junction failure [33-36]. There are conflicting data on QoL, however, with equivalent improvement reported per the Aberdeen Varicose Vein Severity Score [36] and inferior improvement reported per the Chronic Venous Insufficiency Quality of Life Questionnaire [35]. Iliac Vein Stenting If venography has characterized a central occlusive vascular insult as a culprit for disease that involves the iliocaval segments, angioplasty with possible stenting should be performed. Cases with large ulcers that have decreased in size from prior superficial vein ablation usually require iliac vein stenting to complete ulcer healing [8]. Post-thrombotic iliac vein obstruction can lead to many QoL affecting symptoms including pain, swelling, and VLU. Multiple studies have shown iliac vein stenting to be advantageous with iliac vein stenosis >50%.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Rossi et al [49] attests that compared with medial therapy alone, QoL and symptomatology are dramatically improved in both the short and long term with iliac vein stenting and medial therapy. A meta-analysis of available studies demonstrated that iliac vein stenting improved pain, swelling, and venous ulcer healing with secondary patency rates acceptable given relatively low overall risk [15]. Microphlebectomy There is no relevant literature regarding the use of microphlebectomy in the treatment of venous ulcers. Ligation and Stripping Higher rates of GSV reflux recurrence are identified with EVLA compared with high ligation and stripping. Both EVLA and high ligation and stripping, however, were noted to have similar metrics on disease specific QoL [37- 39]. Another study comparing high ligation and stripping versus EVLA in patients with GSV incompetence showed no significant difference between the 2 groups in recurrent GSV reflux, recurrent varicose veins, frequency of reoperations, Venous Clinical Severity Score, and QoL scores in a 5-year follow-up [40]. The RELACS study demonstrated, specifically, that high ligation and stripping was superior to EVLA in recurrence rates 5 years post- treatment [38]. Lower Extremity Chronic Venous Disease There are conflicting data regarding procedural complications. Pan et al [24] affirms that there is no significant difference in postprocedural phlebitis and bruising and concludes that there are fewer complications regarding bleeding, hematoma, wound infection, and paresthesia with EVLA. Rass et al [39], on the other hand, affirms that higher rates of phlebitis, tightness, and dyspigmentation were noted with EVLA. Wound Care Although literature has shown benefit in ulcer debridement in improving venous ulcer, the optimal protocol for wound care is yet to be elucidated. Beyond debridement, wound exudate control and surface bacteria management are additional important goals in wound care.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Antibiotic dressings, however, have shown no benefit. Adjuncts such as topical dressings to control wound exudate and maintain moisture as well as skin protectants are also important [6,21]. Variant 5: Suspected pelvic-origin lower extremity varicose veins in females. Initial diagnosis. Catheter Venography Pelvis Catheter-directed venography of the iliac veins has been described as the next step in diagnosis after US of the iliac veins, ovarian veins, renal veins, and IVC, CTV/MRV has characterized an occlusion or stenosis [9]. Venographic findings can be grouped into normal, stenosis, and occlusion [8]. Pelvic varices can sometimes be demonstrated with direct catheterization plus or minus balloon occlusion. CTV Abdomen and Pelvis There is no relevant literature regarding the use of CTV abdomen and pelvis in the evaluation of pelvic-derived lower extremity varicose veins in women. This examination can be useful in evaluating the anatomy of dilated ovarian veins and nutcracker phenomenon, which can explain connections to pelvic-origin lower extremity varicose veins. CTV of the abdomen and pelvis has been suggested in the literature in cases with signs of iliac or IVC involvement [9]. Further anatomic characterization before therapy can ensure appropriate and effective treatment thus reducing the frequency for reintervention [10-13]. Understanding the anatomy could aid in the selection of an appropriate treatment modality and reduce recurrence and complication rates. US Intravascular Iliac Veins IVUS has been cited as the most sensitive and specific imaging modality for detecting deep vein obstructive disease. Compared to multiplanar venography, IVUS has been found to be more sensitive for detecting significant stenosis. One study found that in 26.3% of patients, significant lesions were detected with IVUS not initially seen with 3- view venography [42].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Up to 10% of significant stenotic lesions, however, could not be seen via IVUS and required trial balloon angioplasty to unmask stenosis [8]. US Intravascular Renal Veins There is no relevant literature regarding the use of IVUS for renal veins in the evaluation of pelvic-derived lower extremity varicose veins in women, although it can accurately characterize the severity of a stenosis of a renal vein but compression over the adjacent aorta and superior mesenteric artery. MRV Abdomen and Pelvis MRV of the abdomen and pelvis can identify stenosis, occlusion, venous atresia, collaterals, and edema. In addition, MRV can show webs, trabeculations, and vein wall thickening [9]. MRV can also demonstrate the diameters of pelvic veins and ovarian veins to identify those that are varicose (>5 mm periuterine and periovarian veins and >6- 8 mm in diameter ovarian veins) [50]. Further highlighting the importance of MRV before intervention is a high Lower Extremity Chronic Venous Disease rate of recurrence 2 years postintervention (15%-35%). Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Characterization of these potential variants is important for treatment planning purposes. US Duplex Doppler Lower Extremity It is widely agreed upon that duplex US should be the first assessment of the lower extremity venous system [1,9,14]. Duplex US is currently the most common imaging technique because it is noninvasive. Evaluation should include direction of blood flow, assessment for venous reflux, and venous obstruction [20]. Duplex US evaluation should additionally include condition of the deep venous system, GSV, SSV, and accessory saphenous veins. Presence and location of clinically relevant perforating veins and extent of possible alternative refluxing superficial venous pathways should also be included in any duplex US evaluation [1].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. In a study of 56 women with pelvic varicose veins, 44 patients demonstrated varying degrees of venous insufficiency. This information suggests a connection between pelvic varicose veins and venous insufficiency. Duplex US of the lower extremities may then be a very reasonable evaluation in patients with known pelvic varicose veins [51]. In addition, Khilnani et al [52] notes that duplex US in patients with varicose veins in the posterior thigh, vulva, and inguinal regions (nonsaphenous pelvic origin varicose veins) can help identify venous escape points from reflux in the internal iliac venous system. US Duplex Doppler Pelvis It is widely agreed upon that duplex US should be the first assessment of the lower extremity venous system [1,9,14]. Duplex US is currently the most common imaging technique because it is noninvasive. Evaluation should include direction of blood flow, assessment for venous reflux, and venous obstruction [20]. If there are vulvar varicose veins, operators are rarely able to trace these vessels to a pelvic origin. These examinations require a very experienced sonographer to acquire relevant information. Most often, it is necessary to characterize with advanced imaging [1]. US Duplex Doppler IVC and Iliac Veins There is no relevant literature regarding the use of US for evaluation of the IVC and iliac veins in the treatment of pelvic-origin lower extremity varicose veins. As in arterial vasculature, critical stenosis is defined by a sharp reduction in forward flow; in venous vasculature, critical stenosis is related to venous hypertension. In fact, the beneficial effects of venous stenting are related to peripheral venous decompression [44]. This is an important distinction to make because Doppler US can be used to evaluate for this metric via peak systolic velocities.