ACR Appropriateness Criteria ® Sudden Onset of Cold, Painful Leg

Abstract

Acute limb ischemia (ALI) requires urgent diagnosis and treatment to prevent limb loss. Invasive digital subtraction arteriography (DSA) is the gold standard for diagnosing ALI. DSA is the only diagnostic modality that permits simultaneous treatment of acute arterial occlusion. Noninvasive imaging with MRA or CT angiography may also be appropriate before treatment, especially when the diagnosis of ALI is in doubt or where DSA is unavailable. Other imaging and noninvasive physiologic tests may prove important for longer term management but are less recommended in the acute setting. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

A clinical case series of COVID-19-associated acute limb ischemia: real-world situation

“…Ankle Brachial Index (ABI) can also be the simplest tool for predicting outcomes (ABI < 0.7 is considered critical) [ 12 ]. Despite other imaging modalities, such as DUS, MRA, and CTA, interventional angiography is the gold standard because it coincides with the necessary treatment [ 10 – 12 , 23 ]. In the COVID-19 situation, imaging modalities might be challenging to perform due to hospital regulation, and patient transfers from the isolation ward might increase the risk of exposure to other patients.…”

Editor's Choice – European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia

“…In terms of diagnostic accuracy, digital subtraction angiography (DSA) is still considered the standard investigation for ALI. 39 DSA can delineate aetiology and offers the advantage of allowing treatment in the same setting; in modern practice this should be considered in association with endovascular surgery. The presence of a crescent shaped occlusion, or meniscus sign, combined with the normal appearance of the remaining vessels is typical of an embolic occlusion ( Fig.…”

ACR Appropriateness Criteria® Nonatherosclerotic Peripheral Arterial Disease

“…Varicose veins and deep vein thrombosis are common venous diseases of the lower extremities, with deep vein thrombosis having an estimated annual incidence of 5 per 10,000 in the general population [11]. Guidelines addressing lower-extremity atherosclerotic vascular disease and deep vein thrombosis have been addressed in previously published ACR Appropriateness Criteria Ò : "Vascular Claudication-Assessment for Revascularization" [12], "Lower Extremity Arterial Revascularization-Post-Therapy Imaging" [13], "Sudden Onset of Cold, Painful Leg" [14], and "Suspected Lower Extremity Deep Vein Thrombosis" [11].…”