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Purpose: The aim of this study was to report data from the first 3 years of operation of the RSNA-ACR 3D Printing Registry., Methods: Data from June 2020 to June 2023 were extracted, including demographics, indications, workflow, and user assessments. Clinical indications were stratified by 12 organ systems. Imaging modalities, printing technologies, and numbers of parts per case were assessed. Effort data were analyzed, dividing staff members into provider and nonprovider categories. The opinions of clinical users were evaluated using a Likert scale questionnaire, and estimates of procedure time saved were collected., Results: A total of 20 sites and 2,637 cases were included, consisting of 1,863 anatomic models and 774 anatomic guides. Mean patient ages for models and guides were 42.4 ± 24.5 years and 56.3 ± 18.5 years, respectively. Cardiac models were the most common type of model (27.2%), and neurologic guides were the most common type of guide (42.4%). Material jetting, vat photopolymerization, and material extrusion were the most common printing technologies used overall (85.6% of all cases). On average, providers spent 92.4 min and nonproviders spent 335.0 min per case. Providers spent most time on consultation (33.6 min), while nonproviders focused most on segmentation (148.0 min). Confidence in treatment plans increased after using 3-D printing (P < .001). Estimated procedure time savings for 155 cases was 40.5 ± 26.1 min., Conclusions: Three-dimensional printing is performed at health care facilities for many clinical indications. The registry provides insight into the technologies and workflows used to create anatomic models and guides, and the data show clinical benefits from 3-D printing., (Published by Elsevier Inc.)

Objective: There is a paucity of utility and cost data regarding the launch of 3D printing in a hospital. The objective of this project is to benchmark utility and costs for radiology-based in-hospital 3D printing of anatomic models in a single, adult academic hospital., Methods: All consecutive patients for whom 3D printed anatomic models were requested during the first year of operation were included. All 3D printing activities were documented by the 3D printing faculty and referring specialists. For patients who underwent a procedure informed by 3D printing, clinical utility was determined by the specialist who requested the model. A new metric for utility termed Anatomic Model Utility Points with range 0 (lowest utility) to 500 (highest utility) was derived from the specialist answers to Likert statements. Costs expressed in United States dollars were tallied from all 3D printing human resources and overhead. Total costs, focused costs, and outsourced costs were estimated. The specialist estimated the procedure room time saved from the 3D printed model. The time saved was converted to dollars using hospital procedure room costs., Results: The 78 patients referred for 3D printed anatomic models included 11 clinical indications. For the 68 patients who had a procedure, the anatomic model utility points had an overall mean (SD) of 312 (57) per patient (range, 200-450 points). The total operation cost was $213,450. The total cost, focused costs, and outsourced costs were $2,737, $2,180, and $2,467 per model, respectively. Estimated procedure time saved had a mean (SD) of 29.9 (12.1) min (range, 0-60 min). The hospital procedure room cost per minute was $97 (theoretical $2,900 per patient saved with model)., Discussion: Utility and cost benchmarks for anatomic models 3D printed in a hospital can inform health care budgets. Realizing pecuniary benefit from the procedure time saved requires future research., (Copyright © 2022 American College of Radiology. All rights reserved.)

Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in Cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care., (Copyright © 2022 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Pulmonary embolism (PE) remains a common and important clinical condition that cannot be accurately diagnosed on the basis of signs, symptoms, and history alone. The diagnosis of PE has been facilitated by technical advancements and multidetector CT pulmonary angiography, which is the major diagnostic modality currently used. Ventilation and perfusion scans remain largely accurate and useful in certain settings. MR angiography can be useful in some clinical scenarios and lower-extremity ultrasound can substitute by demonstrating deep vein thrombosis; however, if negative, further studies to exclude PE are indicated. In all cases, correlation with the clinical status, particularly with risk factors, improves not only the accuracy of diagnostic imaging but also overall utilization. Other diagnostic tests have limited roles. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2022 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Objective: To meet hospital preparedness for the coronavirus disease 2019 pandemic, the Centers for Disease Control and Prevention and ACR recommended delay of all nonemergent tests and elective procedures. The purpose of this article is to report our experience for rescheduling nonemergent imaging and procedures during the pandemic at our tertiary academic institution., Methods: We rescheduled the nonemergent imaging and procedures in our hospitals and outpatient centers from March 16 to May 4, 2020. We created a tiered priority system to reschedule patients for whom imaging could be delayed with minimal clinical impact. The radiologists performed detailed chart reviews for decision making. We conducted daily virtual huddles with discussion of rescheduling strategies and issue tracking., Results: Using a snapshot during the rescheduling period, there was a 53.4% decrease in imaging volume during the period of March 16 to April 15, 2020, compared with the same time period in 2019. The total number of imaging studies decreased from 38,369 in 2019 to 17,891 in 2020 during this period. Although we saw the largest reduction in outpatient imaging (72.3%), there was also a significant decrease in inpatient (40.5%) and emergency department (48.9%) imaging volumes., Discussion: The use of multiple communication channels was critical in relaying the information to all our stakeholders, patients, referring physicians, and the radiology workforce. Teamwork, quick adoption, and adaptation of changing strategies was important given the fluidity of the situation., (Copyright © 2020 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Patient-centric care has garnered the attention of the radiology community. The authors describe a patient-centric approach to iodinated contrast administration designed to optimize the diagnostic yield of contrast-enhanced CT while minimizing patient iodine load and exposure to ionizing radiation, thereby enhancing patient safety while providing reasonable diagnostic efficacy. Patient-centric CT hardware settings and contrast media administration are important considerations for clinical CT quality and safety., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Peripheral arterial disease (PAD) affects millions across the world and in the United States between 9% to 23% of all patients older than 55 years. The refinement of surgical techniques and evolution of endovascular approaches have improved the success rates of revascularization in patients afflicted by lower extremity PAD. However, restenosis or occlusion of previously treated vessels remains a pervasive issue in the postoperative setting. A variety of different imaging options are available to evaluate patients and are reviewed within the context of asymptomatic and symptomatic patients with PAD who have previously undergone endovascular or surgical revascularization. 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., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Although the incidence of thoracic aortic aneurysm is on the rise, initial imaging diagnosis can present a challenge for many clinicians. Providers are faced with many imaging choices as part of the initial workup. Considering level of invasiveness, relative radiation level, and quality of associated diagnostic data, CT angiography and MR angiography are believed to be the most appropriate options for radiological diagnosis of suspected thoracic aortic aneurysm. 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., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Breast cancer is the most common malignancy in women in the United States. Breast reconstruction surgery is a commonly used therapy for patients with breast cancer. The technique for the deep inferior epigastric perforator flap uses a preserved rectus muscle, which decreases donor site morbidity. Accurate identification and measurement of the perforator branches of the deep inferior epigastric artery is pivotal during pre-operative planning so that the surgeon can prioritize the best vessel to use and ultimately improve clinical outcome. 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., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Aortic stenosis is a common valvular condition with increasing prevalence in aging populations. When severe and symptomatic, the downstream prognosis is poor without surgical or transcatheter aortic valve replacement. Transcatheter aortic valve replacement is now considered a viable alternative to surgical aortic valve replacement in patients considered high and intermediate risk for surgery. Pre-intervention imaging with echocardiography and CT are essential for procedure planning and device selection to help optimize clinical outcomes with MR angiography playing largely a complementary role. Modern 3-D cross-sectional imaging has consistently shown to help reduce procedural complications from vascular access injury to paravalvular regurgitation and coronary obstruction. 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., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the patterns of Appropriate Criteria application among orthopedic specialists and other fields of medicine for use of MRI and radiography and the subsequent necessity for surgical intervention., Methods: The hospital electronic medical record was used to identify all shoulder MRI studies at a single large urban teaching hospital between January 2, 2011, and June 30, 2011. For each study, variables collected included ordering department, patient age, patient gender, patient's self-reported race/ethnicity, whether the patient obtained surgery for an issue related to the MRI diagnosis, the type of MRI ordered, the date of pain onset, the date of x-ray (if any), and the date of the MRI., Results: A total of 475 patients who underwent shoulder MRI were included in our study. We found significant associations between a patient having had a prior x-ray and ordering department (P < .0001), male gender (P = .0005), and subjects who had subsequent surgery (P = .0006). Neither age nor race and ethnicity had an influence on x-ray before MRI. Orthopedic specialists ordering MRIs had the highest percentage of patients undergo subsequent surgery (33.3%) compared with the second-most, primary care (18.4%), and all other ordering departments (P = .0009)., Conclusions: Detailed analysis suggests that providers who do not have specific training in shoulder pathology should consider consultation with an orthopedic surgeon before ordering shoulder MRI for patients who may need additional imaging after radiography., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Upper gastrointestinal bleeding (UGIB) remains a significant cause of morbidity and mortality with mortality rates as high as 14%. This document addresses the indications for imaging UGIB that is nonvariceal and unrelated to portal hypertension. The four variants are derived with respect to upper endoscopy. For the first three, it is presumed that upper endoscopy has been performed, with three potential initial outcomes: endoscopy reveals arterial bleeding source, endoscopy confirms UGIB without a clear source, and negative endoscopy. The fourth variant, "postsurgical and traumatic causes of UGIB; endoscopy contraindicated" is considered separately because upper endoscopy is not performed. When endoscopy identifies the presence and location of bleeding but bleeding cannot be controlled endoscopically, catheter-based arteriography with treatment is an appropriate next study. CT angiography (CTA) is comparable with angiography as a diagnostic next step. If endoscopy demonstrates a bleed but the endoscopist cannot identify the bleeding source, angiography or CTA can be typically performed and both are considered appropriate. In the event of an obscure UGIB, angiography and CTA have been shown to be equivalent in identifying the bleeding source; CT enterography may be an alternative to CTA to find an intermittent bleeding source. In the postoperative or traumatic setting when endoscopy is contraindicated, primary angiography, CTA, and CT with intravenous contrast are considered appropriate. 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., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Vascular claudication is a symptom complex characterized by reproducible pain and weakness in an active muscle group due to peripheral arterial disease. Noninvasive hemodynamic tests such as the ankle brachial index, toe brachial index, segmental pressures, and pulse volume recordings are considered the first imaging modalities necessary to reliably establish the presence and severity of arterial obstructions. Vascular imaging is consequently used for diagnosing individual lesions and triaging patients for medical, percutaneous, or surgical intervention. Catheter angiography remains the reference standard for imaging the peripheral arteries, providing a dynamic and accurate depiction of the peripheral arteries. It is particularly useful when endovascular intervention is anticipated. When combined with noninvasive hemodynamic tests, however, noninvasive imaging, including ultrasound, CT angiography, and MR angiography, can also reliably confirm or exclude the presence of peripheral arterial disease. All modalities, however, have their own technical limitations when classifying the location, extent, and severity of disease. 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., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Clinical palpation of a pulsating abdominal mass alerts the clinician to the presence of a possible abdominal aortic aneurysm (AAA). Imaging studies are important in diagnosing and categorizing the extent of the aneurysm and may aid in treatment planning. The consensus of the literature supports the use of ultrasound as the initial screening test in patients with suspected AAA. Population-based ultrasound screening studies have been recommended and have proved effective for male patients > 65 years of age. For diagnosis and pre-intervention evaluation, either multidetector CT or CT angiography is the optimal choice for detailed characterization of the aneurysm. MR angiography may be substituted if CT cannot be performed (for example, because the patient is allergic to iodinated contrast material). Invasive angiography has little role in the diagnosis of AAA and PET and CT remain experimental in patients with suspected aneurysms. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision 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., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The intent of CAD-RADS - Coronary Artery Disease Reporting and Data System is to create a standardized method to communicate findings of coronary CT angiography (coronary CTA) in order to facilitate decision-making regarding further patient management. The suggested CAD-RADS classification is applied on a per-patient basis and represents the highest-grade coronary artery lesion documented by coronary CTA. It ranges from CAD-RADS 0 (Zero) for the complete absence of stenosis and plaque to CAD-RADS 5 for the presence of at least one totally occluded coronary artery and should always be interpreted in conjunction with the impression found in the report. Specific recommendations are provided for further management of patients with stable or acute chest pain based on the CAD-RADS classification. The main goal of CAD-RADS is to standardize reporting of coronary CTA results and to facilitate communication of test results to referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will provide a framework of standardization that may benefit education, research, peer-review and quality assurance with the potential to ultimately result in improved quality of care., (Copyright © 2016 Society of Cardiovascular Computed Tomography and the American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Pulmonary arteriovenous malformations are often included in the differential diagnosis of common clinical presentations, including hypoxemia, hemoptysis, brain abscesses, and paradoxical stroke, as well as affecting 30% to 50% of patients with hereditary hemorrhagic telangiectasia (HHT). Various imaging studies are used in the diagnostic and screening settings, which have been reviewed by the ACR Appropriateness Criteria Vascular Imaging Panel. Pulmonary arteriovenous malformation screening in patients with HHT is commonly performed with transthoracic echocardiographic bubble study, followed by CT for positive cases. Although transthoracic echocardiographic bubble studies and radionuclide perfusion detect right-to-left shunts, they do not provide all of the information needed for treatment planning and may remain positive after embolization. Pulmonary angiography is appropriate for preintervention planning but not as an initial test. MR angiography has a potential role in younger patients with HHT who may require lifelong surveillance, despite lower spatial resolution compared with CT. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Thoracic outlet syndrome is a clinical entity characterized by compression of the neurovascular bundle, and may be associated with additional findings such as venous thrombosis, arterial stenosis, or neurologic symptoms. The goal of imaging is to localize the site of compression, the compressing structure, and the compressed organ or vessel, while excluding common mimics. A literature review is provided of current indications for diagnostic imaging, with discussion of potential limitations and benefits of the respective modalities. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. In this document, we provided guidelines for use of various imaging modalities for assessment of thoracic outlet syndrome., (Copyright © 2015 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The US health care system is in the midst of disruptive changes intended to expand access, improve outcomes, and lower costs. As part of this movement, a growing number of stakeholders have advocated dramatically increasing consumer transparency into the quality and price of health care services. The authors review the general movement toward American health care value transparency within the public, private, and nonprofit sectors, with an emphasis on those initiatives most relevant to radiology. They conclude that radiology, along with other "ancillary services," has been a major focus of early efforts to enhance consumer price transparency. By contrast, radiology as a field remains in the "middle of the pack" with regard to quality transparency. There is thus the danger that radiology value transparency in its current form will stimulate primarily price-based competition, erode provider profit margins, and disincentivize quality. The authors conclude with suggested actions radiologists can take to ensure that a more optimal balance is struck between quality transparency and price transparency, one that will enable true value-based competition among radiologists rather than commoditization., (Copyright © 2015 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: Available data are limited on the level of adherence to established guidelines for appropriate utilization of MR in musculoskeletal imaging. This study estimates the percentage of MRI examinations for knee and shoulder pain or tendonitis performed without prior radiography, which thus may fall outside the ACR Appropriateness Criteria for the Medicare and commercially insured populations., Methods: The percentage of MRI examinations for knee and shoulder pain or tendonitis performed without prior radiography was estimated among patients in the Medicare 5% carrier claims limited data set and among commercially insured patients in the Truven Marketscan Treatment Pathways database in 2010., Results: Approximately 28% of all knee MRIs, and 35%-37% of all shoulder MRIs were performed without recent prior radiographs. The extrapolated expense of these potentially unwarranted MRIs in the entire fee-for-service Medicare population was between $20 and $35 million. Between 20% and 23% of patients undergoing knee MRI, and 27%-32% undergoing shoulder MRI, did not have radiographic examination at any point before the MRI in the same calendar year., Conclusions: MRI performed without prior radiography represents a potential gap in care and should be considered as an area for establishment of performance measures., (Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Performance measures in radiology play an increasingly significant role in health care quality assessment and now form the basis for a variety of pay-for-performance programs, including those administered by CMS. This article introduces the measure development process, beginning with topic selection, followed by measure development and testing, National Quality Forum endorsement, and implementation. Once implemented, measures may undergo further testing and be re-endorsed, modified, or retired. Radiologists should familiarize themselves with the measures relevant to their practice, develop ways to collect and report data efficiently, and implement the necessary practice changes to meet measure criteria and improve the quality of their practice., (Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Although aortic valve replacement is the definitive therapy for severe aortic stenosis, almost half of patients with severe aortic stenosis are unable to undergo conventional aortic valve replacement because of advanced age, comorbidities, or prohibitive surgical risk. Treatment options have been recently expanded with the introduction of catheter-based implantation of a bioprosthetic aortic valve, referred to as transcatheter aortic valve replacement. Because this procedure is characterized by lack of exposure of the operative field, image guidance plays a critical role in preprocedural planning. This guideline document evaluates several preintervention imaging examinations that focus on both imaging at the aortic valve plane and planning in the supravalvular aorta and iliofemoral system. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The American College of Radiology (ACR) and the American College of Cardiology Foundation (ACCF) have jointly developed a method to define appropriate utilization of cardiovascular imaging. The primary role of this method is to create a series of documents to define the utility of cardiovascular imaging procedures in relation to specific clinical questions, with the aim of defining what, if any, imaging tests are indicated to help to determine diagnosis, treatment, or outcome. The methodology accomplishes this aim through the application of systematic evidence reviews integrated with expert opinion by means of a rigorous Delphi process. By obtaining broad input during the development process from radiologists, cardiologists, primary care physicians, and other stakeholders, these documents are intended to provide practical evidence-based guidance to ordering providers, imaging laboratories, interpreting physicians, patients, and policymakers as to optimal cardiovascular imaging utilization. This document details the history, rationale, and methodology for developing these joint documents for appropriate utilization of cardiovascular imaging., (Copyright © 2013 American College of Cardiology Foundation and the American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Upper-extremity venous thrombosis often presents as unilateral arm swelling. The differential diagnosis includes lesions compressing the veins and causing a functional venous obstruction, venous stenosis, an infection causing edema, obstruction of previously functioning lymphatics, or the absence of sufficient lymphatic channels to ensure effective drainage. The following recommendations are made with the understanding that venous disease, specifically venous thrombosis, is the primary diagnosis to be excluded or confirmed in a patient presenting with unilateral upper-extremity swelling. Contrast venography remains the best reference-standard diagnostic test for suspected upper-extremity acute venous thrombosis and may be needed whenever other noninvasive strategies fail to adequately image the upper-extremity veins. Duplex, color flow, and compression ultrasound have also established a clear role in evaluation of the more peripheral veins that are accessible to sonography. Gadolinium contrast-enhanced MRI is routinely used to evaluate the status of the central veins. Delayed CT venography can often be used to confirm or exclude more central vein venous thrombi, although substantial contrast loads are required. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment., (Copyright © 2012 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Lower extremity deep vein thrombosis (DVT) is a common clinical concern, with an incidence that increases with advanced age. DVT typically begins below the knee but may extend proximally and result in pulmonary embolism. Pulmonary embolism can occur in 50% to 60% of patients with untreated DVT and can be fatal. Although clinical examination and plasma d-dimer blood evaluation can often predict the presence of DVT, imaging remains critical for the diagnostic confirmation and treatment planning of DVT. Patients with above-the-knee or proximal DVT have a high risk for pulmonary embolism and are recommended to receive anticoagulation therapy. On the other hand, patients with below-the-knee or distal DVT rarely experience pulmonary embolism, and anticoagulation therapy in these patients remains controversial. However, one sixth of patients with distal DVT may experience extension of their thrombus above the knee and therefore are recommended to undergo serial imaging assessment at 1 week to exclude proximal DVT extension if anticoagulation therapy is not initiated. Ultrasound is the preferred imaging method for evaluation of patients with newly suspected lower extremity DVT. Magnetic resonance and CT venography can be especially helpful for the evaluation of suspected DVT in the pelvis and thigh. Contrast x-ray venography, the historic gold standard for DVT assessment, is now less commonly performed and primarily reserved for patients with more complex presentations such as those with suspected recurrent acute DVT., (Published by Elsevier Inc.)

Lower-extremity arteriopathy patients can be managed nonsurgically, but there is no standard algorithm for follow-up. The authors present a consensus on appropriate postangioplasty studies in the setting of claudication or a threatened limb. Physical examination with measurements of the ankle-brachial index should be the first step in patients with recurrent symptoms. When there is high clinical suspicion for a threatened limb, the patient should proceed directly to catheter angiography for possible reintervention. However, in the setting of claudication alone, segmental Doppler pressures and pulse volume recordings are the initial test of choice. Magnetic resonance angiography or ultrasound can be used in conjunction to further characterize lesions with more detail. Computed tomographic angiography may also be used to image lower-extremity vasculature but is limited by the presence of large amounts of vascular calcifications. Novel techniques, including dual-energy computed tomographic angiography and noncontrast magnetic resonance angiography, may provide clinicians with alternative approaches in patients with large amounts of vascular calcifications and renal insufficiency, respectively.

Although the relationship between cardiologists and radiologists has a thorny history, advanced cardiac imaging technology and the promise of cardiac computed tomography are forcing both specialties back to the negotiation table. These discussions represent an opportunity for better communication, collaboration, and resource allocation. The authors address the aspects of interdepartmental conflict management and negotiation through their radiology department's ongoing efforts to provide high-quality advanced noninvasive cardiovascular imaging services at a large academic institution. The definition and causes of conflict are defined, with a specific focus on noninvasive cardiovascular imaging, followed by a description of steps used in the negotiation process. The authors encourage radiologists to entertain an open dialogue with cardiology, because in many cases, both sides can benefit. The benefits of a negotiated outcome include minimizing internal competitors, incorporating cardiologists' expertise to cardiac imaging algorithms, and more effective training opportunities.