Original articleACR Appropriateness Criteria® Suspected Upper Extremity Deep Vein Thrombosis
Section snippets
Introduction/Background
Upper-extremity venous thrombosis often presents as unilateral arm swelling. The differential diagnosis includes a mass lesion or other lesion compressing the veins and causing a functional venous obstruction, venous stenosis, or an infection causing edema [1]. Bilateral upper-extremity swelling may also be due to right-sided heart failure, although this is typically associated with generalized swelling, in contrast to central vein obstruction, which can cause swelling limited to the upper
MRI
Approaches to venous imaging using MRI include black-blood and flow-based or contrast-enhanced bright-blood techniques [34]. Black-blood techniques include conventional T1 or T2 spin-echo [28, 35] or fast spin-echo imaging. However, the black-blood effect on routine spin-echo imaging may not be consistent, and newer double inversion-recovery techniques provide more reliable black-blood imaging [34]. Using black-blood imaging, the presence of thrombus is inferred from focal high signal, often
CT
Computed tomography can be used to determine the presence of centrally located thrombi or stenoses within the jugular veins [51, 52], the brachiocephalic veins [53, 54], and the superior vena cava [53]. The presence of an extrinsic process causing venous obstruction of the venous channels can also be determined [55]. Computed tomography is the main imaging modality for staging neoplastic involvement in the mediastinum and axillae, which can include vascular invasion or compression. Perivascular
Summary
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Despite the availability of noninvasive imaging techniques, contrast venography remains the best reference standard diagnostic test for suspected upper-extremity acute venous thrombosis.
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Contrast venography may be needed whenever other noninvasive strategies fail to adequately image the upper-extremity veins. Additionally, because venography is the first step in direct catheter-based thrombolysis, in situations such as acute upper-extremity DVT in which the likelihood of percutaneous
Anticipated Exceptions
Nephrogenic systemic fibrosis is a disorder with a scleroderma-like presentation and a spectrum of manifestations that can range from limited clinical sequelae to fatality. It seems to be related to both underlying severe renal dysfunction and the administration of gadolinium-based contrast agents. It has occurred primarily in patients on dialysis, rarely in patients with very limited glomerular filtration rates (ie, <30 mL/min/1.73 m2), and almost never in other patients. There is growing
Relative Radiation Level Information
Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level indication has been included for each imaging examination. The relative radiation levels are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk
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