Original article
ACR Appropriateness Criteria® Suspected Upper Extremity Deep Vein Thrombosis

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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.

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

  • Despite the availability of noninvasive imaging techniques, contrast venography remains the best reference standard diagnostic test for suspected upper-extremity acute venous thrombosis.

  • 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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    The ACR 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.

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