Thoracic Outlet Syndrome

Variant: 1 Neurogenic thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography chest	Usually Appropriate	☢
MRI chest without and with IV contrast	Usually Appropriate	O
MRI chest without IV contrast	Usually Appropriate	O
US duplex Doppler subclavian artery and vein	May Be Appropriate	O
CT chest with IV contrast	May Be Appropriate	☢☢☢
CTA chest with IV contrast	May Be Appropriate	☢☢☢
Arteriography upper extremity	Usually Not Appropriate	☢
Catheter venography upper extremity	Usually Not Appropriate	☢☢☢
MRA chest without and with IV contrast	Usually Not Appropriate	O
MRA chest without IV contrast	Usually Not Appropriate	O
MRV chest without and with IV contrast	Usually Not Appropriate	O
MRV chest without IV contrast	Usually Not Appropriate	O
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢
CT chest without IV contrast	Usually Not Appropriate	☢☢☢
CTV chest with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 2 Venous thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.

Procedure	Appropriateness Category	Relative Radiation Level
US duplex Doppler subclavian artery and vein	Usually Appropriate	O
Radiography chest	Usually Appropriate	☢
Catheter venography upper extremity	Usually Appropriate	☢☢☢
CT chest with IV contrast	Usually Appropriate	☢☢☢
MRA chest without and with IV contrast	May Be Appropriate	O
MRA chest without IV contrast	May Be Appropriate (Disagreement)	O
MRI chest without and with IV contrast	May Be Appropriate	O
MRI chest without IV contrast	May Be Appropriate	O
MRV chest without and with IV contrast	May Be Appropriate	O
MRV chest without IV contrast	May Be Appropriate	O
CT chest without IV contrast	May Be Appropriate	☢☢☢
CTV chest with IV contrast	May Be Appropriate	☢☢☢☢
Arteriography upper extremity	Usually Not Appropriate	☢
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢
CTA chest with IV contrast	Usually Not Appropriate	☢☢☢

Variant: 3 Arterial thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.

Procedure	Appropriateness Category	Relative Radiation Level
US duplex Doppler subclavian artery and vein	Usually Appropriate	O
Arteriography upper extremity	Usually Appropriate	☢
Radiography chest	Usually Appropriate	☢
MRA chest without and with IV contrast	Usually Appropriate	O
CTA chest with IV contrast	Usually Appropriate	☢☢☢
MRA chest without IV contrast	May Be Appropriate	O
MRI chest without and with IV contrast	May Be Appropriate	O
MRI chest without IV contrast	May Be Appropriate	O
CT chest with IV contrast	May Be Appropriate	☢☢☢
CT chest without IV contrast	May Be Appropriate	☢☢☢
Catheter venography upper extremity	Usually Not Appropriate	☢☢☢
MRV chest without and with IV contrast	Usually Not Appropriate	O
MRV chest without IV contrast	Usually Not Appropriate	O
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢
CTV chest with IV contrast	Usually Not Appropriate	☢☢☢☢

Panel Members

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Discussion of Procedures by Variant

Variant 1: Neurogenic thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.

Variant 1: Neurogenic thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
A. Arteriography Upper Extremity

Variant 1: Neurogenic thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
B. Catheter Venography Upper Extremity

Variant 1: Neurogenic thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
C. CT Chest

Variant 1: Neurogenic thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
D. CTA Chest

Variant 1: Neurogenic thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
E. CTV Chest

Variant 1: Neurogenic thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
F. MRI Chest

Variant 1: Neurogenic thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
G. MRA Chest

Variant 1: Neurogenic thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
H. MRV Chest

Variant 1: Neurogenic thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
I. Radiography Chest

Variant 1: Neurogenic thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
J. US Duplex Doppler Subclavian Artery and Vein

Variant 2: Venous thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.

Variant 2: Venous thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
A. Arteriography Upper Extremity

Variant 2: Venous thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
B. Catheter Venography Upper Extremity

Variant 2: Venous thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
C. CT Chest

Variant 2: Venous thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
D. CTA Chest

Variant 2: Venous thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
E. CTV Chest

Variant 2: Venous thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
F. MRI Chest

Variant 2: Venous thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
G. MRA Chest

Variant 2: Venous thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
H. MRV Chest

Variant 2: Venous thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
I. Radiography Chest

Variant 2: Venous thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
J. US Duplex Doppler Subclavian Artery and Vein

Variant 3: Arterial thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.

Variant 3: Arterial thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
A. Arteriography Upper Extremity

Variant 3: Arterial thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
B. Catheter Venography Upper Extremity

Variant 3: Arterial thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
C. CT Chest

Variant 3: Arterial thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
D. CTA Chest

Variant 3: Arterial thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
E. CTV Chest

Variant 3: Arterial thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
F. MRI Chest

Variant 3: Arterial thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
G. MRA Chest

Variant 3: Arterial thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
H. MRV Chest

Variant 3: Arterial thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
I. Radiography Chest

Variant 3: Arterial thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention.
J. US Duplex Doppler Subclavian Artery and Vein

Summary of Recommendations

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.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

References

1.	Demondion X, Herbinet P, Van Sint Jan S, Boutry N, Chantelot C, Cotten A. Imaging assessment of thoracic outlet syndrome. Radiographics. 2006; 26(6):1735-1750.
2.	Hussain MA, Aljabri B, Al-Omran M. Vascular Thoracic Outlet Syndrome. [Review]. Semin Thorac Cardiovasc Surg. 28(1):151-7, 2016.
3.	Thompson JF, Winterborn RJ, Bays S, White H, Kinsella DC, Watkinson AF. Venous thoracic outlet compression and the Paget-Schroetter syndrome: a review and recommendations for management. Cardiovasc Intervent Radiol. 2011; 34(5):903-910.
4.	Thompson JF, Jannsen F. Thoracic outlet syndromes. Br J Surg. 83(4):435-6, 1996 Apr.
5.	Angle N, Gelabert HA, Farooq MM, et al. Safety and efficacy of early surgical decompression of the thoracic outlet for Paget-Schroetter syndrome. Ann Vasc Surg. 15(1):37-42, 2001 Jan.
6.	Aljabri B, Al-Omran M. Surgical management of vascular thoracic outlet syndrome: a teaching hospital experience. Ann Vasc Dis. 6(1):74-9, 2013.
7.	Doyle A, Wolford HY, Davies MG, et al. Management of effort thrombosis of the subclavian vein: today's treatment. Ann Vasc Surg. 21(6):723-9, 2007 Nov.
8.	Guzzo JL, Chang K, Demos J, Black JH, Freischlag JA. Preoperative thrombolysis and venoplasty affords no benefit in patency following first rib resection and scalenectomy for subacute and chronic subclavian vein thrombosis. J Vasc Surg. 52(3):658-62; discussion 662-3, 2010 Sep.
9.	Lee JT, Karwowski JK, Harris EJ, Haukoos JS, Olcott C 4th. Long-term thrombotic recurrence after nonoperative management of Paget-Schroetter syndrome. J Vasc Surg. 43(6):1236-43, 2006 Jun.
10.	Povlsen B, Hansson T, Povlsen SD. Treatment for thoracic outlet syndrome. [Review][Update of Cochrane Database Syst Rev. 2010;(1):CD007218; PMID: 20091624]. Cochrane Database Syst Rev. (11)CD007218, 2014 Nov 26.
11.	Schneider DB, Dimuzio PJ, Martin ND, et al. Combination treatment of venous thoracic outlet syndrome: open surgical decompression and intraoperative angioplasty. J Vasc Surg. 40(4):599-603, 2004 Oct.
12.	Remy-Jardin M, Remy J, Masson P, et al. CT angiography of thoracic outlet syndrome: evaluation of imaging protocols for the detection of arterial stenosis. J Comput Assist Tomogr. 24(3):349-61, 2000 May-Jun.
13.	Remy-Jardin M, Remy J, Masson P, et al. Helical CT angiography of thoracic outlet syndrome: functional anatomy. AJR. 2000; 174(6):1667-1674.
14.	Rubin GD, Rofsky NM. CT and MR Angiography: Comprehensive Vascular Assessment. Philadelphia, PA: Lippincott, Williams& Wilkins; 2009.
15.	American College of Radiology. ACR–NASCI–SIR–SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA). Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=164+&releaseId=2.
16.	Aralasmak A, Cevikol C, Karaali K, et al. MRI findings in thoracic outlet syndrome. Skeletal Radiology. 41(11):1365-74, 2012 Nov.
17.	Demondion X, Bacqueville E, Paul C, Duquesnoy B, Hachulla E, Cotten A. Thoracic outlet: assessment with MR imaging in asymptomatic and symptomatic populations. Radiology. 2003; 227(2):461-468.
18.	Aralasmak A, Karaali K, Cevikol C, Uysal H, Senol U. MR imaging findings in brachial plexopathy with thoracic outlet syndrome. AJNR Am J Neuroradiol. 2010;31(3):410-417.
19.	Ersoy H, Steigner ML, Coyner KB, et al. Vascular thoracic outlet syndrome: protocol design and diagnostic value of contrast-enhanced 3D MR angiography and equilibrium phase imaging on 1.5- and 3-T MRI scanners. AJR Am J Roentgenol. 2012; 198(5):1180-1187.
20.	Gharagozloo F, Meyer M, Tempesta B, Strother E, Margolis M, Neville R. Proposed pathogenesis of Paget-Schroetter disease: impingement of the subclavian vein by a congenitally malformed bony tubercle on the first rib. J Clin Pathol. 2012; 65(3):262-266.
21.	Viertel VG, Intrapiromkul J, Maluf F, et al. Cervical ribs: a common variant overlooked in CT imaging. AJNR Am J Neuroradiol. 2012; 33(11):2191-2194.
22.	Gu R, Kang MY, Gao ZL, Zhao JW, Wang JC. Differential diagnosis of cervical radiculopathy and superior pulmonary sulcus tumor. Chin Med J. 125(15):2755-7, 2012 Aug.
23.	Chang KZ, Likes K, Davis K, Demos J, Freischlag JA. The significance of cervical ribs in thoracic outlet syndrome. J Vasc Surg. 57(3):771-5, 2013 Mar.
24.	Balakrishnan A, Coates P, Parry CA. Thoracic outlet syndrome caused by pseudoarticulation of a cervical rib with the scalene tubercle of the first rib. J Vasc Surg. 2012;55(5):1495.
25.	Kirschbaum A, Palade E, Csatari Z, Passlick B. Venous thoracic outlet syndrome caused by a congenital rib malformation. Interact Cardiovasc Thorac Surg. 2012;15(2):328-329.
26.	O'Brien PJ, Ramasunder S, Cox MW. Venous thoracic outlet syndrome secondary to first rib osteochondroma in a pediatric patient. J Vasc Surg. 2011;53(3):811-813.
27.	Davis GA, Knight SR. Pancoast tumors. Neurosurg Clin N Am. 19(4):545-57, v-vi, 2008 Oct.
28.	Demondion X, Vidal C, Herbinet P, Gautier C, Duquesnoy B, Cotten A. Ultrasonographic assessment of arterial cross-sectional area in the thoracic outlet on postural maneuvers measured with power Doppler ultrasonography in both asymptomatic and symptomatic populations. J Ultrasound Med. 2006; 25(2):217-224.
29.	Demondion X, Herbinet P, Boutry N, Fontaine C, Francke JP, Cotten A. Sonographic mapping of the normal brachial plexus. AJNR Am J Neuroradiol. 24(7):1303-9, 2003 Aug.
30.	Torriani M, Gupta R, Donahue DM. Sonographically guided anesthetic injection of anterior scalene muscle for investigation of neurogenic thoracic outlet syndrome. Skeletal Radiol. 2009; 38(11):1083-1087.
31.	Chang KZ, Likes K, Demos J, Black JH 3rd, Freischlag JA. Routine venography following transaxillary first rib resection and scalenectomy (FRRS) for chronic subclavian vein thrombosis ensures excellent outcomes and vein patency. Vasc Endovascular Surg. 46(1):15-20, 2012 Jan.
32.	Zurkiya O, Donahue DM, Walker TG, Ganguli S. Safety and Efficacy of Catheter-Directed Therapies as a Supplement to Surgical Decompression in Venous Thoracic Outlet Syndrome. AJR Am J Roentgenol. 210(2):W80-W85, 2018 Feb.
33.	Kim TI, Sarac TP, Orion KC. Intravascular Ultrasound in Venous Thoracic Outlet Syndrome. Ann Vasc Surg. 54:118-122, 2019 Jan.
34.	Poretti D, Lanza E, Sconfienza LM, et al. Simultaneous bilateral magnetic resonance angiography to evaluate thoracic outlet syndrome. Radiol Med (Torino). 120(5):407-12, 2015 May.
35.	Lim RP, Bruno M, Rosenkrantz AB, et al. Comparison of blood pool and extracellular gadolinium chelate for functional MR evaluation of vascular thoracic outlet syndrome. Eur J Radiol. 83(7):1209-1215, 2014 Jul.
36.	Charon JP, Milne W, Sheppard DG, Houston JG. Evaluation of MR angiographic technique in the assessment of thoracic outlet syndrome. Clin Radiol. 2004; 59(7):588-595.
37.	Gillard J, Perez-Cousin M, Hachulla E, et al. Diagnosing thoracic outlet syndrome: contribution of provocative tests, ultrasonography, electrophysiology, and helical computed tomography in 48 patients. Joint Bone Spine. 2001; 68(5):416-424.
38.	Stapleton C, Herrington L, George K. Sonographic evaluation of the subclavian artery during thoracic outlet syndrome shoulder manoeuvres. Man Ther. 2009; 14(1):19-27.
39.	Molina JE, Hunter DW, Dietz CA. Protocols for Paget-Schroetter syndrome and late treatment of chronic subclavian vein obstruction. Ann Thorac Surg. 2009; 87(2):416-422.
40.	Wadhwani R, Chaubal N, Sukthankar R, Shroff M, Agarwala S. Color Doppler and duplex sonography in 5 patients with thoracic outlet syndrome. J Ultrasound Med. 2001; 20(7):795-801.
41.	Hasanadka R, Towne JB, Seabrook GR, Brown KR, Lewis BD, Foley WD. Computed tomography angiography to evaluate thoracic outlet neurovascular compression. Vasc Endovascular Surg. 2007; 41(4):316-321.
42.	Takei N, Miyoshi M, Kabasawa H. Noncontrast MR angiography for supraaortic arteries using inflow enhanced inversion recovery fast spin echo imaging. J Magn Reson Imaging. 2012; 35(4):957-962.
43.	American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.

Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.