Thoracic Venous Occlusions-Suspected Superior Vena Cava Syndrome

Variant: 1 Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.

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

Variant: 2 Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.

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

Anant D. Bhave, MD^a; Nathan Franssen, MD^b; Minhaj S. Khaja, MD, MBA^c; Nima Kokabi, MD^d; William F. Browne, MD^e; Murthy R. Chamarthy, MD^f; Benjamin N. Contrella, MD^g; Baljendra S. Kapoor, MD, MBA^h; Nicole A. Keefe, MDⁱ; Mahammed Z. Khan Suheb, MD^j; Karen M. Kim, MD^k; Julie Lahiri, MD^l; Andrea Obi, MD^m; Sherry Scovell, MDⁿ; Daniel P. Sheeran, MD^o; Seda Tierney, MD^p; Nkiruka Udejiofor, MD^q; Madison Wulfeck, MD, MBA^r; Bill S. Majdalany, MD^s.

Summary of Literature Review

Introduction/Background

Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).

Discussion of Procedures by Variant

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
A. Catheter venography upper extremity and SVC

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
B. CT chest with IV contrast

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
C. CT chest without and with IV contrast

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
D. CT chest without IV contrast

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
E. CT neck and chest with IV contrast

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
F. CT neck and chest without and with IV contrast

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
G. CT neck and chest without IV contrast

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
H. CTA and CTV chest with IV contrast

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
I. CTA chest with IV contrast

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
J. CTA chest without and with IV contrast

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
K. CTV chest with IV contrast

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
L. MRA and MRV chest without and with IV contrast

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
M. MRA chest with IV contrast

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
N. MRA chest without and with IV contrast

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
O. MRA chest without IV contrast

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
P. MRI chest with IV contrast

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
Q. MRI chest without and with IV contrast

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
R. MRI chest without IV contrast

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
S. MRV chest without and with IV contrast

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
T. MRV chest without IV contrast

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
U. Radiography chest

Variant 1: Adult. Suspected acute superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
V. US duplex Doppler upper extremity and chest

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
A. Catheter venography upper extremity and SVC

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
B. CT chest with IV contrast

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
C. CT chest without and with IV contrast

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
D. CT chest without IV contrast

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
E. CT neck and chest with IV contrast

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
F. CT neck and chest without and with IV contrast

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
G. CT neck and chest without IV contrast

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
H. CTA and CTV chest with IV contrast

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
I. CTA chest with IV contrast

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
J. CTA chest without and with IV contrast

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
K. CTV chest with IV contrast

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
L. MRA and MRV chest without and with IV contrast

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
M. MRA chest with IV contrast

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
N. MRA chest without and with IV contrast

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
O. MRA chest without IV contrast

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
P. MRI chest with IV contrast

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
Q. MRI chest without and with IV contrast

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
R. MRI chest without IV contrast

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
S. MRV chest without and with IV contrast

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
T. MRV chest without IV contrast

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
U. Radiography chest

Variant 2: Adult. Suspected chronic superior vena cava or brachiocephalic vein occlusion. Initial Imaging.
V. US duplex Doppler upper extremity and chest

Summary of Highlights

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.

Gender Equality and Inclusivity Clause

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

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

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 (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

References

1.	Friedman T, Quencer KB, Kishore SA, Winokur RS, Madoff DC. Malignant Venous Obstruction: Superior Vena Cava Syndrome and Beyond. Semin Intervent Radiol 2017;34:398-408.
2.	Kalra M, Sen I, Gloviczki P. Endovenous and Operative Treatment of Superior Vena Cava Syndrome. Surg Clin North Am 2018;98:321-35.
3.	Yu JB, Wilson LD, Detterbeck FC. Superior vena cava syndrome--a proposed classification system and algorithm for management. J Thorac Oncol 2008;3:811-4.
4.	Ierardi AM, Jannone ML, Petrillo M, et al. Treatment of venous stenosis in oncologic patients. Future Oncol 2018;14:2933-43.
5.	Zhao Y, Yang L, Wang Y, Zhang H, Cui T, Fu P. The diagnostic value of multi-detector CT angiography for catheter-related central venous stenosis in hemodialysis patients. Phlebology. 36(3):217-225, 2021 Apr.
6.	Choong CK, Pasricha SS, Li X, et al. Dynamic four-dimensional computed tomography for preoperative assessment of lung cancer invasion into adjacent structures . European Journal of Cardio-Thoracic Surgery. 47(2):239-43; discussion 243, 2015 Feb.
7.	Akin Y, Cagli K, Okten RS, Keles T, Golbasi Z. Pacemaker-associated superior vena cava syndrome: Role of contrast echocardiography. Echocardiography. 39(4):647-653, 2022 04.
8.	Sonavane SK, Milner DM, Singh SP, Abdel Aal AK, Shahir KS, Chaturvedi A. Comprehensive Imaging Review of the Superior Vena Cava. [Review]. Radiographics. 35(7):1873-92, 2015 Nov-Dec.
9.	Sundaram B, Kuriakose JW, Stojanovska J, Watcharotone K, Parker RA, Kazerooni EA. Thoracic central venous evaluation: comparison of first-pass direct versus delayed-phase indirect multidetector CT venography. Clinical Imaging. 39(3):412-6, 2015 May-Jun.
10.	Azizi AH, Shafi I, Shah N, et al. Superior Vena Cava Syndrome. JACC Cardiovasc Interv 2020;13:2896-910.
11.	Lacout A, Marcy PY, Thariat J, Lacombe P, El Hajjam M. Radio-anatomy of the superior vena cava syndrome and therapeutic orientations. Diagn Interv Imaging 2012;93:569-77.
12.	National Academies of Sciences, Engineering, and Medicine; Division of Behavioral and Social Sciences and Education; Committee on National Statistics; Committee on Measuring Sex, Gender Identity, and Sexual Orientation. Measuring Sex, Gender Identity, and Sexual Orientation. In: Becker T, Chin M, Bates N, eds. Measuring Sex, Gender Identity, and Sexual Orientation. Washington (DC): National Academies Press (US) Copyright 2022 by the National Academy of Sciences. All rights reserved.; 2022.
13.	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.