Health services research and policy
Original article
ACR Appropriateness Criteria Imaging in the Diagnosis of Thoracic Outlet Syndrome

https://doi.org/10.1016/j.jacr.2015.01.016Get rights and content

Abstract

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.

Section snippets

Introduction/Background

Thoracic outlet syndrome (TOS) is a clinical entity characterized by compression of the neurovascular bundle of the upper limb, as it passes from the upper thoracic aperture to the axilla. Although thrombosis of the axillosubclavian vein was first reported by Paget in 1875 and Von Schroetter in 1884, and was coined “Paget-Schroetter syndrome” by Hughes in 1949, the term “thoracic outlet syndrome” was coined in the 1950s to reflect the fact that TOS has many variants, ranging from vascular

Summary

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    TOS is characterized by compression of the neurovascular bundle as it passes from the upper thorax to the axilla. The form that it takes can be arterial, venous or neurogenic.

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    TOS may be congenital or acquired and may be secondary to bony tissues, such as first-rib abnormalities, cervical ribs, and bony tubercles, or soft-tissue anomalies, such as fibrous bands or cervical muscle hypertrophy.

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    The goal of further imaging is to confirm the diagnosis of TOS, exclude mimics, such as cervical

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. This disorder has occurred primarily in patients on dialysis, rarely in patients with a very limited glomerular filtration rate (ie, <30 mL/min/1.73m2), and almost never in other patients. The

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are important to consider when selecting the appropriate imaging procedure. Because a wide range of radiation exposures are associated with various 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.

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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.

    Jeffrey P. Kanne, MD, is a consultant for Parexcel Informatics.

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