Diagnosis and initial management of acute thoracic central venous obstruction

TCVO: thoracic central venous obstruction; DVT: deep vein thrombosis; CECT: contrast-enhanced computed tomography; IJ: internal jugular; SC: subclavian; BCV: brachiocephalic vein; SVC: superior vena cava; MR: magnetic resonance.

* Symptoms may be unilateral or bilateral.

¶ The presence of any of these symptoms indicates the need for an expedited evaluation.

Δ Ultrasound can directly identify obstruction in the axillary or distal SC veins. Identification of obstruction in the proximal central veins is indirect based on dampening of waveforms with loss of venous pulsatility and loss of respiratory variation.

◊ Equivocal findings on ultrasound or inadequate study for technical reasons in a patient with a clear clinical picture of TCVO. High D-dimer (>500 ng/mL) suggests the presence of thrombus.

§ CECT identifies venous obstruction and can identify surrounding soft tissue and bony abnormalities. MR venography is an alternative. If advanced imaging will be delayed, obtain plasma D-dimer and initiate anticoagulation if >500 ng/dL unless bleeding risk is high.

¥ Other causes for symptoms may include arteriovenous fistula, peripheral venous obstruction, trauma, lymphedema, congenital venous anomalies, arm cellulitis, and systemic or other disease (eg, liver, cardiac, renal, endocrine).

‡ Additional imaging may be needed to definitively determine whether thrombus is present before initiating anticoagulation, particularly for patients at high risk for bleeding. The dose and duration of anticoagulation for thrombotic TCVO is per standard protocols for venous thromboembolism.

† Evaluation may require additional imaging including CECT or MR venography if not already performed.

** Patients with thrombotic TCVO and moderate-to-severe symptoms may require endovenous thrombolysis or aspiration mechanical thrombectomy to uncover an underlying intrinsic venous stenotic lesion. Treatment of TCVO may require relief of external obstruction, venous stenting, open venoplasty, or a combination of these.