Body and Extremity MR Venography: Technique, Clinical Applications, and Advances

Magnetic resonance venography (MRV) represents a distinct imaging approach that may be used to evaluate a wide spectrum of venous pathology. Despite duplex ultrasound and computed tomography venography representing the dominant imaging modalities in investigating suspected venous disease, MRV is increasingly used due to its lack of ionizing radiation, unique ability to be performed without administration of intravenous contrast, and recent technical improvements resulting in improved sensitivity, image quality, and faster acquisition times. In this review, the authors discuss commonly used body and extremity MRV techniques, different clinical applications, and future directions.

Ferumoxytol-enhanced MR venography for diagnosis of venous thoracic outlet syndrome

Venous thoracic outlet syndrome commonly results in arm swelling and pain as the subclavian vein is obstructed within the thoracic inlet. We report the use of ferumoxytol-enhanced contrast MRI in the diagnosis of venous thoracic outlet syndrome in a male adolescent. In this patient who presented with right upper extremity thrombosis, ferumoxytol-enhanced MRI of the chest was able to show both chronic subclavian vein thromboses and dynamic occlusion of the subclavian veins with arm abduction consistent with Paget-Schroetter syndrome.

Novel Diagnostic and Treatment Techniques for Neurogenic Thoracic Outlet Syndrome

Neurogenic thoracic outlet syndrome is a challenging condition to diagnose and treat, often precipitated by the triad of repetitive overhead activity, pectoralis minor contracture, and scapular dyskinesia. The resultant protracted scapular posture creates gradual repetitive traction injury of the suprascapular nerve via tethering at the suprascapular notch and decreases the volume of the brachial plexus cords and axillary vessels in the retropectoralis minor space. A stepwise and exhaustive diagnostic protocol is essential to exclude alternate pathologies and confirm the diagnosis of this dynamic pathologic process. Ultrasound-guided injections of local anesthetic or botulinum toxin are a key factor in confirming the diagnosis and prognosticating potential response from surgical release. In patients who fail over 6 months of supervised physical therapy aimed at correcting scapular posture and stretching of the pectoralis minor, arthroscopic surgical release is indicated. We present our diagnostic algorithm and technique for arthroscopic suprascapular neurolysis, pectoralis minor release, brachial plexus neurolysis, and infraclavicular thoracic outlet decompression.

Clinical Significance of Maximum Intensity Projection Method for Diagnostic Imaging of Thoracic Outlet Syndrome

The aim of this study was to use the magnetic resonance imaging maximum-intensity projection (MRI-MIP) method for diagnostic imaging of thoracic outlet syndrome (TOS) and to investigate the stricture ratios of the subclavian artery (SCA), subclavian vein (SCV), and brachial plexus bundle (BP). A total of 113 patients with clinically suspected TOS were evaluated. MRI was performed in a position similar to the Wright test. The stricture was classified into four grades. Then, the stricture ratios of the SCA, SCV, and BP in the sagittal view were calculated by dividing the minimum diameter by the maximum diameter of each structure. Patients were divided into two groups: surgical (n = 22) and conservative (n = 91). Statistical analysis was performed using the Mann-Whitney U test. The stricture level and ratio in the SCV were significantly higher in the surgical group, while the stricture level and the ratio of SCA to BP did not show significant differences between the two groups. The MRI-MIP method may be helpful for both subsidiary and severe diagnoses of TOS.

Modern Treatment of Neurogenic Thoracic Outlet Syndrome: Pathoanatomy, Diagnosis, and Arthroscopic Surgical Technique

Compressive pathology in the supraclavicular and infraclavicular fossae is broadly termed "thoracic outlet syndrome," with the large majority being neurogenic in nature. These are challenging conditions for patients and physicians and require robust knowledge of thoracic outlet anatomy and scapulothoracic kinematics to elucidate neurogenic versus vascular disorders. The combination of repetitive overhead activity and scapular dyskinesia leads to contracture of the scalene muscles, subclavius, and pectoralis minor, creating a chronically distalized and protracted scapular posture. This decreases the volume of the scalene triangle, costoclavicular space, and retropectoralis minor space, with resultant compression of the brachial plexus causing neurogenic thoracic outlet syndrome. This pathologic cascade leading to neurogenic thoracic outlet syndrome is termed pectoralis minor syndrome when primary symptoms localize to the infraclavicular area. Making the correct diagnosis is challenging and requires the combination of complete history, physical examination, advanced imaging, and ultrasound-guided injections. Most patients improve with nonsurgical treatment incorporating pectoralis minor stretching and periscapular and postural retraining. Surgical decompression of the thoracic outlet is reserved for compliant patients who fail nonsurgical management and respond favorably to targeted injections. In addition to prior exclusively open procedures with supraclavicular, infraclavicular, and/or transaxillary approaches, new minimally invasive and targeted endoscopic techniques have been developed over the past decade. They involve the endoscopic release of the pectoralis minor tendon, with additional suprascapular nerve release, brachial plexus neurolysis, and subclavius and interscalene release depending on the preoperative work-up.

Pectoralis minor syndrome - review of pathoanatomy, diagnosis, and management of the primary cause of neurogenic thoracic outlet syndrome

Thoracic outlet syndrome is an umbrella term for compressive pathologies in the supraclavicular and infraclavicular fossae, with the vast majority being neurogenic in nature. These compressive neuropathies, such as pectoralis minor syndrome, can be challenging problems for both patients and physicians. Robust understanding of thoracic outlet anatomy and scapulothoracic biomechanics are necessary to distinguish neurogenic vs. vascular disorders and properly diagnose affected patients. Repetitive overhead activity, particularly when combined with scapular dyskinesia, leads to pectoralis minor shortening, decreased volume of the retropectoralis minor space, and subsequent brachial plexus compression causing neurogenic thoracic outlet syndrome. Combining a thorough history, physical examination, and diagnostic modalities including ultrasound-guided injections are necessary to arrive at the correct diagnosis. Rigorous attention must be paid to rule out alternate etiologies such as peripheral neuropathies, vascular disorders, cervical radiculopathy, and space-occupying lesions. Initial nonoperative treatment with pectoralis minor stretching, as well as periscapular and postural retraining, is successful in the majority of patients. For patients that fail nonoperative management, surgical release of the pectoralis minor may be performed through a variety of approaches. Both open and arthroscopic pectoralis minor release may be performed safely with effective resolution of neurogenic symptoms. When further indicated by the preoperative workup, this can be combined with suprascapular nerve release and brachial plexus neurolysis for complete infraclavicular thoracic outlet decompression.

Endovascular reconstruction of bilateral upper limbs ischemia in a patient with arterial outlet syndrome: A case report and literature review

Background

Acute upper limb ischemia in a patient with thoracic outlet syndrome is a rare but serious clinical disorder. If the disease is not treated promptly due to underdiagnosis, it could lead to distal artery embolization and limb-threatening ischemia. Revascularizing upper extremity arteries in a timely manner could rescue ischemic limbs and improve the patient’s quality of life. We reported here a case of a patient who presented with bilateral upper limb ischemia caused by arterial thoracic outlet syndrome.

Case presentation

A 63-year-old woman who presented with sudden bilateral upper extremity cold, numbness, pulselessness, and altered temperature sensation was first diagnosed with arterial thoracic outlet syndrome. The patient had performed a lot of pull-up and lat pull-down exercises in the 2 months prior to the onset of the above symptoms. Color Doppler ultrasonography showed thrombosis in the right axillary artery and left subclavian and axillary artery. The patient received Rotarex mechanical thrombectomy combined with drug-coated balloon percutaneous transluminal angioplasty (PTA) to complete revascularization of the upper extremities and achieved a full recovery finally.

Conclusions

Complete endovascular revascularization for treating arterial thoracic outlet syndrome is a minimally invasive and effective method, especially for upper extremity ischemic lesions caused by nonbone compression.

Neurogenic thoracic outlet syndrome in the overhead and throwing athlete: A narrative review

Thoracic outlet syndrome is an important cause of shoulder pain and dysfunction due to compression of neurovascular structures as they traverse the thoracic outlet. Symptoms are most commonly due to compression of the brachial plexus called neurogenic thoracic outlet syndrome (nTOS). Throwing athletes are at increased risk of nTOS because of a variety of biomechanical factors. However, because nTOS symptoms are often nonspecific, delayed diagnosis is common. Neurogenic thoracic outlet largely remains a diagnosis of exclusion with advanced imaging ruling out vascular involvement and diagnostic injections gaining favor in helping localize sites of compression. Although rehabilitation alone may improve symptoms in some athletes, many require surgical treatment for long-term relief. This generally entails decompression of the thoracic outlet by some combination of muscle release, brachial plexus neurolysis, and first rib resection. Outcomes tend to be successful in athletes with most achieving resolution of symptoms and return to athletic activity. NTOS is an important cause of shoulder pain and dysfunction in throwing athletes. The history and physical examination should focus on activities that exacerbate symptoms. Treatment of nTOS generally requires surgical intervention and allows throwing athletes to return to sport.

Venous thoracic outlet syndrome and Paget-Schroetter syndrome

Venous thoracic outlet syndrome represents a relatively rare but important diagnosis in the adolescent population with increasing recognition. Compression of the subclavian vein within the costoclavicular space can lead to episodic venous outlet obstruction in the upper extremity, with edema, rubor and functional symptoms. Over time, cumulative injury and compression can lead to thrombosis of the vein, referred to as "effort thrombosis" or the Paget-Schroetter syndrome. This progression can lead to the need for acute management of the venous thromboembolism, requirement for thoracic outlet decompression surgery and the potential for long-term sequelae such as post-thrombotic syndrome. Management is focused on clot minimization, anticoagulation during the period of endothelial injury and inflammation and surgical decompression via first rib resection, anterior scalenectomy and venolysis to remove external compression of the vein. This manuscript reviews the diagnosis, evaluation and treatment of venous thoracic outlet syndrome and Paget-Schroetter syndrome.

Evaluation and Management of Arterial Thoracic Outlet Syndrome

Arterial thoracic outlet syndrome is rare and may be associated with a bony anomaly. Patient presentation can range from mild arm discoloration and claudication to severe limb-threatening ischemia. For patients with subclavian artery dilation without secondary complications, thoracic outlet decompression and arterial surveillance is sufficient. Patients with subclavian artery aneurysms or distal embolization require decompression with reconstruction or thromboembolectomy and distal bypass respectively.

ACR Appropriateness Criteria® Suspected Upper Extremity Deep Vein Thrombosis

This publication includes the appropriate imaging modalities to assess suspected deep vein thrombosis in the upper extremities. Ultrasound duplex Doppler is the most appropriate imaging modality to assess upper-extremity deep vein thrombosis. It is a noninvasive test, which can be performed at the bedside and used for serial evaluations. Ultrasound can also directly identify thrombus by visualizing echogenic material in the vein and by lack of compression of the vein walls from manual external pressure. It can indirectly identify thrombus from altered blood-flow patterns. It is most appropriate in the evaluation of veins peripheral to the brachiocephalic vein. CT venography and MR venography are not first-line imaging tests, but are appropriate to assess the central venous structures, or to assess the full range of venous structures from the hand to the right atrium. Catheter venography is appropriate if therapy is required. Radionuclide venography and chest radiography are usually not appropriate to assess upper-extremity deep vein thrombosis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is the clinical entity that occurs with compression of the brachial plexus, subclavian artery, and/or subclavian vein at the superior thoracic outlet. Compression of each of these structures results in characteristic symptoms divided into three variants: neurogenic TOS, venous TOS, and arterial TOS, each arising from the specific structure that is compressed. The constellation of symptoms in each patient may vary, and patients may have more than one symptom simultaneously. Understanding the various anatomic spaces, causes of narrowing, and resulting neurovascular changes is important in choosing and interpreting radiological imaging performed to help diagnose TOS and plan for intervention. This publication has separated imaging appropriateness based on neurogenic, venous, or arterial symptoms, acknowledging that some patients may present with combined symptoms that may require more than one study to fully resolve. Additionally, in the postoperative setting, new symptoms may arise altering the need for specific imaging as compared to preoperative evaluation. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Thoracic Outlet Syndrome: Diagnostic Accuracy of MRI

BACKGROUND

Thoracic outlet syndrome (TOS) is challenging to diagnose, as the physical findings and investigations lack sensitivity and/or specificity. Magnetic resonance imaging (MRI) with dynamic manoeuvres can rule out a tumour and detect anatomical abnormalities potentially responsible for compression. The objective of this study was to assess the sensitivity and specificity of MRI for identifying anatomical structures responsible for compression in TOS, using intra-operative findings as the diagnostic reference standard.

HYPOTHESIS

MRI is effective in diagnosing the source of compression in TOS, notably within the scalene triangle and at the pleural apex.

METHODS

We retrospectively included 48 patients who underwent surgery for TOS after a work-up that included MRI (1.5-T, n=29 and 3-T, n=19). The MRI scans were reviewed for the study by a specialised radiologist who was unaware of the intra-operative findings. The sensitivity and specificity of MRI for diagnosing TOS were estimated using the intra-operative findings as the reference standard.

RESULTS

MRI identified a structure potentially responsible for TOS in 34 (71%) patients; thus, the false-negative rate was 14/48 (29%). The sensitivity of MRI was 28% for compression at the suspensory ligament of the pleural dome, 81% for hypertrophy of the anterior scalene muscle, and 50% for an accessory scalene muscle. For diagnosing a cervical rib, MRI had 100% sensitivity and 100% specificity.

CONCLUSION

MRI can contribute to the diagnosis of TOS. Specificity is sufficiently high to provide guidance for planning the surgical procedure. Sensitivity, however, is too low for MRI to be useful as a screening test. MRI should be used in combination with the clinical assessment and other investigations to assist in the diagnosis of TOS.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

An overview of the findings of dynamic upper limbs’ arterial and venous duplex in cases of vascular thoracic outlet syndrome

Background

To describe the findings of the dynamic upper limb arterial and venous duplex in the assessment of vascular compression in cases of VTOS. This study was conducted on 58 patients with VTOS; they were evaluated by dynamic duplex examination.

Results

Vascular compression was subdivided into a venous compression that was detected in (84.4%,n = 49), arterial compression that was seen in (1.7%,n = 1), and combined arterial and venous compression that was present in (13.7%,n = 8); bilateral compression was existing in (94.4%,n = 55), compression at the scalene triangle was seen in (1.7%,n = 1), at the costo-clavicular space was seen in (91.3%,n = 53), and at the retro-pectoral space was depicted in (8.6%,n = 5).

Complicated arterial compression was detected in (1.7%,n = 1), whereas venous complications were seen in (6.8%,n = 4).

Conclusion

Dynamic duplex ultrasound offered a simple, noninvasive, and quick technique that can help in the evaluation of the vascular thoracic outlet syndrome without exposure to ionizing radiation or contrast media administration like that in CT; nevertheless, it is done with the patient in the upright position, thus avoiding the high false-negative results associated with the supine position that is used in the CT and MRI studies.

CT and MR imaging of the upper extremity vasculature: pearls, pitfalls, and challenges

Imaging is needed for diagnosis, treatment planning, and follow-up of patients with pathologies affecting upper extremity vasculature. With growth and evolution of imaging modalities [especially CT angiography (CTA) and MR angiography (MRA)], there is need to recognize the advantages and disadvantages of various modalities and obtain the best possible imaging diagnostic test. Understanding various limitations and pitfalls as well as the best practices to minimize and manage these pitfalls is very important for the diagnosis. This article reviews the upper extremity arterial vascular anatomy, discusses the CTA and MRA imaging, various pitfalls, and challenges and discuss imaging manifestations of upper extremity arterial pathologies.

Concomitant neurogenic and vascular thoracic outlet syndrome due to multiple exostoses

We report a rare case of multiple hereditary exostosis where patient presented with bilateral base of neck exostoses with concurrent compression of brachial plexus and subclavian artery and vein. The patient was a young 26-year-old woman with chief complaints of pain in the left upper extremity, paresthesia in the left ring and little finger, and weakness in hand movement and grip. On referral, history, physical examination, radiological imaging, and electrodiagnostic tests evaluated the patient. Due to severe pain and disability in performing routine activities, surgical intervention was necessary. In the current case, the patient had thoracic outlet syndrome with concomitant venous, arterial, and neurogenic sub types. Radial pulse returned and pain associated with brachial plexus compression was resolved after the surgery.

Vascular CT and MRI: a practical guide to imaging protocols

Non-invasive cross-sectional imaging techniques play a crucial role in the assessment of the varied manifestations of vascular disease. Vascular imaging encompasses a wide variety of pathology. Designing vascular imaging protocols can be challenging owing to the non-uniform velocity of blood in the aorta, differences in cardiac output between patients, and the effect of different disease states on blood flow. In this review, we provide the rationale behind—and a practical guide to—designing and implementing straightforward vascular computed tomography (CT) and magnetic resonance imaging (MRI) protocols.

Teaching Points

• There is a wide range of vascular pathologies requiring bespoke imaging protocols.

• Variations in cardiac output and non-uniform blood velocity complicate vascular imaging.

• Contrast media dose, injection rate and duration affect arterial enhancement in CTA.

• Iterative CT reconstruction can improve image quality and reduce radiation dose.

• MRA is of particular value when imaging small arteries and venous studies.

Frequency of the Pectoralis Minor Compression Syndrome in Patients Treated for Thoracic Outlet Syndrome

BACKGROUND

Pectoralis minor compression syndrome (PMCS) is a compression of the neurovascular structures in the subpectoral tunnel and remains underestimated in the management of patients with thoracic outlet syndrome (TOS). Its underdiagnosis may be responsible for incomplete or failed treatment. The aim of the study was to evaluate the frequency of PMCS in our experience.

METHODS

We retrospectively reviewed all patients treated for TOS in our department. We selected those in whom PMCS was diagnosed with a systematic dynamic arteriography. Surgery was performed using the Roos axillary approach when a first rib resection was associated or an elective approach when a first rib resection was not associated.

RESULTS

From January 2004 to December 2014, 374 surgeries for TOS were performed in 279 patients, which included 90 men (sex ratio = 0.48) with a mean age of 40.1 ± 10 years old. Among these patients, 63 (22.5%) underwent 82 interventions (21.9%) for PMCS, including 26 men (sex ratio = 0.70, P < 0.05) with a mean age of 37.9 ± 9.4 years old. Tenotomy of the pectoralis minor muscle was performed using axillary approach if it was associated with a first rib resection in 74 cases (90.2%) or through an elective approach in 8 cases (9.8%) if it was isolated. Four (4.9%) postoperative complications were found (1 hematoma [1.2%], 1 hemothorax [1.2%], 1 scapula alata [1.2%], and 1 subclavian vein thrombosis [1.2%]), all after an axillary approach. In 63 cases (79.7%), preoperative symptoms were resolved. In 14 cases (17.7%), symptom resolution was incomplete, and 2 patients (2.6%) had recurrent symptoms.

CONCLUSIONS

Evaluation of PMCS in TOS is justified by its frequency and the simplicity and low morbidity of the surgical procedure.

MRI of thoracic outlet syndrome in children

Thoracic outlet syndrome is caused by compression of the neurovascular bundle as it passes from the upper thorax to the axilla. The neurovascular bundle can be compressed by bony structures such as the first rib, cervical ribs or bone tubercles, or from soft-tissue abnormalities like a fibrous band, muscle hypertrophy or space-occupying lesion. Thoracic outlet syndrome commonly affects young adults but can be seen in the pediatric age group, especially in older children. Diagnosis is based on a holistic approach encompassing clinical features, physical examination findings including those triggered by various maneuvers, electromyography, nerve conduction studies and imaging. Imaging is performed to confirm the diagnosis, exclude mimics and classify thoracic outlet syndrome into neurogenic, arterial, venous or mixed causes. MRI and MR angiography are useful in this process. A complete MRI examination for suspected thoracic outlet syndrome should include the assessment of anatomy and any abnormalities using routine sequences, vessel assessment with the arms in adduction by MR angiography and assessment of dynamic compression of vessels with abduction of the arms. The purpose of this paper is to describe the anatomy of the thoracic outlet, causes of thoracic outlet syndrome, the MR imaging techniques used in its diagnosis and the principles of image interpretation.

Imaging of the Patient with Thoracic Outlet Syndrome

Patients with symptoms from compression of the neurovascular bundle in the thoracic outlet are described as having thoracic outlet syndrome (TOS), which is best thought of as three conditions classified according to which structures are involved. The purpose of this article is to review the role of imaging in evaluation of patients with TOS, beginning with diagnosis and extending through postoperative management. While diagnosis of TOS still rests on the patient's presenting history and physical examination, imaging examinations are helpful in supporting the diagnosis, delineating abnormal anatomy, determining which structures are compressed, identifying the site of compression, and excluding other diagnoses. Magnetic resonance imaging is the noninvasive imaging modality of choice in evaluating patients with suspected TOS, but computed tomography also plays an important role, particularly in delineating bone anatomy. Evidence of vascular damage is required to make the diagnosis of TOS at imaging. Dynamic compression of the axillosubclavian vessels at the thoracic outlet can be a finding supportive of the diagnosis of TOS but is not a stand-alone diagnostic criterion, as it can be seen in patients without TOS. As diagnosis and treatment of TOS increase, radiologists will increasingly encounter the TOS patient after decompression surgery. Recognition of the expected postoperative appearance of these patients is critical, as is an understanding of the imaging findings of potential short- and long-term complications. (©)RSNA, 2016.

Magnetic Resonance Angiography of the Upper Extremity

The magnetic resonance angiography (MRA) toolbox includes a wide array of versatile methods for diagnosis and therapy planning in patients with a variety of upper extremity vascular pathologies. MRA can provide excellent image quality with high spatial and high temporal resolution without the disadvantages of ionizing radiation, iodinated contrast, and operator dependency. Contrast-enhanced techniques are preferred for their robustness, image quality, and shorter scan times. This article provides an overview of the available MRA techniques and a description of the clinical entities that are well suited for evaluation with contrast-enhanced MRA.

State-of-the-art Magnetic Resonance Imaging in Vascular Thoracic Outlet Syndrome

Vascular thoracic outlet syndrome is caused by compression of subclavian/axillary vessels during their passage from the thoracic cavity to the axilla. Early diagnosis and treatment is important to prevent debilitating outcomes of vascular thoracic outlet syndrome. Contrast-enhanced three-dimensional (3D) magnetic resonance angiography (MRA) with equilibrium phase using provocative arm positioning is the optimal examination to determine presence, degree of vascular compression, and complications of vascular thoracic outlet syndrome. This article reviews thoracic outlet anatomy, disorders of the vascular component, and typical imaging findings by contrast-enhanced 3D MRA.

Pediatric Chest MR Imaging: Sedation, Techniques, and Extracardiac Vessels

Thoracic MR imaging in the pediatric population provides unique challenges requiring tailored protocols and a practical approach to pediatric issues, such as patient motion and sedation. Concern regarding the use of ionizing radiation in the pediatric population has continued to advance the use of MR imaging despite these challenges. This article provides a practical approach to thoracic vascular MR imaging with special attention paid to pediatric-specific issues such as sedation. Thoracic vascular anatomy and pathology are discussed with an emphasis on protocols that can facilitate accurate diagnosis.

Upper Extremity Runoff: Pearls and Pitfalls in Computed Tomography Angiography and Magnetic Resonance Angiography

Upper extremity vasculature can be affected by various traumatic and nontraumatic pathologies; however, the evaluation of these arteries can be challenging for the radiologists as well as for the clinicians. After an accurate history and clinical examination, imaging plays a vital role in the diagnosis and treatment planning of these patients. Depending on the urgency and the indication, upper extremity arteries may be evaluated by ultrasonography with color Doppler, computed tomography (CT), magnetic resonance imaging (MRI), or digital subtraction angiography. This review article discusses relevant imaging anatomy of the upper extremity arteries, presents CT and MRI protocols, briefly describes the state-of-the-art CT and MRI of various pathologies affecting the upper extremity arteries, and summarizes the important pearls needed for busy practicing radiologist.