D - CT venogram

Given her symptoms, SVC occlusion is likely and a venogram would provide the highest sensitivity for venous patency. It also aids in procedure planning to determine access and tools one may need to have ready to have a successful procedure.

In addition to identifying the obstructive etiology, questions that assess the degree and chronicity of impaired right-heart filling such as ‘how many pillows do you sleep with at night?’ or examining an old photograph (such as driver’s license) to compare the often slow and insidious onset of facial plethora may help gauge the urgency of subsequent intervention. Other symptoms include headache, pain in the face and neck, blurred vision, and hoarseness. Acute obstruction is considered a medical emergency and can be life-threatening primarily due to laryngeal edema and airway compromise. As such, the clinical presentation help determine the urgency of the case for scheduling.

CT venogram yields the following image through the mid-thorax. Where is the abnormality?