Hi, my name is George Berdejo and I'm Director of Vascular Ultrasound Services at the Moses and Weiler Divisions of Montefiore Medical Center in New York City. I am also a member of the Society for Vascular Ultrasounds Product Committee along with Terry Case and Billy Zhang. This program is being supported by an unrestricted educational grant provided by the Radiology and Vascular Ultrasound Division at GE Healthcare and in cooperation with TIPTV. I will be giving a brief overview of the SVU guideline and then Rob Dago will follow with a comprehensive explanation of the upper extremity venous duplex vascular examination. So let's get into the guidelines. The purpose of duplex imaging of the upper extremity veins is to assess the deep and superficial venous structures to determine the presence and or absence of pathology and to facilitate clinical management decisions. Let's talk a little bit about some of the common indications. And this is an important piece of the evaluation because very often the indications will point to the vessels that are referable to the patient's symptoms. The most common indications that you'll find for patients referred for upper extremity venous duplex evaluation are pain and swelling. These symptoms, especially the symptom of swelling, is most often associated with patients who have central vein thrombosis involving either the subclavian and or the inominate vessels. The other indications, including tenderness, palpable cords, really are more referable to the superficial veins, the basilic and the cephalic veins. Another very common indication in patients referred for evaluation of the upper extremity venous system is for evaluation prior to central line placement, also for mapping of the superficial veins prior to cannulation, especially in the jugular and in the subclavian veins. It's not uncommon to have a patient who's had a history of a central line who, after failed multiple attempts at cannulation, comes down for a venous duplex only to find that those vessels are chronically occluded. So it's important to evaluate these patients prior to those procedures. There are some contraindications and limitations that you should be aware of. In obese patients, these vessels can be hard to see. And conversely, in very thin patients, especially in the area of the subclavian vein at the base of the neck because of the bony protrusion of the clavicle in that area, it may be difficult to access the subclavian vein. In very thin patients, the cephalic and basilic veins may be difficult to visualize because of their superficial positions. Patients with cast, overlying cast, obviously will not be able to image as you need direct contact with the skin to image the vessels. Patients who present with trauma or open wounds will be limited in terms of visualization. Patients who have severe edema, scanning in the area of the clavicle is a significant limitation in that the clavicle, there is a portion of the subclavian vein that is obscured because of the overlying clavicle. This really underscores the importance of the Doppler examination as we'll talk about further. Patients with central venous lines and or dialysis access, and this is a significant general consideration because these patients will exhibit changes in the flow waveforms that are significantly important in terms of evaluation for the presence of more central vein thrombosis. So you have to be careful about evaluating the findings in those patients. The patient communication and positioning piece is also very important. It's quite critically important, as a matter of fact, to acknowledge and introduce yourself to the patient before the study begins, also to give them a significant explanation of why the patient has been referred. It helps in terms of easing the tension and the anxiety that's associated with any trip to the hospital. You want to refer specific diagnostic as well as treatment and prognostic questions to the referring physician. However, you can sometimes, you may have to exhibit some judgment in terms of what kinds of questions you can answer. It's appropriate to answer some of the questions, but questions in terms of results, things like that, probably best referred to the referring physician. The patient is positioned in the supine position, at least for evaluation of the subclavian and the inominate vessels, although you may have to use various positions, especially when you're looking out into the periphery and evaluating the axillary, basilic cephalic veins, as well as the brachial veins. You may have to position the patient in a pledge position really to get access to the axillary vessels, and that's important to know. The patient can be examined in the sitting position, however, I would not recommend the sitting position for evaluation of the jugular as well as the central veins, the subclavian and the inominate vessels. It's important to get a history in terms of the patient's current medical status as it relates to the DVT examination. Some questions that might be important are questions as to previous surgeries or other invasive procedures, such as recent or prior dialysis graft surgery, present or previous dialysis catheters. This could be very important in terms of the findings of chronic deep vein thrombosis that may be associated with previous catheters. Also central venous lines or axis port insertions. You should also evaluate the patient for the presence of any risk factors, such as previous thrombosis, recent or past surgery, and also a history of malignancies, all of which are significant risk factors for the formation of deep vein thrombosis. It's also important to inquire as to current medications and or therapies that may be relevant to the upper extremity vein examination. You should ask about the results of other relevant diagnostic imaging procedures, such as venograms, MRVs, or CTVs, or perhaps even previous scans that have been performed within your own laboratory. It's important to perform a physical examination, looking for things such as swelling, inquiring about pain and or tenderness. Keep in mind that the indication in the physical examination may point you to the vessel that's referable to the patient's symptoms. And then after all this information has been acquired, you need to put all those pieces together and then verify that the requested procedure does, in fact, correlate with the patient's clinical presentation and also with the examination that has been ordered by the referring physician. The examination really involves several components, including Doppler analysis with or without color, Doppler imaging, 2D assessment, as well as compression where it's feasible. You should be using an image carrying a frequency of at least 5 megahertz with a Doppler carrier frequency of at least 3 megahertz. All of your examinations need to be documented, and you can do that by way of videotape, film, or digital storage of static images and or Cine Loops. A PAC system is ideal if you have one. All examinations really should follow a standard examination protocol, and this is critically important. I think it's very important to have some type of a written protocol in place before you perform an examination. Not only is it important to have that protocol, but it's much more critically important to be adherent to that protocol. Protocols are put in place really to minimize the potential for error, and so it's important to have a written protocol in place so you know everyone's doing it the same way within your laboratories. Studies may be unilateral with the use of an appropriate algorithm. However, I think that even when a study is performed unilaterally, it is important always to look at the contralateral internal jugular and subclavian vein waveforms to get an idea about what normal flow dynamics are like contralaterally so that you can assess the ipsilateral vessels and really get an idea about what should be going on in terms of the flow. Again, keep in mind that the Doppler component of the upper extremity examination is much more important in terms of the interpretation of the proximal findings than it is in the lower extremity veins. It's also critically important because the compression piece is not as reliable in the upper extremity veins. A complete evaluation incorporates both the B-mode image and the Doppler spectrum with color flow where it's available. Also in the upper extremity, you'll probably be required to use multiple acoustic windows as well as multiple patient positioning techniques. And it's important because when you're looking in the upper extremity, you're looking at vessels of varying depths, vessels in areas that are not as easily accessible using the linear array transducers. You'll have to use a variety of different transducers when you're performing that examination. You want to use B-mode images in the transverse imaging plane, especially where you're performing compression maneuvers. But again, keep in mind that there are areas within the upper extremity venous system that are normally incompressible, especially within the subclavian vein. And also keep in mind that there is that area of the subclavian vein that lies directly under the clavicle that will not be imaged. The infraclavicular as well as the thoracic outlet segments of the subclavian vein can usually be evaluated through the anterior chest wall, although they may not always be compressible even in the absence of thrombus. The internal jugular as well as the subclavian veins are typically assessed by both the Doppler spectral and color flow analysis. Keep in mind that you may need to evaluate the inominate vein when it's appropriate. And that may be needed in cases where the findings of the more peripheral vessels do not elucidate the clinical situation or where you have asymmetry from one side to the left. It may be necessary to image the inominate veins, and we'll show you techniques for how to do that in the imaging session of this program. A standard examination includes representative grayscale imaging documentation with and without transducer compressions, and all compressions are done in the transverse orientation. Where pathology is present, it's important to document compressibility or lack thereof, the appearance of the thrombus, the location as well as the extent of the thrombus that's documented. It's also important to attempt to classify compressibility in terms of its ease or difficulty in terms of compressibility as well as the extent of the compressibility. Is this a partial compression? Is the thrombus soft where it's present? Do you see echoes within the lumen of the venous system? Is there significant dilatation of the vessels that you're looking at? All of these findings go a long way in terms of interpretation and whether or not the thrombus within the venous system is acute versus chronic. And toward that end, it's also important to differentiate between brightly echogenic structures within the lumen versus lightly echogenic thrombi. Also to differentiate between partially or totally non-compressible segments and between free-floating or unattached thrombi and very consolidated thrombus within the veins. It's important where you can to age thrombus. And the way to do it is by looking at all those previous parameters that I've described. It may not always be possible to age the thrombus, but where you can, it's good to make some notation about its age. Acute thrombus refers to thrombus that is usually days to one or two weeks old. The Doppler component is a very important component of the upper extremity vein examination. It's important to identify phasicity as well as abnormal venous flow patterns. In the upper extremity, the two most important components of the flow are phasicity and pulsatility. Those will primarily be seen in the innominate, jugular, and in the subclavian veins. You may not see these signs in the more peripheral vessels, such as the axillary and brachial veins. It's important to obtain Doppler waveforms from each of the specified vessels. And the vessels, in terms of the specified vessels, really will vary and will be institutionally based and will vary according to what your protocols are. Doppler spectral analysis should always be performed in the sagittal plane. When unilateral evaluations are performed, it's always important to obtain a contralateral Doppler spectral waveform from the internal jugular vein and or the subclavian vein. And again, it's very important to compare those waveforms, always using the non-affected side as the, quote, normal side. Any change or any asymmetry between the two sides really should suggest the presence, of course, according to the shape of the waveform, but really should suggest a problem somewhere. In terms of review of the diagnostic exam findings, it's always important to review all data that has been acquired. It's important to explain and document any exceptions to the routine exam, any exceptions to the protocol. In addition to these things, it's important to document examination date, clinical indications, the technologist performing the evaluation, and also to include an exam summary in a laboratory logbook or a vascular lab database if you have one. It's nice if you have some computer software to do these things. When indicated, it's also important to alert the vascular laboratory medical director or the appropriate healthcare provider when immediate medical attention is indicated based on the results of your upper extremity vein evaluation. It's also critically important to provide preliminary finding results as indicated and also as directed by internal guidelines to the referring physician when critical findings are noted. You want to present a record of your diagnostic images, data, explanations, as well as a technical worksheet to the interpreting physician so that he can use to provide a final diagnosis and also for archival purposes. In terms of examination time recommendations, there are really two components, and that's the direct and indirect components. Pre- and post-examination procedures really should take about 30 minutes or so and include obtaining any previous examination data, completing the pre-exam paperwork, preparing the examination room as well as the equipment that is to be used. It also includes time for patient assessment as well as positioning and communication, patient room cleanup, compilation, review, and processing of the examination data, and also preparation of the patient charge and billing activities. Direct exam components, that is the direct imaging portion of the examination, we allow about 35 to 45 minutes for, and that includes equipment optimization as well as the actual hands-on examination time. In terms of continuing professional education, it's incumbent upon the technologist or sonographer to keep up with advances in diagnosis as well as treatment of venous disease and changes in the upper extremity venous duplex evaluation protocols or with published laboratory diagnostic criteria as well as with advances in ultrasound technology used for the upper extremity venous duplex evaluation and with advances in other imaging modalities used for the evaluation of the upper extremity venous system. I want to thank you very much for your attention, and if you need further details regarding these or other vascular technology professional performance guidelines, you can get those at www.svunet.org. Hello, everyone. My name is Rob Daigle, and I'm here to discuss venous imaging of the upper extremities. Venous imaging of the upper extremities is sometimes difficult because we tend not to do it on a daily basis, but understanding the flow hemodynamics and the anatomy will take us a long way towards an accurate diagnosis of venous thrombosis in the upper extremities. Venous upper extremity thrombosis occurs in about 15 to 30 percent of patients that have indwelling subclavian vein catheters. In this image on the right, we see a catheter, probably a PICC line, in the cephalic vein. Now the etiology of venous thrombosis includes intimal injury, and this can be due to the indwelling venous catheter, or it can be due to pacemaker wire or stents. Additionally, stasis can contribute to venous thrombosis, this being either by compression of a mass or thoracic outlet compression, and there are other sources as well, and this can be radiation-induced fibrosis, venipuncture, or IV drug abuse, can all contribute to the development of venous thrombosis in the arms. Now other symptoms of venous thrombosis include pain and swelling, local erythemia and palpable cord, particularly if the thrombosis is in the superficial veins, local tenderness in the arms, shortness of breath or chest pain as an indicator for possible pulmonary embolus, and also catheter infusion difficulties, and there are some miscellaneous symptoms as well. Now the other indications for this examination include preoperative evaluation or preoperative to central line placement, venipuncture guidance, and then preoperative hemodialysis access placement, and we'll touch just briefly on that a little bit later in the presentation. Now the pertinent history that we should learn from the patient prior to the examination is to ask if they've had any vascular surgeries involving the upper extremities, and then also if they have a history of any catheter or access port placement or hemodialysis access placed in the arm. The anatomy of the upper extremities consists of deep veins and superficial veins. The deep veins consist of the superior vena cava, or SVC, the innominate vein, and we have an innominate vein on the left and the right side. It's also called a brachiocephalic vein. We have a subclavian vein, axillary vein, brachial, and then a deep brachial vein, and then radial veins, paired radial veins, and paired ulnar veins. Now, the deep veins, for the most part, have an accompanying artery with them. The superficial veins, there's no adjacent artery, but this consists of the bacillic vein, cephalic vein, and then the median cuboid vein that join the bacillic and the cephalic. Let's take a look at a diagram here of this. The cephalic vein courses along the lateral aspect of the arm, of the biceps muscle, and joins into the axillary vein, and then this becomes the subclavian vein. The axillary vein is formed by the confluence of the brachial vein and the bacillic vein, the brachial vein being the deep venous system, superficial being bacillic. We can see here that the median cuboid vein joins the cephalic system with the bacillic system. Now, down on the forearm, again, the median cuboid vein, the bacillic vein continues on down superficially along the little finger side of the arm, where the cephalic vein continues along the radial side of the arm. We see the deep veins here as well. These are the paired deep radial veins, and then the ulnar veins also. These are usually pretty small veins and difficult to see. The veins that are most prominent in the forearm are the superficial veins, the cephalic and the bacillic. Now, in the more central veins, again, the cephalic vein courses in, joins the axillary to form the subclavian. This is usually about the level of the first rib. So short subclavian vein meets the confluence of the external jugular vein, and then a little bit further down, There's another structure here that I'd like to point out that becomes very prominent when there is inominate obstruction, and that's the anterior jugular vein. The anterior jugular vein communicates with the external jugular vein on the contralateral side and often is a collateral pathway. Now, more central veins, we have a right inominate vein, a left inominate vein, and these inominate veins are usually or consist of the confluence of the internal jugular vein and the subclavian vein on each side to form two inominate veins, the left side being longer than the right side. And these come together, and the confluence of these into the superior vena cava. Now, I'd like to also point out that the internal jugular vein has tributaries that drain the thyroid, and then there are major thyroid veins here that drain the anterior jugular vein. And then there are major thyroid veins here that drain into the brachiocephalic or inominate veins on each side. Now, our exam protocol consists of initially having the hand oriented to the right of the screen. This is because we'll be checking carefully for flow direction in the central vessels, and having the screen oriented correctly to the anatomy is important. I would recommend having the screen oriented or the transducer oriented to display the hand to the right of the screen and the heart to the left of the screen so that we know that flow should always be going on our screen from right to left. Also, for the proximal central veins, because these lie along the clavicle region, these are very difficult to compress. So we'll use a Doppler priority for these central vessels, that being the internal jugular vein, the subclavian, supraclavicular portion of the subclavian, as well as the inominate. We'll rely on our Doppler signals to determine normalcy from disease. But once we get down into the arms, then the flow patterns tend to be not quite as prominent. For these veins, we'll use compressibility techniques. So we use compressibility and Doppler, but we emphasize the priority central veins, Doppler, and the arm veins, mostly compressibility of the veins like we do for the lower extremity. Now, a caveat here is that for the central veins, the patient should be supine. That's because we'll be looking carefully at the waveform patterns, and these waveform patterns will be more typical if the patient is lying supine. Now, for the arms, the patient may actually be sitting or have the torso elevated in a reverse Trendelenburg position. This sometimes helps to put a little bit more pressure in the veins and dilate them out. It makes them a little bit easier to see. Now, we start out in the supraclavicular position, lining up the transducer just along the clavicle, and we look for the subclavian vein in this region. I've sort of done a diagram here showing the subclavian vein with the cephalic. Again, the hand is to the right of the screen. Here's the clavicle. It's difficult to see any blood flow underneath the clavicle. Then we have the subclavian here, the external jugular vein joining in, then a little bit more central to this, the internal jugular vein, and this forms the innominate. So by looking in that supraclavicular region with the transducer, we look specifically for this area. We try and image as much as we can of the innominate, but it's often difficult to see because it dives deep underneath the clavicle and the chest wall. In the normal upper extremity venous flow, we have respiratory phasicity similar to that in the legs, but we also have a very prominent cardiac pulsatility that takes place. In fact, we have to pay careful attention to this and have this not be confused with the subclavian artery that lies in close proximity to this region. So in this waveform, we see sort of a respiratory change taking place. The velocities are a little bit lower here. They get higher here and come down again. And then we also see the strong pulsatility. So this is very typical for the innominate jugular vein in subclavian and axillary. Once we get out into the arms of the vein, this pulsatility may be damped out and may not be present, but we expect to see it in the central vessels. The internal jugular vein as well, the IUD, this typically will have pulsatile flow also. One of the methods that I use, if I'm having difficulty seeing the vasculature in the supraclavicular region with a transducer, I will go to the jugular vein in transverse view or longitudinal view and follow the jugular vein, the internal jugular vein, down to the confluence of the subclavian and then follow it back out along the subclavian. So there are two different approaches that can be used. Now, in addition to evaluating the central vessels in what we call an upper extremity venous exam, even though it's not technically upper extremity, we always look for the jugular vein. And we look in transverse view and in longitudinal view. In this case, we're using color doppler to show that there is thrombus right in the central portion of this internal jugular vein with flow coursing around the perimeter of this thrombus. Here's a longitudinal view of that thrombus. We can see it right in here, this region. And the flow around this tends to look sort of echogenic. And that can sometimes be misconstrued for thrombus itself. Here's a transverse view in which we've altered the image somewhat with our depth gain controller. And here's a longitudinal view. We've altered the image somewhat with our depth gain controls to have the thrombus sort of stand out in this region. One of the things that we need to be somewhat careful of, and it's demonstrated by this short clip here, is that reverberation artifact and what we call Rouleau formation, this is blood cells that are clumping together because of their slow motion, are often seen in the jugular vein. In the freeze frame image, let's see if I can try and freeze this. On the freeze frame, this can sometimes look like thrombus. So we have to look very carefully and actually sort of press on the transducer a little bit to have the walls of the vein move a little bit to help differentiate Rouleau and slow-moving blood from actual thrombus. Now, in the central veins, we'll evaluate these with pulse Doppler. We'll look at the specific vessels that I mentioned and then we'll record Doppler waveforms. The innominate vein, if possible, we try and get a good signal in this region. But again, as I mentioned, on some patients, it's difficult to evaluate the innominate, and that's actually sort of the Achilles' heel of the upper extremity study and why we pay so much attention to the flow patterns in the subclavian and axillary. Now, we also evaluate the proximal subclavian vein, the internal jugular vein, as I mentioned. Then also, it's important, if you can, to look at the external jugular vein. We'll come back to the reason for this a little bit later. I might mention that just seeing flow in these vessels is just not enough. We have to pay attention to flow direction. Now, as you'll see through my presentation, there are some images that show blood flow below the line in a normal direction. We have used technology over the years in which flow going in the appropriate antigrade direction is displayed above the baseline. So just as long as you understand your ultrasound system in terms of which way flow is going, then that's the important thing, and try and standardize on that. Now, once we've accomplished our supraclavicular imaging, then we move the transducer just over the clavicle and position this. I like to use the subclavian artery as my landmark, and I align the transducer initially in transverse and then in longitudinal along the length of the subclavian. And then I tilt the probe just slightly to identify the subclavian vein. Now, the subclavian vein is followed just a very short distance distal to the clavicle, just distal to the confluence of the cephalic vein, and then it technically becomes the axillary vein. So I follow the axillary vein down along towards the axilla, also noting the cephalic confluence right in this area. Now, we identify the subclavian artery, as I mentioned, then move to the adjacent subclavian vein. We follow the subclavian vein, then the axillary vein, to the bacillic brachial confluence in the axilla, and we record spectral waveforms from these regions. Now, a caveat here is that some patients, when they're lying supine and their arm is sort of against their side, there's a compression of the subclavian vein and the axillary vein that's caused just by the chest wall or some of the structures within this region. So to be able to abduct the arm and elevate it somewhat will often eliminate this extrinsic compression and allow you to see the axillary or the subclavian vein much better. So if you're not seeing it in this region, try and reposition the arm. Sometimes moving it up and almost to a pledged position will also alleviate this intermittent extrinsic compression and allow you to evaluate the vein in this region. Now, it's an important part of this program, the upper extremity venous study, to do a contralateral comparison. And this allows us to look specifically at the waveform pulsatility of the left side compared to the right side or vice versa. Because collateralization takes place so quickly in the presence of a nominant obstruction, that evaluating the comparison of these sides can often tell us that there's a problem more centrally. And I'll look at an example of that in just a little bit. Now, to start out in the evaluation of the arm, I use a sort of a pad or a pillow on my lap here and stretch the arm out. I like to start in about the mid-portion of the arm in transverse view. And we use compression and release methods similar to lower extremity venous evaluation. This is the most important part of the test here. Pulsatility and phasic flow may be absent in these vessels. I also find that augmentation maneuvers tend not to work as well as they do in the lower extremities. Now, if the veins are very superficial, you may need to use a frequency, a standoff pad, or just put a lot of gel down onto the vessel and hold the transducer in the gel, but slightly off the skin surface. Because the cephalic vein, particularly, can be very superficial and sort of out of the focal zones of the transducer. So we need to use a high-frequency transducer. Now, by starting in the mid-arm level here, it's easier to differentiate the bacillic vein from the brachial veins. Because in this region, the bacillic vein will lie away from the artery, where up in the axilla, the bacillic vein may lie right beside the artery. It's more difficult to differentiate it from the brachial veins. So I start about at mid-arm. I identify my anatomy, and then I scan proximally up into the axilla, and then I scan back down, doing compression maneuvers every inch or two along the course of the vasculature. We scan the paired brachial veins, and there's a lot of variation in anatomy here, as well as the bacillic vein. Here's a diagram on the left, sort of showing the anatomy in mid-arm, and an ultrasound image on the right showing what this would look like in transverse. This is the brachial artery with the paired brachial veins. These are often of varying size. And this is the larger bacillic vein. As we go up into the axilla, this vein is right beside the brachial artery, and it's difficult to determine whether this is actually a bacillic vein or a brachial vein in the axilla. But by following it from mid-arm up into the axilla, we can clearly denote that this one is the bacillic vein, the superficial vein. Now, our criteria for thrombosis in the arms is visualization of thrombus, as we can see here clearly in this image in transverse view, the lack of vein wall coaptation. This means that when the vein walls actually come together and then open back up again. And then we will not see flow with color doppler or with spectral doppler, spontaneous flow or with augmentation. So those are the three parameters that we look for. But primarily, the lack of compressibility of the veins. Again, being careful that we're not lying on any... the transducer's not lying on any bony structures. So this is what I call some fun facts. The bacillic vein, part of the superficial vein, carries a lot of blood flow out of the arm. This is what I call the bacillic vein is king. All other arm veins, being the brachial veins, are peons, so the outflow peons. Meaning they don't carry as much blood flow as the bacillic vein or the superficial system. And that's quite a bit different from our lower extremity venous profusion in which the superficial system, the great saphenous vein and small saphenous, only carries out about 15% of the blood volume in the legs. But in the arms, the superficial system carries out quite a bit more back towards the heart. Also, anatomic variations are very frequent. Sometimes we see people with missing cephalic veins or a very, very small atresic bacillic vein and the brachial veins are quite large. So be prepared for some venous variations in anatomy. Also, a caveat here is that cephalic veins are small and hard to image unless they're on the most... the easiest cephalic veins to see are usually on men that do physical labor or weightlifters or bodybuilders. These are readily seen on those patients, but very hard to see these veins on females because they tend to be small in the beginning and that musculature may not be developed to the extent where the cephalic vein is carrying a lot of blood flow. So, a few more caveats for you. Skip the cephalic vein and skip the forearm veins if they don't have symptoms down below the elbow. Now, the exception to this is if people have... the PICC lines, and these are, if I can say this correctly, peripherally inserted central catheters. So these are catheters that are put in distally, usually into the cephalic vein or the bacillic vein. These are indwelling catheters, so we will scan the veins in the forearm if they do have a PICC line. And then also for preoperative mapping for vein harvest or for preoperative mapping or for preoperative assessment for hemodialysis access placement. Again, that's a whole different ballgame, whole different procedure, in that we need to determine the suitability of these superficial veins in the forearm. Let's look at some case studies and try to put together what we've seen here in terms of our flow patterns as well as the anatomy that I've demonstrated. This is a 28-year-old female that presented to our laboratory. She awoke with left arm pain and swelling. In fact, she had gone to her physician, and the physician, it was flu season, and he, for some reason, thought she had the flu. But she happened to mention to him that she had an episode of upper extremity venous thrombosis the previous year. So he sent her to the vascular lab, and this case that I'll show is pretty easy because the lady was quite thin, and her vasculature was easily accessible. But this is the clavicle right in this region. This is the cephalic vein seen in transverse. This is the subclavian vein distal to the clavicle, and this is the axillary vein. And we can see echogenic material in here as well as the cephalic vein, and this appeared to be thrombosed. There was no flow detected with color or with spectral Doppler through this region. We went over the clavicle and looked at the, well, actually, I'm sorry, this is the transverse view of the infraclavicular region showing the subclavian artery and the dilated subclavian vein. When we come over the clavicle, we identified this structure right here. This is the subclavian vein. Again, no flow in the more proximal portion of the subclavian vein. I'd like to point this out as a potential pitfall also in the presence of subclavian vein thrombus, the external jugular vein, which lies more superficial to the subclavian, can become a major collateral pathway. And this can become quite large. On a normal person, we might not even notice the external jugular vein, but on someone that has a thrombosed or even partially thrombosed subclavian vein, we often see the external carrying the excess flow as a major collateral pathway. So you have to be careful not to identify, misidentify this vessel as the subclavian vein. Because the subclavian vein here courses underneath the clavicle, and the external jugular vein goes up over the top of the clavicle. So be aware of that potential diagnostic pitfall Now, here we see in the external jugular vein, our typical flow, pulse-style flow pattern, which we expect to see. And this is going in the appropriate direction towards the heart. Again, I have the hand established on the image to the right of the screen. When we image carefully for the proximal portion of the thrombus, we could see the tip of the thrombus right in this region. And this is right at the confluence of the external jugular vein, the external jugular vein, This is the anominate vein showing the pronounced pulsatile flow, as well as a normal flow pattern, very strongly pulsatile in the internal jugular vein. We were able to follow out this thrombus in the axillary vein, just about down to the axilla. And this extended to the basilic and brachial confluence right at the very end of the thrombus. And we were able to follow out this thrombus in the brachial confluence right at the very end of the axillary vein, or actually at the beginning of the axillary vein. Now, the study summary here is that there was left arm acute venous thrombosis on this patient. It extended from the proximal subclavian vein to the distal axillary vein. Also, the proximal portion of the cephalic vein was thrombosed. There was collateralization via the external jugular vein. And the patient was hospitalized and treated with intravenous heparin for this condition. So a very straightforward, clean-cut case, not too difficult, primarily because we had very good access because she was quite thin. Now, this next case I found quite interesting in that the patient presented with a history of left arm swelling, but he also had a fairly recent history of shoulder fracture. Physicians were concerned whether it was the shoulder fracture or possible venous thrombosis that was contributing to this arm swelling. We scanned the left distal subclavian vein. And on this particular system, flow above the line is considered to be normal. So we have a pulsatility here that takes place in the subclavian vein. But I mentioned before about the importance of comparing to the contralateral side. So let's take a look at the right subclavian. Here's the right subclavian. This is distinctly different from that pattern on the left side. Even though there is some pulsatility on the left, it's not as prominent as on the right side. So this is one of the reasons we always compare at least one waveform in about the same location of the right subclavian versus left subclavian on every upper extremity exam. So we followed the subclavian vein in approximately with color Doppler. We get to a region right here where we could not follow the innominate vein up any higher. But that's not atypical. Many patients we can only get to about this region. But you'll notice the color saturation on the internal jugular vein. If we play our color angles game, flow going away from the transducer is displayed as blue. Flow towards the transducer is red. So this means if this is the internal jugular vein and it's red, it means it's flow going towards the transducer. So this is retrograde flow in the internal jugular vein in this view. When we go to a longitudinal view, if there's any question about flow direction, you can always use the common carotid as sort of your reference point. The common carotid colorization is the same as the internal jugular vein. So these vessels are going in the same direction. They're going up the neck. So in this case, the heart is to the right of the screen and the top of the head is to the left. So this is the internal jugular vein. Again, displaying blood flow in the inappropriate direction, going against the direction of this arrow, which means that it's reverse flow component. Now we followed the internal jugular vein up a ways and then we found it sort of ended and there were a bunch of small stringy collaterals that sort of went down into the direction of the thyroid. In this netter drawing right here, we see this is the internal jugular vein and we see that it does supply or it does have branches or tributaries that drain part of the thyroid. It's called the inferior thyroid veins. So blood flow is going up this jugular vein down through these collaterals. Another prominent collateral pathway that's developed on this particular patient is the anterior jugular vein. Normally, the anterior jugular vein flow is in this direction and it drops into the external jugular and then it drops into the subclavian. But in this case, flow is going in a retrograde direction in the internal jugular vein. In fact, this is the anterior jugular vein here, which has become quite large and dilated because it's functioning as a major collateral pathway. This is a diagram that I've just put together kind of showing the circumstances here. This patient had an obstruction in the innominate vein. Blood flow is going up and out the external jugular vein to the contralateral side. Also, flow going up the internal jugular vein. Again, here's a netted drawing sort of showing the arrows of the contralateral flow direction. Now, this anterior jugular vein, of course, is right across the neck. There's a region called the jugular arch, which communicates between the left and the right side. This is not the same patient, but it's a demonstrative venogram showing an anominate thrombosis right here. And blood flow from the left arm comes down, goes across the anterior jugular vein, and enters into the subclavian on the contralateral side, and then down into the innominate. So this is a common collateral pathway that takes place in the presence of innominate obstruction. So the case summary here would include that there is a venous outflow in the arm that's supported by collateralization in the internal jugular vein, the anterior jugular vein, coursing across to the contralateral side, and then via the jugular arch vein. The patient was not treated for venous thrombosis because it was thought that this was maybe a chronic situation because also once the innominate is totally thrombosed, the risk of pulmonary embolism is pretty minimal because the thrombus can't get through this region. And again, a caveat here is it's important to note flow direction in the central vessels as well as the flow patterns. I had one other case that I was discussing just recently that was very similar to this case, and it was someone that was up for a preoperative assessment for a hemodialysis access graft installation. And the technologist had seen flow in the subclavian vein, and it seemed to be pulsatile, but it wasn't pulsatile enough. It was diagnosed as being a normal examination. The patient went for the operative procedure to have a hemodialysis access shunt put in, and while they were on the operating table, they found that the venogram was performed, and they found that the innominate vein was completely thrombosed, and the patient was functioning on collateral. So those are things that we want to find out prior to the installation of a hemodialysis access graft. Just a little cartoon showing that, just a reminder that the veins are, valves are few and far between on the upper extremity veins, so venous flow can go in either direction quite easily just depending on the higher pressure source in the more central venous system. Another pathology that we see in the upper extremities is called the Padgett-Schroeder syndrome. The Padgett-Schroeder syndrome is a spontaneous thrombosis of the subclavian vein and or the axillary vein. This is what we call effort-induced thrombosis, and we most often see this in weightlifters or bodybuilders, and this can be due to anatomical factors that predispose the patient to this condition or to hypercoagulability issues, dehydration being for one, and again, very common in bodybuilders. This is just a brief study showing up, this was a 38-year-old bodybuilder that came in with a three-week history of arm swelling. This is an abbreviated study here, I didn't have time to show it all, but this is the axillary vein with some flow coming over the thrombus. This axillary extended up into the subclavian vein into just the proximal portion of the subclavian vein and then the thrombus had ended, but we assume that this was the Padgett-Schroeder because of the patient's bodybuilding hobby and this being the effort-induced thrombosis. Similar case right here, case number four, another male patient presented with intermittent right arm swelling, particularly when he was lifting weights. He had no history of deep vein thrombosis or venous upper extremity thrombosis and he was a bodybuilder. We found that when we carefully evaluated his upper extremity vasculature, the flows were pretty normal, but we did notice that, because we were suspicious of this effort-induced thrombosis or perhaps a precursor to this, we had the patient elevate and abduct their arm. This is the clavicle here and this is the subclavian vein and when they abducted and elevated the arm, we could see the vein being compressed underneath the clavicle. In fact, it might have been our imagination, but it almost looked like the vein walls tended to be thick right in this region, maybe from repeated trauma. When we looked at this patient in the transverse view, just distal to the clavicle, it was pretty amazing. We found that he had a subclavian vein and it almost looked like Swiss cheese here. This was the subclavian vein. He had another adjacent vein here, another vein here, another vein here. So these were all thought to be collateral veins and this is the subclavian artery. Now, when we had the patient abduct and elevate the arm while we carefully looked at the subclavian vein, we could see the subclavian vein being compressed and the other veins dilating out. Essentially almost occluding this vein, the other veins distended and were carrying blood flow via collateral pathways. So we kind of assumed that this was sort of a precursor to the Padgett-Schroeder syndrome. It was quite interesting to see. So the case study here is the question, is this a precursor to this effort-induced thrombosis? Well, most likely. Also, he had extensive collateral development in the presence of this subclavian vein and this was a precursor to this compression. Also, the infraclavicular region really did look like Swiss cheese. It took us a while to sort of figure out which one of these vessels was the actual subclavian vein. We had to follow it along the course of the subclavian artery. So I felt as though that was an interesting study. Now, I'd like to mention one more condition that we have in the upper extremities and this is the superior vena cava syndrome or the SVC syndrome. Patients typically present with a tremendous amount of edema in the face and the neck from this condition. Occasionally, people will even present with some tongue swelling from this. This is due to an increase in venous pressure and it's often due to either an occlusion or an intrinsic compression of the superior vena cava by some type of a mass or some type of a carcinoma. I'll just show a brief study here. This is a patient that presented with the superior vena cava syndrome, extensive face swelling and neck swelling and actually arm swelling as well and she had just a thin web of quite a strong fibrous band through this region in the superior vena cava. So this was dilated with a angioplasty balloon and that reclosed and the radiologist put a stent right in this region and then the swelling went away and the symptoms went down and the waveforms returned to normal following this. So the bilateral comparison for waveforms can be fallible in the presence of this subclavian obstruction because the waveforms may look similar but they'll look abnormal bilaterally and with very low flow coming into the superior vena cava through the anominate veins in the presence of this condition. So in summary, knowledge of the upper extremity, vascular anatomy, the venous anatomy and the arterial anatomy is essential. So I recommend practicing this method on normals, on your coworkers, et cetera, so that you can get very comfortable with the anatomy of the normal upper extremities. For proximal veins, give priority to waveform assessment because you can't really compress the proximal subclavian or anominate veins or any vein that's around the clavicle. It's too difficult to compress with transducer pressure. In a bilateral comparison, always look to the subclavian in about the same region as the symptomatic side. Look for waveform symmetry. Also assess flow direction in all proximal veins as well as the flow patterns. Additionally, for arms below the axilla, we find that the Doppler compression techniques work better than augmentation or work better than sort of an assessment of Doppler flow. We still use the Doppler but we prioritize compressibility of the veins. So this can be a very rapid exam following the deep system and the superficial system in the arm from the axilla right down. Keep in mind that the Achilles heel of this upper extremity venous exam is the inability to accurately image the anominate veins. And this can be Achilles heel particularly when there's partially occlusive venous thrombosis lying in this region that may be missed. So we feel as though probably the instances of isolated partial thrombosis in the anominate vein is probably uncommon. Almost always it extends up proximal towards the subclavian or into the jugular vein. So we look carefully in this regions. But keep that in mind. This exam is probably not as accurate as our lower extremity deep vein thrombosis in which we can assess pretty much all of the veins. So I'd like to thank you very much for your time and your attention during this educational program. I hope this will be a benefit to your upper extremity venous examination. Thank you. For this test I've selected a transducer with a wide bandwidth range. This transducer is from six megahertz to about nine megahertz, perhaps 10. Because we'll be looking at superficial structures as well as deep structures, having the ability to have variable transducer frequencies is very helpful. I'll start out by showing you how a transducer can be used to measure the frequency of the anomaly. This is very helpful. I'll start out by identifying the jugular vein and then scanning and transversing the jugular vein down to the confluence with the subclavian vein and then into the anominate vein. Remember we have an anominate vein on the right side as well as the left side. Here's the jugular vein right in this region just beside the carotid artery. I'll scan down proximally and it joins the subclavian vein right in this part of the image. I've oriented this so that, as I mentioned in the didactic portion of the program, I've arranged this so that the hand is to the right of the screen and the heart is to the left of the screen. So I'll know that blood flow should be going from right to left in the subclavian and axillary veins. I'll move the jugular vein into subclavian and then this is the anominate portion right down through the tip of the arrow here. Subclavian vein runs out this way. So I'll go longitudinal and sample in that jugular vein. Here's the carotid artery and I'll just move a little bit lateral to that and identify the jugular vein. This is the type of flow that we expect. I've noted that it's going on the screen from left to right because it's jugular flow and also it is pulsatile, as we can see in this waveform. It's pulsatile, almost similar to arterial pulsatilityity and also there's a respiratory phasicity to it as well. So I tend to use a wide or a slow sweep speed on our spectral Doppler so that we can capture not only the pulsatility, but these changes in the velocities or frequencies with respiration. Now I'll go down and sample the anominate. We tend to see not a lot of distance in the innominate or a portion of the innominate, but even if we can get a Doppler sample down on the proximal portion of it, or I should say the distal portion of the innominate. So, similar to the jugular vein, we have a pronounced pulsatility because of the changes in the right side heart pressure. So that's typically normal flow for the innominate vein. I'll next come out and look at the subclavian vein. This is the subclavian right in this region. Now also I'm seeing some other vessels here. This is the subclavian. This vessel is the external jugular vein. This vessel is usually quite small. On this model it's quite prominent. I believe this is the infraclavical vein. So we'll look at flow direction. These should be flowing from the right of the screen to the left. Blue is set up so blue is away from the transducer, so these are flowing as expected from right to left. The reason I pay particular attention to flow direction here is because in the presence of an innominate obstruction, often flow can reverse in these veins as collateral networks form quite quickly in the neck and the chest. There's one other vein that I'd like to point out that we don't see on every person, but we can see on this model, and that's the anterior jugular vein. It's quite large on this model. This is the anterior jugular vein, so flow is coming from this region and drops down into the subclavian, again with the external jugular into the subclavian and anterior jugular as well. So let's look at the subclavian down in this region. Potential pitfall is when this is thrombosed, the external becomes quite large and can carry a lot of blood flow, so be careful you're actually looking at the subclavian and not misidentifying the external jugular as the subclavian. So, this is a normal flow pattern in this portion of the subclavian as well. It's very pulsatile flow and very chaotic flow. So, so far we've looked at the jugular, innominate, and subclavian, as well as a quick look at the flow direction in the external jugular and some of the other vessels in this region, and they all appear to be normal. Now we'll place the transducer on the other side of the clavicle, so we'll come in from an infraclavicular approach, in transverse view, and identify the subclavian artery in transverse and then go longitudinal. This looks like the subclavian artery. I'll turn the transducer to try and elongate. So this is the subclavian vein. Here's a clavicle right here. This is the distal portion of the subclavian vein. This is the cephalic vein coming in. You'll notice I'm having a little difficulty imaging the vein down through this portion. So this is on some patients, or particularly in this model, we sometimes see the axillary vein being compressed by the chest wall. So I'm gonna try a maneuver here to see if this works. So I'm gonna try to do this while I'm imaging in longitudinal, and I'm just gonna elevate and abduct the arm away from the body to see if we can open up this portion of the vein. Here's the artery right here. I think the vein should be right in this region. So there's the distal subclavian vein, or actually the proximal axillary vein. Again, with the arm towards the side, it's compressed. When I bring the arm out, it dilates out quite wide. So for that reason, I'll try and support the arm here and get a Doppler sample right in this region while it's dilated out. Okay, Mike, I'll have you bring your arm in by your side again. So again, we're getting in the axillary, we're getting the pulsatile flow, but the farther we get away from the heart, the more distal we get in the venous system. So I'm gonna try to do this while I'm imaging. So I'm gonna try and support the arm here and get a Doppler sample right in this region. Again, with the arm towards the side, it's compressed. When I bring the arm out, it dilates out quite wide. So for that reason, I'll try and support the arm here while it's dilated out. The farther we get away from the heart, the more distal we get in the venous system. The pulsatility will become less pronounced. I'm gonna go back up and get a sample just at the clavicle in the subclavian vein. And this will be used to compare to the contralateral side. I'll reposition the Doppler here just a little bit because the flow is quite chaotic in this region, but I'm looking for that pulsatility and flow. I'm not satisfied with the flow rate in this region, and I suspect it may be because the axillary vein is compressed. So I'm going to grab a chair and sit down and rest the arm on my lap to sort of elevate and elongate the arm, hyperabduct the arm out to the side to alleviate that compression pressure so that hopefully we can get a little bit more normalized signal in the subclavian vein because I want this to be normal to be able to compare to the contralateral side. I've elevated the arm away from the body, abducted it away from the body, and repositioned in the subclavian. Now I'm getting a better signal, more pulsatility, going the appropriate direction, and I'll freeze this image right here. Now normally I would go to the other side and compare the waveform to this waveform from the contralateral subclavian, but I've already accomplished this just for the sake of time. And we'll bring up the image here. So here we can see the right subclavian waveform just distal to the clavicle. And from a very similar site on the left side, we have a very similar waveform, pulsatility with some respiratory variation. So the comparison of the sides is important because on some patients when the anominate is obstructed, the collateral pathways may carry the flow to a point it almost looks like a normal subclavian flow. Alright, I'm going to start to scan out along the clavicle here and down into the axilla. I finished scanning the central vessels just over the clavicle and the subclavian and axillary portion just distal to the clavicle. And I've now moved on to the arm veins. I've done two things here to help optimize the exam, and one was to elevate the head of the bed somewhat so that we can put more pressure in the veins, makes them a little bit easier to see. I've also changed to a transducer that's a wide bandwidth high frequency transducer. It goes up to 14 megahertz. So I'll identify the brachial artery. We can see this right at the head of the arrow. And then this is the basilic vein. This is usually much larger than the brachial veins. We can see that this collapses quite easily with probe pressure. So for that reason, I try to use a very, very light touch when I'm scanning this vein, otherwise it's too easy to collapse it and you may not see the vein itself. So I'll follow the basilic vein down. You can see a valve right in this region. And I compress periodically as we come down. And as I approach the antecubital fossa, I see quite a large tributary coming in here. And this is the median cubital vein that courses across the antecubital fossa and joins the cephalic vein. I'll continue to follow the basilic vein. And I start seeing this model is quite muscular and he has a lot of branches down in this area, a lot of tributaries. So this is still the basilic vein, but there are a number of large tributaries that extend down into the forearm. So if the patient were symptomatic in these vessels or if there was a palpable cord, I would follow these veins down to the wrist level. And for the sake of this demonstration or for a normal patient, a patient that does not have symptoms in the forearm, it doesn't really make sense to scan these superficial or the deep veins in the forearm unless they're symptomatic or if it's a pre-op for dialysis access placement. So with this, I'll go back to the median cubital vein, back to the basilic vein. I'll shift my transducer now. Here's the brachial artery right here with the brachial veins right very close to it. And now I'll shift over to the cephalic side. I'm going to use some more gel on this portion of the arm. So here's the large cephalic vein right here. There's another small tributary coming in. And I'll start to follow this upwards along the arm. You'll notice I'm having a little trouble staying in contact because if I use anything other than a very light touch, the vein compresses. So the idea is to kind of scan along, compress the vein, making sure the vein walls touch each other along the course of the cephalic vein. I'm up over the shoulder now. And then this gets difficult because it sometimes dives through the muscle here and joins the axillary to form the subclavian vein. Now with the camera on, I'd like to show sometimes it's useful to use a large sort of pile of gel if the vein is very superficial. And I use the gel as essentially a standoff. And I don't have the transducer right on the skin. I just have it in the gel itself. You can see that this is all gel standoff. And it puts the transducer or the vessel a little bit deeper in the field of view and into the focal zones of the transducer. So we sometimes have to do that with very superficial veins. Now the paired radial veins and the paired ulnar veins are also, they're very hard to find down in the arm. They lie right along the artery, radial artery and the ulnar artery. But again, these are so rarely involved in venous thrombosis that it's perhaps inappropriate to scan those or not necessary to scan those unless the patient is symptomatic in that region. So I hope this scan will be useful. The points I'd like to just reiterate is a bilateral comparison between the subclavian veins just distal to the clavicle on each patient. And also to pay attention to the flow direction in the central vessels. We use our Doppler for flow confirmation of flow patterns in the proximal vessels. In the vessels in the arm and the peripheral vessels, we use compression techniques. We can use Doppler here as well, but it tends not to work as well as just the straight old compression of the veins. So hopefully this will be helpful in your laboratory and make it a little bit easier to scan these arm veins.

duplex imaging

upper extremity veins

common indications

contraindications

limitations

examination protocol

Doppler analysis

2D assessment

compression techniques

patient communication

positioning