Venous Doppler upper limb

Venous Doppler upper limb by Dr. Sulav Pradhan

1. Venous doppler study of upper limb Dr Sulav Pradhan 1 st year resident Radiodiagnosis , NAMS

2. Anatomy

3. Superficial veins Cephalic Vein Basilic Vein Median vein of forearm Deep veins Brachial vein Axillary vein Subclavian Vein

4. Cephalic vein origin : radial aspect of the superficial venous network of the dorsum of the hand location :  courses upwards on the lateral aspect of the forearm and arm drainage : palm of the hand, lateral aspect of the forearm and arm tributaries : median cubital vein and accessory cephalic veins. Termination : medial aspect of the axillary vein or the lateral aspect of the subclavian vein

5. Basilic vein origin : ulnar aspect of the superficial venous network of the dorsum of the hand location : courses upwards on the medial aspect of the forearm and arm drainage : palm of the hand, medial aspect of the forearm and arm tributaries : median cubital vein and median antebrachial vein Termination : At the level of the teres major muscle, it joins with the paired deep brachial veins

6. Brachial vein origin:  union of the ulnar and radial veins in the cubital fossa location:  courses superiorly in the upper arm, often in close proximity to the brachial artery drainage:  deep and superficial palmar venous arches termination:  union of the brachial and basilic veins at the inferior border of  teres major  forms the  axillary vein

7. Axillary vein origin : formed by the union of the paired brachial veins and the basilic vein location : courses medial and superficial to the  axillary artery in the axilla drainage : upper limb, axilla and superolateral chest wall tributaries : include the cephalic vein and five other tributaries which correspond to the branches of the axillary artery

8. Subclavian vein starts at the crossing of the lateral border of the 1 st  rib Arches cephalad , posterior to the medial clavicle before curving caudally and receiving its only tributary, the  external jugular vein  joins the internal jugular vein posterior to the sternoclavicular joint, where it forms the  brachiocephalic vein The right and left brachiocephalic veins merge to form the superior vena cava, which subsequently enters the right atrium.

9. Perforating veins form important pathways of collateralization in the presence of partial thrombosis. In the absence of thrombus they are typically too small to see, but become more pronounced when they are recruited to divert flow around a clot. Valves are present within the veins of the UE. As one moves peripherally the location of the first valve is quite variable, but typically is encountered in the proximal brachial vein.

10. Advantages: Doppler study is a noninvasive imaging method B mode US combined with color flow doppler study provide anatomical and physiological information as good as that obtained with venography Relatively low cost Widely available Portabillity Proven high accuracy has lead to its primary role in diagnosis of venous thrombosis

11. Disadvantages dependence on the skill of the operator technical difficulties in patients with oedema , wounds or obesity low sensitivity for assessing DVT in the upper thorax and arms (overlying skeleton, lungs and large venous collateral pathways) difficulty in differentiating recanalized thrombus from fresh thrombus

12. USES Evaluation of suspected DVT Evaluation of venous incompetence Preoperative vein mapping Evaluation of venous system for patency before the placement of venous catheter For initial evaluation of vascular malformation.

13. Pathophysiology of DVT

14. Catheter-related thrombosis: caused by several factors. The vessel wall may be damaged during catheter insertion or during infusion of medication. Also, the catheter may impede blood flow through the vein and cause areas of stasis

15. Although the cause of upper extremity DVT differs from that of the lower extremity, the pathophysiology of its evolution is similar.

16. The sequelae of upper extremity thrombosis are less severe than those of lower extremity thrombosis. Only 10% to 12% of patients with arm DVT develop pulmonary emboli - majority of these are insignificant. manifestations of venous stasis and venous insufficiency caused by DVT in the arm are less common and less severe than in the leg. Chronic swelling, skin changes, and nonhealing venous ulcers are rare in the arm because of two major factors : extensive collateral pathways and low hydrostatic pressure as compared to leg veins

17. Diagnostic Accuracy of Ultrasound The accuracy of ultrasound versus venography in patients with acute DVT of the upper extremity has not been studied as extensively as in the lower extremity . The available literature shows sensitivity ranging from 78% to 100% and specificity of 92% to 100 %. The lower accuracy in the upper extremity compared with the lower extremity is a result of the greater number of technical challenges facing the examiner.

18. TECHNICAL PROCEDURES Similar principles to examination of lower extremity venous examination: - gray scale compression - color Doppler - spectral Doppler Typically, a 9-MHz linear array transducer – for internal jugular vein and the arm veins through the axillary vein. 6-MHz transducer with color Doppler ultrasound capability is often necessary to visualize the subclavian vein.

19. Positioning patient is positioned supine, with the arm to be examined slightly abducted and rotated externally. patient’s head is turned slightly to the opposite side

20. Scanning Technique Subclavian Vein Patient supine on bed, arms by their side. Scan in transverse at the antero -lateral base of the neck. A coronal, supraclavicular , inferiorly angled approach is used medially, and a coronal, infraclavicular , superiorly angled approach is used laterally Using colour doppler , find the Jugular vein and follow inferiorly to the junction with the subclavian vein. Follow the subclavian vein laterally using colour doppler in both longitudinal & transverse planes to exclude non occlusive filling defects.

21. Internal jugular vein examined initially with compression sonography in the transverse plane and is followed inferiorly to its junction with the subclavian and brachiocephalic veins An inferiorly angled, coronal, supraclavicular approach- to evaluate the superior portion of the brachiocephalic vein and the medial portion of the subclavian vein. Due to the proximity to the heart, duplex Doppler spectral tracings in these sites will show greater transmitted pulsatility than in the leg veins . Loss of this pulsatility may be caused by a more central venous obstruction .

22. Axillary vein Patient still supine on bed with ipsilateral hand on their head, elbow flexed laterally to permit easy access to the axilla . Find the distal subclavian artery and follow through the axilla with colour doppler and compression using b-mode in the transverse plane  In the proximal arm, the axillary vein will divide into the basilic and brachial veins.

23. Upper Arm Veins (Brachial & Basilic ) The basilic vein is the larger and is more superficial. Usually single but may be duplicated. Continue from the axillary vein checking in transverse that the basilic and brachial veins of the upper arm are compressible. best acheived with the patient sitting on the side of the bed with their arm supinated . At the antecubital fossa , the brachial vein will divide into the radial & ulnar veins. 

24. Forearm veins (Radial & Ulna) Still with the patient seated on the side of the bed, follow the radial and ulnar veins to the wrist confirming compressibility and flow. As with the veins in the calf, the veins of the forearm generally run in pairs (venous commantantes )

25. Ultrasound and Compression Fresh thrombus may be extremely hypoecoic – difficulty in visualization - therefore, essential to perform venous compression in a transverse plane to rule out the presence of UE DVT. Compression should be light because fresh clots are soft and firm pressure may give a false impression of patency. cannot be used in portions of subclavian vein and in the inominate vein because of the overlying structures – Color Doppler and Spectral Doppler assessment

26. Ultrasound Color-Doppler As a result of right atrial contraction (a-wave) -pushes back on venous return in the larger central veins- resulting in a temporary reversal of flow. The color Doppler signal will fluctuate in direction . With the pulse repetition frequency adjusted to a higher level , the wall filter may suppress perception of slower laminar flow along the wall, appearance that can be confusing, mimicking a clot adherent to the wall . On the other hand, in the larger veins with the color-Doppler pulse repetition frequency set relatively low , with a brisk augment, aliasing may occur.

27. Ultrasound Spectral-Doppler

28. If no thrombus occluding the vein- color spontaneously saturates all lumen of the vessel. Because the veins of the UE are in close proximity to the heart, it is normal to see a cardiac pulsatility in the spectral analysis. Spectral analysis of the caudal internal jugular vein and the medial subclavian vein demonstrate central venous transmitted cardiac pulsatility with a, c, v peaks, and x and y descents – rules out obstruction In contrast to the lower extremity veins, the velocity of blood flow in the veins of the upper extremity increases during inspiration ( inspiratory sniff) due to negative intrathoracic pressure and increased venous return toward the heart.

29. In a normal venous system there will be a rapid rise and fall in the frequency shift, whereas if there is a thrombosed venous segment it will resist flow with damping or absence of the augmentation response. squeeze should be rapid and not excessive – risk of thrombus dislodgement.

30. In addition to the rapid phasic changes in cardiac pulsatility from atrial contractions, there is a further variation in amplitude due to normal respiratory variation.

31. Phasicity Flow changes with respiration Slow Apnea Rapid

32. Augmented flow in vein Aug Valve closed Competent vein

33. Normal and abnormal response to sniff test . A, Duplex spectral analysis of the internal jugular vein shows an increase in blood flow velocity with inspiratory sniff, a normal response suggestive of central venous patency . B, Duplex spectral analysis of the contralateral internal jugular vein shows no increase in blood flow velocity with inspiratory sniff, an abnormal response suggestive of brachiocephalic or superior vena cava obstruction

34. Diagnostic criteria of upper extremity deep vein thrombosis

35. Fig : A Gray-scale sonogram of the left internal jugular vein (arrows) in the transverse view shows some echogenic material within it . Fig B: Probe pressure is being exerted over the vein and the thrombus is preventing the compression of the vein. This is the key to positively identifying the presence of this non-occlusive thrombus within the vein.

36. Triplex sonogram in the longitudinal view shows an occlusive thrombus in the left axillary vein. Patent segment below the clot demonstrates some slow anterograde flow without respiratory variation or cardiac pulsatility .

37. POTENTIAL PITFALLS Rouleaux Blood flow is anechoic because individual red blood cells are too small to reflect the incoming sound wave. However , in certain conditions as infection, diabetes mellitus or cancer , red blood cells may stick to each other, a finding that is named rouleaux - aggregates are large enough to interact with the insonating beam, manifesting as echoes in the bloodstream, and are more likely to occur in areas of slow flow, especially in the sinus behind the cusps of valves . If compression easily dislodges these Rouleaux aggregates , presence of a clot is excluded.

38. Gray-scale sonogram in the longitudinal view shows an area of slow flow in the right internal jugular vein mimicking deep venous thrombosis.

39. 2. Arm abduction Caution should be exercised in interpreting the distal subclavian vein, which may appear falsely narrowed as it crosses between the clavicle and the first rib at the thoracic inlet, due to complete abduction of the upper extremity during examination . 3. Limited acoustic window due to bandages used to secure the catheters, radiation-induced changes on the chest wall or the presence of indwelling catheters 4. Large venous collaterals In chronic obstruction, large venous collaterals often coexist and can be misinterpreted as representing patent normal vessels.

40. CHRONIC CHANGES AFTER UEDVT 1. Valves If valve cusps appear rigid or fixed, this usually represents the sequela of prior UEDVT . 2. Walls The walls of a normal vein are smooth and non obstructive. Following recanalization after DVT they become irregular, thickened, echogenic and rarely calcified . Decreased diameter of venous lumina . 3. Venous collaterals Over a period of time the intramuscular venous channels expand and become apparent on color Doppler.

41. Acute & chronic thrombus Signs interpreted according to clinical history Anechoic or hypoechoic Brightly echogenic Homogenous Heterogenous Poorly attached or floating Well attached Smooth borders Irregular borders Spongy & deformable More rigid Increase in vein diameter Small & contracted vein Small collaterals Large collaterals Acute thrombus Chronic thrombus

42. Ultrasound Venous Mapping for Preoperative Planning of Dialysis Access non dominant arm first The vein mapped to receive the arterial anastomosis be measured after it is dilated ( use of sequential tourniquet placement or an inflated blood pressure cuff on the arm ) - closely approximates the size of the arterialized vein after fistula formation . forearm vein most commonly used for AVF creation is the cephalic vein. - assessed for compressibility, thrombus , and size - minimal diameter of 0.25 cm for all veins used for an AVF - measured at 7 to 8 sites on arm and forearm Veins must be relatively superficial to be easily cannulated after placement of a fistula . The depth from the skin surface to the cephalic veins of adequate diameter may be measured to assess the need for a subsequent superficialization procedure.

43. If no suitable upper arm vein for AVF creation is found, the largest brachial vein and the axillary vein should be measured for potential graft placement as previously described. A vein with a diameter of at least 0.4 cm is needed for grafts

44. Large branches of veins near the site of a fistula can result in nonmaturation of the fistula. So, the sites and sizes of vein branches may be noted. The internal jugular and subclavian veins should be examined bilaterally to document symmetric respiratory phasicity and transmitted cardiac pulsatility as well as to exclude outflow stenosis .

45. References Diagnostic Ultrasound 4 th edition, Rumack http://www.ultrasoundpaedia.com https://www.researchgate.net/publication/277248895_Upper_Extremity_Venous_Ultrasound_Doppler_Clinical_Perspectives_Technical_Procedures_and_Pictorial_Review http://www.aium.org/resources/guidelines/preDialysisAccess.pdf