Vascular Anatomy Chapter 4 PDF

Chapter 4 Vascular Anatomy Ann Marie Kupinski Upper Extremity Arm Vein Diagram Just like in the lower extremity, upper...

Chapter 4 Vascular Anatomy Ann Marie Kupinski Upper Extremity Arm Vein Diagram Just like in the lower extremity, upper extremity veins originate distally and drain towards the heart Veins return blood back to the heart Vessel anatomy is described from the wrist to the chest Vessel location (prox, mid, distal) are identified from the proximity to the heart Deep veins have an accompanying artery Forearm and brachial veins are typically duplicated (axillary veins may also be duplicated) Copyright © 2023 Wolters Kluwer · All Rights Reserved Source: Size, Gail P., et al. Inside Ultrasound Vascular Reference Guide. Inside Ultrasound, Inc, 2018.  Upper Extremity Veins – Memory Tricks Brachial Veins – are paired, deep veins and often look like Mickey Mouse. Think: A Disney trip will break (“brach”) the bank Source: https://neiuindependent.org/12633/uncategorized/disney-has-5- billion-dollar-movies-in-a-year/#modal-photo Basilic Vein – is a singular superficial vein that snakes all the way down the arm Think: Harry Potter fought the Basilisk (a single snake) Source: https://easy-peasy.ai/cdn- cgi/image/quality=80,format=auto,width=700/https://fdczvxmwwjwpwbeeq cth.supabase.co/storage/v1/object/public/images/3be80134-bb6e-45c4- 833d-ead023e889c4/6bbce9b6-a975-42a5-a1ce-52a96104cbb7.png Radial Veins - are paired, deep veins on the THUMB side of the forearm Think: Thumbs can twirl in a circle and a circle Figure 4-13. Venous has a radius. Source: https://tenor.com/view/duimen-method2-gif-7554606 drainage of the hand and veins of Ulnar Veins - are paired, deep veins on the upper extremity. the PINKY side of the forearm Think: P.U. (Pinky / Ulnar) something smells. Copyright © 2023 Wolters Kluwer · All Rights Reserved Source: https://prestigemedigroup.com/pee-ew-why-does-my-urine-smell-and- other-things-you-wanted-to-know-about-urine/ Forearm Veins - Radial and Ulnar Radial and ulnar veins o Paired deep veins o Follow the path of the arteries o Unite near antecubital fossa to form brachial veins Ulnar veins arise from the tributaries of the palmar venous arch in the hand. With the palm up, the UV travel along the medial aspect of the forearm, joining near the elbow to form an ulnar trunk Radial veins arise from the dorsal metacarpal veins and travel up the lateral aspect of the forearm, joining near the elbow to form the radial trunk Copyright © 2023 Wolters Kluwer · All Rights Reserved Entire Arm Vein - Cephalic Vein Cephalic vein o Superficial vein o Longest vein in the arm o Originates from the medial component of the dorsal venous arch o Winds around radial border of forearm Source: https://www.pinterest.com/pin/779545016728790562/ o Continues along lateral border of biceps muscle o Empties into axillary vein The Cephalic Vein is typically used as a landmark to differentiate the subclavian vein from the axillary vein Copyright © 2023 Wolters Kluwer · All Rights Reserved Entire Arm Vein - Basilic Vein Basilic vein o Superficial vein o Originates from the ulnar component of the dorsal venous arch o Courses along ulnar aspect of forearm Source: https://www.pinterest.com/pin/779545016728790562/ o Continues along medial border of biceps muscle o Joins brachial vein to form axillary vein *Both cephalic and basilic veins communicate with median cubital vein Copyright © 2023 Wolters Kluwer · All Rights Reserved Median Cubital Vein Median Cubital Vein o Superficial vein o Crosses the antecubital fossa obliquely Source: https://geekymedics.com/cubital-fossa/ o Connects the basilic and cephalic veins o Several possible anatomic variations Copyright © 2023 Wolters Kluwer · All Rights Reserved Source: Size, Gail P., et al. Inside Ultrasound Vascular Reference Guide. Inside Ultrasound, Inc, 2018. Upper Arm Vein Diagram Figure 4-14. View of the upper extremity veins crossing the axillary region. Copyright © 2023 Wolters Kluwer · All Rights Reserved Upper Arm Veins – Brachial Veins Brachial veins o Deep veins o Usually paired o Follow course of artery o The brachial veins usually join near the axilla to form the axillary vein Copyright © 2023 Wolters Kluwer · All Rights Reserved Upper Arm Vein – Axillary Vein Axillary vein o Usually single vein o Begins at junction of brachial and basilic veins o The axillary vein runs along the shoulder until joining the cephalic vein where it becomes the subclavian vein, usually near the upper border of the first rib Copyright © 2023 Wolters Kluwer · All Rights Reserved Chest Area Vein – Subclavian Vein Subclavian vein o Continuation of the axillary vein, just past confluence with cephalic vein o Begins just past outer border of first rib o The subclavian vein joins the internal jugular vein to form the brachiocephalic vein (or innominate vein) at the clavicular level Copyright © 2023 Wolters Kluwer · All Rights Reserved Neck Veins – Internal and External Jugular Veins Internal Jugular Vein (IJV) o Runs adjacent to the common carotid artery o Receives blood from the face and neck o The IJV joins the subclavian vein to form the brachiocephalic (innominate) vein External Jugular Vein (EJV) o Drains blood from the cranium, face, and neck o Drains into the subclavian vein Copyright © 2023 Wolters Kluwer · All Rights Reserved  Chest Area Veins - Brachiocephalic / Innominate Veins Brachiocephalic / Innominate Veins o Formed at junction of internal jugular and subclavian veins at the clavicular level o One at each side of the base of the neck Copyright © 2023 Wolters Kluwer · All Rights Reserved Source: Size, Gail P., et al. Inside Ultrasound Vascular Reference Guide. Inside Ultrasound, Inc, 2018.  Chest Area Vein – Superior Vena Cava (SVC) Superior vena cava o Formed by the junction of the right and left brachiocephalic veins o Courses just behind the right side of the sternum o The SVC enters the heart at the right atrium Copyright © 2023 Wolters Kluwer · All Rights Reserved  Chapter 18 Duplex Ultrasound Imaging of the Upper Extremity Venous System Steven R. Talbot and Mark Oliver Objectives ❑Describe the components of the upper extremity venous system ❑Define the normal image and Doppler characteristics of the venous system ❑Identify the image characteristics that aid in thrombus aging ❑Describe the Doppler waveform characteristics associated with various pathologies ❑List risk factors associated with venous thrombosis in the upper extremity Copyright © 2023 Wolters Kluwer · All Rights Reserved Background Protocol techniques for upper extremity veins are similar to those for lower extremity Three differences 1. Thrombi in lower extremity often caused by stasis; not so in the upper extremity (no soleal sinuses) 2. Superficial veins affected more in arms than in legs; in addition, superficial thrombosis may have greater clinical significance in arm than leg 3. Venous anatomy of upper extremity is more variable than lower extremity Copyright © 2023 Wolters Kluwer · All Rights Reserved Pathophysiology Virchow’s triad o Venous stasis o Hypercoagulability o Vessel wall injury Source: https://www.researchgate.net/profile/Faizan-Khan- 9/publication/317266064/figure/fig1/AS:500804423766016@1496412487140/rchows-triad-of- the-three-broad-categories-of-factors-that-are-thought-to-contribute-to.png Upper extremity thrombosis more commonly due to injury to vessels wall o More frequent introduction of needles and catheters into arm veins Copyright © 2023 Wolters Kluwer · All Rights Reserved  Paget–Schroetter Syndrome Paget–Schroetter syndrome o Venous thrombosis associated with compression of subclavian vein at the thoracic outlet o Also known as venous thoracic Source: https://pocusjournal.com/article/2022-07-iss-01p131-133/ outlet syndrome (VTOS) or as effort thrombosis o Typical patients are young/athletic/muscular males, but can occur in other individuals Source: https://angiologist.com/paget-schroetter-syndrome/https://angiologist.com/paget-schroetter-syndrome/ Copyright © 2023 Wolters Kluwer · All Rights Reserved Catheters as Causes of Upper Extremity Thrombosis Subclavian and internal jugular veins commonly used for indwelling catheters and pacemaker wire introduction o Can be associated with upper extremity thrombosis Peripherally inserted central catheters (PICCs) also cause thrombosis o Catheter is inserted through basilic or cephalic vein and then positioned near right atrium Copyright © 2023 Wolters Kluwer · All Rights Reserved Signs & Symptoms Similar to those of lower extremity Can include: o Unilateral arm or hand swelling o Superficial palpable cord o Erythema o Pain and tenderness o Facial swelling or dilated chest wall collaterals ▪ Suggestive of superior vena cava thrombosis Patients may present with indwelling catheters or history of venous catheters Copyright © 2023 Wolters Kluwer · All Rights Reserved Other Indications for an UEV Examination Asymptomatic patients may be examined before central catheter placement or before pacemaker placement o Duplex may also be used to confirm placement of the abovementioned devices. Upper extremity veins may also be evaluated in patients suspected of pulmonary embolism (PE) PE symptoms include chest pain, tachypnea, or tachycardia Copyright © 2023 Wolters Kluwer · All Rights Reserved Sonographic Examination Techniques Similar technique is used for upper extremity as for lower extremity Transducer compression performed over all upper extremity veins possible o Gentle transducer compression is used directly over vein so that vein walls coapt o Compression maneuver is repeated every 2 to 3 cm along course of each vein Spectral Doppler waveforms are recorded from all major veins Copyright © 2023 Wolters Kluwer · All Rights Reserved Patient Preparation Examination procedure should be explained to the patient Relevant history should be obtained, including questioning of signs and symptoms Upper extremity clothing Source: https://www.semanticscholar.org/paper/Neuromuscular-Ultrasound-in-Polyneuropathy-Lee- and jewelry should be Cartwright/f15c55e2ca97b5f7172d625ec4e05316d322b6dd removed, and patient gown or drape provided Copyright © 2023 Wolters Kluwer · All Rights Reserved Patient Positioning No need to tilt bed for examination o Internal jugular and subclavian veins need to be examined with patient lying flat ▪ Arm can be positioned at patient’s side during evaluation of jugular and subclavian veins Arm should be abducted to evaluate remaining veins Copyright © 2023 Wolters Kluwer · All Rights Reserved Equipment Two transducers recommended o Midrange (5 to 10 MHz) linear array ▪ Used to evaluate internal jugular, brachiocephalic, subclavian, axillary, deep brachial, and brachial veins o Higher frequency (10 to 18 MHz) linear array ▪ Used for more superficial veins (cephalic and basilic) and small forearm veins (radial and ulnar) o Curved or sector array may be useful for deeper vessels near clavicle and sternum. Copyright © 2023 Wolters Kluwer · All Rights Reserved  Transducer Option Images “vascular” or “small parts” Source: https://www.ultrasoundtraining.co.uk/musculoskeletal-ultrasound-probes/ Copyright © 2023 Wolters Kluwer · All Rights Reserved Scanning Technique - Internal Jugular Veins Veins in neck should be routinely evaluated as thrombus from arm can extend upward o Also are an important collateral pathway Carotid artery can be used as landmark to identify internal jugular vein (IJV) IJV will be collapsed if patient is sitting or standing, but Valsalva will increase IJV size (why?) Evaluation of IJV should include transverse views with transducer compression as well as spectral Doppler waveforms Copyright © 2023 Wolters Kluwer · All Rights Reserved IJV Transverse Images Figure 18-1. A transverse view Figure 18-2. A grayscale image of the internal jugular vein (transverse) of the location of (IJV) and the common carotid the internal jugular vein (IJV) artery (CCA) with color. alongside the common carotid artery (CCA). Copyright © 2023 Wolters Kluwer · All Rights Reserved IJV Spectral Doppler Image Figure 18-3. A spectral Doppler waveform from the internal jugular vein. Copyright © 2023 Wolters Kluwer · All Rights Reserved Scanning Technique - External Jugular Veins External jugular vein (EJV) o Lighten up transducer pressure and slide posterior from internal jugular vein o Runs without an accompanying artery very close to skin surface o Usually terminates into subclavian vein o Should be documented in transverse with transducer compression and with spectral Doppler o Serves as an important collateral pathway *Many labs do not include EJV in standard examination but add if indicated Copyright © 2023 Wolters Kluwer · All Rights Reserved Scanning Technique - Brachiocephalic Veins Challenging due to position behind bony landmarks Most often evaluated at the confluence of the IJV and subclavian veins Compressions cannot be performed o Documentation of patency depends on grayscale image, color-flow imaging, and spectral Doppler waveforms. o Spectral Doppler should demonstrate phasicity and pulsatility Copyright © 2023 Wolters Kluwer · All Rights Reserved Brachiocephalic Veins Color Doppler Figure 18-4. Color image of the brachiocephalic vein. IJV, internal jugular vein; SCV, subclavian vein. Copyright © 2023 Wolters Kluwer · All Rights Reserved Brachiocephalic Veins Spectral Doppler Figure 18-5. Spectral Doppler waveform from the brachiocephalic vein. Copyright © 2023 Wolters Kluwer · All Rights Reserved Scanning Technique - Subclavian Vein Can be visualized above and below the clavicle Accompanied by subclavian artery Cephalic vein terminates into subclavian vein just after it passes under clavicle. Can be difficult to compress due to the position of clavicle o Patient can perform a sniff or take a quick, deep breath in through pursed lips—this will cause subclavian vein to collapse Color and spectral Doppler should also be documented Copyright © 2023 Wolters Kluwer · All Rights Reserved Transverse Subclavian Vein Figure 18-6. A transverse view of the subclavian artery (SCA) and subclavian vein (SCV). Copyright © 2023 Wolters Kluwer · All Rights Reserved Cephalic Vein Draining Into Subclavian Vein Figure 18-7. A: Grayscale image of the cephalic vein terminating into the subclavian vein (SCV). B: Color-flow imaging at the cephalic vein termination. Copyright © 2023 Wolters Kluwer · All Rights Reserved Scanning Technique - Cephalic Vein Travels superficially near skin across shoulder and along anterolateral border of biceps muscle Communicates with median cubital vein at antecubital fossa In the forearm, usually travels as two vessels—one on the volar aspect and one on the dorsal aspect Document in transverse with transducer compressions; color and spectral Doppler can also be used Copyright © 2023 Wolters Kluwer · All Rights Reserved Transverse Compression of Cephalic Vein Figure 18-8. A transverse view of the cephalic vein in the upper arm noncompressed on the left and compressed (arrow) on the right. Copyright © 2023 Wolters Kluwer · All Rights Reserved Sagittal Color image of Cephalic Vein Figure 18-9. A longitudinal view of the cephalic vein with color added. Copyright © 2023 Wolters Kluwer · All Rights Reserved Median Cubital Vein Connects cephalic and basilic veins Resides in the antecubital fossa but pattern of connection is variable Common site of venipuncture and therefore thrombus Compressed and noncompressed images should be documented Copyright © 2023 Wolters Kluwer · All Rights Reserved Transverse Median Cubital Vein Figure 18-10. A transverse view of the median cubital vein (MCV) as it passes superiorly over the brachial artery (A) and brachial vein (V). Copyright © 2023 Wolters Kluwer · All Rights Reserved Scanning Technique - Axillary Vein Terminates at the junction of the cephalic and subclavian veins Deep vein accompanied by axillary artery Courses deeply from shoulder through axilla Basilic vein terminates into axillary vein in near the distal axilla. Compressed and noncompressed images should be recorded along with color and spectral Doppler Copyright © 2023 Wolters Kluwer · All Rights Reserved Transverse Color Image of the Axillary Vein Figure 18-11. A transverse view of the axillary artery (A) and vein (V) with color over the shoulder. Copyright © 2023 Wolters Kluwer · All Rights Reserved Transverse Color Axillary Vein from Within the Axilla Figure 18-12. A transverse view of the axillary artery (in red) and vein (in blue) taken from the axilla. Note how there is spatial separation between the two vessels. Copyright © 2023 Wolters Kluwer · All Rights Reserved Scanning Technique - Brachial Veins Terminates when the basilic vein enters to become axillary vein Usually small, paired deep veins with accompanying brachial artery Formed by the junction of the two radial and two ulnar arteries near the antecubital fossa Should be documented with compressed and non- compressed images Color and spectral Doppler may also be included Copyright © 2023 Wolters Kluwer · All Rights Reserved Transverse Color Brachial and Basilic Veins Figure 18-13. A transverse view of the brachial artery (A) and veins (V) in the upper arm. The basilic vein is also noted. Copyright © 2023 Wolters Kluwer · All Rights Reserved Scanning Technique - Radial Veins Course along volar aspect of forearm Paired deep veins that course with accompanying radial artery Very small vessels and rarely involved in venous thrombosis Often not included in routine upper extremity venous examination Copyright © 2023 Wolters Kluwer · All Rights Reserved Transverse Color Radial Veins Figure 18-14. A transverse view of the radial artery (A) and veins (V). The cephalic vein is also noted. Copyright © 2023 Wolters Kluwer · All Rights Reserved Scanning Technique - Ulnar Veins Also travel along volar aspect of forearm Deep, paired veins that course with the accompanying ulnar artery Also very small and often not examined unless indicated by presenting symptoms Copyright © 2023 Wolters Kluwer · All Rights Reserved Transverse Ulnar Veins Figure 18-15. A transverse view of the ulnar artery (A) and veins (V). The basilic vein is also noted. Copyright © 2023 Wolters Kluwer · All Rights Reserved Scanning Technique - Basilic Vein Terminates into the axillary vein in upper arm Courses medially and superficially without a companion artery Usually largest vein in upper arm region Communicates with cephalic vein via median cubital vein in the antecubital fossa Usually has two branches in forearm—one on volar aspect and one on dorsal aspect Should be documented with compressed and noncompressed images Color and spectral Doppler can also be used Copyright © 2023 Wolters Kluwer · All Rights Reserved Transverse Basilic Vein Figure 18-16. A transverse view of the basilic vein in the upper arm. The brachial artery (A) and veins (V) are also in view. Copyright © 2023 Wolters Kluwer · All Rights Reserved Pitfalls Compressions are not possible in several locations in the upper extremity. o Color and spectral Doppler are relied on in these areas. Patient may have dressings or intravenous catheters, which limit access to veins o Color and spectral Doppler are also important in these cases Nearby nerve bundles can be mistaken for a thrombosed vein Copyright © 2023 Wolters Kluwer · All Rights Reserved Diagnosis Diagnostic criteria are same for upper extremity as it was for lower extremity o Normal vein walls will completely compress with transducer pressure. ▪ Compressions performed in transverse plane. o Vein walls should be smooth and thin with anechoic vessel lumen. o Vein diameter will change slightly with respiration Copyright © 2023 Wolters Kluwer · All Rights Reserved Diagnosing Thrombus If vein walls do not coapt, thrombus should be suspected Echogenic material should be observed within vein lumen Acute thrombus: Poorly attached to vessel wall, thrombus is spongy, vein is dilated, varying echogenicity, smooth surfaced Chronic post-thrombotic changes: Brightly echogenic thrombus, well attached, rigid, irregular surfaced, and contracted vein Superficial vein thrombus will have same appearance as deep vein thrombosis o Hypoechoic areas may be present around vein due to inflammation Copyright © 2023 Wolters Kluwer · All Rights Reserved Transverse IJV with Compression Figure 18-17. Transverse view of a patent internal jugular vein (IJV) noncompressed (left) and compressed (right). Copyright © 2023 Wolters Kluwer · All Rights Reserved Transverse & Sagittal IJV with Thrombus Figure 18-18. An acute thrombus in the internal jugular vein (IJV). A: Transverse view. B: Longitudinal view. Copyright © 2023 Wolters Kluwer · All Rights Reserved Axillary Vein Chronic Post-Thrombotic Changes Figure 18-19. An axillary vein demonstrating chronic post- thrombotic changes. A: Noncompressed view. B: Compressed view illustrating inability to fully compress the vein. (Image courtesy of Steve Knight, BSc, RVT, RDCS, Steilacoom, WA.) Copyright © 2023 Wolters Kluwer · All Rights Reserved Color and Spectral Doppler Important diagnostic tools in upper extremity veins that cannot be compressed Color should be seen filling entire vessel lumen Spectral Doppler waveforms should demonstrate o Respiratory phasicity o Augmentation with distal compression o Pulsatility, which is common due to proximity to heart Copyright © 2023 Wolters Kluwer · All Rights Reserved Subclavian Vein Spectral Doppler Figure 18-21. A Doppler spectral waveform taken from a subclavian vein demonstrating normal pulsatile flow. Copyright © 2023 Wolters Kluwer · All Rights Reserved Abnormal Color and Spectral Doppler With complete thrombus, no spectral Doppler signals or color filling will be obtained Partial thrombus may result in continuous flow as will proximal thrombosis or extrinsic compression Retrograde flow is uncommon; however, jugular veins may demonstrate reversed flow if they are serving as a collateral pathway Arterialized venous flow may be present in patients with hemodialysis fistula or graft Copyright © 2023 Wolters Kluwer · All Rights Reserved Venous Catheters Indwelling venous catheters are commonly encountered in arm Catheters appear as bright, straight, parallel echoes within vessel lumen Thrombus may develop around these catheters o Appears as echogenic material around catheter surface o Spectral Doppler signals will be diminished and/or continuous. o Catheter must be removed if it becomes thrombosed. Copyright © 2023 Wolters Kluwer · All Rights Reserved Normal Venous Catheter on Ultrasound Figure 18-22. A longitudinal view of a catheter (arrow) inside a vein. Copyright © 2023 Wolters Kluwer · All Rights Reserved Thrombus forming on a Venous Catheter Figure 18-23. A longitudinal view of a thrombus (arrow) forming on a venous catheter. Copyright © 2023 Wolters Kluwer · All Rights Reserved Residual Fibrous Sheath after Removing a Venous Catheter with Thrombus Figure 18-25. A longitudinal view of a remnant fibrous sheath (arrow) left in the view after removal of a catheter. Note how this appears to resemble a catheter. Copyright © 2023 Wolters Kluwer · All Rights Reserved Treatments For Upper Extremity Thrombus Treatment considerations include: o Anticoagulation o Catheter removal o Thrombolytic therapy o Surgical compression of thoracic inlet with or without venous reconstruction o Conservative treatment Copyright © 2023 Wolters Kluwer · All Rights Reserved