Duplex Ultrasound Upper Extremity Venous System PDF

DUPLEX ULTRASOUND IMAGING OF THE UPPER EXTREMITY VENOUS SYSTEM SON2177C 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 consistent with acute and chron...

DUPLEX ULTRASOUND IMAGING OF THE UPPER EXTREMITY VENOUS SYSTEM SON2177C 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 consistent with acute and chronic thrombus  Describe the Doppler waveform characteristics associated with various pathologies  List risk factors associated with venous thrombosis in the upper extremity SUPERFICIAL VEINS OF THE UPPER EXTREMITY  Cephalic vein  Superficial vein  Contains a dorsal and volar branch along the radial aspect of the forearm that unite at the antecubital fossa  Continues along lateral border of biceps muscle  Empties into axillary vein  Basilic vein  Superficial vein  Contains a dorsal and volar branch along the ulnar aspect of the forearm that unite at the antecubital fossa  Continues along medial upper arm  Joins brachial vein to form axillary vein  Median cubital vein  Vein seen in antecubital fossa that communicates with Basilic and Cephalic veins  Common site for veni-puncture DEEP VEINS OF UPPER EXTREMITY  Radial and Ulnar veins  Paired deep veins with an accompanying Radial and Ulnar Artery  Unite near antecubital fossa to form brachial veins  Brachial veins  Usually paired  Follow course of Brachial artery UPPER EXTREMITY VEINS—(CONT.) Figure 4-13. Veins of upper extremity. DEEP AND CENTRAL VEINS OF UPPER EXTREMITY  Axillary vein  Usually single vein  Begins at junction of brachial and basilic veins  Subclavian vein  Continuation of the axillary vein at level of terminal Cephalic vein  Begins just past outer border of first rib  External jugular drains into Subclavian vein  Internal Jugular Vein  Can be seen on either side of the neck lateral to the accompanying Carotid artery  Joins with the Subclavian Vein to form the Brachiocephalic (Innominate Vein)  External Jugular Vein  Seen more posterior IJV.  Runs without an accompanying artery very close to skin surface  Usually terminates into subclavian vein  May be used as a collateral in case of IJV obstruction DEEP AND CENTRAL VEINS OF UPPER EXTREMITY  Brachiocephalic (Innominate) veins  Formed at junction of internal jugular and subclavian veins  One at each side of the base of the neck  Superior vena cava (SVC)  Formed by the junction of the two brachiocephalic veins  Courses just behind the right side of the sternum UPPER EXTREMITY VEINS—(CONT.) Figure 4-14. View of the upper extremity veins crossing the axillary region.  EJV IJV Anterior jug v Subclavian v Axillary v Cephalic v Subclavian v (deep) Axillary v (deep) Cephalic v (super) Basilic v (super) Brachial v (deep) Median cubital v (super) BACKGROUND  Protocol techniques for upper extremity veins are similar to 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; additionally, superficial thrombosis may have greater clinical significance in arm than leg. 3. Venous anatomy of upper extremity is more variable than lower extremity. PATHOPHYSIOLOGY  Virchow’s triad  Venous stasis  Hypercoagulability  Vessel wall injury  Upper extremity thrombosis more common due to injury to vessel wall  Iatrogenic injury  More frequent introduction of needles and catheters into arm veins  Subclavian and internal jugular veins commonly used for indwelling catheters and pacemaker wire introduction  Peripherally inserted central catheters (PICCs) also cause thrombosis. Catheter is inserted through basilic or cephalic vein then positioned near right atrium. INDICATIONS: SIGNS & SYMPTOMS  Similar to those of lower extremity  Can include  Unilateral arm or hand swelling  Signs of pulmonary (chest pain, tachypnea, or tachycardia)  Superficial palpable cord – sign of superficial thrombophlebitis  Erythema  Pain and tenderness  Facial swelling or dilated chest wall collaterals  Suggestive of superior vena cava thrombosis  Labs: Positive D-dimer  Patients may present with indwelling catheters or history of venous catheters. OTHER INDICATIONS  Patients may be examined before central catheter placement or prior to pacemaker placement.  Duplex may also be used to confirm placement of above devices. UPPER EXTREMITY VENOUS DISORDERS Thoracic Outlet Syndrome (TOS)  Extrinsic compression of the brachial plexus, Subclavian artery or vein in the thoracic outlet or space between the collarbone and the first rib of the upper extremity, resulting in symptoms of pain or neurologic deficit.  Paget-Schroetter syndrome  Type of thoracic outlet syndrome associated with venous obstruction.  AKA effort thrombosis  Venous thrombosis associated with compression of subclavian vein at the thoracic outlet. Repeated trauma to the vein may result in thrombosis  Typical patients are young, athletic, and muscular males.  Evaluate vein for thrombosis. Include measurements UPPER EXTREMITY VENOUS DISORDERS  Superior Vena Cava Syndrome  Occlusion or compression of SVC  Increased venous pressure  Edema of neck, face and arms, usually bilaterally SONOGRAPHIC EXAMINATION TECHNIQUES  Similar technique is used for upper extremity as for lower extremity.  Transducer compression performed over all upper extremity veins possible  Gentle transducer compression is used directly over vein so that vein walls coapt.  Compression maneuver is repeated every 2 to 3 cm along course of each vein.  Spectral Doppler waveforms are recorded from all major veins. PATIENT PREPARATION  Examination procedure should be explained to the patient.  Relevant history should be obtained, including questioning of signs and symptoms.  Upper extremity clothing and jewelry should be removed and patient gown or drape provided. PATIENT POSITIONING  No need to tilt bed for exam.  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. EQUIPMENT  Two transducers recommended  Mid range (5 to 10 MHz) linear array  Used to evaluate internal jugular, brachiocephalic, subclavian, axillary, deep brachial, and brachial veins  Higher frequency (10 to 18 MHz) linear array  Used for more superficial veins (cephalic and basilic) and small forearm veins (radial and ulnar)  Curved or sector array may be useful for deeper vessels near clavicle and sternum. SCANNING TECHNIQUE—INTERNAL & EXTERNAL JUGULAR VEINS  Veins in neck should be routinely evaluated as thrombus from arm can extend upwards.  Carotid artery can be used as landmark to identify internal jugular vein (IJV).  IJV will be collapsed if patient is sitting or standing.  Evaluation of IJV should include transverse views with transducer compression as well as spectral Doppler waveforms. SCANNING TECHNIQUE—INTERNAL & EXTERNAL JUGULAR VEINS—(CONT.) Figure 18-1. A transverse view of the internal Figure 18-2. A grayscale image (transverse) jugular vein (IJV) and the common carotid of the location of the internal jugular vein artery (CCA) with color. (IJV) alongside the common carotid artery (CCA). SCANNING TECHNIQUE—INTERNAL & EXTERNAL JUGULAR VEINS—(CONT.) Figure 18-3. A spectral Doppler waveform from the internal jugular vein. SCANNING TECHNIQUE—INTERNAL & EXTERNAL JUGULAR VEINS—(CONT.)  External jugular vein (EJV)  Lighten up transducer pressure and slide posterior from internal jugular vein and can be seen terminating into Subclavian Vein  Should be documented in transverse with transducer compression and with spectral Doppler *Many labs don’t include EJV in standard exam but add if indicated. 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.  Documentation of patency depends on grayscale image, color-flow imaging, and spectral Doppler waveforms.  Spectral Doppler should demonstrate phasicity and pulsatility. SCANNING TECHNIQUE—BRACHIOCEPHALIC VEINS— (CONT.) Figure 18-4. Color image of the brachiocephalic vein. SCANNING TECHNIQUE—BRACHIOCEPHALIC VEINS— (CONT.) Figure 18-5. Spectral Doppler waveform from the brachiocephalic vein (V). 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 position of clavicle  Patient can take a quick, deep breath in through pursed lips—this will cause subclavian vein to collapse.  Color and spectral Doppler should also be documented. Supraclavicular Scan Position SCANNING TECHNIQUE—SUBCLAVIAN VEIN—(CONT.) Figure 18-6. A transverse view of the subclavian artery (SCA) and subclavian vein (SCV). 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. SCANNING TECHNIQUE—SUBCLAVIAN VEIN & CEPHALIC VEIN—(CONT.) Figure 18-7. A view of the cephalic vein as it terminates into the subclavian vein (SCV). CEPHALIC VEINS ARE SMALL AND HARD TO IMAGE, UNLESS, OF COURSE, YOU’RE A EX-GOVERNOR. SCANNING TECHNIQUE—CEPHALIC VEIN—(CONT.) Figure 18-8. A transverse view of the cephalic vein (arrow) in the upper arm. SCANNING TECHNIQUE—CEPHALIC VEIN—(CONT.) Figure 18-9. A longitudinal view of the cephalic vein with color added. 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. ABDUCT ARM TO ALLEVIATE TRANSIENT AXILLARY VEIN COMPRESSION AXILLARY VEIN. RELY ON WAVEFORM MORPHOLOGY AXILLARY VEIN INFRACLAVICULAR SECTION  SCANNING TECHNIQUE—AXILLARY VEIN—(CONT.) Figure 18-11. A transverse view of the axillary artery (A) and vein (V) over the shoulder.  SCANNING TECHNIQUE—AXILLARY VEIN—(CONT.) 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. SCANNING TECHNIQUE—BRACHIAL VEIN  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 veins near the antecubital fossa  Should be documented with compressed and noncompressed images.  Color and spectral Doppler may also be included. SCANNING TECHNIQUE—BRACHIAL VEIN—(CONT.) Figure 18-13. A transverse view of the brachial artery (A) and veins (V) in the upper arm. The basilic vein is also noted. 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 SCANNING TECHNIQUE—RADIAL VEINS—(CONT.) Figure 18-14. A transverse view of the radial artery (A) and veins (V). The cephalic vein is also noted. 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  SCANNING TECHNIQUE—ULNAR VEINS—(CONT.) Figure 18-15. A transverse view of the ulnar artery (A) and veins (V). 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. SCANNING TECHNIQUE—BASILIC VEIN—(CONT.) Figure 18-16. A transverse view of the basilic vein in the upper arm. Often the deep brachial veins are seen as well. Mid-upper Arm Transverse brachial v brachial a. basilic vein brachial v At mid-arm the basilic vein lays away from the brachial complex  SCANNING TECHNIQUE 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  SCANNING TECHNIQUE MEDIAN CUBITAL VEIN Figure 15-10. A transverse view of the median cubital vein (MCV) as it passes superiorly over the brachial artery (A) and brachial vein (V). PITFALLS/CONTRAINDICATIONS  Compressions are not possible in several locations in the upper extremity.  Color and spectral Doppler is relied on in these areas.  Patient may have dressings or intravenous catheters, which limit access to veins.  Color and spectral Doppler is also important in these cases.  Occasionally, normal upper extremity structures may be visualized such as muscles, tendons, and nerves. Take care not to mistake for thrombosed vessels.  Exam is contraindicated if patient cannot be safely repositioned  Pitfalls continued… Reverberation artifact and “Rouleaux ” (blood cell clumping) are commonly seen in the jugular vein. http://youtu.be/O7YXsGfDgYw DIAGNOSIS  Diagnostic criteria are same for upper extremity as it was for lower extremity.  Normal vein walls will completely compress with transducer pressure.  Compressions performed in transverse plane  Vein walls should be smooth and thin with anechoic vessel lumen.  Vein diameter will change slightly with respiration. DIAGNOSIS—(CONT.)  If vein walls don’t 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  Chronic thrombus: brightly echogenic thrombus, well-attached, rigid, and contracted vein  Superficial vein thrombus will have same appearance as deep vein thrombosis.  Hypoechoic areas may be present around vein due to inflammation.  Positive DVT/Thrombus findings are considered a medical emergency and will need to be reported upon exam completion. Ensure patient is safely brought back to their designated room or outpatient’s may need to report to the emergency room. Follow hospital protocols or ordering physician’s instructions. DIAGNOSIS—(CONT.) Figure 18-17. An acute thrombus in the internal jugular vein. DIAGNOSIS—(CONT.) Figure 18-18. A chronic thrombus in the axillary vein. DIAGNOSIS—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  Respiratory phasicity  Augmentation with distal compression  Pulsatility, which is common due to proximity to heart DIAGNOSIS—COLOR AND SPECTRAL DOPPLER— (CONT.) Figure 18-19. A Doppler spectral waveform taken from a subclavian vein demonstrating normal pulsatile flow. DIAGNOSIS—COLOR AND SPECTRAL DOPPLER— (CONT.)  With complete thrombus, no spectral Doppler signals or color filling will be obtained.  Continuous flow will be seen distal to occlusive 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.  Criteria For Diagnosis of Venous Thrombosis Upper Extremities Visualization of thrombus Lack of vein coaptation No flow : color and Basilic vein thrombus spectral Doppler Abnormal flow patterns and flow direction in central veins. Diagnosis continued… Carefully image for IJV Thrombus IJV CCA IJV thrombus longitudinal IJV thrombus transverse DIAGNOSIS CONTINUED Basilic Vein Brachial artery  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.  Appears as echogenic material around catheter surface  Spectral Doppler signals will be diminished and/or continuous.  Catheter must be removed if it becomes thrombosed.  VENOUS CATHETERS—(CONT.) Transverse view Figure 18-20. A longitudinal view of a catheter (arrow) inside a vein.  VENOUS CATHETERS—(CONT.) Transverse compression image. Note Figure 18-21. A longitudinal view of a how the vein does not coapt to the IV thrombus (arrow) forming on a venous catheter. VENOUS CATHETERS—(CONT.) Figure 18-22. 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.  INCIDENTAL FINDINGS AND DIFFERENTIAL DIAGNOSIS  Nonvascular findings include  Vascular findings include  Edema  Aneurysms  Cysts and hematomas – may  Pseudoaneurysms cause extrinsic compression  Arteriovenous fistulas -  Enlarged lymph nodes arterialized venous flow  Tumors (Neoplasia) – may cause  Significant arterial disease extrinsic compression  Abscesses/Infections (ex. Cellulitis) – hyperemia may be noted TREATMENT AND VASCULAR INTERVENTION WITH ULTRASOUND  Treatment considerations include  Pharmacology - Anticoagulation – heparin, warfarin (coumadin)  Catheter removal  Thrombolytic therapy  Surgical compression of thoracic inlet with or without venous reconstruction  Conservative treatment Vascular Intervention with Ultrasound: Ultrasound used in vascular intervention such as thrombolysis and thrombectomy, may involve intra-procedural guidance/technical evaluation, and/or post-procedure assessment.