Upper Extremity Venous Ultrasound • Generally sicker patients / bedside / overlying dressings with limited Historically access Upper Extremity DVT Protocols • Extremely difficult studies / senior George L. Berdejo, BA, RVT, FSVU technologists • Most of the examination focuses on the central veins Subclavian/innominate/SVC* Ilio-caval Axillary/brachial Femoro-popliteal Radial/ulnar Tibio-peroneal 2021 Leading Edge in Diagnostic Ultrasound Conference MAY 11-13, 2021 • Anatomic considerations* Upper Extremity Venous Ultrasound Upper Extremity Venous Ultrasound Symptoms / Findings • Incidence of UE DVT low when compared to LE but yield of positive studies is higher ✓Central Vein Thrombosis • Becoming more prevalent with increasing use of UE veins for • Swelling of arm, face and /or neck access • Sometimes asymptomatic http://stroke.ahajournals.org/content/3 • Injury to the vessel wall is most common etiology • Dialysis access dysfunction 2/12/2945/F1.large.jpg ✓Peripheral Vein Thrombosis • Other factors: effort thrombosis, thoracic outlet compression, mass compression, venipuncture, trauma • Local redness • Palpable cord • Tenderness • Asymmetric warmth Upper Extremity Venous Ultrasound Upper Extremity Venous Ultrasound Vessel Wall Injury • Patients with indwelling catheters / pacer wires • Tip of catheter/ wires cause irritation of vein wall 1 Upper Extremity Venous Ultrasound Upper Extremity Venous Ultrasound Anatomy At the shoulder, the cephalic vein travels Deep Veins between the deltoid and pectoralis major • Radial and ulnar veins form muscles (the deltopectoral groove), and brachial vein; partially superficial enters the axilla region via the clavipectoral triangle. Within the • Brachial joins basilic to form axilla, the cephalic vein empties into axillary Superficial veins of the axillary vein. upper extremity • Axillary becomes subclavian at • Cephalic (radial or thumb side) first rib • Basilic (ulnar or pinky side) Upper Extremity Venous Ultrasound Upper Extremity Venous Ultrasound Subclavian joins jugular and becomes inominate RI LI SVC Subclavian vein anatomy Supra-sternal approach Inominates join to form SVC Upper Extremity Venous Ultrasound Upper Extremity Venous Ultrasound The subclavian vein follows the subc artery and is ✓Technologist Prep separated from the subclavian artery by the insertion • Why is the patient referred /indication of anterior scalene • Review previous studies if available • Tech at head or facing patient? • Use the right equipment • Adhere to technical protocol • Routine, systematic manner, always bilateral (for the initial) 2 Upper Extremity Venous Ultrasound Upper Extremity Venous Ultrasound Patient Prep and Positioning Technical Protocol • Size will vary with respiration • Remove barriers to permit access; sterile technique • Thrombus will usually result in significant enlargement • Arm board and/or pledge position allows visualization of axillary and arm veins • Supine position w/ arms at side to start (IJ, subc) Upper Extremity Venous Ultrasound Upper Extremity Venous Ultrasound Technical Protocol • IJV can be compressed except for base of neck Technical Protocol • Size can also vary w/ patient position • Subc, innominate and SVC • Assess for flow direction using color or spectral • Small footprint transducer Doppler • Supraclavicular / suprasternal • Reversal may Sensitivity 81% indicate proximal approach PPV 91% occlusion • Color Doppler NPV 78% Nack et al, JVT, 1992 Upper Extremity Venous Ultrasound Upper Extremity Venous Ultrasound Technical Protocol (subc, inom, SVC) Pitfalls • Veins between neck and the shoulder cannot be RI LI - compressed because of adjacent bony structures and protected position SVC - visualized because overlying bony anatomy Supra-sternal approach 3 Upper Extremity Venous Ultrasound Upper Extremity Venous Ultrasound Pulsed Doppler • Bilateral examination • Technically difficult examinations • Comparison of signals at same level • Look for asymmetry • Doppler is critical Flow is characterized according to: • Always compare findings to contralateral side •Pulsatility • Adherence to protocol • Spontaneity • Phasicity; augmentation Resources www.sonoworld.com • www.SVUnet.org 4.