Upper limb vascular ultrasound

My DDU point form notes on upper limb ultrasound…

The rest of my DDU notes are here.

Upper limb vascular tree

2 compartments

deep

superficial

deep venous system

SVC

brachiocephalic vein left is longer • joined by IJV then called the…

subclavian vein

runs separately from artery in front of anterior scalene

when crosses lateral border of 1^st rib, becomes…

axillary vein

joined by the cephalic vein

brachial vein(s) usually paired running with brachial a • formed at elbow from

radial veins run paired with artery

ulnar veins run paired with artery

superficial veins of interest

cephalic vein

drains dorsum → lateral forearm → antecubital fossa → lateral aspect of biceps → deltopectoral groove → pierces clavipectoral fascia → axillary vein

basilic vein

drains palm → medial arm → penetrates fascia in lower aspect of upper arm → brachial vein

upper limb DVT causes

commonest subclavian, axillary

catheters

thoracic outlet syndrome

effort induced

scanning technique

warm, supine, low PRF and colour wall filters

arm abducted, supinated, supported avoid muscle contraction

minimal pressure when searching for veins

sequence

from McLean et al with extra comments

internal jugular vein

start transversely at apex of triangle formed by 2 head of SCM + clavicle

IJV superficial to carotid

compress

compress from jaw to clavicle at 2-3 cm intervals

tilt inferiorly to see more of IJV

subclavian vein

keep tilting → see junction of IJV and subclavian (longitudinal)

incompressible so use

CFD

fill to confirm patency

spectral Doppler

spontaneous phasicity with respiration to confirm more proximal patency

expect pulsatile flow pattern due to atrial contraction (superimposed on phasic flow)

manoeuvres

again, useful re proximal patency

multiple sniffing → subclavian vein contracts

Valsalva → cessation / reversal of flow, then ↑ flow on expiration

v easy to miss proximal thrombosis – acknowledge limitations

follow laterally

lose as it exits between first rib and clavicle

axillary vein

slip probe over clavicle → oblique view of axillary

rotate to get transverse → compress

follow distally → dives under pectoralis major and minor → axilla

image as high as possible in axilla with marker to the sky (transverse)

compress + sniff

(no discrete landmark where becomes brachial vein)

brachial vein

transverse (marker to sky)

compressions to elbow

sequence from Thrush et al

with additions from McLean

brachial vein

transverse

compression / CFD / spectral Doppler with augmentation compress forearm

axillary vein

use combination of transaxillary (up high, marker to sky) and infraclavicular probe positions to examine in transverse

adjacent to artery

compression + CFD usually required, ± sniff

↑ cephalic vein flow → think of distal axillary thrombus

subclavian

infraclavicular in transverse until lost

inferior to subclavian artery

supraclavicular in longitudinal and transverse

incompressible so use

CFD

fill to confirm patency

spectral Doppler

spontaneous phasicity with respiration to confirm more proximal patency

manoeuvres

again, useful re proximal patency

Valsalva → cessation / reversal of flow, then ↑ flow on expiration

multiple sniffing → subclavian vein contracts

v easy to miss proximal thrombosis – acknowledge limitations

expect pulsatile flow pattern due to atrial contraction (superimposed on phasic flow)

IJV

occasional thrombus – assess in transverse from jaw to clavicle then tilt down to IJV-subclavian junction

brachiocephalic

usually impossible to image – infer from axillary, subclavian flow patterns

reporting

normal vs abnormal

level and extent of thrombosis

appearance – mobile?

limitations of scan

other pathology (mimics)

Cover image: Arm veins by Brave Heart on Flickr