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Ultrasound
Therese M. Weber, MD*, Mark E. Lockhart, MD, MPH,
Michelle L. Robbin, MD
Sonography plays a major role in evaluating
the upper extremity venous system. The most
widely used applications include evaluation for
thrombus and vessel patency, localization during
venous access procedures, preoperative venous
mapping for hemodialysis arteriovenous stula
(AVF) and graft placement, and postoperative
hemodialysis AVF and graft assessment. Knowl-
edge of anatomy, scanning technique, and atten-
tion to detail are important to the success of
demonstrating abnormalities in the upper extrem-
ity venous system. Sonographic evaluation of the
upper extremity venous system is more challeng-
ing than evaluation of the lower extremity venous
system.
This article presents methods that allow easy
identication of the sometimes complex anatomy
and the avoidance of pitfalls that can lead to com-
mon and uncommon errors.
Normal anatomy
The venous anatomy of the neck and arm is illus-
trated in Fig. 1.
Deep venous system
The more clinically important aspect of the venous
systemof the upper extremity is the deep system, es-
pecially the proximal aspect of the venous systemin-
cluding the internal jugular vein, the subclavian
vein, and the brachiocephalic vein. One easy way
to tell if a vein is supercial or deep is to assess
whether it has an artery running with it. In the upper
extremity only deep veins have arteries running with
them. The radial and ulnar veins in the forearm,
which usually are paired, unite caudal to the level
of the elbowto formthe brachial veins. The brachial
veins in the upper arm join with the basilic vein at
a variable location, typically at the level of the teres
R A D I O L O G I C
C L I N I C S
O F N O R T H A M E R I C A
Radiol Clin N Am 45 (2007) 513524
Department of Radiology, University of Alabama at Birmingham, 619 19th Street, South, JT N312, Birming-
ham, AL 35249-6830, USA
* Corresponding author.
E-mail address: tweber@uabmc.edu (T.M. Weber).
- Normal anatomy
Deep venous system
Supercial venous system
Normal arterial anatomy
- Sonographic examination technique
Peripheral deep venous system
Potential pitfalls
- Imaging protocol
- Clinical diagnosis
- Upper extremity venous thrombosis
- Acute deep venous thrombosis
- Chronic deep venous thrombosis
- Venous access procedures
- Sonographic evaluation before and after
placement of hemodialysis access
Preoperative mapping
Arteriovenous stula maturity assessment
- Summary
- Acknowledgments
- References
513
0033-8389/07/$ see front matter 2007 Published by Elsevier Inc. doi:10.1016/j.rcl.2007.04.005
radiologic.theclinics.com
major muscle. The conuence of the brachial and
basilic veins continues as the axillary vein, which
passes through the axilla from the teres major mus-
cle to the rst rib. As the axillary vein crosses the rst
rib, it becomes the lateral portion of the subclavian
vein. The medial portion of the subclavian vein re-
ceives the smaller external jugular veinandthe larger
internal jugular vein to form the brachiocephalic
(innominate) vein. Bilateral brachiocephalic veins
join to form the superior vena cava.
The authors dene the central veins as the bra-
chiocephalic veins and superior vena cava, which
usually cannot be demonstrated sonographically.
Some angiographers include the subclavian vein
when they discuss central veins. Therefore, it is im-
portant to be very specic about the vein segment
examined in describing sonographic ndings. The
presence or absence of signicant central stenosis
or thrombosis needs to be inferred by evaluating
the transmitted cardiac pulsatility and respiratory
phasicity in the medial subclavian vein and caudal
internal jugular vein, as discussed later.
Supercial venous system
The supercial venous system of the upper extrem-
ity comprises the cephalic vein located more later-
ally and the basilic vein located more medially.
The basilic and cephalic veins typically have a varia-
bly larger vein connecting them caudally near the
elbow, the median antecubital vein.
Normal arterial anatomy
The brachial artery begins in the upper arm at the
lower margin of the teres major muscle tendon
and usually ends about 1 cm below the elbow
where is divides into the radial and ulnar arteries.
Anatomic variants of the radial artery include
a high take-off or high bifurcating radial artery. In
some cases, the radial artery may take off from the
cranial aspect of the brachial artery in the upper
arm. One way to distinguish a high take-off of the
radial artery from a large elbow branch artery is to
follow it into the forearm down to the radial artery
region at the wrist. A large arterial branch to the el-
bow traverses toward the elbow and does not ex-
tend into the forearm. Rarely, the ulnar artery may
be absent.
Sonographic examination technique
Sonographic evaluation of the upper extremity ve-
nous system is more technically challenging than
evaluation of the lower extremity venous system.
These technical challenges include the inability to
compress the subclavian vein because of the overly-
ing clavicle and the need to differentiate large
venous collaterals from normal veins in cases of ve-
nous obstruction.
The patient is scanned in a supine position with
the examined arm abducted from the chest and
with the patients head turned slightly away from
the examined arm. Real-time B-mode imaging
with spectral and color ow analysis is performed
using the highest frequency linear transducer that
still gives adequate penetration. Typically the exam-
ination is best performed using a 5- to 10-MHz lin-
ear-array transducer moving to a higher frequency
in the upper arm and forearm if possible. A
curved-array transducer or sector transducer may
Fig. 1. Normal venous anat-
omy. The deep veins of the
arm (dark blue) include the
brachial vein and axillary
vein. The brachiocephalic
vein is formed by the inter-
nal jugular and subclavian
veins. The two brachioce-
phalic veins join to become
the superior vena cava. Su-
percial veins (light blue)
include the cephalic vein,
basilic vein, and external
jugular vein.
Weber et al 514
be useful in larger individuals, especially in the ax-
illary area, because of the increased depth of pene-
tration and larger eld of view.
All veins are examined with compression every
1 to 2 cm in the transverse plane. Gray-scale trans-
verse images with and without compression or
cine clips during compression are obtained from
the cranial aspect of the internal jugular vein in
the neck near the mandible to the thoracic inlet
caudally. Longitudinal color and spectral images
are performed also. The subclavian vein is evaluated
from its medial to lateral aspect with longitudinal
color and spectral images, demonstrating transmit-
ted respiratory variability, cardiac pulsatility, and
color ll-in. An inferiorly angled, supraclavicular
approach with color Doppler is necessary to dem-
onstrate the superior brachiocephalic vein and the
medial portion of the subclavian vein. Use of
a small-footprint sector probe in or near the supra-
sternal notch may facilitate visualization of the bra-
chiocephalic veins and the cranial aspect of the
superior vena cava. The midportion of the subcla-
vian vein, located deep to the clavicle, frequently
is imaged incompletely. An infraclavicular, superi-
orly angled approach is used to demonstrate the lat-
eral aspect of the subclavian vein. Frequently, the
subclavian vein can be compressed.
Spectral waveform evaluation is critical to upper
extremity venous evaluation. Documentation of
normal ow features in the medial subclavian
vein is extremely important, because it conrms
patency of the brachiocephalic vein and superior
vena cava, which cannot be examined directly.
Each spectral image is evaluated for spontaneous,
phasic, and nonpulsatile ow. These samples are
obtained in the longitudinal plane of the vessel
with angle of insonation maintained at less than
60