Upper Limb Venous Duplex Examination

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Upper Limb Venous Duplex Examination : 

Upper Limb Venous Duplex Examination Technique and interpretation

Etiology of UL venous thrombois : 

Etiology of UL venous thrombois Catheter 70% Caner 15% Physical strain Hypercoaculable state Drug abuse Obesity Steriods pregnancy

Too Many Veins in the UE : 

Too Many Veins in the UE

Venous Evaluation : 

Venous Evaluation Lower extremity -Compression most helpful -Duplex and imaging secondary role Upper extremity -imagind=colour=spectral are more important

Slide 5: 

Upper limb collateral can be as big as the veins we are studying and causing a common wrong diagnosis of patent subclavian and innominate veins

UE Technique : 

UE Technique Supine , symmetrical posture 5 MHz small foot print transducer preferable Supraclavicular for central veins Infraclavicular for peripheral veins Jugular,innominate,subclavian and axillay veins first Arm veins as needed Some patients limited study of arms

Compression in UE : 

Compression in UE Difficult and not always possible Use Sniff test

Technical considerations : 

Technical considerations Use small footprint transducers that allows easier central evaluation Color Doppler is easier than in LE Use color , sniff where compression is impossible Bilateral study is usueal , Asymmetrical spectral waveform a common clue to disease

Compression Ultrasound : 

Compression Ultrasound

Left innominate breath holding : 

Left innominate breath holding

Sniff early and late : 

Sniff early and late

UE Venous Protocol : 

UE Venous Protocol Imaging color and spectral doppler of Jugular , innominate , central subclavina and mid subclavian and peripheral subclavian and axillay vein and SVC if possible Long and short axis if possible Compression to jugular , axillary , arm veins and peripheral part of subclavian vein .

Normal Jugular vein : 

Normal Jugular vein

Normal UE Doppler Findings : 

Normal UE Doppler Findings Cental veins : Pulsatile and phasic variation Peripheral veins Phasic variation Pulsatible variation +/- Bilateral symmetry Color filling in all veins

Normal Right Innominate Vein : 

Normal Right Innominate Vein

Normal Right Innominate : 

Normal Right Innominate With prominent cardiac pulsations

Right Subclavian Veins central : 

Right Subclavian Veins central

Normal Right Mid Subclavian vein : 

Normal Right Mid Subclavian vein

Normal Right P Subclavian vein : 

Normal Right P Subclavian vein

Normal Axillary Vein : 

Normal Axillary Vein Normally have a flow reversal of blood

Normal Left Innominate : 

Normal Left Innominate

Innominate and SVC : 

Innominate and SVC

Abnormal UE Doppler Findings : 

Abnormal UE Doppler Findings Loss of Pulsatile variation centrally Continous signal Absent signal Reversal flow Stenotic jet Asymmetry between sides

Obstructive Waveform : 

Obstructive Waveform

Asymmetry Axillary : 

Asymmetry Axillary

Echogenic area inside the vein : 

Echogenic area inside the vein Normal Innominate Vein

Reversed Jugular vein : 

Reversed Jugular vein The jugular vein is the commenest in seeing reverse flow Reverse flow occur in response to central obstruction

Subclavian stenosis : 

Subclavian stenosis

Spectral Doppler Interpretation : 

Spectral Doppler Interpretation Abnormal Doppler indicated A- Ostruction ( unknown aetiology , may be acute or chronid or extrinisic compression) B-Site of abnormality inicated level of obstruction

Venous Thrombus ;Imaging : 

Venous Thrombus ;Imaging Clot visualization Varies by its echogenicity Noise may oscure or minic clot Sniffing may simulate compression Noncompressibility as appropriate

Catheters and Pitfallas : 

Catheters and Pitfallas

Thrombus Aging : 

Thrombus Aging Acure Thrombus Expand vein Free floating Smooth Deformable if compressed

Jugular vein thrombus recent : 

Jugular vein thrombus recent

Axillary vein thrombosis chronic : 

Axillary vein thrombosis chronic

Pericatheter DVT noncompressible : 

Pericatheter DVT noncompressible

Pericatheter Fibrin Sleeve : 

Pericatheter Fibrin Sleeve

Missed/Found DVT left : 

Missed/Found DVT left

DVT Hared to see gray scale : 

DVT Hared to see gray scale

Scarring (Chronic Changes) : 

Scarring (Chronic Changes) Normal or small Firm Irregular Retracted Circumferential narrowing Synechia Stenosis can cause arm swelling

Scarring : 

Scarring

UE Pitfalls : 

UE Pitfalls Not all veins are compressible Entire vein may not be imaged Reverberation , noise may mimic clot Nonobstructive thromus may not alter Doppler Collateral may mimic normal vein

What is this : 

What is this

Venogram : 

Venogram