UPPER LIMB DVT ULTRASOUND - Normal

 

ANATOMY

 

 Basic anatomy of the deep veins of the arm  Basic anatomy of the superficial veins of the arm

Basic deep venous anatomy of the arm.

Click to enlarge.

Basic superficial venous anatomy of the arm.

Click to enlarge.

 

DEEP VEINS OF THE NECK & SHOULDER

 Scan plane for the proximal subclavian and jugular veins.  Proximal subclavian vein and jugular vein with colour doppler
The red line shows the subclavian vein origin scan plane. Doppler of the Subclavian vein origin.

 

 Ultrasound of the Jugular vein, pre and post compression.  

The Jugular vein pre & post compression.

Asking the patient to valsalva (or just 'puff their cheeks out') will help distend the neck veins.

 

 

AXILLARY VEIN

 Ultrasound scan plane for the axillary vein.  Ultrasound of the normal Axillary vein.
Other than the deepest portion of the axillary vein, the veins from the distal subclavian to the wrist should be readily compressible.
The Axillary vein, pre & post compression.

 

 Ultrasound of the normal common Axillary vein  Doppler of the Axillary vein
The vein is easily compressed so light transducer pressure is important. Depending on arm movement and respiration, the Axillary and subclavian veins may appear pulsatile.

 

DEEP VEINS OF THE UPPER ARM -Brachial vein

 Scan plane for ultrasound of the Brachial vein.  Ultrasound of the Brachial and Basilic veins.

Transverse mid upper arm.

Hover mouse over to see the scan plane.

Transverse view of the Brachial and Basilic veins.

 

 Axial view of upper arm anatomy Ultrasound of the normal Brachial and Basilic veins.
An axial view of the upper arm vein anatomy.

Transverse view of the Brachial and Basilic veins and nerves of the upper arm.

 

FOREARM VEINS

The veins will be easier to assess with the patient erect to allow better venous distension. The patient will be comortable seated with a pillow under their arm for support and this allows for easy scanning access.

 Ultrasound of the forearm veins scan plane  Axial forearm anatomy
Scan plane for the deep forearm veins.
Insert caption here

 

 Ultrasound of the radial veins.  Ultrasound of the Ulna veins.
The Radial artery and veins. The Ulna artery and veins.

 


 

Ultrasound of the Upper Limb DVT - Protocol

Role of Ultrasound

 To exclude or confirm the presence of deep and or superficial venous thrombosis as a cause of pain and swelling in the upper limb.

Patients with known altered coagulation status, on oral contraceptive pill, weight lifters, upper limb, neck or breast surgery or trauma are susceptible to clots in this region.

 

Limitations

Obese patients, or those with severe oedema will limit the scan quality resulting in only being able to exclude occlusive thrombus Acoustic windows and detail may be limited in patients with open wounds/sutures.

The mid subclavian vein is obscured by the clavicle.

Equipment Selection

Use a mid frequency probe (5-8MHZ). Often using a curvi-linear probe is easier than a linear probe, particularly when doing compression views.

Low PRF (velocity) colour / power / Doppler settings with low wall filter when assessing veins with low velocity flow. Be prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures.

Patient position

  1. Begin with the patient supine, arms by their side.
  2. Supine wth haid on head.
  3. Patient sitting on side of bed, arm supinated.

What am I looking for?

Non compressibility or filling defects with colour doppler.

Acute thrombus will be hypoechoic and difficult to see on B-mode without increasing your gain settings. It will generally slightly distend the vein and be focally tender. The thrombus propogates proximally with a 'tongue' projecting into the lumen at its moost proximal end. As the thrombus ages, it becomes more echogenic. Old, chronic thrombus will be echogenic, retracted from the vein walls with recanalised flow through and around it.

 

Scanning Technique

Examine the deep veins from the neck and brachiocephalic vein to the hand.

Subclavian Vein

Patient supine on bed, arms by their side. Scan in transverse at the antero-lateral base of the neck. Using colour doppler, find the Jugular vein and follow inferiorly to the junction with the subclavian vein. Follow the subclavian vein laterally using colour doppler in both longitudinal & transverse planes to exclude non occlusive filling defects.

Axillary vein

Patient still supine on bed with ipsilateral hand on their head, elbow flexed laterally to permit easy access to the axilla. Find the distal subclavian artery and follow through the axilla with colour doppler and compressing using b-mode in the transverse plane
As you reach the proximal arm, the axillary vein will divide into the basilic and brachial veins.

Upper Arm Veins (Brachial & Basilic)

The basilic vein is the larger and is more superficial. Usually single but may be duplicated. Continue from the axillary vein checking in transverse that the basilic and brachial veins of the upper arm are compressible.

This may be best acheived with the patient sitting on the side of the bed with their arm supinated.

At the antecubital fossa, the brachial vein will divide into the radial & ulnar veins.
.

Forearm veins (Radial & Ulna)

Still with the patient seated on the side of the bed, follow the radial and ulnar veins to the wrist confirming compressibility and flow.

As with the veins in the calf, the veins of the forearm genarally run in pairs (venous commantantes).

 

For images of ARM DVT and associated pathology.

 

Basic Hard Copy Imaging

An upper limb DVT series should include the following minimum images

  • Sublavian vein proximal & distal with colour flow
  • Axillary vein showing colour flow and pre/post compression
  • Proximal & distal brachial vein pre/post compression
  • Proximal & distal basilic veins pre/post compression
  • Radial veins proximal & distal pre/post compression
  • Ulna veins proximal & distal pre/post compression
  • Cephalic vein as necessary

Document the normal anatomy. Any pathology found in 2 planes, including measurements and any vascularity.


 
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