Week 11 Flashcards
- UE venous exams are not as ____ as LE venous exams
- ____% of pulmonary embolism originate in the LE veins
- common
- 90
!!! Important to know
There are ____ innominate (brachiocephalic) artery but there are ____ brachiocephalic veins
1 artery
2 veins
What are the reasons to perform UE duplex ultrasound? (3)
- rule out DVT: presents with UE pain/edema & documentation of a source of PE
- evaluation of the veins in patients that are in end stage renal failure and need dialysis access with either a fistsula or graft in arm
- evaluate patency of a UE central catheter (PICC line) - used for administration of chemotheraphy and other medication
Anatomy of UE
1. They are divided into ____ and ____ veins
2. anatomical variation can be present, cmmonly paired veins. ____ and ____ are the most common to be paired
- deep and superficial
- radial and ulnar
What are the names of deep veins in UE? (7)
- internal jagular vein (IJV)
- innominate (brachiocephalic) vein
- subclavian vein
- avillary vein
- brachial vein
- radial vein
- ulnar vein
What are the names of the superficial veins? (2)
- cephalic vein
- basilic vein
Identify the vessels 1-4
- internal jagular vein
- external jagular vein
- subclavian vein
- innominate (brachiocephalic) vein
Identift the vessel 1 - 9
- internal jagular vein
- axillary vein
- cephalic vein
- (top one) median cubital vein, (bottom one) radial veins
- ulnar veins
- Basilic vein
- brachial veins
- innominate (brachiocephalic) vein
- subclavian vein
Anatomy: IJV
- runs from the ____ vein up to the ____ neck
- IJV is ____ to the common carotid artery (seen best in TVR plane)
- innominate, lateral
- lateral
Anatomy:** innominate/brachiocephalic** vein
1. formed (confluence) by the ____ and the ____
2. The right and left innominate veins join to form the ____
3. There are ____ innominate veins
4. !!!! Left innominate vein is ____ than the right
- internal jagular vein and subclavian vein
- SVC
- 2
- longer *RA is on the right side = shorter on the right side
Anatomy: subclavian vein
It runs transversely under the ____ and joins the _____ to form the _____
clavicle, IJV, innominate
Anatomy: Axillary vein
- The ____ vein turns into the axillary vein at the top of the arm level of the axilla called: ____
- crosses the border of the 1st rib to form the ____
- axillary vein is ____ to the axillary artery
- brachial
- thoracic outlet
- subclavian vein
- medial
Anatomy: brachial vein
- formed by the ____ and ____ veins once they cross the _____
- runs up the upper arm from just above the _____ to the axilla
- commonly ____ veins
- radial and ulnar, antecubital fossa
- antecubital fossa
- paired
Anatomy: radial vein
- runs up to the ____ aspect of the forearm to join the ____ vein just above the antecubital fossa to form the ____ vein
- commonly ____ veins
- lateral, ulnar, brachial
- paired
Anatomy: Ulnar vein
- runs up the ____ aspect of the forearm to join the ____ vein just above the anatecubital fossa to form the ____ vein
- commonly ____ veins
- medial, radial, brachial
- paired
Anatomy: basilic vein
- runs along the ____ side of the forearm
- typically joins the _____ vein at the lower aspect of the upper arm (insertion can be variable, and sometimes, insertion at the distal ____ vein)
- drains blood from the ____ and ____ aspect of the hand
- medial (ulnar)
- brachial, axillary
- palm, ventral
Anatomy: cephalic vein
- originates at the base of the ________ surrface of the hand at the anatomic _____, crosses the forearm _____, transverse the antecubital fossa, and continues up the ____ upper arm to the shoulder where it terminated by joining the ____ vein
- runs up the ____ aspect of the forearm
- drains the ____ surface of the hand
- dorsal, snuff box, anteriorly, anterior, axillary
- lateral (radial)
- dorsal
What is this?
snuff box
the indentation on the radial side that is prominent with extension of the thumb
sings/symptoms to perform UE Duplex ultrasound? (4)
- swelling
- limb pain
- SOB with known LE or UE venous thrombosis
- new UE pain while on anticoagulation
Pertinent (relevant) patient history: (7)
- previous DVT/SVT
- UE trauma
- extremity immobilization
- recent major surgery
- history of cancer
- current medication/therapies
- IV drug abuse
Patient position for the UE Duplex?
Semi-Fowler’s position
*helps pool blood in the upper extremity veins - better visualization with US
Patient position: If having trouble visualizing the internal jagular veins or subclavian veins, a ____ position may help
trendelenburg
Type of TDR
Identify the anatomy 1-2
- IJV
- carotid
Identify the anatomy 1-3 & to get this view, angle TDR ____
- jagular vein
- subclavian vein
- brachiocephalic vein
Identify the anatomy
supraclavicular approach for prx and mid positions, infraclavicular approach for distal portion
subclavian vein
Identify the anatomy 1-2
- axillary vein
- axillary artery
Identify the anatomy 1-3
- basilic vein
- brachial veins
- brachial artery
Identify the anatomy
radial and ulnar veins
Identify the anatomy
basilic vein
*locate underneath the facia
Identify the anatomy
cephalic vein *very superficial
UE veins: normal vein characteristics (4)
- The vein should appear clear, no internal echoes
- easily compressible with TDR compression
- complete color filling of the lumen
- phasicity & pulsatility
UE veins: what are the two normal flow charcteristics ?
- cardiac pulsatility
- respiratoy variation
cardiac pulsatility is seen as choppy and sometimes demonstrates a biphasic flow pattern. They are usually seen in the following veins (4) as they are close to the heart
- internal jagular
- innominate
- subclavian
- axillary
If there is a unilateral loss of pulsatility, there is a _____
central venous obstruction, usually innominate vein
If there are bilateral loss of pulsatility, there is a ____
central venous obstruction at the SVC or bilateral innominate veins
Respiratory Variation:
Prominent in the upper extremities, with increased flow during ____ and decreased flow on ____
inspiration, expiration
*opposite in lower extremities
Upper Extremity Veins:
what are the 7 abnormal characteristics?
- internal echoes present
- non-compressible with TDR pressure
- vein may be distended (if an acute DVT is present)
- incomplete color fill of the lumen
- collateral veins present
- absence of spectral Doppler signal
- non=phasic and non-pulsatile flow
What are the 2 characteristcs of abnormal waveform?
- waveform alteration/waveform asymmetry
- venous collaterals
waveform alteration (monophasic, flattened or damped) or waveform asymmetry can indicate more ____ such as ____ , ____ thrombosis or obstruction that is difficult to visualize directly
central, innominate, SVC
Where is the most common site for DVT in upper extremities? (2)
subclavian and axillary
upper extremity thrombus can be acute or chronic; what are the causes?
Virchow’s triad
- stasis
- immobility, trauma
- hypercoagulable states
What are the pathologies that mimic DVT? (4)
- thrombophlebitis
- hematoma
- cluulitis
- lymphedema
What are the pathologies that mimic DVT? (4)
- thrombophlebitis
- hematoma
- cluulitis
- lymphedema
____ thrombus is more clinically urgent in the upper extremities than the lower extremities
superficial
Dialysis Access: Fistulas & Grafts
- UE duplex exams an be performed to check patency before ____ access as well as for evaluating existing ____ access
- purpose: create a channel from an artery to a vein
- low resistive pathway
- high volume blood flow (needed for dialysis)
- Dialysis
Dialysis Access: **Fistulas **
- directly joins an artery to a vein
- The ____ becomes the dialysis channel
- It has better, long-term ____ compared to graft
- has a disadvantage of needing ____ to mature (vein enlarges and wall thicken)
- vein
- patency
- several weeks to a few months
Most common site for fistsula (2)
- radial artery to cephalic vein @ wrist
- brachial artery to cephalic vein @ the AC
Dialysis Access: Grafts
- ____ channel from artery to vein
- most common site: ________
- right below the skin to it can be access for dialysis
- usually ____ is used
- synthetic
- One end in the brachial artery, a loop running down & back up the forearm, and the other end in the cephalic vein
- Gore-tex (double wall sonographic appearance
Dialysis Access: Fistulas & Grafts
Duplex Evaluation:
- always helpful to know where fistula or graft is placed before performing exam
- normal flow appearance: ____
- abnormal flow: ______
- turbulent
- focal acceleration, slow flow
Dialysis Access: Fistulas & Grafts
pre fistula or pre graft
1. assess arterial inflow
2. assess venous outflow including central veins - most problems occur at the _____
3. assess fistula or graft channel, especially venous and arterial anastamoses
- venous flow anastamosis
Dialysis Access: Fistulas & Grafts
What are the 3 problems associated with fistulas & grafts?
1. thrombosis (most frequent)
- thrombectomy can be performed to save the graft or fistula if it caught early enough
- unable to access or if there is a loss of the “thrill”
2. aneurysm (aka true aneurysm): a weakening and bulging of part of the vein in a fistula
3. pseudoaneurysm: a contained area of blood flow escapeing the vein or graft
Dialysis Access: Fistulas & Grafts
grafts and fistula are very superficial so when scanning remember 3 things:
1. don’t apply too much TDR pressure
2. use enough gel or standoff pad t
