Wks 11-14 Flashcards
Brachiocephalic vein vs artery
BCV has right and left branches
BCA on has right branch
Central veins
BCV, SCV
Which BCV is longer
Left because vena cava lies more to the right side compared to aorta
Thyrocervical branches
Transverse scapular
Anterior jugular vein and arch
External jugular
Primary cause of UE DVT
IVs and catheters
Secondary cause of UE DVT
effort thrombosis
Effort thrombosis
Aka paget-van shrotters syndrome.
Strong, young athletic people who put too much stain on area
Thoracic outlet compression
Vein artery and nerve compressed by clavicle and 1sr rib
Causes of UE DVT
IVs/catheters Effort thrombosis Thoracic outlet compression Tumors IV drug use Post-op complications
Anatomical variations
Normal anatomy layout is different. Patient might have SCV over rib instead of under
Physical assessment of UE
Edema
Pain
Dilated superficial shoulder veins
Edema
Entire arm effected could be subclavian obstruction
SVC syndrome-facial edema
At IV site-infiltration
Hand edema-lymphadema
Pain (phys assess)
Heaviness
Aches pain
Hand pain possible arterial embolus
SVC syndrome
Superior vena cava obstructed
Venous collaterals form
Dilated chest veins, very visible and VERY likely DVT
Hickman catheter
3 ports or 2 ports
Catheter fed into SCV into SVC
End of port sticks outside patients chest area
Portacath
Long term central venous catheter with subcutaneous parts.
All parts are underneath skin
PICC
Peripherally inserted central catheter
Catheter threaded from arm all the way to Superior vena cava.
Advantages of PICC
Longer term 3 months-1 year
At home option
Use basilic vein for ease of patient mobility
Disadvantages of PICC
Stasis often occurs since PICC is same side as vein
Slows venous drainage
PICC removal reasons
If thrombus forms
Infection
Damaged line
Fibrin sheath
Deposits of fibrin formed from the circulation blood
Fibrin sheath after line removal
Fibrin sheath remains in the vein
Almost like a snake leaving behind shedded skin
Appears on image same as the real line
Fibrin sheath formation
Catheter is foreign substance so plasma proteins coat catheters surface.
Promoted the adherence of blood platelets and bacteria.
Staph bacteria sticks to fibronectin which activates the coagulation
Fibrin sheath complications
thick and glue like
difficult to remove
Forms within 24 hours after placement, fully surrounded in 5-7 days
Pertinent history
Confirm test Symptoms History of DVT Surgery or trauma IVs or catheters Triad symptoms
Patient prep
Supine for neck area
Cover non scanning body area
Patient is not an arm rest
Patients arm can lay on your lap
Veins collapsing
If patient is upright veins will collapse due to pressure
Symptoms of PE
Swelling Pain Inflammation of IV site Preop Malfunctioning central lines
Protocol for IJV
Start in mid neck in trans
Scan distally and proximal
Protocol for BCV
Probe points deep towards chest
RT BCV will be vertical
LT BCV will be slightly pointed to right of pt
Prox SCV on screen
Horizontal
Bright echo below due to pleural
Pleura
Membranes around lungs
Visceral and parietal
Cephalic vein past clavicle
Cephalic vein junctions occurs just past clavicle
Radial and ulnar unlikely to be scanned
Areas at low DVT risk
Catheters not placed there due to artery closeness
Sniff test
Technique available if veins are hard to compress
Respiration
UE inhales increases chest pressure
Exhale halts flow
Normal UE Doppler
Spontaneous Pulsatile above axillary Phasic with pulsatility Augment below axillary-lower response than LE Similar side to side
Why is normal Doppler pulsitile
Due to reflected waveforms from closeness to heart
Subclavian vs suprascapular
Don’t mistake suprascapular vein for SCV
SCV is horizontal on screen!!
Techniques for competency
Augment
Patient cough
Sniff test
Compare to opposite side
vein variations
Many variations in UE
2 brachial veins for artery
3 brachial veins
Etc
Median nerve
Near brachial vein
Has stripes/streaks/striations
Superficial veins
Basilic and cephalic
Within fascia near skin surface
Nice catheter locations
Abnormal for brachiocephalic vein
Nonphasic
Non pulsatile especially compared to other side
Velocity, low is occlusion. High is stenosis
Retrograde flow in IJV sign of prox BCV obstruction
IJV obstruction
Facial vein collaterals
Superior thyroid collaterals
Determining thrombus age
Acute-dilated vessel with soft echos
Indeterminate-not as dilated; soft echos
Chronic-not dilated, bright echos
Signs of thrombus
Non compressible
Lack of color
No flow
Collaterals seen
Occluded vein Doppler
Doppler changes when vein is completely ocludded
No flow in thrombus area
Distal waves are non pulsatile and non phasic
Pitfalls to US testing
Poor identification of veins
Compressing difficulties due to structures and lack of skill
Good collaterals seen may cause normal flow distal
Mirror image
Artifact
True vessel is superficial
Mirror image deeper
Caused by pleura being bright enough to cause a reflection type occurrence p
PE in upper
Less likely compared to LE due to no calf muscle pump
0-25% reported
Treatment of UE DVT
Rest Heat Elevation External compression Anticoagulant Catheter removal Stents
Totally occluded UE vein
Will have swelling distal to that section
Patient with bilateral arm and neck swelling and prominent superficial chest veins likely has
Superior vena cava syndrome
Pager-schrotters syndrome AKA
Effort thrombosis
Which superficial vein joins the axillary to become subclavian
Cephalic vein
Best position for venous duplex to detect DVT in central veins
Supine
Best position for sonographer to examine central veins
At patients head
Ways normal venous signal in proximal deep veins is different than in LE
Pulsatile
Phasic
Less reaction to augments due to low volume
Paired veins
Brachial
Radial
Ulnar
Venous flow is typically
Towards the heart
What is seen after a line is removed from central veins often resembling the line itself
Fibrin sheath
Common PICC location
Basilic
PICC stands for
Peripherally inserted central catheter
Common IV locations
Basilic and cephalic
Maneuver to obtain respiratory variation in central vein
Sniff test
Or small cough
True or false
DVT in UE treated differently than LE
False
Young patient complains of acute swelling and pain in right arm.
What’s a good question to ask
Any recent heavy lifting
Strenuous activities using a that arm
Most common cause of superior vena cava syndrome
Malignancy
Size veins to be marked
Great her than 2mm
Vein mapping purpose
Assess supervisor vins for length, diameter, condition
Used prior to ablation of varicose veins
Superficial veins used for
Bypass grafts
Dialysis fistula
CABG coronary art bypass graft
Preferred veins for grafts?
Natural veins, last longer. But could become aneurysmal due to now having arterial pressure
Which veins are mapped
Gsv **
Ssv
Cephalic or basilic (last resort)
GSV location
Starts by inside ankle bone (medial malleolus)
Travels the whole length of leg into groin area
Patient position for vein mapping
Exaggerated reverse trendelunburg
Vein mapping requires
Very delicate touch. Superficial veins are easy to collapse
Vein mapping technique
Follow connections to deep system Scan entire vein Measure diameter, find suitable sized vein Mark vessels over 2mm Find the best vessel, no stenosis
Location of GSV on screen
Within fascia near top of screen
Vessel outside fascia could be a branch
Mapping locations
Gsv: Groin P thigh M thigh D thigh Knee P calf M calf D calf Ankle
Small saphenous vein
Located between lateral malleolus and Achilles’ tendon. Runs up the back of calf to pop.
Looks like an eye on screen
Giacomini vein
When SSV continues above popliteal
Mapping SSV
Above knee for giacomini Knee P calf M calf D calf Ankle
Condition of veins during mapping that are bad use of graft options
Varicose veins
Stenosis
Thrombosed
Sclerosed
Graft options
Natural vein
Synthetic or man made materials-gortex, Dacron
Radial artery for coronary graft
Why would synthetic grafts be used
When patient has had multiple grafts done and no longer has any other viable sections
Anterior jugular vein is enlarged with flow moving from right to left neck is due to
Right brachiocephalic vein is thromobosed
PPG reflux exam purpose
Evaluate venous valve incompetence
Deep vs superficial venous incompetence
PPG reflux exam technique/setup
Patient on edge of bed Feet dangling PPG places on inner gaiter area Baseline Compress calf with both hands 5 Times
Normal results for PPG reflux test
Calf squeeze will show decrease in wave
Slow and steady rise back to baseline, over 20sec
Shows that venous system is allowing enough time for leg to fill back up
Abnormal PPG reflux results
Recovery time under 20 secs
No venous emptying during calf squeeze
Indicates deep and or superficial vein incompetence
Tourniquet test
Abnormal PPG reflux test will result in Tourniquet test.
Used to occlude the GSV at thigh so only deep veins will be tested
Repeat PPG reflux test.
Still abnormal then move tourniquet to calf and repeat
Chronic venous insufficiency causes
Primary varicose vein. No underlying disease Secondary varicose veins. Post thrombus DVT Valve incompetence Venous claudication
Symptoms of CVI
Ambulatory venous hypertension
Hyperpigmentation
Lipodermatosclerosis
Ulceration
Duplex exam for CVI
Deep venous system
Saphenous vein
Varicose vein
Perforators
