Diagnostic ultrasound ( PDFDrive )

CHAPTER 27 Peripheral Vessels 991
elbow to form the brachial veins. he brachial veins in the upper
arm join with the basilic vein at a variable location, typically at
the level of the teres major muscle. he conluence of the brachial
and basilic veins continues as the axillary vein, which passes
through the axilla from the teres major muscle to the irst rib.
As the axillary vein crosses the irst rib, it becomes the lateral
portion of the subclavian vein. he medial portion of the
subclavian vein receives the smaller external jugular vein and
the larger internal jugular vein (IJV) to form the brachiocephalic
(innominate) vein.
Most ultrasound laboratories deine the central veins as the
brachiocephalic veins and superior vena cava, which oten are
diicult to visualize sonographically. Because some angiographers
include the subclavian vein when they describe the central
veins, it is important to be very speciic about the vein segment
examined when describing sonographic indings. he presence
or absence of clinically important central stenosis or thrombosis
may be inferred by evaluating the transmitted cardiac pulsatility
and respiratory phasicity in the medial subclavian vein and
distal IJV. 96
he cephalic and basilic veins comprise the most important
supericial named veins of the upper extremity. he more laterally
located cephalic vein traverses in the supericial sot tissues of
the shoulder to drain into the axillary vein in the lateral chest.
he basilic vein is located more medially, and typically joins the
brachial veins to form the axillary vein.
Ultrasound Examination and Imaging Protocol
Upper extremity Duplex evaluation consists of gray-scale
compression and color and spectral Doppler assessment of all
the visualized portions of the IJV and subclavian, axillary, and
innominate veins, as well as compression gray-scale ultrasound
of the brachial, basilic, and cephalic veins in the upper arm
to the elbow. A high-frequency, small-footprint transducer
can be applied to the suprasternal notch to better demonstrate
the brachiocephalic junction and IVC, oten diicult to see
because of overlying sternum and lung. Venous compression
is applied to accessible veins in the transverse plane with
adequate pressure on the skin to completely obliterate the normal
vein lumen.
he patient is scanned in a supine position with the examined
arm abducted from the chest, with the patient’s head turned
slightly away from the examined arm. Typically a 5- to 10-MHz
linear array transducer will be used, with a higher frequency
transducer chosen for more supericial veins. A curved array
transducer or sector transducer may be more efective in larger
patients, especially in the axillary area, because of its increased
depth of penetration and larger ield of view. All veins are
examined with compression every 1 to 2 cm in the transverse
plane. Gray-scale transverse images with and without compression
or cine clips during compression are obtained from the cranial
aspect of the IJV in the neck to the thoracic inlet caudally (Fig.
27.40, Video 27.20). Longitudinal color and spectral images are
obtained.
he subclavian vein is evaluated from its medial to lateral
aspect with longitudinal color and spectral images, assessing for
transmitted respiratory variability, cardiac pulsatility, and color
ill-in. To demonstrate the superior brachiocephalic vein and
the medial portion of the subclavian vein, an inferiorly angled,
supraclavicular approach with color Doppler is necessary. A
small-footprint sector probe in or near the suprasternal notch
may improve visualization of the brachiocephalic veins and the
cranial aspect of the superior vena cava (Fig. 27.41). he midportion
of the subclavian vein, located deep to the clavicle, frequently
is incompletely imaged. An infraclavicular, superiorly angled
approach can be used to demonstrate the lateral aspect of the
A
B
FIG. 27.40 Normal Internal Jugular Vein (IJV) and Subclavian Vein (SCV) Spectral Doppler Waveforms. (A) Normal IJV spectral Doppler
waveform, with transmitted cardiac pulsatility and respiratory phasicity, with spectral waveform going to the baseline. Accompanying Video 27.20
shows normal IJV compression. (B) Normal medial SCV spectral Doppler, with transmitted cardiac pulsatility and respiratory phasicity, and spectral
waveform going to the baseline.