Duplex Ultrasound Imaging of the Upper Extremity Venous System

A comprehensive set of question-and-answer flashcards summarizing anatomy, pathophysiology, scanning technique, diagnostic criteria, pitfalls, catheter considerations, and treatment of upper-extremity veins using duplex ultrasound.

What are the three key differences between upper- and lower-extremity venous duplex protocols?

1) Upper-extremity thrombi are less often caused by stasis (no soleal sinuses). 2) Superficial veins are affected more often and are clinically more significant in the arm. 3) Upper-extremity venous anatomy is more variable.

Which clinical findings are suggestive of superior vena cava (SVC) thrombosis?

Facial swelling and/or dilated chest-wall collateral veins.

Name two situations in which asymptomatic patients may undergo upper-extremity venous duplex before a procedure.

1) Prior to central venous catheter placement. 2) Prior to pacemaker insertion.

What three factors make up Virchow’s triad?

Venous stasis, hypercoagulability, and vessel wall injury.

Which component of Virchow’s triad most commonly causes upper-extremity thrombosis?

Vessel wall injury from frequent needle or catheter insertion.

Which two veins are most commonly used for indwelling central catheters and pacemaker wires?

The subclavian vein and the internal jugular vein.

Through which superficial veins is a peripherally inserted central catheter (PICC) placed, and where is its tip usually positioned?

Inserted through the basilic or cephalic vein and advanced so the tip lies near the right atrium.

What is another name for Paget–Schroetter syndrome?

Effort thrombosis of the subclavian vein.

Describe the typical patient profile for Paget–Schroetter syndrome.

Young, athletic, muscular males with subclavian vein compression at the thoracic outlet.

How often should gentle probe compressions be applied along an upper-extremity vein during scanning?

Every 2–3 cm along the course of the vein.

During evaluation of the internal jugular and subclavian veins, how should the patient be positioned?

Lying flat with the arm resting at the patient’s side.

Which transducer frequencies are recommended for deep versus superficial upper-extremity veins?

5–10 MHz linear array for deeper veins (IJV, subclavian, axillary, brachial); 10–18 MHz linear for superficial veins (cephalic, basilic, small forearm veins).

Which superficial neck vein runs close to the skin without a companion artery and serves as an important collateral pathway?

The external jugular vein (EJV).

Why can’t brachiocephalic veins be compressed, and what modalities confirm their patency?

They lie behind bony structures; grayscale imaging, color flow, and spectral Doppler (showing phasicity and pulsatility) are used instead.

Which breathing maneuver can temporarily collapse the subclavian vein to aid in assessing compressibility?

A quick, deep breath in through pursed lips.

Which superficial vein travels along the anterolateral border of the biceps muscle?

The cephalic vein.

What vessel forms the primary connection between the cephalic and basilic veins at the elbow?

The median cubital vein.

Into which vein does the basilic vein terminate?

The axillary vein.

Which vein is usually the largest in the upper-arm region?

The basilic vein.

Why are radial and ulnar veins seldom included in routine upper-extremity venous examinations?

They are very small paired deep veins and rarely develop thrombosis.

List two common pitfalls when imaging upper-extremity veins.

1) Inability to compress veins located under the clavicle or sternum. 2) Dressings or IV catheters limiting probe access.

What are the normal sonographic criteria for a patent upper-extremity vein?

Complete wall coaptation with gentle probe pressure, thin smooth walls, anechoic lumen, and slight diameter change with respiration.

Give four ultrasound characteristics of an acute thrombus.

Poorly attached to the wall, spongy texture, vein dilation, variable (often low) echogenicity with a smooth surface.

List four sonographic features of chronic post-thrombotic change.

Brightly echogenic thrombus, well attached, rigid or irregular surface, and a contracted-appearing vein.

Which three Doppler characteristics indicate normal flow in upper-extremity veins?

Respiratory phasicity, augmentation with distal compression, and cardiac pulsatility (especially central veins).

What Doppler and color-flow findings indicate a completely thrombosed vein?

Absence of spectral Doppler signal and absence of color filling within the vessel lumen.

Continuous (non-phasic) venous flow may be produced by which three conditions?

Partial intraluminal thrombus, proximal obstruction, or extrinsic compression.

Under what circumstance might internal jugular veins display reversed (retrograde) flow?

When they act as collateral pathways for central venous obstruction.

How does an indwelling venous catheter appear on ultrasound?

As bright, straight, parallel echogenic lines within the vessel lumen.

What sonographic finding suggests thrombus formation around a venous catheter?

Echogenic material encasing the catheter with diminished and/or continuous Doppler signals.

What is the required management if a venous catheter becomes thrombosed?

The catheter must be removed.

Name four treatment options considered for upper-extremity venous thrombosis.

Anticoagulation, catheter removal, thrombolytic therapy, and surgical thoracic-inlet decompression with or without venous reconstruction (conservative measures may also be chosen).

What Doppler waveform characteristics should be present in a normal brachiocephalic vein?

Both respiratory phasicity and cardiac pulsatility.

Which maneuver provides Doppler signal augmentation during an upper-extremity venous exam?

Distal (hand or forearm) compression of the vein.

When compression cannot be performed because of bony landmarks, which ultrasound modalities are relied upon?

Color-flow imaging and spectral Doppler analysis.

What is meant by arterialized venous flow, and in whom might it be observed?

High-velocity, pulsatile venous flow caused by an arteriovenous connection, often seen in patients with hemodialysis fistulas or grafts.

Thrombosis of which vein can cause unilateral facial swelling and chest-wall collaterals?

The superior vena cava or its tributaries (e.g., brachiocephalic or subclavian veins).