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Upper Extremity Venous DopplerUltrasoundTherese M. Weber, MD*, Mark E. Lockhart, MD, MPH,Michelle L. Robbin, MD

Sonography plays a major role in evaluatingthe upper extremity venous system. The most

widely used applications include evaluation forthrombus and vessel patency, localization during

venous access procedures, preoperative venousmapping for hemodialysis arteriovenous fistula(AVF) and graft placement, and postoperativehemodialysis AVF and graft assessment. Knowl-edge of anatomy, scanning technique, and atten-tion to detail are important to the success of

demonstrating abnormalities in the upper extrem-ity venous system. Sonographic evaluation of the

upper extremity venous system is more challeng-ing than evaluation of the lower extremity venoussystem.

This article presents methods that allow easyidentification of the sometimes complex anatomyand the avoidance of pitfalls that can lead to com-mon and uncommon errors.

Normal anatomy

The venous anatomy of the neck and arm is illus-trated inFig. 1.

Deep venous system

The more clinically important aspect of the venoussystem of the upper extremity is the deep system, es-pecially the proximal aspect of the venous system in-cluding the internal jugular vein, the subclavian

vein, and the brachiocephalic vein. One easy wayto tell if a vein is superficial or deep is to assess

whether it has an artery running with it. In the upperextremity only deep veins have arteries running withthem. The radial and ulnar veins in the forearm,

which usually are paired, unite caudal to the levelof the elbow to form the brachial veins. The brachial

veins in the upper arm join with the basilic vein ata variable location, typically at the level of the teres

R A D I O L O G I CC L I N I C S

O F N O R T H A M E R I C A

Radiol Clin N Am 45 (2007) 513524

Department of Radiology, University of Alabama at Birmingham, 619 19th Street, South, JT N312, Birming-ham, AL 35249-6830, USA* Corresponding author.E-mail address: [email protected](T.M. Weber).

- Normal anatomyDeep venous systemSuperficial venous systemNormal arterial anatomy

- Sonographic examination techniquePeripheral deep venous systemPotential pitfalls

- Imaging protocol- Clinical diagnosis- Upper extremity venous thrombosis

- Acute deep venous thrombosis- Chronic deep venous thrombosis- Venous access procedures- Sonographic evaluation before and after

placement of hemodialysis accessPreoperative mapping

Arteriovenous fistula maturity assessment- Summary- Acknowledgments- References

513

0033-8389/07/$ see front matter 2007 Published by Elsevier Inc. doi:10.1016/j.rcl.2007.04.005radiologic.theclinics.com
mailto:[email protected]:[email protected]


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major muscle. The confluence of the brachial andbasilic veins continues as the axillary vein, whichpasses through the axilla from the teres major mus-cle to the first rib. As the axillary vein crosses the firstrib, it becomes the lateral portion of the subclavian

vein. The medial portion of the subclavian vein re-ceives the smallerexternal jugular vein and the largerinternal jugular vein to form the brachiocephalic(innominate) vein. Bilateral brachiocephalic veinsjoin to form the superior vena cava.

The authors define the central veins as the bra-chiocephalic veins and superior vena cava, which

usually cannot be demonstrated sonographically.Some angiographers include the subclavian vein

when they discuss central veins. Therefore, it is im-portant to be very specific about the vein segment

examined in describing sonographic findings. Thepresence or absence of significant central stenosis

or thrombosis needs to be inferred by evaluatingthe transmitted cardiac pulsatility and respiratoryphasicity in the medial subclavian vein and caudalinternal jugular vein, as discussed later.

Superficial venous system

The superficial venous system of the upper extrem-

ity comprises the cephalic vein located more later-ally and the basilic vein located more medially.

The basilic and cephalic veins typically have a varia-bly larger vein connecting them caudally near the

elbow, the median antecubital vein.

Normal arterial anatomy

The brachial artery begins in the upper arm at thelower margin of the teres major muscle tendon

and usually ends about 1 cm below the elbowwhere is divides into the radial and ulnar arteries.Anatomic variants of the radial artery includea high take-off or high bifurcating radial artery. Insome cases, the radial artery may take off from thecranial aspect of the brachial artery in the upperarm. One way to distinguish a high take-off of theradial artery from a large elbow branch artery is tofollow it into the forearm down to the radial arteryregion at the wrist. A large arterial branch to the el-bow traverses toward the elbow and does not ex-tend into the forearm. Rarely, the ulnar artery may

be absent.

Sonographic examination technique

Sonographic evaluation of the upper extremity ve-nous system is more technically challenging than

evaluation of the lower extremity venous system.These technical challenges include the inability tocompress the subclavian vein because of the overly-ing clavicle and the need to differentiate large

venous collaterals from normal veins in cases of ve-

nous obstruction.The patient is scanned in a supine position with

the examined arm abducted from the chest and

with the patients head turned slightly away fromthe examined arm. Real-time B-mode imaging

with spectral and color flow analysis is performedusing the highest frequency linear transducer thatstill gives adequate penetration. Typically the exam-ination is best performed using a 5- to 10-MHz lin-ear-array transducer moving to a higher frequencyin the upper arm and forearm if possible. Acurved-array transducer or sector transducer may

Fig. 1.Normal venous anat-omy. The deep veins of thearm (dark blue) include thebrachial vein and axillaryvein. The brachiocephalicvein is formed by the inter-

nal jugular and subclavianveins. The two brachioce-phalic veins join to becomethe superior vena cava. Su-perficial veins (light blue)include the cephalic vein,basilic vein, and external

jugular vein.

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be useful in larger individuals, especially in the ax-illary area, because of the increased depth of pene-tration and larger field of view.

All veins are examined with compression every1 to 2 cm in the transverse plane. Gray-scale trans-

verse images with and without compression or

cine clips during compression are obtained fromthe cranial aspect of the internal jugular vein inthe neck near the mandible to the thoracic inlet

caudally. Longitudinal color and spectral imagesare performed also. The subclavian vein is evaluatedfrom its medial to lateral aspect with longitudinalcolor and spectral images, demonstrating transmit-ted respiratory variability, cardiac pulsatility, andcolor fill-in. An inferiorly angled, supraclavicularapproach with color Doppler is necessary to dem-onstrate the superior brachiocephalic vein and the

medial portion of the subclavian vein. Use ofa small-footprint sector probe in or near the supra-sternal notch may facilitate visualization of the bra-chiocephalic veins and the cranial aspect of thesuperior vena cava. The midportion of the subcla-

vian vein, located deep to the clavicle, frequentlyis imaged incompletely. An infraclavicular, superi-orly angled approach is used to demonstrate the lat-eral aspect of the subclavian vein. Frequently, the

subclavian vein can be compressed.Spectral waveform evaluation is critical to upper

extremity venous evaluation. Documentation of

normal flow features in the medial subclavianvein is extremely important, because it confirmspatency of the brachiocephalic vein and superior

vena cava, which cannot be examined directly.Each spectral image is evaluated for spontaneous,phasic, and nonpulsatile flow. These samples areobtained in the longitudinal plane of the vessel

with angle of insonation maintained at less than60 (Fig. 2). Spectral analysis of the caudal inter-nal jugular vein and medial subclavian vein is

mandatory to evaluate for the presence of trans-

mitted cardiac pulsatility and respiratory phasicity.Loss of this pulsatility may be caused by a more

central venous stenosis or obstruction (Fig. 3)[1]. A normal spectral tracing should return tobaseline.

Spectral tracings from the medial subclavian veinshould be compared with tracings from the lateralsubclavian vein. A change between the two tracingssuggests subclavian vein stenosis in the midportionof the subclavian vein. Response to a brisk inspira-tory sniff or Valsalvas maneuver may assist in eval-uating venous patency. With a sniff, the internal

jugular vein or subclavian vein normally decreasesin diameter or collapses completely. Patients whohave significant stenosis or obstruction of the cen-

tral brachiocephalic vein or superior vena cavalose this response[1].

Peripheral deep venous system

The remainder of the examination includes com-pression every 1 to 2 cm of the axillary vein, thecranial, midportion, and caudal aspect of the bra-chial veins, and the basilic and cephalic veins in

the upper arm. Evaluation of the axilla may belimited by body habitus with subsequent limita-

tion in seeing the vessels sonographically. Typi-cally, the upper extremity is imaged to theantecubital fossa. If the patient has focal pain orswelling or a palpable mass in the forearm, thesymptomatic area is assessed sonographically. Ves-sels in the forearm usually are assessed only aspart of a focused evaluation of a painful or swol-len area or a palpable cord.

Potential pitfalls

Pitfalls to avoid include[24]

1. Axillary versus cephalic vein: The axillary veincan be traced through its anatomic course intothe subclavian vein. In addition, the cephalic

vein, a superficial vein, does not have an adja-

cent artery running along its course. It may benecessary to abduct the arm further, bend the el-bow, and place the hand near the patients head

to access the axilla adequately. Excessive abduc-tion, however, can cause alteration in the venous

waveform that falsely suggests a more proximalvenous stenosis or occlusion. This alterationresolves with a change in position.

2. Caudal occlusion of the internal jugular vein:It is imperative to follow the caudal aspect ofthe internal jugular vein into the junction withthe medial subclavian vein as it forms the

Fig. 2.Normal subclavian vein. Longitudinal color andspectral Doppler of the subclavian vein shows normal

filling of the vessel with color. There is normal trans-mitted respiratory phasicity and cardiac pulsatilitywith transient reversal of flow below baseline.

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brachiocephalic vein. The internal jugular veinusually is in close proximity to the carotid artery.

A vein located further away probably represents

a collateral vessel. An additional pitfall is thatnormal respiratory phasicity may be seen in

well-developed collaterals. The collaterals usu-ally follow the course of the occluded vein. Col-laterals frequently are multiple, somewhat

serpiginous veins, rather than the normal singlevein following the associated artery.

3. Mirror-image artifact: Because of reflection fromthe lung apex or clavicle, mirror-image artifactmay give the appearance of two subclavian veins

in the supraclavicular region

Imaging protocol

Training, skill, and experience are extremely impor-tant in performing all vascular ultrasound examina-tions, including upper extremity venous Doppler

ultrasound. Participation in one of the vascular ac-creditation programs, such as the American Collegeof Radiology or the Intersocietal Commission for

the Accreditation of Vascular Laboratories, isstrongly recommended.

The upper extremity venous imaging protocol in-

cludes the following images for each deep venoussegment:

1. Transverse gray-scale image at rest and withcompression or a cine clip of the compressionmaneuver

2. Longitudinal color Doppler with spectral wave-form demonstrating transmitted cardiac andrespiratory variability

A. Internal jugular veincranial and caudalportions

B. Subclavian veinmid, medial, lateral

C. Axillary vein

D. Brachial veincranial, mid, caudal

E. Basilic veinupper arm

F. Cephalic veinupper arm

Clinical diagnosis

Undiagnosed and untreated deep venous thrombo-

sis (DVT) can result in the fatal outcome of pulmo-nary embolism. In 12% to 16% of pulmonaryembolism cases, the source of thrombus is the up-

per extremities [5,6]. Fatal pulmonary embolismcaused by DVT of the upper extremity has beenreported[7].

Wells and colleagues [8] previously demon-strated that the use of a clinical model allows thephysician to determine accurately the probabilitythat a patient has DVT before diagnostic tests areperformed. Clinical factors associated with in-

creased probability of DVT include active cancer,immobility, localized tenderness along the distribu-tion of the deep venous system, swollen entireextremity, pitting edema confined to the symptom-atic extremity, collateral superficial veins, and previ-

ously documented DVT. The D-dimer assay hasa high negative predictive value, and D-dimer isa sensitive but nonspecific marker for DVT[911].

Wells and colleagues[12]concluded that DVT canbe ruled out in a patient who is judged clinically un-likely to have DVT and who has a negative D-dimertest and that ultrasound evaluation can be omittedsafely in these patients. A problem may arise whena D-dimer is obtained without first evaluating theclinical model. D-dimer may be positive in patients

who have had recent surgery or trauma, infection,atherosclerosis, congestive heart failure, or

Fig. 3.Central venous occlusion. (A) Longitudinal Doppler demonstrates abnormal monophasic flow in the rightbrachiocephalic vein (Doppler gate). (B) Extremely high-velocity flow (329 cm/s) in the vein suggests high-gradestenosis at this level.

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disseminated intravascular coagulation and in preg-nant, puerperal, or elderly individuals. This workaddressed lower extremity DVT and did not addresscentral lines, a frequent cause of upper extremityDVT (UEDVT).

Upper extremity venous thrombosis

The most common indication for venous Dopplerultrasound of the upper extremity is to identifyDVT. Indications for upper extremity venous Dopp-ler ultrasound, as listed in the 2006 American Col-

lege of Radiology practice guideline for theperformance of peripheral venous ultrasound ex-amination, include but are not limited to[13]

1. Evaluation of possible venous obstruction or

thrombus in symptomatic or high-risk asymp-

tomatic individuals2. Assessment of dialysis access grafts3. Venous mapping before harvest for arterial by-

pass or reconstructive surgery4. Evaluation of veins before venous access5. Evaluation for DVT in patients suspected of hav-

ing pulmonary embolism

6. Follow-up for patients who have known venousthrombosis

Other causes include pain and or swelling at the

site of prior phlebotomy or intravenous access site

and, uncommonly, effort-related thrombosis. Thepathogenesis of effort-related thrombosis is relatedto an anatomic constriction of the vein by the clav-

icle and first rib complex associated with repetitivetrauma to the vein and resultant changes in the vein

wall itself [14]. Radiation therapy, effort-inducedthrombosis, and malignant obstructions from com-pression or direct venous invasion by adjacenttumor or metastatic nodal disease are more com-mon causes of venous obstruction in the chestand arm than in the lower extremities.

Unlike the lower extremity, most cases of UEDVTare related to the presence of a central venous cath-eter or electrode leads from an implanted cardiacdevice. Thirty-five percent to 75% of patients whohave upper extremity venous catheters develop

thrombosis, approximately 75% of which areasymptomatic [1517]. The complication rate

varies greatly, depending on whether the catheter

access site is the subclavian or the internal jugularvein. Examining only patients who had symptom-atic UEDVT, Trerotola and colleagues [18] founda greater incidence of DVT in patients who had sub-clavian venous access than in those who had inter-nal jugular access. Thirteen percent of the patients

who had subclavian venous catheters had DVT,compared with only 3% of patients who had inter-nal jugular vein catheters. Thus, the placement of

large-bore catheters into the subclavian vein is tobe discouraged, especially in patients who haveend-stage renal disease for whom dialysis access isbeing considered. The development of subclavian

vein stenosis or thrombosis would limit dialysisaccess possibilities for that upper extremity.

Only 12% to 16% of patients who have UEDVTdevelop pulmonary embolism [6,19]. Most acutepulmonary emboli in patients who have UEDVT oc-

cur in untreated patients[5,20]. The risk of pulmo-nary embolism is greater in catheter-related UEDVTthan in UEDVT from other causes[21]. Associated

complications such as venous stasis and insuffi-ciency caused by venous thrombosis are less com-mon and less severe in the upper extremity thanin the leg. Physiologic factors that exist in the leg,such as exposure of the deep venous system to

high hydrostatic pressure, do not exist in the arm.The tendency toward development of extensive col-lateral venous pathways in the arm and chest after

venous thrombosis or obstruction contributes tothese differences.

Acute deep venous thrombosis

Current literature shows the sensitivity of venous

Doppler ultrasound for UEDVT to range from78% to 100% and its specificity to range from82% to 100%[2227]. The acute deep vein throm-

bus is seen as an enlarged, tubular structure filledwith thrombus showing variable echogenicity andabsence of color Doppler flow (Fig. 4). Nonocclu-sive thrombus may show flow outlining the throm-bus, with a variable appearance depending on

whether the nonocclusive thrombus is acute or

Fig. 4.Occlusive deep venous thrombosis. On longitu-dinal color Doppler of internal jugular vein, no flowis present around the heterogeneous clot.



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chronic. Nonocclusive thrombus usually does notresult in enlargement of the vein (Fig. 5). When ob-struction is incomplete, monophasic flow is dem-onstrated when the luminal narrowing issignificant enough to affect the transmitted cardiac

pulsatility and respiratory phasicity from the tho-rax. As with lower extremity venous Doppler ultra-sound, attention to detail is important in areas of

duplicated veins to avoid overlooking thrombusin one of the paired veins (Fig. 6).

Spectral analysis can assist in the evaluation ofcentral thromboses. The presence of a nonpulsatile

waveform (similar to portal venous flow) stronglysuggests central venous disease such as thrombosis,stenosis, or extrinsic compression from an adjacentmass [22]. It is important to compare the suspicious

waveform with the contralateral side to confirm its

presence on only the symptomatic side. Patel andcolleagues [28] found that absent or reduced car-diac pulsatility was a more sensitive parameter in

patients who had unilateral venous thrombosis,even though respiratory phasicity often was asym-metric. In bilateral subclavian vein or superior

vena cava occlusions the process is bilateral, and

Fig. 5.Nonocclusive deep venous thrombosis. (A) Transverse gray-scale image shows hypoechoic thrombus thatdoes not completely fill the internal jugular vein. (B) On longitudinal color and spectral Doppler, flow is presentin the vein alongside the clot, and normal respiratory phasicity is present.

Fig. 6.Deep venous thrombosis in one paired brachial vein. (A) On transverse gray-scale image of brachial veins,paired veins are visible without compression. (B) A potential pitfall in detecting deep vein thrombosis is shownas one of the two paired brachial veins compresses normally (arrow). The other does not compress because ofocclusive clot (arrowhead).

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a high level of suspicion must be maintained to de-tect central thrombus or stenosis. Also, because ofhigh-volume flow, there may be absence of phasic-ity without stenosis in the central veins if a hemodi-alysis graft is present in the upper arm (Fig. 7).

Chronic deep venous thrombosis

As in the lower extremity, diagnosis of chronic ve-

nous disease may be more difficult than the diagno-sis of acute venous disease. Suggestive findingsinclude frozen valve leaflets, synechia, recanalized

veins with internal channels of flow, and small-cal-iber veins with noncompressible, thickened walls(Fig. 8) [22]. In some cases of chronic venousthrombosis, the vein may be collapsed, fibrosed,and not visible sonographically in the expected an-atomic location. For example, if only one brachial

vein is demonstrated, chronic scarring from priorDVT of the other brachial vein should be suggested.

Flow direction and collateral pathways should benoted also. In rare cases of brachiocephalic throm-bosis, drainage may occur in a retrograde fashionthrough the internal jugular vein to collateral ves-sels (Fig. 9). In cases of occluded veins, the develop-

ment of large venous collaterals may be mistakenfor the thrombosed vessel. Collateral veins are tor-tuous venous structures that are not in the normal

venous location, adjacent to the artery (Fig. 10).These collateral veins may show normal respiratoryphasicity because they communicate with veins thatare subject to changes in intrathoracic pressure.

The presence of a chronic thrombus in a symp-tomatic patient without evidence for new acute

thrombus suggests postthrombotic syndrome. Post-

thrombotic syndrome is the most common latecomplication of DVT. Signs and symptoms includepain, edema, hyperpigmentation, and skin ulcera-tion. Without the presence of acute thrombus, anti-coagulant therapy is not indicated[29]. Therefore,it is important in patient management to differenti-ate acute from chronic changes whenever possible.

Rubin and colleagues[30,31] demonstrated that so-nographic elasticity imaging, a technique that mea-sures tissue hardness, can discriminate betweenacute and chronic thrombi and can perform at leastas well as thrombus echogenicity. Although thistechnique currently is not available commercially,

it may play a future diagnostic role.

Fig. 7. Monophasic flow in subclavian vein withoutstenosis. Longitudinal color and spectral Dopplershow monophasic waveforms due to high flow vol-umes from an upper arm hemodialysis graft. Therewas no central stenosis present on angiography.

Fig. 8.Chronic superficial venous thrombosis. On lon-gitudinal gray-scale image, thickening of the basilicvein (cursors) is present at site of previous catheterplacement. The basilic vein is a superficial vein andusually does not require anticoagulation if a throm-bus is present.

Fig. 9. Brachiocephalic vein occlusion. Reversal offlow is present on color Doppler of the internal jugu-lar vein (arrow). Note the internal jugular vein andcarotid artery (arrowhead) both demonstrate cranialflow.



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Areas of stenosis related to prior thrombosis orline placement can be demonstrated with gray-scaleand color Doppler examination. A segment of vein

may be narrowed significantly relative to the adja-cent segments. Thickening or irregularity of the

vein wall may be present. Turbulence with aliasingon color Doppler or high-velocity flow on spectralanalysis may be demonstrated in these areas. Flowin the narrowed segment is not normal and mayshow increased pulsatility as compared with damp-ened, nonphasic flow in the more peripheral wave-form (Fig. 11)[22].

Other vascular entities, such as a carotid arteryto internal jugular fistula, may be associated withupper extremity swelling and mimic DVT(Fig. 12). Additional factors may alter venous

hemodynamics. Pain and colleagues [32] demon-strated significant alteration of axillary venousflow patterns in patients who had axillary lymph

node dissection and breast cancerrelated lymphe-dema. The etiology of breast cancerrelated edemais multifactorial, and abnormalities of venousdrainage are a contributory factor. Further investiga-tion is needed.

When Doppler findings are indeterminate, espe-cially regarding central thrombosis or stenosis, or

when there is high clinical suspicion for UEDVTwithout confirmatory sonographic findings, corre-lation with MR venography or catheter venographymay be needed. In the authors experience, the mostfrequent indications for MR venography are sus-pected central thrombosis and stenosis with

Fig. 10. Occlusive deep venous thrombosis with collaterals. (A) Color Doppler of internal jugular vein showsthrombus without visible flow. (B) A large collateral vessel is visible communicating with the external jugularvein as it bypasses the level of internal jugular vein obstruction, confirming the chronic component of the ob-struction. (C) Catheter venogram in another patient shows absence of contrast in the left brachiocephalic vein(arrows) and presence of collateral vessels (arrowheads).

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unilateral or bilateral abnormal respiratory phasic-ity in the medial subclavian vein and internal jugu-lar vein.

Venous access procedures

In patients who need venous access or catheteriza-tion, upper extremity venous Doppler ultrasoundcan identify an appropriate vessel for access. This

access vessel should be screened for the possibilityof central stenosis or occlusion. Ultrasound alsocan demonstrate the target vessel during the proce-

dure to improve the accuracy of venipuncture,decrease potential complications, and reduce pro-cedure time. The variability in location of vascularstructures relative to external landmarks is a strongreason to use ultrasound. Povoski and Zaman[33]recommend the use of preoperative ultrasound inpatients who have had previous central venous ac-cess associated with deep venous thrombosis to as-sess for central stenosis or occlusion. In addition,

they recommend intraprocedural venographywhen there is difficulty advancing the guidewireor catheter centrally or when preoperative ultra-

sound is negative despite previous central venousaccess with DVT. In an existent catheter that has

been in place for a prolonged time, upper extremityultrasound can demonstrate thrombus or fibrinsheath around a catheter (Fig. 13).

Sonographic evaluation before and afterplacement of hemodialysis access

Preoperative mapping

Ultrasound vascular mapping before hemodialysisaccess placement now is an established procedure.Robbin and colleagues[34]demonstrated that pre-operative sonographic mapping before placementof hemodialysis access can change surgical manage-ment, with an increased number of AVFs placed andan improved likelihood of selecting the most func-tional vessels. Superficial and deep veins of the

Fig. 11.Stenosis of cephalic vein. (A) Longitudinal color Doppler of the cephalic vein demonstrates focal narrow-ing (arrow) of the vessel with aliasing. (B) Spectral Doppler shows a waveform that is abnormally monophasic.(C) Medial to the area of stenosis, spectral Doppler shows normal venous phasicity.



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forearm and upper arm, as well as arteries, are eval-uated for their suitability for graft or fistula place-ment. Criteria such as the diameter of the veinand the depth of the superficial vein from the skinare used to determine whether a fistula or a graftis recommended[35].

Arteriovenous fistula maturity assessment

Ultrasound also has a role after access placement.Upper extremity venous Doppler ultrasound canplay a key role in addressing the two primary goals

of the Vascular Access Work Group of the NationalKidney Foundation, to increase the prevalence anduse of native AVFs and to detect access dysfunctionbefore occlusion [36]. Ultrasound evaluation willplay an increasingly important role in determiningthe maturity of a hemodialysis AVF[37,38]. Using

color duplex ultrasound surveillance, Grogan andcolleagues[38]found an unexpectedly high preva-lence of critical stenoses in patent AVFs before initi-

ation of hemodialysis and concluded that stenosesseem to develop rapidly after arterialization of theupper extremity superficial veins. They postulatedthat turbulent flow conditions in AVFs might playa role in inducing progressive vein wall and valveleaflet intimal thickening, although stenoses maybe caused by venous abnormalities that predate

AVF placement. Detection of stenosis, graft degener-

ation, or pseudoaneurysm formation may be im-portant in triaging the patient toward appropriatecare[39]. Ultrasound may prove useful in triagingpatients toward the appropriate therapy for an im-mature AVF. When an AVF has low-volume flow,

and one or more accessory or competing veinsthat may be sumping flow from the AVF are de-tected, ligation of accessory vein branches may beuseful[40].

Because of the large amounts of arterialized flowin the hemodialysis access, there may be changes inthe spectral venous flow characteristics of the drain-

ing vein. Specifically, there may be loss of the nor-mal respiratory phasicity in the absence of centralstenosis or occlusion. This loss of phasicity occursmore commonly in patients who have upper ex-tremity hemodialysis grafts than in those whohave fistulas.

Summary

It is important to understand thoroughly the nor-mal anatomy and common variations of the upper

extremity veins and arteries to avoid misdiagnosis.This understanding is particularly important be-cause the incidence of upper extremity venous dis-ease is increasing. The widespread use of central

venous catheters, percutaneous interventional pro-

cedures performed with access through the upperextremity venous system, and implanted cardiacdevices is increasing the number of patients who

have upper extremity thrombosis. Ultrasoundplays an important role in evaluating the upper ex-tremity venous system and is the initial imagingmodality of choice. When sonographic findingsare equivocal or nondiagnostic, especially regard-ing central thrombosis, correlation using MR ve-nography or catheter venography may be helpful.Ultrasound can provide an accurate, rapid, low-cost, portable, noninvasive method for screening,

Fig. 13. Clot around catheter. Gray-scale Dopplershows occlusive clot surrounding an existing jugularvenous catheter (arrow), a common complication ofvenous catheter placement.

Fig. 12. Carotid-jugular fistula. Color Doppler showsdirect communication (arrow) between the carotidartery and internal jugular vein. Arterialized flowwas present in the internal jugular vein (not shown).

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mapping, and surveillance of the upper extremityvenous system.

Acknowledgments

The authors thank Trish Thurman for her assistance

in manuscript preparation.

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