Sonography Evaluation of the Upper Extremity Venous System Evaluation for Deep and Superficial Venous Thrombosis

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1 Sonography Evaluation of the Upper Extremity Venous System Evaluation for Deep and Superficial Venous Thrombosis Wayne C Leonhardt, BA, RDMS, RVT Mission Imaging Asheville, North Carolina

2 Disclosure Information I have no financial relationships to disclose and I will not discuss off label use and/or investigational use in my presentation

3 Upper Extremity Venous Duplex Examination Objectives; Review Normal/Abnormal Upper Extremity Venous Anatomy, Collateral Circulation, Hemodynamics, & Waveforms Review Classifications of UEDVT and Associated Syndromes Review the Natural Hx of Thrombus & Acuity Assessment of UEDVT/SVT Review Sonographic findings with Central Venous Obstruction and Tumor Thrombus Review Technical Considerations

4 Upper Extremity Venous Duplex Examination UEDVT and PE Prevalence of symptomatic and asymptomatic PE in Pts with UEDVT is as high as 10-30% similar to Lower Extremity DVT Patients with Catheter-Associated UEDVT have a higher risk for PE Mortality Rate (10-50%) Related Mainly to Underlying Malignancy & Fatal PE RA Thrombus Pulmonary Embolus Intro to Vasc Ultrasonography, 2012

5 Upper Extremity Venous Duplex Examination UEDVT & SVT Overview Incidence of UEDVT; Primarily seen SCV (18-67%), AXV (5-25%), Brach V (4-11%), IJV/Innom V (20-30%), Basilic/Cephalic v s (20-30%) Upper Extremity DVT Accounts for 11% of all cases of DVT The incidence of UEDVT is increasing with the frequent use of Central Venous Catheters Superficial V s PICC Primary Route of Thrombus of Extension to the Central Veins Complications; Post-Thrombotic and SVC syndrome, loss of vascular access The American Journal of Medicine (2011) 124, Vascular Medicine 16 (3) Int J Crit Ill Inj SCI 2012, Jan-Apr; 2 (1): 21-26

6 Upper Extremity Venous Duplex Examination Classification of UEDVT Primary Spontaneous UEDVT (20%-30%) Divided into Effort -Related Thrombosis & Idiopathic Effort Thrombosis or Paget-Schroetter syndrome (Rare 1-2 per 100,00 people per Yr; Yearly incidence in US 3,000-6,000) Acute Onset Axillosubclavian Vein Thrombosis following Strenuous & Repetitive Activity upper extremities (Hyperextension & Extension) Most Pts have underlying Venous Thoracic Outlet Syndrome (VTOS); External Compression of the SCV at the Costoclavicular Jct (anterior portion of the thoracic outlet) and by the Posterior Triangle formed by the Anterior and Medial Scalene Muscles Idiopathic Thrombosis; No obvious risk factors or underlying disease J Vasc Surg 2010;51:

7 Upper Extremity Venous Duplex Examination Paget-Schroetter Syndrome/Effort Thrombosis Venous Thoracic Outlet Syndrome Axillosubclavian Vein Thrombosis; resulting from intermittent and positional vein compression during exercise Strenuous/Repetitive Activity, Arm Positioning (hyperabduction) & Anatomic Abnormalities; Congenital or Acquired at the Costoclavicular Jt Key Factors Exertion causes microtrauma of the endothelium leading to inflammation, thrombosis, intimal hyperplasia, scarring, stenosis Dominate arm involvement; 2:1 Ratio Men/Women age early 30 s 60%-80% of Pts report vigorous exercise resulting in syndrome 40% of Pts report prolonged hyperabduction ie..painting, Weight Lifting, Swimming, Tennis, Baseball Pitching, etc Journal of Vasc Surg, Vol 51, No 6, June 2010

8 Upper Extremity Venous Duplex Examination Paget-Schroetter Syndrome/Effort Thrombosis Clinical Presentation: Sudden onset of a blue, swollen, heavy, painful arm Patients with intermittent positional venous obstruction will present with episodic arm discoloration & swelling, usually elicited by exercise or arm elevation (hyperabduction) Prominent collateral veins across the shoulder, upper arm, & neck develop in many Pts, especially if occlusion is chronic Journal of Vasc Surg, Vol 51, No 6, June 2010 SCV Acute Thrombus

9 Upper Extremity Venous Duplex Examination Venous TOS Diagnosed With Duplex US Duplex Ultrasound recommend study for initial diagnosis Some Pts presenting with UE swelling without thrombosis, have McCleery syndrome or intermittent compression of the SCV When clinical symptoms appear to be positional, perform Duplex US (Pt Supine) using shoulder abduction maneuvers at various degrees (90-180) in the Subclavian & Axillary veins Duplex Findings for VTOS; Damped monophasic waveform (90 degrees) Increased velocities Absent color flow & pulse wave Doppler (135 degrees) JDMS 27 (5) , 2011 Vascular Medicine 2015, Vol 20 (2)

10 Upper Extremity Venous Duplex Examination Classification of UEDVT Secondary UEDVT (80%) Catheter-Related (28-61%) Use of Peripherally Inserted Central Venous Catheters (PICC), Pacemaker/Defibrillator leads) Malignancy Associated (45%- 64%) Hypercoagulable States (hereditary and acquired) Arm/Neck/Shoulder Surgery or Trauma Chest Wall Masses J Ultrasound Med 2005;24: American Journal of Medicine (2011) 124,

11 Upper Extremity Venous Duplex Examination: CVC/PICC Multiple Lumen Normal PICC Multiple Lumen Normal PICC Thrombosed SCV PICC Multiple Lumen Single Lumen

12 Upper Extremity Venous Duplex Examination: Fibrin Sheaths Early Catheter Sheath Development SCV Fibrin Sheaths: Adherent coating of fibrin and collagen that envelopes the CVC (as early as 24Hrs) Occurs in up to 47% of Pts with CVCs Benign complication, but can cause catheter malfunction Mural thrombus can cause stenosis/thrombosis of venous lumen Multi-Lumen Catheters Echogenic Sheaths-Post Catheter Removal Annals of Oncology, , Oct 2007

13 Upper Extremity Venous Duplex Examination: Pacemaker Leads Normal SCV Pacemaker Normal SCV Pacemaker Damped Vein Wall Response- Respiratory Maneuver Thrombosed Prx SCV

14 Upper Extremity Venous Duplex Examination Normal Anatomy Central/Deep Veins Peripheral Deep Veins Superficial Veins Intro to Vasc Ultrasonography, 2012

15 Upper Extremity Venous Duplex Examination: Common Collateral Pathways Jugular Venous Arch/EJV Tributaries SCV Thrombosis; (Suprascapular V, EJV, AJV, Venous Arch) Innominate V Obstruction; (EJV/AJV, IJV) Retrograde Flow Key Points; In the presence of SCV Thrombosis, adjacent veins may become quite large such as the EJV and its Tributaries Caution: Note the location and adjacent artery to confirm the native SCV VS a Collateral R Innom SCV L Innom SVC SCV RadioGraphics 1992, 12: Techniques in Noninvasive Vascular Diagnosis, 2010

16 Upper Extremity Venous Duplex Examination Sonographic Anatomy: Thoracic Inlet (Central Veins) IJV SCV Distal SCV/ART Innominate Axillary V: Medial to Art. Internal JV: Lateral to CCA Innominate/Brachiocephalic V: Bilateral V s formed by IJV/Subcl V Intro to Vasc Ultrasonography, 2012 Radiographics 15: , 1995 Scv: Anterior/Inferior to Art Mid Clavicle

17 Upper Extremity Venous Duplex Examination: Anatomy Peripheral Deep Veins Brachial V s Paired V s that join the Basilic V to form the Axillary V Radial V s Radial/ULnar V s: Paired V s unite at the elbow to form the Brachial VV Ulnar V s Radial/Ulnar V s

18 Upper Extremity Venous Duplex Examination: Brachial Plexus Mimicking Chronic Brachial V DVT Network of nerve fibers running from the spine formed by cervical and thoracic nerve roots proceeding through the neck, axilla, upper arm, forearm, & hand Major nerves in the Upper Arm; Median, Radial, & Ulnar US; Avascular hypoechoic rounded nodules, or linear hypoechoic structure with echogenic striations representing connective tissue surrounding the nerve fibers Nerve Bundle AJR:171, December 1998

19 Upper Extremity Venous Duplex Examination: Anatomy Superficial Veins Basilic V : Joins Brach V to form the Ax V Ceph V: Joins the Superior aspect of Ax V before it becomes the SCV

20 Upper Extremity Venous Duplex Examination: Anatomy Superficial Veins MCV ( Median Cubital Vein) Median Cubital V: Ascends from the CV on the lateral side to connect with the Basilic V on the medial side of the elbow Intro to Vasc Ultrasonography, 2012

21 Upper Extremity Venous Duplex Anatomy High Brachial Artery Bifurcation High origin of the Radial & Ulnar artery is the most common variation of the Brachial artery Occurs in Approximately 12%-14% of the population Origin varies; Prx, Mid, Distal Upper Arm US; Shows 2 Arteries and 4 Veins) * Basilic Vein Check Cubital Fossa for conventional anatomy Seminars in Dialysis-Vol 25, No 2 (March-April), 2012

22 Upper Extremity Venous Duplex Examination: Anatomy Superficial Neck Veins EJV AJV EJV Thyroid AJV s Jugular Venous Arch Sternal Clavicular AJV; Begins near the hyoid bone and passes down the front of the neck deep to the SCM and opens into the termination of the External JV. There are normally two AJVs.

23 Upper Extremity Venous Duplex Examination: Anatomy Superficial Neck Veins EJV EJV IJV EJV IJV IJV SCV Rt Innominate SCV Rt SCV Infraclavicular Approach Supraclavicular Approach Rt Innominate V External Jugular Vein: Runs perpendicular down the neck, lateral to the IJV; empties into the supraclavicular portion of the SCV just before the IJV/SCV Confluence EJV SCV Transverse Cervical Suprascapular Lt

24 Upper Extremity Venous Duplex Examination: Normal Characteristics Thoracic Inlet/Central Veins Compressible Thin-walled, smooth Anechoic lumen (except w stasis) with Visible Valve Motion Observed Vein Wall Motion with Respiration Absent Intraluminal Thrombus Complete lumen filling with Color Intro to Vasc Ultrasonography, 2012

25 Upper Extremity Venous Duplex Examination: Compressible Thin-walled, smooth Anechoic lumen (except w stasis) with Valve Motion Complete lumen filling with Color Normal Characteristics Peripheral Deep & Superficial Veins Brachial V s Brachial V s Intro to Vasc Ultrasonography, 2012

26 Upper Extremity Venous Duplex Examination: Non Compressible vein size compared to artery Abnormal Response of Vein Wall Motion to Respiratory Maneuvers Intraluminal echoes Abnormal Characteristics SCV Acute Thrombus Median Cubital V Rest Sniff AX V Bas V Intro to Vasc Ultrasonography, 2012 Acute Thrombus Brach V Acute Complete IJV Thrombus

27 Upper Extremity Venous Duplex Examination Normal : Spectral Doppler Central Veins Spontaneous Symmetric Transmitted Atrial Pulsatility & Respiratory Phasicity Augmentation; Distal Compression or Sniff maneuver IJV Innominate/BCV Techniques in Noninvasive Vascular Diagnosis. 2012

28 Upper Extremity Venous Duplex Examination Normal : Spectral Doppler Peripheral Veins Spontaneous Respiratory Phasicity Augmentation Basilic Vein Brachial V s Inside US ;Vascular Reference Guide, June 2015

29 Upper Extremity Venous Duplex Examination: Absent Spontaneous Flow Abnormal: Spectral Doppler Asymmetry of Waveforms R Subcl V L Subcl V Damped Decreased Velocity Retrograde Flow Intro to Vasc Ultrasonography, 2012 Prx Obstruction Ext JV

30 Upper Extremity Venous Duplex Examination: Continuous/Turbulent Abnormal: Spectral Doppler PICC Pacemaker Stenosis Stent Intro to Vasc Ultrasonography, 2012

31 Upper Extremity Venous Duplex Examination: Thrombus forms behind valve cusps Propagates & becomes free floating Attaches to wall & fills lumen Recanalization: Complex Process that involves retraction, neovascularization, and resorption (fibrinolysis) May resolve completely (50%), scar 35%, or remain (15%) Natural HX of Thrombus Early Thrombus formation Recanalization Webbing Vein Expansion and Attachment Intimal Thickening J Vasc Surg 2002; 35: Circulation,2003; 107:I-11-I-30

32 Upper Extremity Venous Duplex Examination: Acute: Acuity Assessment of DVT Increased vein size compared to artery Variable Echogenicity, may appear virtually anechoic Poorly Attached Smooth borders Deformable SCV Acute AXV Acute SCV Acute CV Acute Comp Gentle Compression

33 Upper Extremity Venous Duplex Examination: Acute Thrombus Innominate/Subclavian

34 Upper Extremity Venous Duplex Examination: Acuity Assessment of DVT Scarring, Residual Thrombus, Chronic Changes: Normal to Small vein compared to artery Echogenic Fibrotic Cord Rigid and Firmly Attached Irregular Borders Calcifications, Synechiae, Intimal Thickening Stenosis IJV AXV Echogenic Fibrotic Cord IJV Synechiae SCV Synechiae IJV Intimal Thickening SCV Stenosis

35 Upper Extremity Venous Duplex Examination: Acute DVT PICC Acute SCV Acute AXV Ext JV Acute SCV DVT Acute Brach VV DVT Acute IJV DVT Prx IJV

36 Upper Extremity Venous Duplex Examination: Acute DVT & SVT PICC AX V Basilic V Acute Basilic V SVT Acute Basilic V SVT Acute Brach VV DVT AX V Bas V Brach V Acute SCV DVT/Pacemaker Acute SCV DVT Acute DVT/SVT

37 Upper Extremity Venous Duplex Examination: Acute SVT Rest Comp Median Cubital V Cephalic V Median Cubital Vein Cephalic V Basilic Veins

38 Upper Extremity Venous Duplex Examination: Acute SVT Bas V Non Occlusive Ant JV/Distal Br L Brach V Ant Midline Non Occlusive Lt EJV /Prx SCV Occlusive Jugular Venous arch

39 Upper Extremity Venous Duplex Examination: Chronic Changes Scarring Cephalic V Intimal Thickening Basilic V Damped IJV WF SCV Scarring Cephalic V IJV Scarring

40 Upper Extremity Venous Duplex Examination: Hx; 35 Yr old female with persistent LUE Swelling S/P Pacemaker 6 months Central Obstruction Normal Flow Reverse Flow Techniques in Noninvasive Vasc Diagnosis, 2010 Lt Ext JV Lt IJV SCV Rt SCV Contrast No Contrast Around Pacemaker Wires in Lt SCV Lt Confluence Reverse Flow Reverse Flow Lt Ant JV With Contrast

41 Upper Extremity Venous Duplex Examination: Hx; 40 Yr old male with RUE Swelling S/P Power Port, 4 Months on Chemotherapy also has Hx of multiple CVC s in the past Central Obstruction Rt SCV Lt SCV Rt Innom Stenosis Rt Innominate

42 Upper Extremity Venous Duplex Examination: Refers to Mass of Cells that mimic Typical Thrombus Extremely Rare; Commonly arise from a Primary Cancer Outside the Blood Vessels Presents as a Soft Tissue Mass Heterogeneous Extending into the Venous Wall, with Arterialized Blood Vessels within the Thrombus Can Exhibit both Arterial and Venous Flow Paramount to Evaluate Surrounding Anatomic Structures in Patients with a HX of Primary Carcinoma Tumor Thrombus Journal for Vasc Ultrasound 30 (2):87-91, 2006 CCA IJV M CCA M Metastatic Renal Cell CA IJV With Arterial Flow IJV with Tumor Thrombus Courtesy of Marie Gerhard-Herman, MD, RVT

43 Upper Extremity Venous Duplex Examination: Technical Considerations Unilateral Exams When performing a unilateral venous exam, obtain the contralateral subclavian waveform to exclude the presence of a central obstruction RUE Swelling R/O DVT

44 Upper Extremity Venous Duplex Examination: Technical Considerations Veins proximal to the Axillary Vein demonstrate respiratory phasicity and cardiac pulsatility Doppler waveforms should be symmetric bilaterally Persistent retrograde flow in the IJV or Ext JV suggests Central venous obstruction Use a Supraclavicular Coronal Oblique View; with a sector or convex transducer to image the IJV/Subclavian Confluence in large and muscular patients

45 Upper Extremity Venous Duplex Examination: Technical Considerations Patient Position/Vein Diameter Optimal Visualization and Venous Distention of the Central Veins, Scan the Patient Supine The pressure gradient between arm veins and Rt Atrium is insignificant IJV Supine IJV Upright Peripheral Veins; Scan Pt Upright for Maximum Vein Distention SCV Supine SCV Upright

46 Upper Extremity Venous Duplex Examination: Technical Considerations Color Doppler Color Doppler : Patency, Flow Direction, Recanalization, Detect Collateral Channels, and Venous Stenosis Normal Flow Direction Central Obstruction GS Stent Same Patient Collateral Stent Stenosis J Ultrasound in medicine 2005; 24: Lt SCV/EJV Occlusive Thrombus

47 Upper Extremity Venous Duplex Examination: Technical Considerations Anatomic Relationship UEDVT Identifying the normal anatomic relationship of the Vein to it s adjacent Artery, is an important clue in differentiating native veins from enlarged collaterals Collateral Vessel Lt SCV/EJV Jct Occlusive Thrombosis J Ultrasound in medicine 2005; 24:

48 Upper Extremity Venous Duplex Examination: Technical Considerations Scanning Approach Use a Supraclavicular Coronal Oblique View to optimally visualize the confluence of the IJV/SCV of the subclavian vein; an Infraclavicular approach limits anatomy access of the central portion of the subclavian vein due to shadowing of the sternoclavicular joint Rt IJV/SCV Confluence SC JT SCV Central

49 Upper Extremity Venous Duplex Examination: Limitations Patients with open wounds and or bandages limiting acoustic access Patients with severe arm and neck pain that cannot tolerate transducer compression Morbidly obese patients with deep vessels Very Thin patients with superficial veins Uncooperative and or Combative patients Patients who cannot be adequately positioned

50 Upper Extremity Venous Duplex Examination Summary Upper extremity venous thrombosis can be diagnosed with a sensitivity of (78-100%) and a specificity of (82-100%) Other imaging tests( Magnetic Resonance, Computed Tomography and Contrast Venography) maybe required in cases of equivocal Doppler findings, or when the exam is negative and central venous obstruction is suspected Accurate diagnosis is dependent on the sonographer s clinical & anatomical knowledge of the causes and hemodynamics resulting in UEDVT & SVT J Ultrasound Med 2005;24: