Upper extremity venous Doppler ultrasound

ACR Appropriateness Criteria® Suspected Upper Extremity Deep Vein Thrombosis

This publication includes the appropriate imaging modalities to assess suspected deep vein thrombosis in the upper extremities. Ultrasound duplex Doppler is the most appropriate imaging modality to assess upper-extremity deep vein thrombosis. It is a noninvasive test, which can be performed at the bedside and used for serial evaluations. Ultrasound can also directly identify thrombus by visualizing echogenic material in the vein and by lack of compression of the vein walls from manual external pressure. It can indirectly identify thrombus from altered blood-flow patterns. It is most appropriate in the evaluation of veins peripheral to the brachiocephalic vein. CT venography and MR venography are not first-line imaging tests, but are appropriate to assess the central venous structures, or to assess the full range of venous structures from the hand to the right atrium. Catheter venography is appropriate if therapy is required. Radionuclide venography and chest radiography are usually not appropriate to assess upper-extremity deep vein thrombosis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Incidence and risk factors of superficial and deep vein thrombosis associated with peripherally inserted central catheters in children

Essentials Pediatric studies on peripherally inserted central catheter (PICC)-related thrombosis are scarce. This study analyzes incidence and risk factors for PICC-related venous thrombosis in children. PICC-related thrombosis is a common, and nearly always, asymptomatic complication. Echo-guided insertion and a catheter to vein ratio < 0.33 may notably decrease this complication.

SUMMARY

Background Upper-extremity venous thrombosis is associated with the use of peripherally inserted central catheters (PICCs). Few pediatric studies have focused on this issue. Objectives To determine the incidence and risk factors for PICC-related superficial vein thrombosis (SVT) and deep vein thrombosis (DVT) in children. Patients/methods An observational follow-up cohort study was conducted at a single hospital between June 2012 and June 2015. All patients receiving a PICC were enrolled and followed up, with weekly Doppler ultrasound examination of the catheterized limb until PICC removal. Patient, procedural and follow-up data were analyzed. Results In the study period, 265 PICCs were inserted (median age of patients 6.5 years, interquartile range [IQR] 2.4-13 years; median weight 20 kg, IQR 11-38 kg; 54% males; 67.9% chronically ill), and patients were followed up for a total of 9743 days. The median indwelling time was 21 days (IQR 12-37 days). During follow-up, 88 (33.2% of insertions) PICC-related thromboses (incidence rate [IR] 9.03 per 1000 catheter-days) were diagnosed, 66 (24.9%) as isolated SVT, seven (2.6%) as isolated DVT, and 15 (5.7%) as SVT with associated DVT (IR 6.78, 0.71 and 1.54 per 1000 catheter-days, respectively). Only 9.9% of patients with SVT and 18.2% of those with DVT were symptomatic. The main risk factors for PICC-related SVT and DVT were a catheter/vein ratio of > 0.33 and thrombosis of the catheterized superficial vein, respectively. Conclusions PICC-related thrombosis is a common and nearly always asymptomatic complication in children, the SVT rate being approximately three times higher than the DVT rate. Optimal vein and catheter selection, yielding the lowest possible catheter/vein ratio, may decrease the rate of PICC-related thrombosis.

Use of diagnostic modalities for assessing upper extremity vascular pathology

Vascular pathology of the upper extremity requires consideration of constitutional, anatomic, and functional factors. The medical history and physical examination are essential. The Allen test can be performed alongside a handheld Doppler for arterial mapping. Useful studies include digital-brachial index measurements, digital plethysmography, laser Doppler, and color ultrasounds. Three-phase bone scintigraphy still plays a role in the evaluation of vascularity after of frostbite injury. Angiogram remains the gold standard radiographic instrument to evaluate vascular pathology of the upper extremity, but computed tomography and magnetic resonance scans have an increasing role in diagnosis of vascular pathology.

Nerve Hematoma Mimicking DVT

This case study describes a patient who underwent an upper extremity venous examination to evaluate for possible deep vein thrombosis (DVT). Sonography showed no evidence of thrombus in the veins of the deep or superficial system. Adjacent to the veins of the peripheral arm, however, an enlarged hypoechoic structure was visualized that had a very similar appearance to DVT. With further imaging, hyperechoic linear bands were visualized at the proximal end of the hypoechoic structure. The appearance suggested that this structure was related to the median nerve, but its normal appearance was altered by a large mass inside the nerve sheath. Given the patient’s history, the finding most likely represents a nerve hematoma.

Venous International Assessment, VIA Scale, Validated Classification Procedure for the Peripheral Venous System

Purpose

VIA scale is a dynamic performance status tool of the peripheral venous system that is divided into five different grades, composed of three parameters: number of observable puncture points; optimal catheter size for cannulation and ease of performing venipuncture and risk of extravasation.

Methods

Prospective single-center, observational, open, non-randomized study divided into two phases. In the first longitudinal phase, we studied the clinical characteristics and the changes in their peripheral venous systems during intravenous chemotherapy for 16 patients (n=16) for an average period of 24 months. In the second transverse phase, we measured the vein's diameter at the selected puncture points with a high-resolution ultrasound and paired this figure with VIA scale. We selected a group of oncology patients (n=52) and a control group (n=56).

Results

In the first phase, the level of agreement between the three reviewers was excellent. The second step was to assess the relationship between the measurements obtained with ultrasound and the VIA scale. The vein diameter measurements show a decrease directly related to the assessment of observers in the VIA scale.

Conclusions

The VIA scale is a simple, easy and practical method for classification of the peripheral venous system in terms of vascular access. The practical application of our VIA scale significantly increases the quality of life of patients by increasing the chances of successful venipuncture and cannulation and thus reducing the risk of extravasation and material costs, allowing both an economical and a safe venous assessment tool.

Upper-extremity deep venous thrombosis: a review

Upper-extremity deep venous thrombosis is less common than lower-extremity deep venous thrombosis. However, upper-extremity deep venous thrombosis is associated with similar adverse consequences and is becoming more common in patients with complex medical conditions requiring central venous catheters or wires. Although guidelines suggest that this disorder be managed using approaches similar to those for lower-extremity deep venous thrombosis, studies are refining the prognosis and management of upper-extremity deep venous thrombosis. Physicians should be familiar with the diagnostic and treatment considerations for this disease. This review will differentiate between primary and secondary upper-extremity deep venous thromboses; assess the risk factors and clinical sequelae associated with upper-extremity deep venous thrombosis, comparing these with lower-extremity deep venous thrombosis; and describe an approach to treatment and prevention of secondary upper-extremity deep venous thrombosis based on clinical evidence.

Peripherally inserted central venous catheters and central venous catheters related thrombosis in post-critical patients

BACKGROUND

Peripherally inserted central venous catheters (PICC) have been proposed as an alternative to central venous catheters (CVC). The aim of this study was to determine the thrombosis rate in relation to PICC placement in patients discharged from the intensive care unit (ICU).

METHODS

Data of patients admitted to the ICU (Careggi Teaching Hospital, Florence, Italy; January-August 2008) and discharged with a central venous device were sequentially studied. During the first 4 months, CVCs were used (CVC group), whereas during the last 4 months, PICCs were used (PICC group). Demographic/clinical and catheter-related data were collected. Intensivists performed Doppler examination at ICU discharge and 7, 15, and 30 days after placement.

RESULTS

Data of 239 patients were analyzed (125 of CVC group, 114 of PICC group). A total of 2,747 CVC-days and 4,024 PICC-days of observation were included. Patient characteristics were comparable between groups. Patients with PICC had a significantly higher incidence rate of deep venous thrombosis (DVT) than patients with CVC (27.2 vs. 9.6%, P = 0.0012). The rate of DVT/1,000 catheter days was 4.4 for CVCs and 7.7 for PICCs. Eighty percent of DVTs occurred within 2 weeks after insertion. Binary logistic analysis showed a two-fold increased risk for women and a three-fold increased risk when using the left basilic vein in the PICC group.

CONCLUSIONS

In our post-critically ill population, PICCs were associated with a higher rate of DVT complications than CVCs. Routine ultrasound surveillance for the first 2 weeks after patient discharge from the ICU with a PICC and preferential use of CVC for these patients may be warranted.

Accuracy and Cost Comparison of Ultrasound Versus Alternative Imaging Modalities, Including CT, MR, PET, and Angiography

Ultrasound (US) has become widely used in clinical medicine for the diagnosis of a variety of disease processes. The unique ability of US to provide accurate information through an efficacious, painless, portable, and nonionizing method has expanded its role and application in diverse medical settings. Given the current economic environment and the related interest in creating the greatest value for health care expenditures, US has been evaluated to compare its clinical accuracy/efficacy and cost-effectiveness versus other imaging modalities. The following literature review reports the results of research studies aimed at comparing the accuracy/efficacy and cost of US versus alternative imaging modalities, including magnetic resonance imaging, computed tomography, contrast angiography, and single-photon emission computed tomography.

The medical Doppler in hand surgery: its scientific basis, applications, and the history of its namesake, Christian Johann Doppler

The word Doppler is used synonymously in hand surgery for evaluating patency of vascular structures; however, the science and history behind the Doppler effect are not as well-known. We will present the theories behind the Doppler effect and the history of the person who made this discovery.