 Hello, this is Dr. Mridhula Bapad and today I will be speaking about evaluation of the upper extremity venous system. So certain anatomy which we need to know, the upper extremity veins are divided into superficial and deep just like the lower extremity. In the superficial veins you have the calfalic and the basalic. The calfalic begins at the dorsum of the distal forearm and courses in the forearm collecting various tributaries. It usually drains into the subclavian vein high up and sometimes it may also drain into the axillary vein as an anatomical variation. The basalic vein begins medially just below the cubital fossa and continues medially in the arm and it is many times seen to join the brachial vein. Both the calfalic and the basalic together have a common communicating median cubital vein usually seen at the cubital fossa and this anatomy can always show variations in day to day scans. We need to document those variations. The deep veins, the deep veins include the subclavian and the internal juggler. They have a characteristic waveforms which we will be subsequently seeing. So coming on to evaluation of the calfalic vein and the basalic vein first. So superficial veins they are very easy to identify. The calfalic vein is seen coursing along the dorsum of the forearm and one should include a proper b-mode evaluation in which you use copious gel. Try with minimum compression so that the vein is not compressed as you evaluate and b-mode compression once the lumen is completely obliterated you rule out any thrombosis. That's how a normal calfalic vein is to be evaluated as much cranial or as much proximal as you can and further continue evaluating it or further continue tracing it into the arm where you can see it goes deeper, pierces the fascia and is subsequently seen to enter the subclavian vein. So this is a normal calfalic vein where you see thin walls. You can actually measure it from wall to wall and this is a very good 3 millimetre sized calfalic vein which is usually an excellent kind of diameter for selection for an arteriovenous fistula in the RF patients. This is an example of a very small calfalic vein with real thick walls, patchy thrombosis and onto your right and the lower image shows a thickened venous wall which is very characteristic of superficial phlebitis. So similarly just like the calfalic vein you should also include the evaluation of the basalic vein and after you finish this superficial venous evaluation you move on to visualization of the deep veins. So in the deep vein you have the internal jugular and the subclavian which have a confluence at the root of the neck and they go and form the brachiocephalic vein. So this is a central brachiocephalic vein, you have the internal jugular and you have the subclavian vein and you are almost always fortunate to see these typical venous valves in these. On your right is a figure where you have an HD catheter there in the internal jugular vein very commonly seen in patients who are on hemodialysis especially through the central veins. So coming on to your interpretation, so on gray scale you have no intra-leuminal echoes and the vein easily compresses. On color Doppler the vein fills completely, shows a phasic pattern and also shows a pulsatile pattern. So let's go on to actually see what pulsatility and phasicity means and what is the importance of these two terms. So the upper extremity, the subclavian and the internal jugular vein typically have a phasicity and pulsatility which is an indicator that the central veins are patent. So this is important when you are evaluating upper extremity DVT. Now primary, it's a rare disorder also described as pageage-shorter syndrome or idiopathic DVT. It may occur after microtrauma in otherwise healthy individuals after strenuous activity and secondary it is almost seen after insertion of central venous catheters patient under critical care hemodialysis and chemotherapy. So this is an example where you are lucky enough to directly visualize the thrombus the vein is almost obliterated the internal jugular here and here you can see a partial thrombus occluding the right subclavian vein. So when you are doing a Doppler you need to document certain waveforms. So when you document the subclavian vein when you switch on color you first typically see a pulsatile it's red changing over to blue. So that tells you that the vein is pulsatile on your initial color Doppler evaluation itself and when you actually sample the vein you see that it has a typical pulsatile pattern in which you have a deep or deeper wave there which is due seen during inspiration as the intrathoracic pressure dips while inspiration. So you have a better venous flow there and during expiration the same peak is weakened. So this is a typical phase respiratory phases which is seen and of course the pulsatility is self-explanable. So this tells you that your central veins are patent as transmitted cardiac pulsations are very well depicted in the veins of the neck and hence indirectly it's a sign that your central brachiocephalic and your SVCR patent. So while doing a scan it's always a good habit to even document the cranial most portion of the brachiocephalic vein in your scans. So here's the anatomical representation you have the internal jugular and the subclavian joining to form your brachiocephalic vein and exactly the same thing is shown here in the color Doppler image. Then coming on to this loss of pulsatility which I just said so on the right you have a completely patent neck venous system so you get the typical pulsatility whereas on the left side you can typically see a thrombus occluding the IJV and hence when you sample the cranial portion of the IJV here you see this typical loss of pulsatility which is because the thrombus is not allowing your cardiac pulsations to be transmitted through into the proximal vessel. So absence of pulsatility thus is highly indicative of a central venous thrombosis. So in addition to be more and color flow documentation of spectral waveforms is a must for upper extremity deep veins that is the subclavian and the internal jugular veins as presence of pulsatility and phasicity rules out central venous thrombosis thus color Doppler is an excellent tool for evaluation of the upper extremity veins. Thank you very much and I hope you've found this video useful.