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The Speed of Sound

The Speed of Sound

Upper-Extremity Vein US Is Easier than You Think

Butts, Christine MD

doi: 10.1097/01.EEM.0000688864.63301.c2
    ultrasound, upper extremity
    ultrasound, upper extremity:
    Left: A diagram of the veins of the upper extremity. SC: subclavian, C: cephalic, A: axillary, BR: brachial, B: basilic, R: radial, U: ulnar. Note in this image that the brachial is shown branching into two veins, which is not uncommon. Right: A DVT visualized in the internal jugular vein (IJ). Note the IJ lumen is filled with a hypoechoic clot, unlike the carotid (C) lumen, which is anechoic (black).

    When we talk about deep venous thrombosis (DVT), we are almost always referring to the lower-extremity veins. This ultrasound study is commonly ordered and very easy to perform at the bedside. What about upper-extremity DVT? It is not commonly ordered, but ultrasound of the upper-extremity veins is also easy to perform at the bedside.

    The venous system of the upper extremity is detailed in Image 1. The system truly begins in the neck with the internal jugular and subclavian veins. The internal jugular vein meets the subclavian vein at the base of the neck, and the subclavian can then be followed laterally toward the shoulder. The subclavian vein becomes the axillary vein once it passes the inferior border of the teres minor (although this is somewhat of an arbitrary designation) and dives deep into the axilla. Typically, the cephalic vein (which is part of the superficial venous system) branches off the subclavian near this junction.

    As the axillary vein progresses through the axilla, it splits into two branches: the brachial (often referred to as the deep brachial vein) and the basilic veins. The basilic vein is typically more superficial, and both veins are more medial than the cephalic. The brachial vein continues distally with the brachial artery until bifurcating into the radial and ulnar veins at the antecubital fossa. The basilic vein joins the superficial system at the antecubital fossa by the median cubital vein.

    To perform the study, select a high-frequency transducer and start at the neck. Locate the internal jugular in cross-section, and follow it proximally until you see it join the subclavian vein. You may need to rock the transducer slightly forward (angling it toward the clavicle) to find this junction. The subclavian vein cannot be compressed, so care should be taken to evaluate the lumen for a clot, which will appear hypoechoic. (Image 2.) The subclavian should be followed laterally toward the shoulder by moving the transducer inferior to the clavicle.

    At this point, it may be helpful to ask the patient to place her arm on her head, palm side down. Continue to follow the subclavian as it transitions to the axillary vein, compressing lightly to ensure that the lumen completely collapses. The axillary should be followed through its bifurcation into the basilic and brachial veins, evaluating them individually for compression. Alternatively, it may be easier to start your assessment medially at the elbow, locate the basilic vein, and follow it proximally. Check online for detailed images and videos. (

    Top left: Placement of the transducer to begin tracing the internal jugular vein proximally to the subclavian and the base of the neck. Top right: Placement of the transducer to visualize the subclavian vein, lateral to the clavicle, near the point of branching of the cephalic vein. Bottom left: Placement of the transducer to begin tracing the axillary vein through its bifurcation into the brachial and basilic veins. Bottom right: Placement of the transducer to identify the distal end of the brachial vein. Watch a video of this at

    The focus is usually on DVT of the upper extremity, but superficial thrombophlebitis is also commonly encountered. Patients with recent venous access or a history of intravenous drug use may present with complaints of localized swelling or pain. Bedside ultrasound can quickly assess the area and determine whether the vein involved is superficial or deep by tracing the affected area proximally. Using ultrasound in these situations can be a quick way to reassure patients (and yourself).

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    Dr. Buttsis the director of the division of emergency ultrasound and a clinical assistant professor of emergency medicine at Louisiana State University at New Orleans. Follow her on Twitter@EMNSpeedofSound, and read her past columns at

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