I agree with you. In my experience - additional specialized training is
usually needed where upper extremity venous diagnostics are concerned even
for RVT's. Thus being forced to train uncredentialed persons is most
unfortunate and likely a serious quality of care issue that your hospital QA
committee should be made aware of.
With that said, the most frequent mistakes I see in up. extr. venous exams
that I repeat that have come from other labs is missed innominate vein
obstructions and this is largely due to the fact that those performing the
exams do not understand the hemodynamics and collateral pathways associated
with venous disease. I also think there is a serious lack of printed
material on this subject and I do not know of any reference that can give
you details about collateral flows in this region. The one book I can
recommend is Steve Talbot's venous imaging book. TECHNIQUES OF VENOUS
IMAGING - By: Talbot and Oliver -Pub: Davies Publishing.
Bonnie L. Johnson RDMS, RVT, FSVT
Stanford University Medical Center
Director, Vascular Laboratory Services
Division of Vascular Surgery
The Radiology based US Lab where I work is being pressured to begin
performing upper extremity venous duplex for thrombosis. Unfortunately the
plans are of the "see -one, do one" nature. None of the ARDMS sonographers
are RVT, and although they are proficient at lower extremity DVT studies,
there is considerable doubt amongst them that this is a procedure that they
can quickly master by OJT.
I wrote a proposal outlining some of the differences between UE and LE
venous duplex, intending to point out the dangers of embarking on this
process without adequate mentored training.
I would welcome some comments, and directed references to the literature on
this subject, if possible.(I have already compiled a PubMed bibliography
dealing with prevalence and indications for UE venous .duplex. I would
particularly welcome anecdotal information as to whether experience in LE
duplex is readily transferable to the upper extremity. (One Radiologist said
: They're all veins, what the big difference." !) Incidentally I am
proficient at UE venous duplex, but in my training, I found the learning
curve to be much steeper than LE venous exams.
The anatomy of the UE veins has more variation than the veins of the leg.
This is of concern if the exam is carried out distal to the SCV to include
the cephalic, brachial, and basilic veins, as opposed to a limited exam of
the IJ/SCV/Axillary Vein.
A thrombosed SCV can lead to rapid collateralization, which to the
unskilled, may be mistaken for a patent SCV .
Evaluation of the brachiocephalic vein is primarily by indirect signs such
as respiratory maneuvers, and PW Doppler in the proximal SCV. This expertise
is not quickly mastered. Cardiac and respiratory variation in the proximal
SCV introduces waveform variations not found in the lower extremity.
Familiarity with normal and abnormal waveforms requires extensive
With indwelling catheters the entire catheter needs to be evaluated for
adherent thrombus, in addition to testing for SCV thrombosis. The presence
of catheter adherent clot has an immediate impact on patient treatment and
the continued use of the indwelling line.
Rich Dempsey RDMS/RVT