0:00

So this is an upper extremity case.

0:03

So upper extremities are even a little bit more challenging

0:06

because, um, your direction

0:08

of flu is not always, uh, as obvious.

0:10

So let's go step by step.

0:12

This is a patient who had left upper extremity swelling,

0:16

and so I have the left interal jugular vein here

0:19

and the right internal jugular vein for comparison.

0:22

So if we look at the right inter the normal side,

0:25

the non fallen side, you can see that there is phasic flow.

0:28

And in the upper extremity in particular,

0:30

you should always have phasic flow.

0:33

And now let's look at direction of flow.

0:36

So this is a sagittal image.

0:39

So the, um,

0:41

right intra jugular vein should flow towards the heart.

0:44

So here's head, here's feet.

0:47

So it should flow towards the transer

0:49

because it's going down towards

0:51

the heart, where in the neck.

0:52

And so the flow should be then red, which is this.

0:56

So towards the transducer.

0:58

Now, you can see now that on the other side, the,

1:02

my settings are exactly the same, but what do I see?

1:07

I see that the left jugular vein,

1:09

intra jugular vein has some flow.

1:10

However, the flow is extremely dampened, almost, you know,

1:15

very, very slow flow compared to the normal right side.

1:18

And in addition, the flow is reversed

1:21

because normally the left internal jugular vein should

1:25

flow towards the heart.

1:26

So it should be towards a transistor,

1:28

it should be red, and yet it's reversed.

1:30

Okay? So now we have to see, okay, well

1:34

why is the flow reversed?

1:37

So what we try to do now, that's not always easy,

1:40

but if you have an abnormality, it's important to try

1:43

to look in the, um,

1:47

in the upper media sternum SD best you can.

1:48

Now, you're not always going to be successful,

1:51

but what we do, and you can see

1:52

that we switched transducer from a linear transducer here

1:56

to a curvilinear transducer

1:58

because I basically put the transducer in the stronger notch

2:01

or just below the clavicle and angle down as much as we can.

2:06

And again, we did the right side for comparison.

2:08

There is good flow in the denomin vein,

2:11

and on the left side there's a lot of aliasing.

2:14

Now, the aliasing may be because my scale is very low,

2:17

but this is the only way I could really penetrate deep into

2:20

the upper mediastinum.

2:22

But when we put the doppler,

2:25

and this was angle corrector, you could see

2:27

that there is very, very high

2:30

velocity in that region.

2:33

So basically we concluded

2:35

that this patient has a venous stenosis.

2:37

There is a stenosis of the left in nominated vein

2:43

near its convergence with the internal jugular vein.

2:46

And that is why you had dampen as well

2:48

as reverse flow in the left internal jugular vein.

2:52

So we have to do all these gymnastics.

2:54

Now you're gonna tell me why is that?

2:56

So just think about why would a patient have

2:59

Stenosis?

3:01

Okay, so the patient had stenosis

3:04

because the patient had a pacemaker, which is a risk factor

3:08

for upper extremity stenosis as well, venous stenosis

3:13

as well as upper extremity DVT.

3:16

The same is true for patient

3:17

who have large in dwelling catheters for, for hemodialysis.

3:21

So it's really, otherwise upper extremity

3:25

thrombosis are not that common compared to the,

3:28

uh, lower extremity.

3:29

But usually there is a, there is a, a risk factor,

3:32

a indwelling catheter, PICC line, or a pacemaker.

3:37

So because we picked up that stenosis

3:39

of the lefty nominated vein that the patient was treated

3:41

with balloon angioplasty

3:43

and her left upper extremity swelling got much better.

3:50

Okay? So again, abnormal physicality is

3:54

really, really important.

3:55

I know I keep repeating this,

3:56

but I think it's really, really important

3:58

to, to think about it.

4:00

Um, to at least look

4:04

and make sure you, you either look

4:06

or recommend another study

4:07

to make sure the patient doesn't have a central abnormality,

4:11

um, and then use the contralateral vessel for comparison,

4:16

because inherently the, the physicality will vary

4:19

among different subjects.

4:20

A patient has heart failure, but will be much more physic.

4:23

Some patients have, you know, relatively slow flow with lack

4:26

of physic, but at least it should be relatively comparable

4:31

from side to side.

4:33

Okay? It's important to assess ity during quiet respiration.

4:38

Now of course, there are pitfalls.

4:40

If the patient has very large collaterals

4:43

that are bypassing the area of thrombo narrowing,

4:47

then the transmission transmitted positivity may still be

4:50

present because the, the, the,

4:52

the flow will just go through the large collateral.

4:55

So that's obviously a, a pitfall.

4:57

The other thing is the patient has bilateral dampen phy uh,

5:01

ity because there's a ma big mass, for example,

5:03

sitting on the IVC, then it might be difficult

5:06

to recognize whether it is normal for these patient

5:09

or abnormal.