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Upper Extremity Vein Mapping - Upper Arm Vascular Anatomy, Ultrasound Types, and Vein Mapping Procedure

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Upper extremity vein mapping is an important diagnostic tool to create vascular access for patients requiring hemodialysis or surgery. This article reviews upper arm arteries and vein anatomy and procedure for vein mapping.

Written byDr. Sabhya. J

Medically reviewed byDr. Suman Saurabh

Published At May 25, 2023
Reviewed AtOctober 8, 2024

Introduction

Patients with chronic kidney disease require frequent hemodialysis. Vascular access is important for hemodialysis due to its link with morbidity. The vascular access is monitored throughout to look for thrombosis or failure in maturation.

What Is the Arterial and Vein Anatomy of the Upper Arm?

Arterial Anatomy: Vascularization is dependent on the subclavian artery which is a branch of the aorta on the right side.

1. Subclavian artery.

  • The artery is shorter on the right side.

  • It is a difficult artery to scan due to a shadow by the clavicle.

  • Therefore, the whole trajectory of the artery cannot be analyzed except for thin patients.

2. Axillary artery.

  • It is a short artery.

  • The trajectory of the artery can be visualized clearly from the lower border of the clavicle.

3. Brachial artery.

  • It is a longer artery compared to other arteries in the arm.

  • The artery extends along the entire length of the arm's inner face.

  • The artery can be visualized by placing the arm at 45-degree angulation.

  • The artery bifurcates into radial and ulnar artery at antecubital fossa.

4. Radial artery.

  • The artery is placed in a superficial position.

  • The trajectory of the artery can be visualized.

  • The artery originates from the brachial artery and runs its course from the arm to the wrist.

5. Ulnar artery.

  • It is a terminal branch of the branchial artery.

  • The initial course of the artery runs deep in the tissues whereas, the latter course is superficial.

6. Palmar arch.

  • The anastomosis of radial and ulnar arteries is called a palmar arch.

  • The palmar arch is of two types,

  1. The deep palmar arch is dependent on the anastomosis between the radial or ulnar artery.

  2. The superficial arch in the tributary of the ulnar anastomosis with radial artery.

Arterial mapping is achieved by placing the probe in the transverse plane. The short axis is used to explore arterial diameters.

Venous Anatomy

The venous drainage of the upper arm is superficial and deep.

  1. The deep venous system is located along with arteries. The radial, ulnar, brachial, axillary, and subclavian veins form the deep venous system.

  2. The superficial venous system is preferred for vascular access creation. The veins are well formed. The superficial venous system drains from superficial tissue to the deep venous system. The cephalic vein and basilic vein form the superficial venous system.

What Is Upper Extremity Vein Mapping?

Vein mapping is required to evaluate arm veins and arteries for size, length, and patency before dialysis or arterial bypass surgery. Ultrasound imaging with the use of Doppler ultrasound is used for mapping and is a safe procedure. The mapping can be achieved for arteries and veins. The procedure does not cause radiation exposure or injection of chemicals.

What Are the Types of Ultrasound Used for Upper Vein Mapping?

The ultrasounds used for vein mapping before vascular access implantation are:

  1. B-Mode Ultrasound: It provides a two-dimensional grayscale image of vessel anatomy and associated abnormalities.

  2. Pulse Wave Doppler: It records velocity over a time curve in veins and arteries. The red blood cell velocities can be analyzed.

  3. Color Doppler: The real-time mean velocities of red blood cells are recorded over a colored box.

A gel is used for examination to avoid loss of the examination field due to curvature of the arm.

What Are the Benefits of Ultrasound?

The benefits of ultrasound include:

  • Simple.

  • Fast.

  • Affordable

  • Safe.

  • Easily available.

  • Prevents unsuccessful surgical procedures.

  • Prevents morbidity in end-stage renal disease in patients with non-functional arteriovenous fistula.

What Are the Limitations?

The results can vary based on the operator's expertise in Doppler ultrasound.

What Are the Factors to Determine the Diameter and Blood Flow?

  • The diameter of arteries varies by 20% during the cardiac cycle.

  • Vessel area measurement errors can be 20% for 10mm (millimeter) vessels and an even higher percentage for smaller vessels like the cephalic vein and brachial artery.

  • The pulsatile cardiac cycle causes an error of 20% to 100% in volumetric flow.

What Are the Requisites Before Upper Extremity Vein Mapping?

It is important to analyze patients' tolerability to the procedure or the presence of contraindications. The patient's past medical conditions like diabetes and family history must be recorded and must contain:

  • Treatment planning for the patient.

  • History of deep vein thrombosis.

  • Trauma to the upper arm.

  • Vein harvesting history.

  • Intravenous drug use.

  • Details on current medication and treatment procedure.

  • Other diagnostic evaluation.

  • Swelling, discoloration, or ulceration must be recorded.

What Is the Procedure for Upper Extremity Vein Mapping?

Vein mapping involves the evaluation of arteries, the deep vein system, and the superficial vein system.

  • Patients are made to lie in the supine position, sitting, or reverse Trendelenburg to dilate veins. The arms must be relaxed and extended to the side.

  • The room must be arm and the arm must be covered until the start of the procedure to prevent vasoconstriction.

  • A Doppler ultrasound with a 5 to 7 MHz (megahertz) transducer is used. The superficial structure requires high frequency whereas the deep structure requires low frequency.

  • Subclavian and axillary arteries are examined for any signs of central occlusion or anatomical variations. Subclavian artery imaging requires 2 to 5 MHz transducers.

  • To analyze the patient’s vein the head must be raised to 45 degrees with arms relaxed.

  • After evaluation, a tourniquet is applied on the proximal aspect of the upper arm to block superficial vein flow. However, brachial artery flow remains uninterrupted.

  • With the B-mode of ultrasound, the superficial vein of the upper arm is examined for its diameter at the distal third region of the upper arm.

  • The procedure is repeated for the brachial artery to record anatomic variations, blood flow, and diameter at the distal third of the upper arm.

  • The tourniquet is removed and at the distal third of the upper arm diameter of the dominant superficial vein is measured.

  • The upper arm vein mapping is done bilaterally.

What Are the Indications and Contraindications for Upper Extremity Mapping?

Indications

  • Assess veins to be used as a coronary artery bypass graft.

  • Assess veins and arteries for dialysis.

Contraindications

  • Obesity.

  • Recent surgery in the area of examination or the presence of intravenous lines, casts, open wounds, or hematoma.

  • History of vein harvesting in the same area.

  • Patients with severe edema or swelling in the examination area.

  • Patients who are unable to remain still during the period of examination.

  • Patients suffering from diabetes mellitus have compromised vascular access.

  • Medial calcinosis disrupts the maturation of vascular access due to a lack of arterial dilatation.

  • Any cause of stenosis like the history of central venous catheters or pacemakers.

Conclusion

Ultrasound is an important tool for kidney patients before vascular access formation. Since vascular access is associated with greater mortality risk it needs constant thrombosis monitoring. The test provides rapid results enabling quick decision-making. The upper extremity vein mapping helps with better patient care.

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Frequently Asked Questions

The CPT (current procedural terminology) code used for upper extremity vein mapping is the CPT code 93970. This code is specifically designated for performing a duplex scan of arterial inflow and venous outflow of the upper or lower extremities. This procedure involves using ultrasound to assess the veins in the upper extremities, identifying their structure, and mapping their pathways.
An upper extremity arterial ultrasound involves a non-invasive imaging procedure that employs high-frequency sound waves to produce detailed pictures of the arteries in the arms. This technique helps assess blood flow, identify potential blockages, or detect abnormalities in the upper extremities' arterial system. The ultrasound captures real-time images, enabling healthcare professionals to evaluate the structure and function of the arteries.
The duration of a vein mapping procedure can vary but typically takes approximately 30 minutes to an hour to complete. This time frame includes the initial preparation, the imaging process, and the collected data assessment. The procedure involves using ultrasound technology to examine and map the veins in a specific area, such as the upper extremities.
The typical time frame for vascular mapping, which includes arterial and venous assessments, varies depending on the specific requirements and extent of the mapping. The procedure involves imaging and analyzing the blood vessels' structure and blood flow within a particular area, often the upper or lower extremities. It may take around 30 minutes to an hour to complete both arterial and venous assessments in a single session.
Vein mapping, generally performed through non-invasive ultrasound technology, is not typically associated with significant discomfort or pain. Patients might feel mild pressure or sensation from the ultrasound probe as it glides over the skin during the procedure, but it is generally well-tolerated. The mapping process involves creating images of the veins in a specific area, such as the upper extremities, to identify their structure and paths.
The cumulative length of all the veins in the human body varies from person to person, but collectively, they are estimated to be several thousand miles long. The intricate network of veins carries deoxygenated blood back to the heart from every part of the body, comprising small, intricate vessels to larger veins. While there is not an exact measurement due to individual variability, when all the veins are combined, their extensive length is a testament to the intricate and expansive nature of the body's vascular system.
Veins possess a limited ability to regenerate or repair themselves after injury. While small veins and capillaries may regenerate, larger veins might not entirely grow back once they are cut or damaged. The body can initiate a healing process, forming scar tissue and rerouting blood flow through nearby vessels. However, the regeneration process is limited, and the degree of recovery largely depends on the extent and location of the damage to the veins.
The number of times a vein can be safely punctured or stuck largely depends on various factors, including the vein's health, size, and the technique used during medical procedures. Generally, veins can withstand multiple needle sticks if done properly and without causing excessive damage. However, frequent punctures might lead to scarring, making future insertions more challenging and potentially necessitating alternative veins for medical procedures such as blood draws or intravenous treatments.
Veins consist of three primary layers: the tunica intima, the tunica media, and the tunica externa. The innermost layer, the tunica intima, comprises endothelial cells and connective tissue. The middle layer, the tunica media, contains smooth muscle and elastic fibers, providing structural support. The outermost layer, the tunica externa, is composed of connective tissue, assisting in anchoring the vein to surrounding structures and providing additional support and protection. These layers work together to maintain the veins' structure and function within the body's circulatory system.
An upper extremity venous ultrasound is a diagnostic tool to examine the veins in the arms. It is particularly valuable in evaluating patients with symptoms such as swelling, pain, or suspected vascular problems in the upper limbs. The ultrasound provides real-time imaging, assisting healthcare professionals in accurately diagnosing and managing various arm venous conditions.
The CPT code assigned to the vein mapping procedure typically used for upper extremities is 93970. This code categorizes the duplex scan performed to evaluate arterial inflow and venous outflow in the upper or lower extremities. Healthcare providers use this code for billing and documentation when conducting vein mapping procedures on the upper limbs, ensuring a standardized reference for this particular medical examination.
A vein map for dialysis patients is a comprehensive visual representation of accessible veins, aiding medical professionals in identifying suitable veins for dialysis access. This mapping details the veins' location, size, and condition, which is crucial for creating an effective vascular access plan for hemodialysis treatment. By outlining the most viable veins, the vein map assists in determining the best site for dialysis needle insertion, optimizing the dialysis process, and reducing potential complications for hemodialysis patients.
Ultrasound vein mapping typically takes around 30 minutes to an hour to complete. This non-invasive procedure employs ultrasound technology to examine and map the veins in a specific area, such as the upper extremities. The process involves capturing detailed images of the veins, analyzing their structure and pathways, and providing crucial information for medical evaluation and treatment planning.
Venous ultrasound, a non-invasive imaging technique, typically has minimal side effects. Rarely, some individuals might experience mild discomfort from the ultrasound probe moving over the skin. There is a slight possibility of redness or tenderness at the site of gel application post-procedure. Allergic reactions to the ultrasound gel are exceedingly uncommon. Overall, adverse effects from venous ultrasound are infrequent, making it a safe and widely used diagnostic tool for evaluating vein conditions.
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Dr. Suman Saurabh from iCliniq
Dr. Suman Saurabh

Orthopedician and Traumatology

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