Improvement in the visualization of superficial arm veins being evaluated for access and bypass

Abstract

Duplex ultrasound mapping of arm veins is being performed with increasing frequency. Unlike ultrasound testing in other areas, this has never been subjected to a gold standard invasive test to determine accuracy. Duplex mapping appears to have a good predictive value whenever large veins are demonstrated preoperatively, but its ability to accurately measure minimum-sized veins is unproven. In this study, we compared diameter measurements obtained under six different conditions and used the maximum diameter as the comparison gold standard. A 12-MHz linear probe was used to measure the cephalic and basilic vein cross-sectional diameters at the wrist level in 24 normal volunteers under the following conditions: (1) resting supine with a room temperature of 23 degrees to 24 degrees C, (2) supine with a tourniquet inflated to 65 mm Hg, (3) sitting with the arm dangling, (4) sitting with a tourniquet, (5) sitting after a 2-minute immersion in warm water (44 degrees C), and (6) same with tourniquet. Half the subjects underwent the protocol in a different order. Vein diameters were significantly larger after submersion in warm water compared with supine (P < .05, pair-wise multiple comparison procedure, Student-Newman-Keuls method). Assuming the sitting position (from supine) resulted in a decreased arm vein diameter 58% of the time. In 25% of the normal subjects, the cephalic vein size was <2 mm, which increased to >2 mm after warming. All subjects had either a cephalic or a basilic vein at the wrist that was >3.1 mm after warming. Use of warm water immersion before vein diameter measurement in a sitting position, without a tourniquet, will result in significantly larger diameter findings in normal arm veins. These diameters are likely to more closely resemble the venous diameter after distension with arterial pressure. Further studies are needed to see if warming in patients could result in increased utilization of autogenous arm vein for dialysis access and bypass.