Throughout each examination, the sonographer or examiner should:

• Observe sonographic characteristics of normal and abnormal tissues, structures, and blood flow, allowing necessary adjustments to optimize exam quality.
• Assess and monitor the patient’s physical and mental status, allowing modifications to the procedure plan according to the patient’s clinical status.
• Analyze sonographic findings to ensure that sufficient data is provided to the physician to direct patient management and render a final diagnosis.

Follow a standard imaging protocol per department specific/facility specific anatomic algorithm. A complete venous duplex evaluation incorporates B-mode and spectral Doppler with color and/or power Doppler imaging.

• Studies may be unilateral with the use of an appropriate algorithm. However, it is required to compare the subclavian vein spectral waveform from the contralateral limb, in this event.
• Transverse transducer compressions (when anatomically possible and not contraindicated) should be performed every 2 cm to ensure the entire vein is assessed.
• When compressions are difficult to attain due to bony prominences, request the patient to inhale or sniff to observe appropriate venous responses.
• Representative images are obtained per lab protocol.

Interrogation and documentation of compression of the following vessels is the minimum requirement:

• Internal jugular vein
• Subclavian vein
• Axillary vein
• Brachial vein
• Basilic vein
• Cephalic vein

The following are included if indicated or required by the facility specific-protocol:

• Proximal subclavian vein
• Innominate (brachiocephalic) vein
• Radial veins
• Ulnar veins

Spectral Doppler and long axis B-mode and/or color Doppler images should include the following:

• Internal jugular vein
• Subclavian vein (bilateral)
• Axillary vein

The following are included if indicated or required by the facility specific-protocol:

• Jugular- subclavian junction
• Innominate (brachiocephalic) vein
• Brachial veins
• Radial veins
• Ulnar veins
• Basilic vein
• Cephalic vein

Spectral Doppler waveforms should accurately demonstrate the venous flow characteristics:

• Spontaneity
• Phasicity
• Flow augmentation with distal compression
• Pulsatility

When suspected pathology (thrombus or intraluminal echoes) is present:

• B-mode image should demonstrate the degree of compressibility to differentiate between partially or totally non-compressible segments
• Document the location, extent and echogenicity of thrombus
• Differentiate between unattached proximal thrombus (i.e., free-floating tails of thrombus) and attached thrombus
• Note dilatation/contraction of vein to assist in describing characteristics of aging the thrombus
• Include diameter measurements of any other abnormal structures (e.g., fluid collection, mass, etc.)