Sonographers should follow a standard imaging protocol. A complete evaluation includes B-mode imaging, spectral Doppler analysis, and color Doppler imaging of all accessible portions of the upper extremity vessels. 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
• Accurately annotate B-mode, color and spectral Doppler images

Studies are bilateral unless otherwise indicated:

• Representative images are obtained per lab protocol.
• If veins of the non-dominant arm are determined to be inadequate in size for use as a conduit, or if abnormalities are identified, the dominant arm is then assessed following the same scanning procedure.
• Observe for any indication of proximal or central vein obstruction, such as large collateral veins of the neck, chest, or upper arm.
• Observe continuity of the cephalic and basilic veins into the confluence of the deep venous system. Document the presence of any large branches or anomalies in the upper extremity veins.
• If dilatation of the veins is limited, a tourniquet may be placed high on the upper arm. Warm compresses may also be used to maximize vein dilation and are more comfortable for the patient.
• Vein diameters of the brachial, cephalic, and basilic veins are measured in transverse plane
• The depth of the vein from the skin line is also a useful measurement.
• The median cubital vein should be identified, when possible, noting the area of the proximal and distal antecubital space.
• If duplicated systems are identified and the vessel diameters are adequate, record measurements.
• If requested, map the course of the vein(s) using an indelible marker.

Transverse grayscale images with and without transducer compressions include evaluation of the superficial vein to be used for conduit, and a deep venous evaluation, these include the:

• Internal jugular vein
• Subclavian vein
• Axillary vein
• Brachial vein
• Basilic vein (deep venous confluence to proximal forearm)
• Cephalic vein (deep venous confluence to wrist)
• Medial cubital vein

Diameter measurements are indicated by the planned procedure type, but typically include transverse, anterior wall to posterior wall, measurements of the:

• Basilic vein (deep venous confluence to proximal forearm)
• Cephalic vein (deep venous confluence to wrist)

Spectral and/or color Doppler images include the following:

• 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:
  • Jugular-subclavian junction, innominate (brachiocephalic), radial or ulnar veins

Additional arterial images are included for pre-hemodialysis access mappings, per lab protocol:

• Diameter measurements and spectral Doppler waveforms
  • Brachial artery
  • Radial artery (proximal and distal)
  • Ulnar artery