Deep Veins of the Arm: Anatomical Course and Clinical Significance
Anatomical Definition and Classification
The deep veins of the arm are those located beneath (deep to) the deep fascia, distinguishing them from superficial veins that lie above this fascial layer. 1, 2
The peripheral venous system is divided by the superficial fascia into:
- Superficial (epifascial) system: Veins above the deep fascia 3
- Deep (subfascial) system: Veins below the deep fascia that accompany the arteries 3
- Transfascial system: Perforating veins that interconnect the two systems 3
Deep Veins of the Arm: Specific Vessels and Course
Forearm Deep Veins
- Paired radial veins: Accompany the radial artery as venae comitantes 4
- Paired ulnar veins: Accompany the ulnar artery as venae comitantes 4
- Paired anterior tibial veins (in lower extremity analogy, the forearm follows similar paired arrangement) 3
Upper Arm Deep Veins
- Paired brachial veins: These are the primary deep veins of the upper arm, running alongside the brachial artery 5
- Axillary vein: Formed by the convergence of the brachial veins and receives multiple tributaries including the basilic vein (which transitions from superficial to deep as it pierces the deep fascia in the mid-upper arm) 6
- Subscapular vein: Drains into the axillary vein 6
Central Deep Veins
- Subclavian vein: Continuation of the axillary vein as it passes beneath the clavicle through the costoclavicular space 7
- Brachiocephalic vein: Formed by the union of subclavian and internal jugular veins 8
- Superior vena cava: Formed by the confluence of the brachiocephalic veins 9
Venous Drainage Pattern and Direction
Blood flows from the superficial venous system to the deep venous system through perforating veins, with the deep veins ultimately draining toward the heart. 1, 3
- Deep veins converge into progressively larger single vessels as they approach the heart 1
- Venous valves control the direction of blood flow, with variable numbers throughout the system 5, 3
- The deep veins are surrounded by a venous sheath allowing mobility 3
Clinical Significance for Vascular Access
Preservation Strategy
The KDOQI guidelines emphasize that superficial veins should be evaluated and used before deep veins for vascular access creation, because obliteration or stenosis of deep veins impairs availability of more distal access sites. 1
Key superficial veins to prioritize (NOT deep veins):
Deep Vein Thrombosis Risk
- Indwelling venous devices (peripheral IVs, PICCs, pacemakers) represent the highest risk factor for upper extremity deep vein thrombosis in the deep venous system. 2
- Venous thoracic outlet syndrome (Paget-Schroetter syndrome) causes effort-related thrombosis of the subclavian vein from external compression in the costoclavicular space, particularly in young athletic patients. 2, 7
Diagnostic Imaging Considerations
Ultrasound Limitations
- Duplex ultrasound is most effective for peripheral deep veins (brachial, axillary) but central deep veins (subclavian, brachiocephalic) cannot be compressed due to surrounding bony structures. 8
- Assessment of central veins relies on Doppler flow-pattern analysis, with loss of respiratory variation and cardiac pulsatility indicating obstruction 8
Advanced Imaging for Central Deep Veins
- CT venography is superior for visualizing central deep veins (subclavian, brachiocephalic, superior vena cava) that are difficult to assess with ultrasound. 8, 9
- Contrast administration should be via the contralateral arm when evaluating upper extremity deep veins to avoid artifact 9
Critical Pitfall to Avoid
Do not confuse the basilic vein with deep veins: although the basilic vein pierces the deep fascia in the mid-upper arm and may appear "deep," it is classified as a superficial vein in the forearm and upper arm for vascular access planning purposes. 1, 2 This distinction is crucial because the KDOQI guidelines specifically list the forearm and upper arm basilic veins as superficial vessels to be used before true deep veins 1.