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The venous system, with its complex network of one-way valves, communicating branches, and peripheral pumping mechanisms, connects in a progressive fashion that culminates in an effective system to return blood to the heart even when working against gravity. Venous embryologic development is understood as passing through three main stages: first, as an undifferentiated capillary network composed of primitive mesenchymal tissues; second, differentiation into large plexiform structures; and third, maturation into isolated macroscopic channels, the vein.1,2 The upper extremity, in particular, is unique in that it needs to return blood while being located intermittently both above and below the right atrium to which it flows.3

Veins also act as both conduit and capacitance vessels. The volume of blood contained within a vein can change drastically with only minor changes in pressure, allowing for dynamic adaptations to optimize cardiovascular stability. With less gravity to work against, the valves of the upper extremity are not as numerous as that of the lower extremity, and gravity does not have the same chronic effects on the upper extremity veins as it does that of the lower limbs.

Chronic venous disease in the upper extremities is much less common than in the lower extremities largely because of less gravitational stress. Venous disease does occur, however, in several well-defined situations, which will be the subject of this chapter. In general, problems arise due to increased pressure in the veins, which is caused by central obstruction (with or without iatrogenically increased pressure in the setting of arteriovenous [AV] access). This intraluminal pressure, in turn, creates varying degrees of fluid extravasation which leads to swelling and pain. Skin changes are uncommon and true varicose veins and ulceration, in contrast to lower extremities, are vanishingly rare.

Upper extremity venous disease can conveniently be divided into four broad categories, several of which overlap: chronic venous thoracic outlet syndrome (VTOS), caused by chronic compression and/or injury to the subclavian vein at the costoclavicular junction (CCJ); AV access-associated swelling and dysfunction, caused by stenosis or occlusion at the CCJ or more central veins and exacerbated by the delivery of high pressure to the system; iatrogenic injury from intraluminal devices; and malignancies that affect the central vessels.



Similar to the lower extremities, the upper limbs have both a superficial and deep venous system, the latter of which is generally paired and follows the corresponding artery. The twin radial and ulnar veins run deep to the fascia and join to form the brachial vein at the antecubital fossa. The brachial veins are also generally paired and tend to coalesce at the axilla where they become the single axillary vein and transition into the subclavian vein at the lateral border of the first rib. The superficial veins arise from the dorsum of the hand to drain into the cephalic vein laterally ...

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