Evaluation of upper limb superficial venous percussion as a sign of anatomical location and venous permeability. A comparative study of superficial venous percussion to ultrasound findings on non-renal patients and on chronic kidney disease patients

Abstract

The objective of this study was to evaluate venous percussion in the upper limbs as a possible low-cost clinical sign that may contribute to physical examination of the superficial venous system and be useful in the evaluation for punctures and also for the construction of fistulas.

Methods

An analytical cross-sectional study with 70 individuals divided into two groups. Group A consisted of 35 volunteers who were being preoperatively prepared for the construction of arteriovenous fistula. Group B consisted of 35 non-renal patients selected by convenience. Each participant underwent physical examination, including venous percussion, of the dominant upper limb and then ultrasound. Interobserver agreement was assessed between a trained vascular surgeon performing percussion and fourth-year medical student. Accuracy, sensitivity, specificity, positive predictive value and negative predictive value of percussion were determined in relation to ultrasound. The agreement between the methods, venous percussion and venous duplex ultrasound was also evaluated by the Kappa index.

Results

The overall interobserver agreement for the percussion was 0.74 (95% CI 0.632 to 0.851). It was observed that the results were more favorable in the cephalic vein than in the basilic vein, emphasizing that the cephalic is more used in venous punctures, because of its anatomical location and visibility, and in fistula construction. The 35 percussions of the cephalic forearm vein in Group A resulted in a sensitivity of 1.0 (95% CI 0.63 to 1.00), specificity of 0.96 (95% CI 0.81 to 1.00), a positive predictive value of 0.89(95% CI 0.52 to 1.00) and a negative predictive value of 1.00 (95% CI 0.87 to 1.00), with an accuracy of 0.97 (95% CI 0.85 to 1.00) and Kappa index of 0.92 (95% CI 0.77 to 1.00) in relation to ultrasound. Overall, when all venous segments were analyzed in group A, the Kappa index of agreement between the percussion and the ultrasonography reached 0.56 (95% CI 0.401 to 0.72). All venous segments in Group A had a sensitivity of 0.54 (95% CI 0.37 to 0.70) and a specificity of 0.96 (95% CI 0.90 to 0.99). When all venous segments were analyzed in group B, the Kappa index of agreement between the percussion and the ultrasonography reached 0.48 (95% CI 0.34 to 0.62). All venous segments in Group B had a sensitivity of 0.70 (95% CI 0.59 to 0.79) and a specificity of 0.82 (95% CI 0.69 to 0.91).

Conclusion

Venous percussion of the upper limbs has a high positive predictive value and high specificity, when compared to ultrasound as a way to evaluate the patency and adequacy of the cephalic vein. Although there is not enough evidence to preclude ultrasound, percussion should definitely be included in the traditional physical exam evaluation of upper limbs superficial veins.