What to Write When Requesting a Duplex Scan for Varicosities
Request a "venous duplex ultrasound of the lower extremity" and specify evaluation of the deep venous system, great saphenous vein (GSV), small saphenous vein (SSV), accessory saphenous veins, perforating veins, and assessment for venous reflux and obstruction. 1
Essential Components to Include in Your Request
Standard Indication Statement
Write: "Venous duplex ultrasound for evaluation of varicose veins" - this is the first-line imaging modality universally recommended by current guidelines 1, 2.
Specific Anatomical Areas to Evaluate
Your request should explicitly ask the sonographer to assess:
- Deep venous system - to rule out deep venous thrombosis or post-thrombotic syndrome
- Great saphenous vein (GSV) - most common source of reflux
- Small saphenous vein (SSV) - particularly important for popliteal fossa reflux
- Accessory saphenous veins - often missed but clinically relevant
- Perforating veins - especially if skin changes or ulcers are present
- Presence and location of venous reflux (>500 ms is pathologic)
- Alternative refluxing superficial venous pathways
Clinical Context to Provide
Include the CEAP classification if known (e.g., "C2S" for symptomatic varicose veins, "C3" if edema present, "C4-C6" for skin changes or ulcers). This helps the vascular lab understand the severity and guides their examination 2.
Mention specific symptoms:
- Aching, heaviness, cramping, or pain
- Visible varicosities
- Skin changes (pigmentation, eczema, lipodermatosclerosis)
- History of venous ulcers
- Previous DVT or varicose vein surgery
When to Request Additional Imaging
If popliteal fossa reflux is present clinically, specifically request evaluation to differentiate between:
- Short saphenous vein insufficiency
- Gastrocnemius vein insufficiency
- Popliteal-tibial axis reflux
These cannot be reliably distinguished by physical exam alone 3.
For recurrent varicose veins, request focused evaluation of:
- Residual saphenous vein segments
- Groin and popliteal fossa for neovascularization
- Any persistent connections between deep and superficial systems
If there's suspicion of iliocaval obstruction (diffuse venous reflux, persistent ulcers, or nonphasic common femoral vein waveforms on prior studies), note this in your request as spectral waveform analysis of the common femoral veins will be critical 1.
Sample Request Language
Simple primary varicose veins: "Venous duplex ultrasound lower extremity to evaluate varicose veins. Please assess deep venous system, GSV, SSV, accessory saphenous veins, perforating veins, and document presence/location of venous reflux. Clinical: C2S varicose veins with leg heaviness and aching."
Complex or recurrent disease: "Venous duplex ultrasound lower extremity for recurrent varicose veins. Please evaluate deep venous system patency, residual GSV/SSV, perforating veins, and any neovascularization at prior surgical sites. Include spectral waveform analysis of common femoral veins. Clinical: C5 disease with healed venous ulcer, prior GSV stripping."
Critical Pitfalls to Avoid
Don't rely on clinical exam alone - even experienced clinicians are wrong 12-18% of the time when they feel certain about the diagnosis, and agreement between clinical and duplex findings ranges from only 59-82% 5, 4
Don't skip duplex even for "simple" primary varicose veins - an "all-comers" duplex policy is justified because clinical evaluation is unreliable for planning management 5
Don't forget to request evaluation of the deep system - this is essential to rule out post-thrombotic syndrome or primary deep valvular insufficiency, particularly if there's any history suggestive of prior DVT or if skin changes are present (CEAP C4-C6) 3