What is the recommended initial US (ultrasound) imaging study for a patient with varicose veins presenting with intermittent leg swelling and tingling sensation?

Duplex Doppler Ultrasound is the Recommended Initial Imaging for Varicose Veins with Leg Swelling and Tingling

Duplex Doppler ultrasound of the lower extremity is the first-line imaging study for patients with varicose veins presenting with intermittent leg swelling and tingling sensation. 1

Rationale for Duplex Doppler Ultrasound

Duplex Doppler ultrasound offers several advantages as the initial imaging modality:

• It is widely recognized as the best first assessment of the lower extremity venous system 1
• It provides both anatomical and functional information about the venous system
• It can detect both superficial and deep venous insufficiency
• It is non-invasive and does not require contrast agents
• It allows real-time assessment of venous reflux, which is critical in varicose vein evaluation

What the Ultrasound Should Evaluate

A comprehensive duplex ultrasound evaluation for varicose veins should include:

• Assessment of the deep venous system (to rule out DVT)
• Evaluation of the great saphenous vein (GSV)
• Examination of the small saphenous vein (SSV)
• Assessment of accessory saphenous veins
• Identification of incompetent perforating veins
• Evaluation of alternative refluxing superficial venous pathways
• Examination in both transverse and longitudinal planes
• Assessment of respiratory variation and cardiac pulsations (indicating patent pathway to heart) 1

Technical Considerations

• Venous reflux is defined as retrograde venous flow >500 ms 1
• Evaluation should be performed with the patient in both standing and supine positions
• The examination should assess for both anatomical variants and functional abnormalities

When to Consider Additional Imaging

While duplex ultrasound is the first-line imaging study, there are specific scenarios where additional imaging may be warranted:

• If proximal varicosities are present and iliac vein occlusion/stenosis is suspected, catheter venography of iliac veins may be considered 1
• In cases where ultrasound is limited (e.g., obesity), CT venography (CTV) or MR venography (MRV) can be used adjunctively 1
• For patients with extensive unexplained leg swelling with negative ultrasound and positive D-dimer, iliac veins should be imaged to exclude isolated iliac DVT 1

Unilateral vs. Bilateral Scanning

For patients presenting with unilateral symptoms like yours:

• Initial scanning of the symptomatic leg is appropriate for outpatients 2
• If DVT is found in the symptomatic leg, then bilateral scanning is recommended 2

Key Points to Remember

• Duplex ultrasound should evaluate both superficial and deep venous systems
• The study should assess for both anatomical abnormalities and functional issues (reflux)
• Reflux assessment is critical for determining the severity and extent of venous insufficiency
• Proper documentation of incompetent perforating veins is important for treatment planning

By following this approach, the ultrasound will provide comprehensive information about the patient's venous system, allowing for appropriate treatment planning for the varicose veins and associated symptoms of leg swelling and tingling.