How to evaluate a patient for venous insufficiency?

Evaluation of a Patient for Venous Insufficiency

Duplex ultrasound of the lower extremity venous system should be the first diagnostic test for evaluating patients with suspected venous insufficiency. 1

Clinical Assessment

History

• Assess for symptoms of venous insufficiency:
  • Heaviness in legs (most common symptom, 84.8% of patients) 2
  • Itching (53.9% of patients) 2
  • Pain or discomfort that worsens with prolonged standing
  • Nocturnal leg cramps
  • Swelling that improves with elevation
  • Skin changes or ulceration

Risk Factor Assessment

• Age (>45 years) 2
• Female gender 3
• Family history (present in 47.2% of patients) 2
• Obesity 3
• History of deep vein thrombosis (increases risk 25.7-fold) 3
• History of serious leg injury (increases risk 2.4-fold) 3
• Prolonged standing (reported by 30.7% of patients) 2
• Pregnancy and number of pregnancies 2
• Low physical activity (55.7% of patients) 2

Physical Examination

• Inspect for:

  • Ankle edema (most common sign, 43.6% of patients) 2
  • Telangiectasias (spider veins <1mm) 1
  • Reticular veins (1-3mm) 1
  • Varicose veins (dilated, tortuous veins ≥3mm) 1
  • Skin changes (hyperpigmentation, lipodermatosclerosis)
  • Ulceration (particularly at medial malleolus)

• Palpate for:

  • Tenderness along venous tracts
  • Induration or fibrosis
  • Temperature differences

Diagnostic Testing

First-Line Testing

• Duplex Doppler Ultrasound of Lower Extremity (Usually Appropriate) 1

  • Gold standard initial test for venous insufficiency

  • Should evaluate:

    • Deep venous system
    • Great saphenous vein (GSV)
    • Small saphenous vein (SSV)
    • Accessory saphenous veins
    • Perforator veins
    • Alternative refluxing superficial pathways

  • Technique:

    • Examine in both transverse and longitudinal planes
    • Patient ideally standing on one leg (or at 60° Trendelenburg if standing not tolerated)
    • Assess for reflux (retrograde venous flow >500ms) 1
    • Document abnormal reflux times and locations
    • Assess vein diameters (especially for treatment planning)

  • Diagnostic criteria for venous insufficiency:

    • Reflux >500ms (retrograde flow)
    • Dilated veins
    • Incompetent valves

Ankle-Brachial Index (ABI)

• Should be performed to rule out arterial disease 1
• Interpretation:

  • 1.30: Poorly compressible vessels, arterial calcification

  • 0.90-1.30: Normal
  • 0.60-0.89: Mild arterial obstruction
  • 0.40-0.59: Moderate obstruction
  • <0.40: Severe obstruction

Second-Line Testing (When Ultrasound is Limited or Nondiagnostic)

• CT Venography (CTV) (May Be Appropriate)

  • Useful when ultrasound is limited (e.g., obesity) 1

• MR Venography (MRV) (May Be Appropriate)

  • Alternative when ultrasound is limited or to avoid iodinated contrast 1
  • Helpful for detailed anatomic characterization before therapy
  • Can reduce recurrence rates (15-35% at 2 years) by better planning 1

• Venography (Usually Not Appropriate)

  • Invasive test, rarely used as initial diagnostic test 1
  • May be considered when other tests are inconclusive

Classification

After evaluation, classify venous disease using the CEAP classification system:

• Clinical severity (grade 0-6)
  • C0: No visible or palpable signs of venous disease
  • C1: Telangiectasias or reticular veins
  • C2: Varicose veins
  • C3: Edema
  • C4: Skin changes (pigmentation, eczema, lipodermatosclerosis)
  • C5: Healed venous ulcer
  • C6: Active venous ulcer
• Etiology (congenital, primary, secondary)
• Anatomical distribution (superficial, deep, perforator)
• Pathophysiology (reflux, obstruction, both)

Common Pitfalls and Caveats

1. Don't miss arterial disease: Always assess for arterial insufficiency with ABI measurement, as mixed arterial and venous disease requires different management approaches 1

2. Ultrasound technique matters: Optimal technique involves examining the patient standing on one leg; if not tolerated, use 60° Trendelenburg position 1

3. Don't rely solely on physical examination: Absence of visible varicosities doesn't rule out venous insufficiency; duplex ultrasound is essential for diagnosis 1

4. Consider pelvic sources: In patients with varicose veins in the posterior thigh, vulva, or inguinal regions, consider pelvic venous insufficiency as a source 1

5. Recognize limitations of testing: Body habitus (obesity) and excessive subcutaneous tissue may limit ultrasound evaluation; consider advanced imaging in these cases 1

By following this systematic approach to evaluating patients with suspected venous insufficiency, clinicians can accurately diagnose the condition, determine its severity and etiology, and develop appropriate treatment plans to improve patient outcomes.