What is the recommended work-up for varicose veins?

Recommended Work-up for Varicose Veins

The recommended work-up for varicose veins should begin with venous duplex ultrasound performed in the erect position by a specialist trained in ultrasonography, as this is the gold standard for diagnosing venous reflux and planning appropriate treatment. 1

Initial Assessment

1. Clinical Evaluation:

   • Document specific symptoms: pain, heaviness, swelling, itching
   • Assess visible signs: bulging veins, edema, skin changes, ulceration
   • Classify severity using CEAP classification (Clinical, Etiology, Anatomy, Pathophysiology)
   • Evaluate for risk factors: family history, pregnancy, prolonged standing, obesity

2. Vascular Assessment:

   • Venous duplex ultrasound in erect position (mandatory) 2, 1
   • Measure vein diameter (particularly noting veins >4.5mm) 2
   • Assess for reflux in saphenous veins, perforator veins, and deep veins
   • Identify "feeding veins" even for small varicosities or telangiectasias 1

3. Additional Testing When Indicated:

   • Ankle-Brachial Index (ABI) if arterial disease is suspected 2
   • Transvaginal duplex ultrasound (TVS) using Holdstock-Harrison protocol if pelvic vein reflux is suspected 1
   • Venography or cross-sectional imaging for men or women unable to have TVS 1

Diagnostic Algorithm

1. For visible varicose veins with symptoms:

   • Proceed directly to venous duplex ultrasound
   • Assess for truncal vein incompetence, perforator vein incompetence, and deep venous reflux

2. For "hidden varicose veins" (symptoms without visible veins):

   • Venous duplex ultrasound is still mandatory
   • Rule out other causes of leg symptoms

3. For small telangiectasias or spider veins:

   • Despite cosmetic appearance, venous duplex should still be performed to identify underlying reflux 1

Special Considerations

• Pelvic Source: Consider pelvic vein assessment in patients with varicosities in genital region or upper thigh 1
• Arterial Disease: Always rule out significant arterial disease before planning venous interventions 2
• Recurrent Varicose Veins: More detailed mapping is required to identify causes of recurrence

Common Pitfalls to Avoid

1. Inadequate Ultrasound Assessment:

   • Performing ultrasound in supine position only (erect position is essential)
   • Failure to trace "feeding veins" for small varicosities
   • Having the same physician perform both the ultrasound and treatment (potential conflict of interest) 1

2. Overlooking Systemic Causes:

   • Failing to consider heart failure, renal disease, or other causes of bilateral edema
   • Missing concurrent arterial disease

3. Premature Intervention:

   • Skipping the recommended 3-month trial of conservative management with medical-grade compression stockings (20 mmHg or greater) before considering procedural intervention 2

The American College of Radiology, American Academy of Family Physicians, and American College of Chest Physicians all emphasize the importance of thorough diagnostic evaluation before treatment planning 2. This comprehensive approach ensures that treatment is directed at the underlying cause rather than just the visible manifestations of venous disease.