What imaging modalities are used to diagnose varicose veins?

Imaging for Varicose Veins

Venous duplex ultrasonography is the primary imaging modality of choice for diagnosing varicose veins, especially when venous disease is severe or interventional therapy is being considered. 1

Primary Imaging Modality

Duplex ultrasonography offers several advantages for varicose vein assessment:

• Non-invasive: Simple, painless procedure with no radiation exposure
• Comprehensive: Assesses both anatomy and physiology of the venous system
• Detailed information: Provides critical data on:
  • Incompetent saphenous junctions and their diameters
  • Extent of reflux
  • Location and size of incompetent perforating veins
  • Presence of acute or occult deep venous thrombosis
  • Superficial thrombophlebitis

Reflux is defined as retrograde flow lasting:

• 350 milliseconds in perforating veins

• 500 milliseconds in superficial and deep calf veins

• 1,000 milliseconds in femoropopliteal veins 1

When to Use Imaging

Duplex ultrasonography is indicated in the following scenarios:

• When venous disease is severe (CEAP classification C3-C6)
• When interventional therapy is being considered
• For assessment of recurrent varicose veins
• To evaluate popliteal fossa reflux
• To examine the groin and residual long saphenous vein in recurrent cases 2

Clinical Implications

The information obtained from duplex ultrasonography directly impacts treatment decisions:

• Identifies which saphenous junctions are incompetent
• Determines the extent of reflux
• Maps the location of incompetent perforating veins
• Assesses for deep venous insufficiency
• Guides selection of appropriate intervention (thermal ablation, sclerotherapy, or surgery) 1

Alternative Imaging Modalities

Other imaging techniques are rarely needed and only used in specific circumstances:

• CT angiography: Only if venous ultrasonography is inconclusive or for complex surgical planning
• MR venography: Only if venous ultrasonography is inconclusive or for complex surgical planning
• Venography: Largely replaced by duplex ultrasonography, used only in exceptional cases
• Plethysmography: Rarely used, primarily for research purposes 1

Accuracy Considerations

Hand-held Doppler (HHD) ultrasonography alone is insufficient for planning varicose vein surgery:

• Sensitivity is only 73% at the saphenofemoral junction
• Sensitivity is 77% at the saphenopopliteal junction
• Sensitivity is 51% for thigh perforators
• Surgery planned using HHD alone would leave residual sites of reflux in 24% of cases 3

Clinical Pitfalls to Avoid

1. Relying solely on physical examination: Physical examination is unreliable for detecting sources of reflux in varicose veins 3

2. Using only hand-held Doppler without duplex imaging: This approach misses significant reflux sites in approximately one-quarter of patients 3

3. Failing to scan the entire venous system: Incomplete assessment may miss variant anatomy or secondary sources of reflux

4. Not performing imaging before interventional procedures: Preinterventional duplex ultrasound is a prerequisite for planning endoluminal treatment of varicose veins 4