How is chronic venous insufficiency diagnosed?

Diagnosing Chronic Venous Insufficiency

Duplex ultrasound is the gold standard first-line imaging test for diagnosing chronic venous insufficiency (CVI), with specific diagnostic criteria including retrograde venous flow exceeding 500 milliseconds and vein diameter >4.5 mm. 1

Diagnostic Approach

Clinical Assessment

• Evaluate for typical symptoms:
  • Leg heaviness, aching, fatigue
  • Swelling that worsens with prolonged standing
  • Skin changes (hyperpigmentation, lipodermatosclerosis)
  • Varicose veins
  • Venous ulcers (particularly around ankle/medial malleolus)

Duplex Ultrasound Evaluation

Duplex ultrasound should include comprehensive assessment of:

• Direction of blood flow
• Venous reflux (diagnostic when >500 ms)
• Venous obstruction
• Condition of deep venous system
• Great saphenous vein (GSV) and small saphenous vein (SSV)
• Accessory saphenous veins
• Clinically relevant perforating veins
• Alternative refluxing superficial venous pathways 2, 1

Patient positioning is critical - evaluation should be performed with the patient standing or at 60° Trendelenburg position to accurately assess reflux 1.

Advanced Imaging

For complex cases or when planning interventions, additional imaging may be necessary:

• Pelvic duplex ultrasound: Particularly important when pelvic origin varicose veins are suspected

  • Diagnostic criteria: dilated tortuous pelvic vein >4 mm, slow/reversed blood flow (3 cm/s), dilated arcuate vein in myometrium communicating with pelvic varicosities 2

• CT or MR venography: Consider when:

  • Iliac vein compression is suspected
  • Planning for interventional procedures
  • Duplex findings are inconclusive 3

Diagnostic Criteria

The diagnosis of CVI is confirmed when the following are present:

1. Venous reflux: Retrograde flow >500 milliseconds on duplex ultrasound 1
2. Vein dilation: Vein diameter >4.5 mm 1
3. Clinical manifestations: Corresponding to the CEAP classification system:
   • C0: No visible signs
   • C1: Telangiectasias or reticular veins
   • C2: Varicose veins
   • C3: Edema
   • C4: Skin changes (pigmentation, eczema)
   • C5: Healed venous ulcer
   • C6: Active venous ulcer

Common Pitfalls in Diagnosis

• Incomplete assessment: Failure to evaluate the entire venous system (deep veins, perforators, accessory saphenous veins) can lead to incomplete diagnosis and treatment failure 1

• Overlooking underlying causes: Nonthrombotic iliac vein lesions or cardiac conditions like tricuspid regurgitation can cause CVI symptoms and should be considered in the differential diagnosis 1

• Improper patient positioning: Examining patients only in supine position may miss reflux that would be evident in standing position 1

• Failure to distinguish primary from secondary CVI: Post-thrombotic changes require different management approaches than primary valvular incompetence 4

• Misdiagnosing pelvic origin varicose veins: Vulvar or posterior thigh varicosities may originate from pelvic venous insufficiency rather than lower extremity sources 2

By following this systematic diagnostic approach with appropriate imaging and clinical correlation, chronic venous insufficiency can be accurately diagnosed, allowing for targeted treatment planning.