Diagnosing Venous Insufficiency
Duplex ultrasonography is the gold standard for diagnosing venous insufficiency, providing assessment of blood flow direction, venous reflux, and venous obstruction. 1
Clinical Presentation
- Patients with venous insufficiency may present with localized symptoms including pain, burning, itching, and tingling at the site of varicose veins 1
- Generalized symptoms include aching, heaviness, cramping, throbbing, restlessness, and swelling in the legs, typically worse at the end of the day and after prolonged standing 1
- Symptoms often resolve when patients sit and elevate their legs 1
- Signs of more serious vascular insufficiency include skin pigmentation changes, eczema, infection, superficial thrombophlebitis, venous ulceration, loss of subcutaneous tissue, and lipodermatosclerosis 1
- Women are significantly more likely than men to report lower limb symptoms 1
Risk Factors
- Family history of venous disease 1
- Female sex 1
- Older age 1
- Chronically increased intra-abdominal pressure (obesity, pregnancy, chronic constipation, tumors) 1
- Prolonged standing 1
- Deep venous thrombosis causing valve damage 1
- Arteriovenous shunting 1
Diagnostic Algorithm
Step 1: Clinical Assessment and CEAP Classification
- Document clinical severity using the CEAP classification system 1:
- C0: No visible or palpable signs of venous disease
- C1: Telangiectasias or reticular veins
- C2: Varicose veins
- C3: Edema
- C4: Skin changes (pigmentation, eczema)
- C5: Healed venous ulcer
- C6: Active venous ulcer
- Note presence (S) or absence (A) of symptoms 1
Step 2: Duplex Ultrasonography
- Duplex ultrasonography should be performed when venous disease is severe or interventional therapy is being considered 1
- The examination should include 1:
- Assessment of direction of blood flow
- Evaluation for venous reflux
- Assessment for venous obstruction
- Examination of deep venous system, great saphenous vein (GSV), small saphenous vein (SSV), and accessory saphenous veins
- Identification of perforating veins and alternative refluxing superficial venous pathways
Step 3: Specific Ultrasonography Technique
- Position patient standing or semi-standing with weight on the contralateral leg 1
- Perform Valsalva maneuver to assess for reflux 1
- Three key sonographic criteria for diagnosis of venous insufficiency 1:
- Dilated, tortuous veins >4 mm
- Slow or reversed blood flow (3 cm/s)
- Dilated arcuate veins that communicate with varicosities
Step 4: Additional Imaging (When Indicated)
- For pelvic or iliac vein involvement, consider 1:
- Contrast-enhanced CT venography
- Magnetic resonance venography (MRV)
- For cases with suspected deep vein thrombosis, consider 1:
Pitfalls and Caveats
- Duplex ultrasonography has limitations in imaging central veins (pelvic veins, proximal subclavian vein, IVC, SVC) 1
- Ultrasonography is operator-dependent and requires an experienced sonographer, particularly for pelvic venous insufficiency 1
- Body habitus and bowel gas can limit visualization in pelvic examinations 1
- D-dimer testing is not recommended for diagnosing venous thromboembolism in cancer patients due to high false-positive rates 1
- Venography, while historically considered the gold standard, is now rarely used due to invasiveness, patient discomfort, and potential complications 1
Key Diagnostic Findings
- Incompetent valves allowing blood to flow in reverse direction 1
- Elongated and tortuous veins due to increased pressure 1
- Reflux during Valsalva maneuver or compression/release testing 1
- Peak systolic velocity ratio >2.5 across stenosis indicates hemodynamically significant obstruction 1
By following this systematic diagnostic approach, clinicians can accurately diagnose venous insufficiency and determine its severity, which is essential for developing an appropriate treatment plan that will improve patient morbidity, mortality, and quality of life.