Diagnosing Venous Insufficiency
Duplex ultrasonography is the gold standard for diagnosing venous insufficiency, which should be performed when venous disease is severe or interventional therapy is being considered. 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 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
Risk Factors
- Family history of venous disease 1
- Female sex (women are significantly more likely than men to report lower limb symptoms) 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
1. Clinical Classification (CEAP)
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
2. Duplex Ultrasonography
- Position the patient standing or semi-standing with weight on the contralateral leg 1
- Examine the deep venous system, great saphenous vein (GSV), small saphenous vein (SSV), and accessory saphenous veins 1
- Assess direction of blood flow and evaluate for venous reflux using Valsalva maneuver or compression/release testing 1
- Identify perforating veins and alternative refluxing superficial venous pathways 1
3. Key Sonographic Criteria for Diagnosis
- Dilated, tortuous veins >4 mm 1
- Slow or reversed blood flow (3 cm/s) 1
- Dilated arcuate veins that communicate with varicosities 1
- Incompetent valves allowing blood to flow in reverse direction 1
- Peak systolic velocity ratio >2.5 across stenosis indicates hemodynamically significant obstruction 1
4. Additional Imaging (When Indicated)
- Consider contrast-enhanced CT venography or magnetic resonance venography (MRV) for suspected pelvic or iliac vein involvement 1, 2
- MRV can identify stenosis, occlusion, venous atresia, collaterals, edema, webs, trabeculations, and vein wall thickening 2
- Gadolinium-enhanced MRV with contrast is preferred for high intravascular enhancement and high spatial resolution 2
- Three-dimensional volumetric imaging is preferred over MR direct thrombus or time-of-flight subtraction angiography 2
Specialized Testing for Complex Cases
- Ultrasound Doppler examination of IVC and iliac veins can determine patency; if visualization is limited, spectral waveforms can indirectly assess patency 2
- Loss of respiratory phase variation and monophasic physiology in common femoral veins indicate severe iliac vein occlusive disease (high specificity but low sensitivity) 2
- Invasive venography may be necessary before intervention to clarify the nature of disease and guide therapy in complex cases 2
Common Pitfalls and Caveats
- Duplex ultrasonography should be performed with the patient in standing or semi-standing position to maximize venous filling and detect reflux 1
- Clinical correlation of Doppler ultrasound and thrombosis can be poor; additional imaging may be needed in cases of high diagnostic doubt 3
- Invasive methods like phlebography should be reserved only for cases of very high diagnostic doubt 3
- Ultrasound evaluation should include assessment of both the superficial and deep venous systems, as venous insufficiency may involve either or both 1