Workup for Venous Insufficiency
Duplex ultrasound should be the first and primary diagnostic test for evaluating suspected venous insufficiency, performed with the patient standing or at 60 degrees reverse Trendelenburg to assess for pathologic reflux (>500 ms retrograde flow) in the superficial and deep venous systems. 1
Initial Diagnostic Approach
Begin duplex ultrasound evaluation immediately when patients present with:
- Leg heaviness, aching, or pain worsened by prolonged standing and relieved by elevation 2
- Visible varicose veins 1
- Lower extremity edema that worsens throughout the day 2
- Skin changes including stasis dermatitis, hyperpigmentation, or lipodermatosclerosis 2
- Healed or active venous ulcers (typically near medial malleolus) 2
Comprehensive Duplex Ultrasound Protocol
The duplex examination must systematically evaluate: 1
- Deep venous system patency and competence (femoral, popliteal, tibial veins) 1
- Great saphenous vein (GSV) throughout its entire length 1
- Small saphenous vein (SSV) 1
- Accessory saphenous veins 1
- Perforating veins - document presence, location, and clinical relevance 1
- Alternative refluxing superficial venous pathways 1
Technical requirements for optimal assessment: 1
- Scan in both transverse and longitudinal planes 1
- Verify respiratory variation and cardiac pulsations (indicates patent pathway to heart) 1
- Measure reflux duration with standardized provocative maneuvers - reflux >500 ms is pathologic 1
- Patient positioning: standing on one leg while scanning the other is optimal, though 60-degree reverse Trendelenburg is an acceptable alternative when standing is not tolerated 1
When Duplex Ultrasound is Limited
In rare cases where ultrasound is suboptimal (severe obesity, extensive subcutaneous edema), consider: 1
- CT venography (CTV) as the next imaging modality 1
- MR venography (MRV) when avoiding iodinated contrast is necessary 1
Important caveat: These advanced imaging modalities are adjunctive only and should not replace duplex ultrasound as the initial test. 1
Additional Imaging for Pelvic Venous Involvement
Consider pelvic imaging (CTV or MRV) when: 1
- Bilateral GSV insufficiency is present 1
- Symptoms suggest iliac vein involvement (entire leg swelling, flank/buttock pain) 1
- Planning interventional procedures where comprehensive anatomic understanding affects treatment selection 1
What NOT to Do
Do not order: 1
- Intravascular ultrasound (IVUS) of iliac veins as initial workup - no supporting evidence for routine use 1
- MRV as first-line test - duplex ultrasound is superior and more cost-effective 1
- D-dimer testing - this is for acute thrombosis, not chronic venous insufficiency 3, 4
Clinical Classification After Diagnosis
Once venous insufficiency is confirmed, classify using CEAP system to guide treatment intensity: 5
- Document clinical class (C0-C6) 5
- Identify etiology (congenital, primary, secondary) 5
- Define anatomic distribution (superficial, deep, perforator) 5
- Characterize pathophysiology (reflux, obstruction, or both) 5
Additional Diagnostic Tests (Rarely Needed)
Reserve these specialized tests for complex cases or research settings: 5
- Plethysmography - quantifies venous refilling time 5
- Ambulatory venous pressure measurement - gold standard for hemodynamic assessment but invasive 5
- Venography - only when planning complex interventions or duplex is inconclusive 5
Common Pitfall to Avoid
Never diagnose venous insufficiency on clinical grounds alone without objective duplex ultrasound confirmation - the correlation between symptoms and actual venous pathology is poor, and treatment decisions must be based on documented anatomic and hemodynamic abnormalities. 1, 5