What is the appropriate workup for a patient with suspected venous insufficiency?

Workup of Venous Insufficiency

Begin with duplex ultrasound of the lower extremity veins as the first-line diagnostic test for suspected venous insufficiency—this is the gold standard and should assess the deep venous system, great saphenous vein (GSV), small saphenous vein (SSV), accessory saphenous veins, perforating veins, and evaluate for reflux and obstruction. 1

Initial Clinical Assessment

History and Physical Examination

• Document specific symptoms: leg heaviness, aching, swelling, skin changes (pigmentation, dermatitis), presence of varicose veins, and history of venous ulcers 2, 3
• Identify risk factors: prolonged standing occupation, history of deep vein thrombosis, family history of varicose veins, number of pregnancies in women, and smoking history 4
• Classify disease severity using CEAP classification (Clinical-Etiologic-Anatomic-Pathophysiologic) to standardize assessment and guide treatment 1, 3:
  • C0: No visible venous disease
  • C1: Telangiectasias or reticular veins
  • C2: Varicose veins (≥3 mm diameter)
  • C3: Edema without skin changes
  • C4: Skin changes (pigmentation, eczema, lipodermatosclerosis)
  • C5: Healed venous ulcer
  • C6: Active venous ulcer 5, 3

Primary Diagnostic Test

Duplex Ultrasound (First-Line)

• Perform duplex ultrasound as the initial and most important diagnostic test for all patients with suspected venous insufficiency 1, 2
• The examination must include:
  • Assessment of deep venous system patency and competence 1, 2
  • Evaluation of GSV and SSV for reflux (pathologic reflux defined as reverse flow >0.5 seconds) 1, 3
  • Identification of incompetent perforating veins (diameter ≥3.5 mm with outward flow ≥500 ms) 3
  • Documentation of blood flow direction and presence of obstruction 1, 2
• Perform examination in both supine and semi-standing positions with Valsalva maneuver to maximize sensitivity for detecting reflux 1

Additional Diagnostic Considerations

When Pelvic Venous Involvement is Suspected

• Consider MR venography (MRV) or CT venography of abdomen and pelvis if patient presents with:
  • Varicose veins in atypical distribution (posterior thigh, vulva, inguinal regions not following saphenous distribution) 1
  • Entire leg swelling with flank, buttock, or back pain suggesting iliac vein involvement 1
  • Recurrent varicose veins after prior treatment 1
• MRV can identify: stenosis, occlusion, venous webs, collaterals, and dilated pelvic/ovarian veins (>5 mm periuterine, >6-8 mm ovarian veins are pathologic) 1

Physiologic Testing (Selective Use)

• Ambulatory venous pressure (AVP) measurement can quantify severity of venous hypertension but is invasive and rarely used in routine practice 5, 2
• Plethysmography (air or photoplethysmography) can assess venous refilling time and calf muscle pump function, though duplex ultrasound has largely replaced this 2

Invasive Studies (Rarely Indicated)

• Ascending phlebography demonstrates deep vein anatomy, perforator competence, and post-thrombotic changes but is reserved for complex cases where ultrasound is inadequate 6, 5
• Descending phlebography can assess valve competence in femoral and saphenous veins but is rarely needed with modern ultrasound 6, 5
• Intravascular ultrasound (IVUS) may detect iliac vein stenosis not visible on standard venography in select cases 1

Critical Pitfalls to Avoid

• Do not skip duplex ultrasound—it is non-invasive, widely available, and provides comprehensive anatomic and hemodynamic information that guides all treatment decisions 1, 2
• Do not rely on clinical examination alone—physical findings correlate poorly with underlying venous anatomy and pathophysiology 2, 3
• Do not order invasive phlebography as a first-line test—duplex ultrasound has replaced venography for routine diagnosis 5, 2
• Do not miss pelvic venous sources—if varicose veins have atypical distribution or recur after treatment, image the pelvis with MRV or CT venography 1
• Do not forget to assess perforating veins—incompetent perforators (especially in C5-C6 disease with ulceration) may require treatment 1, 3

Algorithmic Approach

1. Perform detailed history and physical examination → Document CEAP classification 3
2. Order duplex ultrasound of lower extremity veins (bilateral if symptoms bilateral) 1
3. If duplex shows superficial venous insufficiency → Proceed to treatment planning 3
4. If atypical varicose distribution or recurrence → Add pelvic MRV or CT venography 1
5. If severe disease (C4-C6) with ulceration → Specifically assess perforating veins on ultrasound 1, 3
6. Reserve invasive studies (phlebography, IVUS) for complex cases where non-invasive imaging is inadequate or inconclusive 1, 5