Diagnostic evaluation of lower extremity chronic venous insufficiency
- Patrick C Alguire, MD, FACP
Patrick C Alguire, MD, FACP
- Senior Vice President Emeritus for Medical Education
- American College of Physicians
- Barbara M Mathes, MD, FACP, FAAD
Barbara M Mathes, MD, FACP, FAAD
- Clinical Associate, Dermatology
- University of Pennsylvania
- Secretary Treasurer
- American Academy of Dermatology
- Section Editors
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Severe clinical manifestations of chronic venous disease, including edema (which can be unilateral), skin changes, and venous ulceration, are often sufficient to establish a diagnosis of chronic venous insufficiency. However, objective testing may be needed to confirm the diagnosis, determine the etiology (reflux, obstruction, or reflux and obstruction), localize the anatomic site and severity of disease, or identify coexisting peripheral artery disease.
Diagnostic testing identifies patients with venous pathology who may benefit from vein ablation treatments, which are effective in controlling vein-related symptoms and decreasing the incidence of recurrent ulceration in those with superficial venous reflux.
The diagnostic tests available to evaluate the patient with suspected chronic venous insufficiency are reviewed. The pathophysiology, clinical manifestations, and treatment of this disorder are discussed separately. (See "Pathophysiology of chronic venous disease" and "Clinical manifestations of lower extremity chronic venous disease" and "Overview and management of lower extremity chronic venous disease" and "Medical management of lower extremity chronic venous disease" and "Endovenous laser ablation for the treatment of lower extremity chronic venous disease" and "Radiofrequency ablation for the treatment of lower extremity chronic venous disease".)
APPROACH TO THE PATIENT
Localized lower extremity edema and characteristic skin pigmentation strongly support the diagnosis of venous hypertension (picture 1). The history and physical examination are sufficient in many cases for eliminating systemic causes of venous hypertension (eg, hypervolemia, heart failure). (See "Clinical manifestations of lower extremity chronic venous disease" and "Clinical manifestations and diagnosis of edema in adults", section on 'Venous insufficiency or thrombosis' and "Clinical assessment of wounds", section on 'Differentiation of chronic ulcers'.)
A venous duplex ultrasound examination can confirm the presence of venous obstruction or valvular incompetence as the cause of venous hypertension and is used for planning venous ablation procedures [1-3] but is not necessary in all cases of suspected venous insufficiency where intervention is not being considered. (See 'Duplex ultrasonography' below.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2011; 53:2S.
- Obermayer A, Garzon K. Identifying the source of superficial reflux in venous leg ulcers using duplex ultrasound. J Vasc Surg 2010; 52:1255.
- Ghauri AS, Nyamekye IK. Leg ulceration: the importance of treating the underlying pathophysiology. Phlebology 2010; 25 Suppl 1:42.
- Barwell JR, Davies CE, Deacon J, et al. Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial. Lancet 2004; 363:1854.
- Coleridge-Smith P, Labropoulos N, Partsch H, et al. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part I. Basic principles. Eur J Vasc Endovasc Surg 2006; 31:83.
- Labropoulos N, Leon M, Nicolaides AN, et al. Superficial venous insufficiency: correlation of anatomic extent of reflux with clinical symptoms and signs. J Vasc Surg 1994; 20:953.
- Labropoulos N, Leon LR Jr. Duplex evaluation of venous insufficiency. Semin Vasc Surg 2005; 18:5.
- García-Gimeno M, Rodríguez-Camarero S, Tagarro-Villalba S, et al. Duplex mapping of 2036 primary varicose veins. J Vasc Surg 2009; 49:681.
- Zagzebski, JA. Physics and instrumentation in Doppler and B-mode ultrasonography. In: Introduction to vascular ultrasonography, WB Saunders Company, Philadelphia 1992. p.19.
- Zygmunt J Jr. What is new in duplex scanning of the venous system? Perspect Vasc Surg Endovasc Ther 2009; 21:94.
- de Oliveira A, França GJ, Vidal EA, et al. Duplex scan in patients with clinical suspicion of deep venous thrombosis. Cardiovasc Ultrasound 2008; 6:53.
- Baker SR, Burnand KG, Sommerville KM, et al. Comparison of venous reflux assessed by duplex scanning and descending phlebography in chronic venous disease. Lancet 1993; 341:400.
- Buchbinder D, McCullough GM, Melick CF. Patients evaluated for venous disease may have other pathologic conditions contributing to symptomatology. Am J Surg 1993; 166:211.
- Aitken AG, Godden DJ. Real-time ultrasound diagnosis of deep vein thrombosis: a comparison with venography. Clin Radiol 1987; 38:309.
- Bach AM, Hann LE. When the common femoral vein is revealed as flattened on spectral Doppler sonography: is it a reliable sign for diagnosis of proximal venous obstruction? AJR Am J Roentgenol 1997; 168:733.
- Mitchell DC, Grasty MS, Stebbings WS, et al. Comparison of duplex ultrasonography and venography in the diagnosis of deep venous thrombosis. Br J Surg 1991; 78:611.
- Lensing AW, Prandoni P, Brandjes D, et al. Detection of deep-vein thrombosis by real-time B-mode ultrasonography. N Engl J Med 1989; 320:342.
- Dauzat MM, Laroche JP, Charras C, et al. Real-time B-mode ultrasonography for better specificity in the noninvasive diagnosis of deep venous thrombosis. J Ultrasound Med 1986; 5:625.
- Killewich LA, Bedford GR, Beach KW, Strandness DE Jr. Diagnosis of deep venous thrombosis. A prospective study comparing duplex scanning to contrast venography. Circulation 1989; 79:810.
- Georgiev M, Myers KA, Belcaro G. The thigh extension of the lesser saphenous vein: from Giacomini's observations to ultrasound scan imaging. J Vasc Surg 2003; 37:558.
- Delis KT, Knaggs AL, Khodabakhsh P. Prevalence, anatomic patterns, valvular competence, and clinical significance of the Giacomini vein. J Vasc Surg 2004; 40:1174.
- Meissner MH, Moneta G, Burnand K, et al. The hemodynamics and diagnosis of venous disease. J Vasc Surg 2007; 46 Suppl S:4S.
- Coleridge-Smith P, Labropoulos N, Partsch H, et al. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part I. Basic principles. Vasa 2007; 36:53.
- Labropoulos N, Tiongson J, Pryor L, et al. Definition of venous reflux in lower-extremity veins. J Vasc Surg 2003; 38:793.
- Lurie F, Comerota A, Eklof B, et al. Multicenter assessment of venous reflux by duplex ultrasound. J Vasc Surg 2012; 55:437.
- Morbio AP, Sobreira ML, Rollo HA. Correlation between the intensity of venous reflux in the saphenofemoral junction and morphological changes of the great saphenous vein by duplex scanning in patients with primary varicosis. Int Angiol 2010; 29:323.
- Neglen P, Raju S. A comparison between descending phlebography and duplex Doppler investigation in the evaluation of reflux in chronic venous insufficiency: a challenge to phlebography as the "gold standard". J Vasc Surg 1992; 16:687.
- Gaweesh AS, Kayed MH, Gaweesh TY, et al. Underlying deep venous abnormalities in patients with unilateral chronic venous disease. Phlebology 2013; 28:426.
- Gurel K, Gurel S, Karavas E, et al. Direct contrast-enhanced MR venography in the diagnosis of May-Thurner syndrome. Eur J Radiol 2011; 80:533.
- Arnoldussen CWKP, Lam Y, Ito N, et al. Gadobutrol versus gadofosveset-trisodium in MR venography of the lower extremities. Eur Radiol 2017.
- Spritzer CE. Progress in MR imaging of the venous system. Perspect Vasc Surg Endovasc Ther 2009; 21:105.
- Lee W, Chung JW, Yin YH, et al. Three-Dimensional CT venography of varicose veins of the lower extremity: image quality and comparison with doppler sonography. AJR Am J Roentgenol 2008; 191:1186.
- Min SK, Kim SY, Park YJ, et al. Role of three-dimensional computed tomography venography as a powerful navigator for varicose vein surgery. J Vasc Surg 2010; 51:893.
- Christopoulos D, Nicolaides AN, Szendro G. Venous reflux: quantification and correlation with the clinical severity of chronic venous disease. Br J Surg 1988; 75:352.
- Stücker M, Reich S, Robak-Pawelczyk B, et al. Changes in venous refilling time from childhood to adulthood in subjects with apparently normal veins. J Vasc Surg 2005; 41:296.
- Nicolaides AN, Cardiovascular Disease Educational and Research Trust, European Society of Vascular Surgery, et al. Investigation of chronic venous insufficiency: A consensus statement (France, March 5-9, 1997). Circulation 2000; 102:E126.
- Criado E, Farber MA, Marston WA, et al. The role of air plethysmography in the diagnosis of chronic venous insufficiency. J Vasc Surg 1998; 27:660.
- Lattimer CR, Azzam M, Kalodiki E, Geroulakos G. Venous filling time using air-plethysmography correlates highly with great saphenous vein reflux time using duplex. Phlebology 2014; 29:90.
- van Rij AM, Jiang P, Solomon C, et al. Recurrence after varicose vein surgery: a prospective long-term clinical study with duplex ultrasound scanning and air plethysmography. J Vasc Surg 2003; 38:935.
- Bays RA, Healy DA, Atnip RG, et al. Validation of air plethysmography, photoplethysmography, and duplex ultrasonography in the evaluation of severe venous stasis. J Vasc Surg 1994; 20:721.
- Kelechi TJ, McNeil RB. A pilot study of venous photoplethysmography screening of patients with chronic venous disorders. Appl Nurs Res 2010; 23:178.