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172 Chapter 18/Ultrasound Examination of the Patient with Primary Venous Insuffi ciency
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EQUIPMENT
The ultrasound duplex scanner should be able to detect
blood fl ow rates as low as 6 cm/sec.13 This can be done by
dedicated high resolution vascular scanners with Color/
Power-Doppler functions and pulsed-wave Doppler. Linear
transducers in the range of 4–7 megahertz are used.6 The
IVC, pelvic veins, and deep veins in obese patients may be
be imaged with 3 megahertz transducers.
With the advances in technology, duplex scanners have
become smaller, more transportable, and more operator
friendly.14 Miniaturized devices feature transducers designed
with advanced architecture that allow a single probe to
image across a greater range of depths within an application
and across applications. The transducer for peripheral vascular examinations operates from 10–5 MHz and provides
resolution from skin surface to 7 cm in depth. The technology incorporates power Doppler sonography, tissue harmonic imaging, and direct connectivity to a personal
computer. Their overall performance is comparable to the
more traditional ultrasound machines.
14
Additional material needed for a complete examination
include acoustic gel, towels, a walker, and a data collection
diagram.
EXAMINATION
The examination should begin with a complete medical
history. Data concerning family and personal venous history,
symptoms, clinical fi ndings, and previous venous treatments
are collected.13 Comorbidities, allergies, and pharmacologic
history must be documented. The BMI is calculated from
the patient’s height and weight.
The patient should be examined in a standing up position
to better demonstrate patterns of telangiectasias and reticular
and varicose veins.
skin (vein light) may be used to identify reticular veins, and
portable Doppler devices can verify the presence of refl ux
in some superfi cial veins.
grated into the CEAP classifi cation.
Limbs should be classifi ed into one of seven CEAP
classes of increasing severity designated C0 to C6 (see Table
18.1) and identifi ed as symptomatic (S) or asymptomatic
(A).17 Common symptoms associated with CVI are leg
aching, heaviness, and sensation of itching and swelling;
important signs to consider are skin hyperpigmentation, blue
blebs, corona phlebectatica, venous dermatitis, lipodermatosclerosis, active ulcers, and/or scars from previous ulceration. Recently the term chronic venous disease (CVD) has
been referred to the full spectrum of signs and symptoms
associated with classes C
venous insuffi ciency related to classes C4 to C6.
A history of previous deep vein thrombosis or pulmonary
embolism will provide information regarding etiology. The
15,16
Cold light transillumination of the
16
Clinical data should be inte-
0,S
17
to C6, and the term chronic
18
TABLE 18.1 CEAP Classifi cation of Chronic Venous Disease
and Chronic Venous Insuffi ciency
Class Signs of venous disease
Class 0 No visible or palpable signs of Venous Disease (only
symptoms)
Class 1 (a,s) Teleangiectasias or Reticular Veins
Class 2 (a,s) Varicose Veins
Class 3 (a,s) Edema
Class 4 (a,s) Skin changes ascribed to venous disease (e.g.,
pigmentation, venous eczema, lipodermatosclerosis)
Class 5 (a,s) Skin Changes as defi ned above with healed ulceration
Class 6 (a,s) Skin Changes as defi ned above with acticve ulceration
TABLE 18.2 Summary of Important Changes in
Nomenclature of Lower Extremity Veins
Old terminology New terminology
Femoral Vein Common Femoral Vein
Superfi cial Femoral Vein Femoral Vein
Deep Vein of the thigh Profunda Femoris Vein
Greater/Long Saphenous Vein Great Saphenous Vein
Smaller/Short Saphenous Vein Small Saphenous Vein
Sural Veins Soleal Veins
Gastrocnemius Veins
Medial Gastrocnemius Vein
Lateral Gastrocnemius Vein
Intergemellar Vein
Dodd’s Perforator Perforator of the Femoral Canal
Boyd’s Perforator Paratibial Perforator (upper third
of the leg)
Sherman’s Perforator (24 cm) Paratibial Perforator (mid third of
the leg)
Cockett’s Perforators Posterotibial Perforators
17
19,25
method of making the diagnosis of DVT always should be
recorded.
The anatomic distribution and the pathophysiology
within the CEAP system are revealed by the ultrasound
examination.
ULTRASOUND EXAMINATION
In 2002, an International Interdisciplinary Consensus on
Venous Anatomical Terminology proposed a revision and
extension of the Terminologia Anatomica of the lower
extremity venous system (see Table 18.2).19 The new nomenclature has been fully adopted in this chapter.
The ultrasound examination is carried out with the patient
standing in an upright position.20 This position elicits refl ux
by challenging venous valves and maximally dilates the leg
veins. Sensitivity and specifi city in detecting refl ux are
increased in examinations performed with the patient standing rather than when the patient is supine.
examination should be considered to be inadequate.
7,8,20
The supine
The Sapheno-Femoral Junction 173
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FIGURE 18.1 This data entry form outlines the saphenous veins and the relevant deep veins. Refl uxing veins are
added in heavy black lines. Location of perforating veins and aneurysms can be added and distance from the fl oor
indicated. Diameters of perforating veins at the fascial level should also be noted.
Of particular importance is instruction to the patient to
inform the ultrasonographer of any lightheadness, faint
feeling, dizziness, or nausea. These symptoms seem to be
associated with the overall atmosphere of the room and the
audibility of Doppler velocity signals. The symptoms appear
less frequently in patients when the examination is performed silently. If such a tendency to fainting because
of vaso–vagal refl ux is encountered, the examination may
need to be modifi ed with the patient in the semi-upright
position.
14
The veins are scanned by moving the probe vertically up
and down along their course. Duplicated segments, sites of
tributary confl uence, and large perforating veins and their
deep venous connections are identifi ed.
14
Transverse rather than longitudinal scans, and continuous
scanning are performed in order to provide a clear mapping
of the venous system.14 This can be recorded on a premade
datasheet (see Figure 18.1). Patency usually is assessed by
compression of the vein, and refl ux is detected on release.
The augmentation of fl ow, distal compression, and release
of thigh and calf6 should be done sharply and quickly.14
Automated rapid infl ation/defl ation cuffs are cumbersome
but may be used for this purpose, and offer the advantage
of a standardized stimulus.
8,15
The Valsalva maneuver is a
reverse fl ow augmentation stimulus and is used only for the
Sapheno-femoral junction (SFJ) because a competent valve
will render the test useless distally.
REFLUX
The presence of vein refl ux through incompetent vein
valves is the most important pathologic fi nding in CVI.
Refl ux is measured during the release phase of the fl ow
augmentation maneuver and during the closed-epiglottis
apneic phase of the Valsalva (see Figure 18.2). It should be
noted that retrograde backfl ow is present in normal vein
valves immediately before their closure, but a cutoff value
of 500 ms defi nes pathologic refl ux in superfi cial, profunda
femoris, and deep calf veins. The value of 350 ms is used in
perforator veins and 1000 ms for femoral, superfi cial, and
popliteal veins.
20,21
THE SAPHENO-FEMORAL JUNCTION
With the patient standing and the transducer gently
applied in the groin, the SFJ, common femoral vein, superfi cial femoral vein, and profunda femoris veins are identifi ed
(see Figure 18.3). The SFJ is complex and highly variable.
It includes the Great Saphenous vein (GSV), pudendal veins,
and superfi cial epigastric and superfi cial circumfl ex iliac
veins (see Figure 18.4a).
is particularly important in cases of Pelvic Congestive Syndrome in which vulvar varicosities and pudendal refl ux can
19,22
Imaging of the pudendal veins
174 Chapter 18/Ultrasound Examination of the Patient with Primary Venous Insuffi ciency
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FIGURE 18.2 Flow augmentation maneuvers elicit refl ux in incompetent veins. Refl ux is defi ned as retrograde
outfl ow measured during the release phase of the augmentation maneuver and the Valsava’s closed epiglottis apneic
phase for the saphenofemoral junction only. Cuttoff values for different veins are listed in the text.
FIGURE 18.3 A transverse scan of the saphenofemoral junction is dis-
played. Major anatomic landmarks to be noted are femoral vein, femoral
artery, profunda femoris vein, junction (diameter), Great Saphenous
veins.
be observed.23 Incompetence of the ovarian veins is the most
important cause of this syndrome.
24
The diameter of the SFJ at the confl uence of the GSV
and the femoral vein is recorded as this is important in
performing endovenous therapy. The SFJ is usually the
location of the terminal valve.25 More distally another
valve, known as subterminal, is also identifi able (see
Figure 18.4b).
25
The Valsalva and thigh/calf compression-release maneuvers defi ne the presence of refl ux at the saphenofemoral
junction as well as in the femoral vein.
THE GREAT SAPHENOUS VEIN
The Great Saphenous vein is scanned from the groin in
proximal-to-distal direction.
In the thigh, the GSV lies within the saphenous compartment (see Figure 18.5).19 The superfi cial fascia and the
muscular fascia defi ne the saphenous compartment and
provide the typical ultrasound image of an Asian eye (see
Figure 18.5c).
Anterior and posterior accessory veins are often identifi ed in the thigh (see Figure 18.6). These veins are often
incompetent and receive refl ux from the saphenous vein.
Varying patterns of refl ux through the different components of the SFJ and GSV system have been documented.
Classifi cation of abnormal, refl uxing venous patterns has
been a diffi cult task because of the anatomic variability of
the vascular structures involved. In 2005 a panel of experts
proposed a new classifi cation of Great Saphenous vein
refl ux. This classifi cation is shown in Figure 18.7.
25
19
26,27
The Great Saphenous Vein 175
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FIGURE 18.4 A. The saphenofemoral junction includes the Great Saphenous vein, the superfi cial iliac circumfl ex,
the superfi cial epigastric, and the pudendal veins. B. Illustration of the SFJ with its valves. Modifi ed from the De
Venarum Ostiolis, of Jeronimus Fabricius Ab Acquapendente, Venice, 1603. TV, terminal valve; PTV, preterminal valve;
SSV, suprasaphenic valve; ISV, infrasaphenic valve. (Adapted from Caggiati et al.25)
Diameters of the GSV at several levels should always be
recorded. The term superfi cial venous aneurysms has been
proposed for segmental dilations of the GSV and Small
Saphenous vein (SSV).28 The term varicosities refers to
more elongated and dilated superfi cial veins, such as the
accessory saphenous veins (see Figure 18.8). The level, distance from the heel pad or fl oor, and antero-posterior and
FIGURE 18.5 A. The saphenous compartment (SaphC) is bound superfi cially by the saphenous fascia (SF) and deeply
by the muscular fascia (MF). It contains the saphenous veins (SV) and the saphenous nerve (SN). The accessory saphenous veins (ASV) lie external to this compartment, close to the dermis (D). SC, superfi cial compartment; DC, deep
compartment. (Adapted from Reference 19.) B. Axial section from a cadaveric limb. The Great Saphenous vein enclosed
in the saphenous compartment is clearly visualized. MF, muscular fascia; SL saphenous ligament. (Adapted from Reference 25.) C. Sonography of the Great Saphenous vein at mid thigh. The hyperechoic saphenous fascia (SF) and
muscular fascia (MF) defi ne the saphenous compartment in which the Great Saphenous vein courses.
latero-lateral diameters of venous aneurysms should be
recorded.
28
In the leg, anterior and posterior arch veins can ascend
parallel to the GSV (see Figure 18.6).
19
Inter-saphenous veins are often present as communications between the GSV and Small Saphenous vein
(SSV).
176 Chapter 18/Ultrasound Examination of the Patient with Primary Venous Insuffi ciency
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FIGURE 18.6 In 2005, a panel of experts proposed a new classifi cation to be used in a prospective multicenter study
testing the A.S.V.A.L. (selective ablation of varicose veins in local anesthesia) method. The classifi cation reports fi ve
major types of saphenofemoral refl ux. The recognition of each of them can guide different therapeutic approaches, such
as the A.S.V.A.L. (Adapted from Pittaluga et al.
26,27
)
The Great Saphenous Vein 177
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FIGURE 18.7 In 2005, a panel of experts proposed a new classifi cation to be used in a prospective multicenter study
testing the A.S.V.A.L. (selective ablation of varicose veins in local anesthesia) method. The classifi cation reports fi ve
major types of saphenofemoral refl ux. The recognition of each of them can guide different therapeutic approachs, such
as the A.S.V.A.L. (Adapted from Pittaluga et al.
26,27
)
178 Chapter 18/Ultrasound Examination of the Patient with Primary Venous Insuffi ciency
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FIGURE 18.7 Continued
THE SMALL SAPHENOUS VEIN
The study of the SSV starts at the popliteal fossa by
identifi cation of the Sapheno-popliteal junction. Compression-release of the calf provides information concerning
junctional refl ux. The cranial extension of the SSV also can
be identifi ed between the biceps femoris and semimembranous muscles.19 The Vein of Giacomini is another a cranial
extension of the SSV that connects with the GSV in the
posterio-medial aspect of the thigh.19 In the calf, the SSV
courses within a duplication of the superfi cial fascia similar
to the GSV in the saphenous compartment.
19
Throughout the entire examination, compression-release
maneuvers serve to elicit refl ux in the various venous
segments.
PERFORATING VEINS
Perforator veins (PV) penetrate anatomic layers (see
Figure 18.9). Communicating veins, such as intersaphenous
veins, connect veins within the same anatomic layer.
One of the innovations of the new Terminologia Ana-
tomica of the venous system of lower limbs is the complete
elimination of eponyms such as the Boyd, Sherman, and
Cockett perforators. Descriptive terms designating location
19
have been adopted.
A classifi cation of them is shown in
Table 18.3. No doubt, all the eponyms will persist.
19
During the examination, the location of each perforator
is recorded by measuring its distance (in cm) from the fl oor.
The diameter (in cm) of each perforator should be
recorded.
Refl ux is assessed by manual compression and release
maneuvers. Blood fl ow direction and duration following the
compression must be noted.
It has been suggested that an outward (toward the superfi cial veins) blow fl ow of duration greater than 350 ms, following manual distal compression, defi nes a perforator vein
as incompetent.
6
Perforators can be distinguished as exit and reentry veins.
Exit veins are refl uxing perforators usually associated with
clusters of varicose veins and/or important skin changes,
such as hyperpigmentation.
6
Reentry perforators usually are found distal to major
varicose veins and clusters. Their blood fl ow direction is
inward (toward the deep veins) and they are not pathologic
but merely competent.6 Skin changes are not seen adjacent
to reentry perforating veins.
Incompetent perforators usually are observed at the
medial thigh, middle and distal third of the leg, and mid third
of the calf.
6,13
Scanning of the lateral aspect of the lower limb also is
recommended. The lateral venous system that is seen on the
lateral aspect of the thigh and the leg can show varicosities
and important exit and reentry perforators. These are not as
well characterized as the medial perforating veins.
Perforating Veins 179
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FIGURE 18.8 Perforating veins penetrate anatomic layers (A). Distal
manual limb compression rather than proximal (B and C) elicits refl ux in
PVs.35 Refl ux is measured on the release phase of the augmentation maneuver and it is detected as outward fl ow (B) whose duration is greater than
350 ms in incompetent exit perforators.6 Reentry perforators show little or
absent outward fl ow following distal compressions (C).
TABLE 18.3 Perforating Veins
Main groups Subgroups
Foot perforators Medial foot PV
Lateral foot PV
Plantar foot PV
Dorsal foot PVs or intercapitular veins
Plantar PV
Ankle Perforators Anterior Ankle PV
Medial Ankle PV
Lateral Ankle PV
Leg Perforators Medial Leg PV
Paratibial PV
Posterior Tibial PV
Anterior Leg
Lateral Leg
Posterior Leg
Medial Gastrocnemius
Lateral Gastrocnemius
Intergemellar PV
Para-achillean PV
Knee Perforators Medial Knee PV
Suprapatellar PV
Lateral PV
Infrapatellar PV
Popliteal Fossa
Thigh Perforators Medial Thigh PV
PV of the femoral canal
Inguinal PV
Anterior thigh PV
Lateral thigh PV
Posterior Thigh PVs
Pudendal PV
19
FIGURE 18.9 A network of varicose veins and incompetent perforators is often identifi ed in the vicinity of venous ulcers usually beneath the ulcer
(A).31
180 Chapter 18/Ultrasound Examination of the Patient with Primary Venous Insuffi ciency
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TABLE 18.4 Major Interrogation Points for Venous Refl ux Examination
Interrogation points
Femoral Vein
Saphenofemoral Junction
Great Saphenous Vein
Accessory Veins (anterior and posterior)
Arch Veins (anterior and posterior)
Popliteal Vein-Gastrocnemius Veins
ULTRASOUND MAPPING
OF VENOUS ULCERS
Venous ulcers usually are associated with varicose veins
and refl uxing perforators located in the immediate vicinity
of the ulcerated area. A superfi cial network of enlarged and
dilated veins often can be observed underneath the ulcer (see
Figure 18.8).29 The description and the documentation of
refl ux in these veins can help to indicate a particular therapeutic approach.
29–31
DEEP VEINS
The ultrasound examination also must include the deep
veins. Femoral and popliteal veins usually are studied with
the patient in supine position.32 Patency is assessed by distal
compression. Irregularities of the vascular wall may appear
as hyperechoic areas and always should be noted in patients
with superfi cial refl ux and a clinical history suggestive of
previous deep vein thrombosis or pulmonary embolism.
Sural, anterior tibial, posterior tibial, and peroneal veins are
imaged while the patient is in the sitting position, usually
starting from the ankle and proceeding toward the knee.32
Compression and fl ow augmentation maneuvers assess their
patency and presence of refl ux. Deep vein abnormalities
must be recorded.
14
Small Saphenous Vein
Intersaphenous Veins
Medial Thigh PVs
Leg PVs
Ankle PVs
scopically deformed and incompetent terminal valves (Type
III and Type IV valves).
34
In contrast, duplex ultrasound PV identifi cation and
characterization have shown to be more diffi cult and less
accurate.33 Lower sensitivity rates (51%) have been reported
when the number of perforators identifi ed by ultrasound,
ascending phlebography (AP), and subfascial endoscopic
perforator surgery (SEPS) were compared.
33
CONCLUSION
Duplex ultrasound sonography is the optimal diagnostic
modality for assessment of lower extremity refl ux. Insights
into pathology, proper technique, and uniform testing are
essential.13 A clear graphic notation of signifi cant vein
diameters, anomalous anatomy, superfi cial venous aneurysms, perforating veins, and presence and extent of refl ux
should always be recorded during the examination. The
most important interrogation points for the venous refl ux
examination are indicated in Table 18.4. These serve as
basic guidelines because the interested vascular ultrasonographer must trace out duplicated veins and note refl ux in
major tributaries, such as the accessory veins.
References
Duplex ultrasound sonography represents the best choice
in evaluation of venous refl ux in lower limbs.
is noninvasive, generally acceptable to the patient, and inexpensive. It provides direct imaging, localization, and
extent of venous refl ux with a surprisingly high sensitivity
(95%) and specifi city (100%).
Duplex ultrasound fi ndings correlate with the angioscopic
observation of incompetent vein valves in advanced chronic
venous insuffi ciency.34 As demonstrated by Yamaki et al.,
high peak refl ux velocities (>30 cm/s), refl ux duration greater
than 3 s, and an enlarged valve annulus measured by duplex
ultrasonography at the SFJ are closely related to angio-
DISCUSSION
33
6,8,13
This test
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