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124 Chapter 12 DUS scanning for chronic venous obstruction and valvular incompetence
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12.7 (a) Cross-sectional view of an anterior accessory saphenous vein aneurysm in the upper thigh measuring 23mm. The adjacent
vein segment that is partially seen at the 7 o’clock position measured 3.4mm. The aneurysm is free of thrombus, as seen from the
echolucent lumen. This was also documented by its full compressibility. (b) Dense calcication of the great saphenous vein (GSV)
near wall in the lower thigh. Acoustic shadowing is seen throughout the calcication. Phlebosclerosis occasionally is seen in the
lower extremity veins and has no signicant implications, in contrast to calcication in intestinal veins that may lead to signicant
morbidity.
primary CVD, reux in PVs develops in an ascending manner through the adjoining incompetent supercial vein, in
a descending manner from the re-entry ow of a reuxing
supercial vein, and in new locations where the supercial
veins are also involved.
The correction of reux in the supercial system has
been shown to eliminate reux in the PV. This is not the
case when the deep system is incompetent (52). In a prospective study where PVs were treated with surgical ligation using DUS guidance, it was shown that recurrence of
PVs at 3years was very common (76%) (53). The recurrent
PVs were due to neovascularization or the development of
incompetence in new sites and not because of poor surgery. Arecent systematic review on the outcomes of percutaneous treatment of perforating veins has shown that
the available treatment modalities—endovenous laser ablation, radiofrequency ablation, and ultrasound-guided foam
sclerotherapy—have similar 12-month follow-up occlusion
and ulcer healing rates (50).
DUS can also identify other uncommon pathologies in
the veins, such as aneurysms, tumors, and phlebosclerosis
(Figure12.7). These pathologies are not usually associated
with the signs and symptoms of CVD unless there is concomitant reux or obstruction. However, their diagnosis is
important and can alter management.
12.7 PROGRESSION OF CVD
It was previously hypothesized that because of hydrostatic pressure, reux must start at the level of the iliac or
common femoral valves and develop in a retrograde manner. However, studies on the morphology, biochemistry,
and function of the venous wall have demonstrated that
changes can occur in any vein segment, irrespective of the
site and function of the valves (54–57). With the use of
DUS, it has been clearly shown that in the early stages of
CVD, reux develops in most people in the lower thigh,
knee, and calf, without having a connection to the groin
area (46). Reux therefore may have an ascending progression, descending progression, both, or may be multifocal.
These ndings are further supported by a recent study that
examined patients below the age of 30years with varicose
veins and compared them with another group of patients
over the age of 60years (58). It was shown that most often
the saphenous and nonsaphenous tributaries are diseased,
and this was more common in younger patients. Junctional
involvement was signicantly less prevalent in the younger
group (38% vs 59%, P=0.0005).
A prospective study of 126 limbs including three distinct groups of patients with primary, secondary, and no
signs or symptoms of CVD showed that secondary CVD
progresses faster than primary CVD. The authors demonstrated that at 5-year follow-up, skin damage was more
prominent in patients with secondary CVD and that those
skin changes were seen earlier in the course of the disease
in patients with secondary CVD compared to primary
CVD (59). Another study that followed 116 limbs in 90
patients studied the progression of reux in CVD and its
relation to physical ndings (60). These patients had two
or more DUS examinations prior to operation since the
procedure was delayed for various reasons. It was demonstrated that in 73.3% of patients, there was no change in
the DUS examination and extent of reux. In 13 limbs,
there was advancement of CEAP staging, of which 7 also
had progression on DUS as well. Progression of reux was
seen in 26.7% of patients. These results indicated that
physical examination or DUS alone was not reliable for
predicting the progression of disease. Progression of reux
occurred mostly with anatomic extension in an ascending
or descending manner and in both directions. Few patients
developed reux in a different area.
12.8 RECURRENT VARICOSE VEINS
In 1998, an international committee met in Paris to establish guidelines for recurrent varices after surgery (REVAS)
(61). Their ndings and classication were to supplement
the CEAP system, taking into account intervention. This
system accounts for true recurrence, residual disease, and
progression of existing disease. The prevalence of REVAS
has been reported to be 20%–80% (61). The importance
of recurrent varicose veins and the impact on treatment is
such that the CEAP classication was modied in 2020 to
include an “r” descriptor for recurrent varicose veins and
12.9 Use of DUS before, during, and after treatment 125
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ulcers (4). Perrin and colleagues performed a multicenter
study in order to evaluate the etiology, pathophysiology,
and progression of disease in REVAS (62). They enrolled
170 patients with 199 affected limbs in 14 different institutions over a period of 1year. The areas most affected by
recurrent reux in these patients were the SFJ in 47% of
patients and the perforators in 55% of the limbs. Recurrent reux resulted from technical failure to ligate the SFJ,
neovascularization in cases of SFJ disease, and failure to
recognize signicantly diseased perforators in the preoperative evaluation. More patients tended to have below-knee
reux after their procedures rather than thigh reux. This
is because the entire GSV is often obliterated or removed
above the knee and the veins below the knee are simply
ligated or stripped. Technical failure occurred in 19% of
patients, and neovascularization occurred in 20%. Acombination of the two was seen in 17% of the patients. In
35% of the recurrences, the cause was unknown. Recurrence developed in a new site in 32% of the limbs. Family
history had the highest prevalence of recurrence (68%).
This is not a surprising nding, since the strong relationship between hereditary and venous disease has been established (1, 63). Women tended to have more procedures to
correct recurrence than men, even though the severity of
recurrence was greater in men.
12.9 USE OF DUS BEFORE, DURING,
AND AFTER TREATMENT
DUS can also be used as an adjunctive tool during therapy
and for follow-up. The type of treatment is based on the
baseline DUS. In the rst examination, a map is made of
the distribution and extent of reux and obstruction. Additional tests may be necessary if deep vein reconstruction,
endovenous or bypass operations to relieve obstruction, or
pelvic vein reux treatment is planned (64). The effect of the
procedure at a local level (i.e., improvement, elimination,
or worsening of the reux and obstruction) can be documented. In addition, the effect of the procedure in veins
that are proximal and distal to the site of the treatment
can be assessed. However, DUS evaluates one short venous
segment at a time. The overall effect of the treatment in the
limb can be assessed better with physiological testing, such
as plethysmography and pressure measurements.
Endovenous treatment of the supercial veins and PVs
by ablation or sclerotherapy is now performed with DUS
guidance (50, 65). It is important to document the vein
diameter, proximity to the skin, tortuosity, obstruction, and
areas with hypoplasia and aplasia in order to have a good
treatment plan. (40) Saphenous vein diameter is measured
3cm below its respective femoral (SFJ) or popliteal (SPJ)
junction and at mid-thigh for GSV (66).
During the procedure, DUS is used to obtain percutaneous venous access and to guide the wire and catheters.
Accurate positioning at the treatment area of interest is
easily achieved, as the tip of the catheter is placed in the
correct location safely. Before the ablation takes place, the
tumescence uid is injected around the vein. The goal is
to create a halo sign over the entire length of the treated
segment, with the vein being collapsed around the catheter.
During the catheter pullback, the immediate effect on the
vein can be observed. The vein is re-examined at the end
of the procedure to ensure complete ablation and that the
saphenous junctions and deep veins are free of thrombus.
Some vein treatment modalities act over time, and therefore
the complete treatment effect will only be evident after some
time has passed (e.g., sclerosant therapy). If adjunct procedures are performed, such as phlebectomies or sclerotherapy, DUS can also be used to guide that. In many centers,
various forms of sclerotherapy are being performed as sole
treatments, and this is also carried out under DUS guidance
(67–69). Additional data have shown that supercial venous
treatment is safe in patients with deep venous reux (70).
Follow-up of endovenous therapy is important in order
to monitor its success and to identify complications such
as DVT and endovascular heat-induced thrombosis (EHIT)
(71). It is also recommended to perform a DUS study 1year
after endovenous thermal ablation in order to determine
whether the GSV or SSV remains obliterated. If obliterated,
it is likely that the vein will remain so for at least 3–5years
(66). This 1-year follow-up study is also important in
order to identify newly developed incompetent veins at
the same treated site (due to neovascularization or dilation
of pre-existent veins) or new sites. These ndings will aid
further treatment when deemed appropriate by the patient
and the specialist (66).
12
Guidelines, Statements, and Implementation Remarks of the American Venous Forum on duplex scanning for
evaluation of chronic venous disease*
Guideline Grade of recommendation Quality of evidence
12.1 For patients with chronic venous
disease of the lower extremities, we
recommend DUS as the diagnostic test
of choice to evaluate for venous reux.
Implementation Remarks
12.2
Reux is dened as a minimum value >500 msof reversed ow in the supercial truncal veins (great saphenous vein
[GSV], small saphenous vein [SSV], anterior accessory great saphenous vein [AAGSV], posterior accessory great saphenous vein [PAGSV]) and in the tibial, deep femoral, and perforating veins. Aminimum value of >1 second of reversed ow
is diagnostic of reux in the common femoral, femoral, and popliteal veins. There is no minimum diameter required to
have pathologic reux.
1
(strong)
B
(moderate)
(Continued)
126 Chapter 12 DUS scanning for chronic venous obstruction and valvular incompetence
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(Continued)
Implementation Remarks
12.3 Axial reux of the GSV is dened as uninterrupted retrograde venous ow from the groin to the upper calf. Axial reux in
the SSV is dened as being from the knee to the ankle. Axial reux in the AAGSV and PAGSV is retrograde ow between
two measurements, at least 5cm apart. Retrograde ow can occur in the supercial or deep veins, with or without
perforating veins. Junctional reux is limited to the saphenofemoral junction (SFJ) or saphenopopliteal junction (SPJ).
Segmental reux occurs in only a portion of a supercial or deep truncal vein.
12.4 A denition of “pathologic” perforating veins in patients with varicose veins (CEAP [Clinical Class, Etiology, Anatomy,
Pathology] clinical class C2 includes those with an outward ow duration of >500 msand a diameter of >3.5mm on
duplex ultrasound.
Good Practice Statements
12.5 We recommend that evaluation of reux with DUS be performed in an Intersocietal Accreditation Commission– or American College of Radiology–accredited vascular laboratory by a credentialed ultrasonographer, with the patient standing
whenever possible. Asitting or reverse Trendelenburg position can be used if the patient cannot stand.
12.6 We recommend that for evaluation of reux with DUS, the sonographer use either a Valsalva maneuver or augmentation
to assess the common femoral vein and SFJ and distal augmentation with either manual compression or cuff deation
for evaluation of more distal segments. Supercial reux must be traced to its source, including the saphenous junctions,
truncal or perforating veins, or pelvic-origin varicose veins. The study should be interpreted by a physician trained in
venous duplex ultrasound interpretation.
12.7 We recommend that a complete DUS examination for venous reux in the lower extremities include transverse grayscale
images without and with transducer compression of the common femoral, proximal, mid, and distal femoral and popliteal
veins, SFJ, and at least two segments along the GSV and SSV.
12.8 We recommend that a complete DUS examination for venous reux in the lower extremities include measurement of the
spectral Doppler waveform using calipers. Reux at baseline and in response to a Valsalva maneuver or distal augmentation in the common femoral vein and at the saphenofemoral junction and in response to distal augmentation in the
mid-femoral and popliteal vein should be documented. Reux in the GSV at the proximal thigh and knee, in the AAGSV
or PAGSV at the saphenofemoral junction and at the proximal thigh, and in the SSV at SPJ and at the proximal calf
should be documented.
12.9 We recommend that a complete DUS examination for venous reux in the lower extremities include diameter measurements in patients with the leg in the dependent position, from the anterior to the posterior wall, in the GSV 1cm distal to
the SFJ, at the proximal thigh and at the knee, in the AAGSV and PAGSV in the proximal thigh, and in the SSV at the SPJ
and the proximal calf. Images of both normal and abnormal ndings should be documented in the records of the patient.
Consensus Statements
12.10 In asymptomatic patients with telangiectasias or reticular veins (CEAP class C1), DUS evaluation of the lower extremity
veins should not be routinely performed, since testing could result in unnecessary saphenous vein ablation procedures.
12.11 In symptomatic CEAP class C1 patients with bleeding or with severe symptoms of pain or burning due to moderate to
severe telangiectasias or reticular veins, DUS evaluation may be performed toexclude associatedvenousincompetence;however, saphenous ablation for C1 disease without bleeding is rarely required.
12.12 In symptomatic patients with varicose veins (CEAP class C2), the deep venous system should be routinely evaluated for
infrainguinal obstruction or valvular incompetence
12.13 In symptomatic patients with varicose veins (CEAP class C2), evaluation for iliofemoral venous obstruction with DUS or
with other imaging studies should be performed if suprapubic or abdominal wall varicosities are present and in patients
with symptoms of proximal obstruction, including thigh and leg fullness, heaviness, swelling and venous claudication.
CEAP classes 3–6 warrant DUS or other imaging studies to evaluate for iliofemoral obstruction.
12.14 In patients with medial thigh or vulvar varicosities, evaluation of pelvic venous pathology with DUS or other imaging
studies is not indicated if they have no symptoms of pelvic venous disease.
* Adopted from Refs. 2 and 26.
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the role of calf venous pump in chronic
venous disease. J Vasc Surg Venous Lymphat Disord. 2019;7(3):428–40.
56. Raju S, Walker W, May C. Measurement
of ambulatory venous pressure and
column interruption duration in normal
volunteers. J Vasc Surg Venous Lymphat
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57. Raju S, Crim W, Buck W. Factors inuencing peripheral venous pressure in an
experimental model. J Vasc Surg Venous
Lymphat Disord. 2017;5(6):864–74.
58. Caggiati A, Rosi C, Heyn R, Franceschini
M, Acconcia MC. Age-related variations
of varicose veins anatomy. J Vasc Surg.
2006;44(6):1291–5.
59. Labropoulos N, Gasparis AP, Pefanis D,
Leon LR, Tassiopoulos AK. Secondary
chronic venous disease progresses
faster than primary. J Vasc Surg.
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60. Labropoulos N, Leon L, Kwon S, Tassiopoulos A, Gonzalez-Fajardo JA, Kang SS,
etal. Study of the venous reux progression. J Vasc Surg. 2005;41(2):291–5.
61. Perrin MR, Guex JJ, Ruckley CV, dePalma
RG, Royle JP, Eklof B, etal. Recurrent
varices after surgery (REVAS), a consensus document. REVAS group. Cardiovasc
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62. Perrin MR, Labropoulos N, Leon LR, Jr.
Presentation of the patient with recurrent
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Vincenzi I, Carpentier PH. Importance
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Clinical study of 134 families. J Dermatol
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64. Nicolaides AN, Cardiovascular Disease E,
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66. De Maeseneer M, Pichot O, Cavezzi A,
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CHAPTER
13
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Evaluation of venous function by indirect
noninvasive testing (plethysmography)
Kate Gates, Fedor Lurie, and Thom W. Rooke
13.1 INTRODUCTION
Venous disease is typically divided into two broad yet distinct categories: acute and chronic. Acute venous disease is
usually secondary to thrombosis. Therefore, it is important to not only diagnose the presence of thrombus but also
to identify its location, determine its age, and assess any
ongoing changes (i.e., clot propagation, organization, recanalization). Duplex ultrasound has become the standard
test for addressing these diagnostic needs. Chronic venous
disease (CVD) has a much more complex etiology and is
often due to a combination of chronic venous obstruction,
valvular incompetence, and/or muscle pump dysfunction.
The optimal approach for the assessment of CVD severity
is less clear due to the increased complexity of the disease
and need to evaluate (and ideally quantify) the individual
hemodynamic contributions of obstruction, reux, and
pump function.
The clinical manifestations and pathophysiology of
CVD can be objectively classied based on the internationally accepted Clinical-Etiology-Anatomy-Pathophysiology (CEAP) score. The reproducible and reliable CEAP
score is the current standard for classifying CVD in scientic publications [1]. The diagnosis of disease and the
denition of clinical class (“C”) are based on clinical evaluation. Noninvasive testing (usually duplex ultrasound) is
used to identify pathophysiological (“P”) changes (reux
or obstruction) in individual anatomical segments. However, designed as a purely descriptive classication system,
CEAP does not address the severity of CVD. It includes
the identication of reux and/or obstruction but does
not quantify the severity of either. While assessment of
CVD severity is possible by using qualitative and subjective instruments, such as the Venous Clinical Severity
Score, its severity cannot be dened or quantied by imaging modalities such as ultrasound and venography; not
in individual segments, and denitely not for an entire
extremity.
While the management of CVD has made signicant
advances in the past several decades, with new treatment
modalities now available, including complex surgical reconstruction of venous valves, minimally invasive treatment of
supercial veins, and expanded endovascular treatment
options, the assessment of CVD and its severity continues
to be challenging due to the complex and poorly dened
relationship between clinical manifestations, underlying
pathophysiology, and specic hemodynamic contributions
of obstruction, reux, and pump function. Given that the
ultimate goal of CVD treatment is to correct the underlying
hemodynamic abnormality, it is critical to nd diagnostic
modalities that allow for improved evaluation of these factors in order to guide treatment selection and monitor for
response over time.
In this changing environment, the demand for reliable
quantitative testing techniques that can address key clinical
questions specically related to the diagnosis, evaluation,
and severity of CVD is greater than ever. These limitations
dictate the need for testing modalities that can assess the
global lower extremity venous function as well as evaluate
the relative importance of individual components. Although
venous pressure measurements can serve this purpose, they
are invasive and impractical. Plethysmography is a noninvasive alternative that provides quantitative evaluation of
venous hemodynamics, including objective measures for
obstruction, reux, and pump function.
13.2 TECHNICAL PRINCIPLES
All plethysmographs (including impedance, air, and straingauge) measure the same thing—changes in volume—however, they use different techniques for the calculation of
volume change. Air plethysmography (APG) uses a pressure measurement cuff that has been calibrated to reect
volume changes. Strain-gauge plethysmography (SGP)
calculates volume changes from changes in extremity circumference. While these two methods may utilize quantitatively different measurements, they yield qualitatively
identical information.
When applying plethysmography to the evaluation of
the lower extremity venous system, it is assumed that arterial blood supply to the extremity and transcapillary uid
exchange do not vary signicantly throughout the duration of the exam. Therefore, any changes in the extremity’s volume are attributed to venous lling and emptying.
Extremity volume changes can be measured in response to
exercise, postural changes, and proximal tourniquet application/release, which provides a quantiable method for
evaluating venous function, including specic measures for
obstruction, reux, and pump function.
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13.2.1 Identification and assessment of
obstruction
Identication and assessment of venous obstruction by
plethysmography is based on the estimation of the following two parameters: venous capacitance and venous resistance.
A pneumatic cuff is placed around the proximal thigh
and is inated to serve as a partially occluding tourniquet. Although venous pressure rises to equal the pressure of the tourniquet, blood accumulates in the veins
of the studied extremity. Veins easily increase their size
under low pressures and become unextendible once they
reach maximum capacity (usually after pressure exceeds
50–80 mmHg). This maximum increased size of the calf
(maximum venous volume) is visualized as a plateau on
the chart recorder tracing. In limbs with chronic obstruction, veins may be lled close to maximal capacity due to
chronic decreased outow, and the increase in calf volume
from the baseline to maximum venous volume may be
decreased.
Rapid release of the tourniquet creates a pressure gradient between extremity veins, where the pressure is equal to
the pressure of the tourniquet and the central venous pressure, which is close to zero. Dening the pressure gradient makes possible the calculation of venous resistance by
measuring the rate of decrease in the calf volume after the
tourniquet is released. In extremities with venous obstruction, the resistance can exceed normal values by threefold
or more [2], unless the developed collateral ow offsets the
effects of axial vein obstruction. Venous outow fraction
(OF) is calculated by dividing the amount of venous volume emptied in the rst 1 second by the venous volume
(VV) and multiplying by 100. OF values less than 40%
are suggestive of signicant venous outow obstruction
(Figure13.1).
13.2.2 Assessment of reflux severity
The patient is placed with the leg in the drainage position
(elevated to approximately 45 degrees) until a baseline
plateau/steady state is identied, representing a state close
to complete venous emptying. From the drainage position, the patient is then asked to stand with body weight
placed on the contralateral extremity. Increased leg volume (i.e., venous lling) is visualized as a lling curve
on the chart recorder tracing. Aplateau is reached when
the veins are full and have reached maximum capacity at
the upright position, dened as functional VV. Avenous
lling time of 90 (VFT 90) represents the time needed
to reaccumulate 90% of the VV. The venous lling index
(VFI) is then calculated by dividing 90% of the VV by
VFT 90 (Figure13.2).
Venous relling can occur from relatively slow arterial
inow (normal state) or, in the case of valvular incompetence, by rapid reux from a larger proximal venous
segment. Measuring the rate of venous rell (VFI) can
therefore provide an estimate of overall valvular competence and severity of reux in extremities with no venous
obstruction. When limited to patients with isolated supercial vein incompetence, venous relling by plethysmography correlates well with great saphenous vein reux as
determined by duplex scan [3, 4].
13.2.3 Assessment of muscle pump
function
Evaluation of muscle pump function in patients with
CVD is important because its impairment contributes
signicantly to the severity of CVD [5]. Improvement
in muscle pump function through physical therapy
and/or elastic compression can have benecial therapeutic effects [6].
13.1 The blue line represents volume change in a normal limb; the brown line represents volume change in a limb with iliac vein
obstruction. After registering the baseline volume of the calf, a pneumatic tourniquet around proximal thigh is inated to 80 mmHg.
Calf volume increases, reaching a plateau (VC, venous capacity). At this point, the pressure in the calf veins is equal to the pressure in
the tourniquet (80 mmHg), while the pressure in the iliocaval system is close to zero, making the pressure gradient across the tourniquet approximately 80 mmHg. Rapid release of the tourniquet results in the ow with a known pressure gradient, and the resistance
can be calculated by dividing the pressure gradient by the volume ow, which is equal to calf volume change over the rst 1 second.
The pressure gradient is the same in both depicted cases, while the rst 1-second outow is much less in the limb with obstruction
because of signicantly increased resistance to outow.
13.4 Clinical correlations 131
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13.2 Plethysmographic assessment of venous reux and muscle pump function. The patient is placed with the leg elevated to
approximately 45 degrees until a baseline steady state is identied. The patient is then asked to stand with body weight placed
on the contralateral extremity. Increased leg volume until a plateau is reached is dened as functional venous volume (VV). Venous
lling time 90 (VFT 90) represents the time needed to accumulate 90% of the VV. The venous lling index (VFI) is then calculated by
dividing 90% of the VV by VFT 90.
13
Once the maximum venous capacity (or VV) plateau
has been identied, the patient is then asked to perform a
single heel-raise maneuver. The resulting decrease in calf
size, the ejected volume (EV), reects the volume of blood
actively evacuated from the lower extremity via the calf
muscle pump. The ejection fraction (EF) is then calculated
by dividing the EV by the VV and multiplying by 100
(EF=EV/VV × 100). EF is the percentage of VV that is
ejected via the calf in a single heel raise and thus provides a
quantitative measure of overall calf muscle pump function
and efciency (Figure13.2).
After single heel-raise is completed (and EF calculated),
the patient continues standing until the VV plateau is again
identied. The patient is then asked to perform 10 heelraise maneuvers, and another plateau is noted representing
the minimal calf size after complete active evacuation of
all possible venous blood via the calf muscle pump. The
amount of blood remaining in the lower extremity at
the end of the exercise is dened as the residual volume
(RV). The residual volume fraction (RVF) is then calculated by dividing the RV by the VV and multiplying by
100 (RVF=RV/VV × 100). RVF is the percentage of VV
that remains after exercise and represents the net combination of calf muscle pump function and severity of valvular reux. RVF has specically been shown to correlate
well with measurements of ambulatory venous pressure
(AVP) [7]. Recent advances in technology made it possible to evaluate calf muscle function during normal ambulation. RVF measured during such physiological exercise
has been shown to discriminate normal limbs from limbs
with venous disease with better accuracy than during tiptoe maneuver [8].
13.3 PRACTICAL APPLICATIONS
AVP, it is impractical to use as routine screening and/or for
repetitive testing. However, given the correlation of RVF
with AVP, plethysmography can provide a practical, noninvasive, indirect, quantitative measure of venous function
and associated hemodynamic venous changes.
13.4 CLINICAL CORRELATIONS
Plethysmography (APG) parameters have been shown to
correlate with the clinical stages of CVD. Specically, the
degree of venous reux (as measured by VFI) was noted
to correspond to worsening clinical class of CVD [9].
Although the potential for the prediction of ulceration has
been demonstrated in early works [10], more careful analysis revealed that deterioration of venous hemodynamics
(as measured by plethysmography) parallels clinical severity only before skin changes develop [11] or during ulcer
healing [12]. Plethysmography studies can identify both
obstruction and reux; however, they are unable to allocate these changes to specic venous segments. Duplex
ultrasound is the preferable and standard technique for
the identication of reux and, when feasible, obstruction.
When venous obstruction is suspected but not identied
by duplex scan, plethysmography can help to overcome
the low sensitivity of the ultrasound for the detection of
venous obstruction.
An advantage of these indirect tests over ultrasound
is their ability to provide a quantitative measure of the
impact of obstruction and valvular insufciency on the
overall function of the venous system of the lower extremity. In addition, plethysmography can provide a quantitative assessment of muscle pump function. This information
can also be used in the assessment of treatment outcomes
and for follow-up [13, 14].
Historically, AVP has been used as a gold standard for
evaluating hemodynamic changes in venous disease as well
as providing validating comparison for other noninvasive tests. Unfortunately, due to the invasive procedure of
13.4.1 Reliability
The reliability and repeatability of plethysmography have
been demonstrated by Christopoulos and Nicolaides [10]
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and were later conrmed by others [15]. The limits of reproducibility, however, differ signicantly between the reports
and should be dened by systematic investigation [16].
13.5 CONCLUSION
Plethysmography is currently the only practical noninvasive modality for global physiologic evaluation of the
13.4.2 Limitations
Both APG and SGP require considerable patient cooperation. Consistency in performing exercise, maintaining
position, and distributing weight between the legs can
contribute signicantly to variability in the results. External mechanical, thermal, and chemical (pharmacological)
stimuli may also cause signicant changes in the size of the
venous lumen and in venous capacitance. All of these factors, along with changes in central venous hemodynamics
and arterial supply, should be considered when the results
of these indirect tests are analyzed.
venous system of an extremity. It not only provides valuable information on the impact of reux and obstruction
on overall venous function but also provides a way to
assess the calf muscle pump. Plethysmography is a noninvasive modality that complements duplex ultrasound and
can be used to monitor venous hemodynamics over time
and evaluate treatment outcomes. Although imperfect, it
remains the only existing option to assess the hemodynamic effect of obstruction to venous ow and to evaluate
the impact of reconstruction or ablation of a single vein on
venous hemodynamics of the entire limb.
Consensus Statements 13.0 of the American Venous Forum on evaluation of venous function by indirect noninvasive
testing (plethysmography)
No. Consensus Statements
13.1 Venous plethysmography should be used selectively for the noninvasive evaluation of the venous system in patients with
simple varicose veins (CEAP class C2).
13.2 Venous plethysmography is useful for the noninvasive evaluation of the venous system in patients with advanced chronic
venous disease if duplex scanning does not provide denitive information on pathophysiology (CEAP class C3–C6).
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2. Saleem, T., A. Knight, and S. Raju, Effect
of iliofemoral-caval venous intervention on
lower extremity compartment pressure in
patients with chronic venous insufciency.
J Vasc Surg Venous Lymphat Disord, 2020.
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3. Nelzen, P.O.E., etal., Impact on venous
haemodynamics after treatment of
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ultrasound. Phlebology, 2020. 35(7):
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4. Lattimer, C.R., etal., Venous lling time
using air-plethysmography correlates
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29(2): p.90–7.
5. Jayaraj, A., T. Powell, and S. Raju, Effect
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limb reux prevalence and severity after
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Venous Lymphat Disord, 2022. 10(3):
p.640–5, e1.
7. Raju, S., etal., Ambulatory venous pres-
sure, air plethysmography, and the role
of calf venous pump in chronic venous
disease. J Vasc Surg Venous Lymphat
Disord, 2019. 7(3): p.428–40.
8. Maleti, O., etal., Residual volume
fraction during walking using wireless air
plethysmography in patients with chronic
deep venous disease. J Vasc Surg Venous
Lymphat Disord, 2022. 10(2): p.423–9;e2.
9. Dezotti, N.R.A., etal., The clinical
importance of air plethysmography in the
assessment of chronic venous disease. J
Vasc Bras, 2016. 15(4): p.287–92.
10. Christopoulos, D.G., etal., Air-plethysmo-
graphy and the effect of elastic compression on venous hemodynamics of the leg. J
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11. Welkie, J.F., etal., Hemodynamic deteriora-
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12. Araki, C.T., etal., The signicance of
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13. Rhodes, J.M., etal., Endoscopic perforator
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CHAPTER
14
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Direct contrast venography
Haraldur Bjarnason
14.1 INTRODUCTION
The introduction of X-rays by Wilhelm Conrad Röntgen
in 1895, and later, the injection of contrast medium into
a vessel allowed visualization of the normal anatomy and
identication and quantication of vascular abnormalities. Venography became a signicant part of the diagnostic armamentarium in the 1970s and enabled clinicians to
diagnose deep vein thrombosis (DVT) without basing it
only on clinical ndings that is a poor and imperfect way
of identifying this often deadly condition.
Direct venography includes infusion of contrast into a
peripheral vein and relies on preferential ow of the contrast medium toward the heart. The contrast medium will
mix with the blood, making the blood opaque. The blood
ow and, thereby, the lumen of the vessels, can then be imagined with uoroscopy, and still images (X-rays) can be taken
and reviewed. This gives an image of the anatomy and also
of the vascular pathology affecting the vessel. As the blood
ows along a gradient toward the heart, one can also get an
impression of the hemodynamics in the vessels. The venous
circulation can be altered or inuenced by, for example, placing a tourniquet around a limb, typically the ankle or wrist,
forcing the contrast-mixed (enhanced) blood to ow into
the deeper venous system. This technique is commonly used
to evaluate for DVT or to look for incompetent perforator
veins. Atourniquet at the knee level or upper arm can also be
applied to slow contrast ow into the central veins, allowing
for more time to evaluate and image the areas of interest.
Because contrast is heavier than blood, contrast will layer
in the dependent part of the vessel, and high-lying veins may
not ll. As the contrast is layered at the dependent portions
of the larger veins, one may not see the entire circumference
of the vessel. One will therefore see posterior branches (with
the patient supine) such as the internal iliac vein, which may
resemble reux in that instance, leading to a false assumption
of central obstruction. This is a common pitfall of venography.
1
14.2 LOWER EXTREMITY ASCENDING
VENOGRAPHY
Ascending venography, as the name implies, is based on
contrast mixed blood owing upward or central in the
direction of the heart along pressure gradients. This is the
DOI: 10.1201/9781003328971-16
traditional direct venography and was one of the most
performed radiologic procedures for the diagnosis of DVT
until ultrasound replaced it.
is also technically an ascending venography, but the term
is mainly used for lower extremity venograms. Ascending
venography can be used to examine deep veins, supercial
veins, and the connections between these two—the perforating veins. Introduced rst in 1923 by Berberich and
3
Hirsch,
diagnosing DVT following demonstration of its utility for
imaging blood clots by Dos Santos in 1938.
contrast venography became the gold standard for
2
Upper extremity venography
4
14.2.1 Technique
Rabinov et al.1 and others5 described the technique of
ascending venography in 1971 and 1972. The procedure
is preferentially performed with the patient lying supine
on a tilt-table, with the head end of the table raised to
40–60 degrees. At the foot end of the table, there should
be a “footboard” with an elevation upon which the patient
will rest the contralateral leg and bear any weight on the
contralateral leg; the leg being examined should be nonweight-bearing. An 18- to 20-gauge plastic catheter (Angiocath) is placed into a peripheral dorsal foot vein of the side
being examined. The more peripheral the needle is placed,
the better, as the contrast should be dispersed evenly into
the venous bed. Distal directed puncture is recommended
for that reason. One should avoid medial foot vein access,
as the contrast will then preferably ow into the greater
saphenous vein rather than the deep venous system.
Typically, a tourniquet is tightly placed around the
ankle at the beginning of the examination (Figure14.1).
The purpose of the maneuver is to direct the contrast into
the deep venous system from the supercial veins. This
enables examination of the deep veins of the calf. Because
of how supercial the anterior tibial vein is at the ankle
level, it may not ll with the tourniquet applied. When the
deep veins have been evaluated, the tourniquet is released;
the supercial veins will ll with further contrast injection,
as will the anterior tibial vein and the muscular branches, if
they have not lled already (Figure14.1).
Typically, a second tourniquet is placed around the leg
just below the knee. The purpose of this is to delay the contrast ow to the thigh veins, allowing time to adequately
evaluate the lower leg veins. This tourniquet is released,
typically after the ankle tourniquet is released, and then a
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