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314 Chapter 31 Clinical presentation and assessment of patients with venous disease
https://t.me/med1917
malignancy. If there is concern about the adequacy of
the deep venous outow, the arm can be observed for
swelling after application of a light supercial tourniquet.
Symptoms of PE should prompt a full cardiorespiratory
examination.
31.3 THE LOWER LIMB
Chronic venous disease is extremely common in the Western world, with a variable incidence reported worldwide.
Up to 80% of the general population will display evidence
of venous disease, with 20%–64% suffering from varicose
veins and 1%–2% affected by venous ulceration.
markedly increases in the elderly population. Venous disease is known to negatively impact quality of life
a signicant association with depression.
14
Furthermore,
European and U.S. data have estimated the cost of venous
disease to be approximately 1%–2% of the annual health
care budget.
15
31.3.1 Superficial venous
thrombophlebitis
SVT can occur spontaneously or secondary to trauma or
intervention. Iatrogenic injury from intravenous cannulation and infusion of causative agents is the most common cause in normal veins. This can present as a tender
lump or cord along the course of the vein. Treatment is
via removal of the intravenous catheter, and resolution of
the condition can take months. Iatrogenic thrombophlebitis may be complicated by bacterial infection, particularly
in patients undergoing long-term intravenous cannulation.
Septic phlebitis and suppurative thrombophlebitis are serious complications requiring antibiotic treatment and even
surgical debridement in some cases. Systemic features and
abscess formation are uncommon.
SVT can also arise in association with a known or occult
malignancy and, in this circumstance, is often migratory. It
may also be associated with thrombophilia.
Thrombophlebitis can occur in diseased varicose veins
in the form of sterile thrombosis. This is particularly common in pregnancy and presents as a hard, tender knot in
the vein, with intense pain and overlying erythema. The
inammatory process can extend beyond the vein wall,
resulting in bleeding. Phlebitic episodes in varicose veins
are an indication for interventional treatment.
The main risk with SVT is the development of deep
venous propagation. The risk of venous thromboembolism
can be as high as 25% in the acute setting and up to 10%
at 3 months follow-up, challenging the widely held belief
that SVT is a benign entity.
The diagnosis of SVT is made based on the history
and clinical examination, which often reveals erythema,
warmth, and tenderness (Figure 31.3). Upon resolution,
there is often a residual mass or cord in the affected supercial vein.
Duplex ultrasound assessment can help characterize the
extent of SVT and the presence of any deep venous propagation, which may be present in the absence of clinical
symptoms.
16
12
This
13
and has
31.3 Supercial thrombophlebitis of the left thigh.
31.3.2 Deep venous thrombosis
DVT leading to PE is a leading cause of preventable hospital death in adult patients, with an annual incidence
of 1:1000 adults.
hypercoagulability) and environmental (surgery, hospitalization, trauma, pregnancy, hormone therapy, obesity, and
cancer) factors. It is of paramount importance that a possible diagnosis of DVT be considered in patients at risk and
that appropriate risk assessment tools are employed as a
preventative measure in these patients.
The mortality rate of those diagnosed with PE is
approximately 10%. Cadaveric studies have, however,
identied PE in up to 30% of individuals with a DVT, highlighting the fact that many PEs are subclinical. In fact, CT
pulmonary angiography is now able to identify very small,
subclinical pulmonary emboli.
It is helpful to consider the development of DVT in two
phases: embolic (early) and thrombotic (late). In the early
phase, the thrombus is nonocclusive and not yet organized.
As a result, there is no swelling, inammation, or distension of supercial collateral veins, and the leg may appear
quite normal despite a signicant risk of embolism. In the
late phase, the thrombus becomes occlusive and causes a
phlebitic reaction, anchoring it to the vein wall; in addition, inammatory signs and symptoms due to peri-phlebitis become apparent. The patient develops all the “typical”
clinical features of DVT. At this stage, however, the risk of
PE is low. The clinical diagnosis of DVT is difcult to make
due to the poor sensitivity and specicity of clinical signs.
Even when symptoms are present, studies show that fewer
than half of such patients have a DVT. Homan sign (pain
in the calf elicited upon passive dorsiexion of the foot in a
patient in the supine position with the knee exed) is unreliable, painful, and should not be performed.
The Wells scoring system
probability of a patient having DVT before diagnostic tests
are performed (see Chapter 18, Table 18.1). Patients with a
score of 2 or more are more likely to have DVT.
Anatomically, it is useful to consider three patterns of
disease (calf, femoral, and iliofemoral), although thrombosis is a dynamic process and proximal propagation is
common.
17
Risk factors include innate (age and
18
19
is used to determine the
31.3 The lower limb 315
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Calf vein thrombosis is usually localized to one or
two of the three major veins of the lower leg. Often, the
thrombi are nonobstructive, and due to the pairing of tibial
and peroneal veins, venous drainage may remain adequate.
Calf tenderness may be present, but signicant swelling is
usually absent. In fact, most patients have no symptoms or
signs whatsoever. About 20%, if untreated, may propagate
into an above-knee deep vein. Calf vein thrombosis is the
most common site of lower limb DVT and may propagate
to the femoral vein. When the popliteal or femoral vein
is involved, there may be swelling at the ankle and at the
calf of greater than 1 cm in most patients, but this rarely
extends above the patella unless outow via the deep femoral vein is compromised.
Iliofemoral DVT may originate in the pelvic veins and
not involve the distal femoral or calf veins in over 30% of
patients. Consequently, duplex ultrasound commonly fails
to detect it. Clinically, thigh swelling can be present in addition to calf swelling. If the inferior vena cava is involved,
signs and symptoms are usually bilateral. This type of
thrombosis frequently has a marked inammatory component, especially in pregnant women. Patients suspected of
having this condition are best investigated via contrast CT
venography or magnetic resonance venography.
31.3.3 Phlegmasia cerulea dolens
Phlegmasia cerulea dolens is very rare and describes total
venous outow obstruction. In the lower limb, this usually
affects the iliocaval or the iliofemoral segment with rapid
extension into deep and supercial veins. Phlegmasia of
the lower limb sequesters a considerable proportion of the
patient’s blood and body uids, especially if bilateral. This
can result in severe systemic effects, which may include
hypovolemic shock and renal failure, in addition to the
signs and symptoms, including venous gangrene.
31.3.4 Arteriovenous malformations
These most commonly affect the lower limb; KTS and PWS
can present with abnormal varicosities.
KTS is a low-ow vascular malformation with capillary, venous, and lymphatic abnormalities. Patients characteristically exhibit the clinical triad of port wine stain,
varicose veins, and limb hypertrophy. The lower limb is
affected in approximately 70% of individuals.
with KTS can present with SVT and bleeding from enlarged
supercial veins. Typically, the varicose veins can present as
anomalous veins or persistent embryonic veins; these are
present in 72% of patients with KTS. The most common
abnormality is the persistence of a lateral embryonic vein,
identiable in the lateral thigh and not joining the deep
system. Abnormal medial or suprapubic veins are less com-
20
mon.
PWS usually affects the lower limb and is characterized by the presence of high-ow arteriovenous stulae.
Patients present with cutaneous capillary malformations,
limb hypertrophy, and arteriovenous malformations.
Supercial veins are prominent secondary to increased
pressure. A bruit, or machinery murmur, is audible in the
affected limb, and a thrill is palpable throughout the cardiac cycle.
16
Patients
31.3.5 Varicose veins
31.3.5.1 Epidemiology
Varicose veins are a common venous presentation, often
found in older patients, those with a positive family history, and in individuals with a high BMI. Height is an additional risk factor recently reported to be associated with
the presence of varicose veins. Their prevalence is expected
to continue to rise due to the aging population and obesity
epidemic.
Varicose veins can be primary or secondary. Primary
varicosities arise spontaneously and can be associated
with underlying incompetence, or reux, in the supercial
veins, or in the junctions between the supercial and deep
venous systems (saphenofemoral, saphenopopliteal, or
perforator incompetence). Secondary varicosities arise as
a result of underlying pathology that has led to the development of venous hypertension in the supercial venous
system. This includes DVT, deep venous incompetence,
an intra-abdominal mass causing pressure on the pelvic
veins, and obesity.
31.3.5.2 Trunk varices
Truncal varices are varicose veins originating from the
main stem and/or major tributaries of the great saphenous
vein (GSV) (80% of cases) and/or the small saphenous vein
(SSV) (20% of cases). They are usually ≥3 mm in diameter, lie subcutaneously, are palpable, and do not discolor
or affect the overlying skin. Although more women than
men present for assessment and treatment of their varicose
veins, the actual prevalence is roughly equal between the
sexes.
31.3.5.3 Reticular varices
These veins lie deep in the dermis, are 2–3 mm in diameter,
are not palpable, and may render the overlying skin blue in
color. They do not blanch on pressure and may or may not
be associated with trunk varices.
31.3.5.4 Telangiectasia
Also termed spider or hyphen web veins, they are intradermal, 1 mm or less in diameter, impalpable, blanching, and
render the overlying skin purple or bright red. Again, they
may be associated with trunk and reticular varices and are
present in 80% of adults.
31.3.5.5 Symptoms
The presentation of venous disease occurs across a spectrum, including asymptomatic disease, varicose veins, skin
changes, and ulceration. This is best described and assessed
via the CEAP (Clinical, Etiological, Anatomical, Pathophysiological) classication, an international system that
enables the assessment of venous disease and its severity
(see Chapter 9, Table 9.1).
Thread and reticular veins can be unsightly but are not
symptomatic. Although rarely life threatening, trunk varicose veins can have a signicant detrimental effect on a
patient’s quality of life that should not be ignored.
rate of depression with trunk varicose veins is more than
double that of the general population.
21,22
13
The
14
This may be due
31
316 Chapter 31 Clinical presentation and assessment of patients with venous disease
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in part to the cosmetic aspect and in part to the chronicity
of the signs and symptoms of venous disease, which can
interfere with patients’ daily activities.
Previous local guidance in the UK advised general practitioners to refer a patient with varicose veins to secondary
care only in the presence of what was dened as advanced
disease (C4–C6). Lower CEAP grades were to be managed in the community with conservative measures, such
as compression and lifestyle advice. Referral to secondary
care was warranted in the presence of ulceration, bleeding,
progressive skin changes, recurrent SVT, and symptoms
having a severe impact on quality of life.
However, the evidence for this approach is lacking
and intervention on symptomatic varicose veins has been
shown to be a clinically and cost-effective exercise in multiple randomized controlled trials. This has led to changes in
recommendations both in the UK and internationally, with
a greater emphasis on treating symptomatic venous disease
before it progresses to skin damage and ulceration. This is
exemplied by the Society of Vascular Surgery (SVS), European Society of Vascular Surgery (ESVS), and the National
Institute of Health and Care Excellence (NICE) guidelines
(Table 31.1).
23–25
Patients with varicose veins can be challenging to
assess, as they may present with a wide variety of lower
limb symptoms, including aching, a dragging feeling, heaviness and tension, swelling, tiredness, restless legs, nocturnal
cramps, and itching. These symptoms are not specic to
varicose veins and are extremely common in the general
population. It is important to consider differential diagnoses (e.g., back pain) and arrange for the appropriate investigations to conrm the clinical suspicion. Management of
patient expectations is paramount in the presence of nonspecic symptoms, particularly when discussing treatment
options. In a patient with evidence of reux on venous
duplex, it is important to inform them that intervention
may not resolve their symptoms.
31.3.6 Chronic venous insufficiency
Varicose veins are a manifestation of chronic venous disease. Chronic venous insufciency (CVI) describes complications from the presence of elevated venous pressures in
the lower limb, resulting in the cutaneous changes that are
characteristic of the disease. Ultimately, this leads to skin
damage, which may result in ulceration of the lower leg.
31.3.6.1 Symptoms
All the symptoms described earlier for varicose veins may
be associated with CVI, and there is a stronger relationship
between symptoms and disease severity in this group. This
group of patients is signicantly older and, as such, comorbidities are more common, including peripheral vascular
disease and diabetes. When assessing these patients, arterial
disease and musculoskeletal problems should not be overlooked. Unlike patients with simple varicose veins, in whom
actual swelling is unusual, most patients with CVI have a
degree of edema. This is usually of mixed etiology: venous
hypertension, cardiac failure, and a degree of lymphedema.
Severe pain is unusual and suggests that the patient may
have coexisting arterial disease and/or infection.
31.3.6.2 History
This should explore the current episode of skin change/
venous ulceration and any previous episodes. A history of
vascular risk factors should be taken, including previous
thrombotic episodes; vascular and nonvascular interventions to the lower limb, pelvis, and abdomen; malignancy;
arterial risk factors; diabetes; autoimmune disease; and
smoking. A general history, including family history, medications, and allergies, should also be taken. Furthermore,
patients should be asked if venous symptoms are present,
such as itching, restlessness, aching, heaviness, swelling,
and fatigue.
TABLE 31.1 National Institute for Health and Care Excellence (NICE) guidance 2013
Referral to a vascular service
• Patients with symptomatic primary or recurrent varicose veins
• Patients with skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufciency
• Supercial venous thrombosis and suspected venous incompetence
• A venous leg ulcer
• A healed venous leg ulcer
• Immediate referral to a vascular service is warranted if there is a bleeding varicose vein
Imaging
• Duplex ultrasound should be used to conrm the diagnosis of varicose veins and the extent of truncal reux and to plan treatment for
individuals with suspected primary or recurrent varicose veins
Treatment
• Endothermal ablation (radiofrequency or laser) is rst line
• If endothermal ablation is unsuitable, offer ultrasound-guided foam sclerotherapy
• If ultrasound-guided foam sclerotherapy is unsuitable, offer surgery
• If incompetent tributaries are present, consider treating them at the same time
• Do not offer compression hosiery to treat varicose veins unless interventional treatment is unsuitable
• Intervention should be avoided in pregnancy, where compression stockings should be offered instead
Source: Adapted from National Institute for Health and Care Excellence. (2013). Varicose veins: diagnosis and management. (NICE guideline CG168). www.
nice.org.uk/guidance/cg168/resources/varicose-veins-diagnosis-and-management-pdf-35109698485957.
31.3 The lower limb 317
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31.3.6.3 Examination findings
31.3.6.3.1 Position
The patient should be examined standing under a good
light and in a warm room. Patients may feel faint, and a
support should be available. The examiner should ideally
be level with the lower limbs (e.g., sitting on a small tool
with the patient on a platform with a handrail for balance).
31.3.6.3.2 Inspection
Varicose veins are dilated and tortuous due to the pathological reux being commonly, but not exclusively, associated with a cephalad incompetent valve. The main trunks
themselves may be dilated, but they are rarely tortuous,
as they are supported by the deep fascia. The distribution
of varices can give an indication as to whether they are
GSV or SSV tributaries (or both) (Figure 31.4). However,
in obese patients or those with a history of previous surgical intervention, the anatomy may be less well dened.
In thin, athletic patients, highly visible and enlarged veins
may be erroneously considered to be pathological. These
are uniformly dilated and do not exhibit tortuosity. It is
also important to note the presence of telangiectasia during
inspection.
Veins lying in an abnormal distribution (such as laterally along the leg, vulval, or in the abdominal wall) are suggestive of a congenital cause, an underlying pathological
process (e.g., intra-abdominal mass), or pelvic congestion
syndrome.
The signs of CVI include corona phlebectatica, venous
eczema, lipodermatosclerosis, hemosiderin deposition, and
open (or healed) ulceration. These are most often found
around the gaiter area, above the medial malleolus. Corona
phlebectatica describes a fan-shaped are of small intradermal varices on the medial aspect of the ankle and foot. The
apex of the are is in the region of one or more incompetent perforators and fans out toward the sole of the foot.
Lipodermatosclerosis may be acute or chronic. In the acute
phase, it is an inammatory reaction that may be mistaken
for cellulitis or phlebitis. It will overlie an area of perforator
incompetence, but, unlike cellulitis, the overlying skin will
not be warm. In the chronic phase, the skin of the mid to
lower calf is pigmented, shiny, hard to the touch, and xed
to the underlying chronically inamed and contracted subcutaneous tissue. Surrounding dermatitis is common, and
there may be a sensitivity reaction to topical medication
applied to the area. White scar tissue (atrophie blanche)
is often present. The site of lipodermatosclerosis relates to
maximum ambulatory pressure, usually communicated by
incompetent perforators, which cause localized high-pressure damage to the surrounding tissues and skin. This also
applies to the sites of ulceration, although as ulcers increase
in size, this association becomes less dened. An ulcer characterized by a location or shape typical of pressure damage
is an important pointer to coexisting arterial disease (see
Table 31.2).
31
31.4 Varicose veins in the right great saphenous vein distribution.
31.3.6.3.3 Palpation
Features such as temperature change, the presence of pulses
or thrills, tenderness, induration, and edema provide useful
information regarding the underlying disease process. The
varicosities should also be palpated and an assessment of
their course determined. In individuals with bilateral varicose veins, an abdominal and groin examination is essential to identify signs of intra-abdominal pathology.
Clinical tests such as the “tap” test of Chevrier or the
Trendelenburg test have been historically employed to help
assess the patient with venous disease. The “tap” test of
Chevrier consists of percussing over a varix while palpating caudally to help trace out the vein. A palpable transmitted impulse suggests an incompetent vein between the
two sites. The Trendelenburg test consists of applying a
tourniquet to the upper thigh to compress the GSV. The
patient is then asked to stand, with the examiner assessing
for supercial vein lling. The test can be repeated at different levels to identify the level of incompetence. Handheld
Doppler can be used as an adjunct to insonate over the site
of incompetence. Again, this was said to be useful in the
obese patient but has been found to have a sensitivity of as
low as 56% at the saphenofemoral junction and 23% at
the saphenopopliteal junction.
been found to be poorly predictive of venous anatomy and
should not be relied upon to plan surgery. Duplex ultrasound is the gold-standard investigation tool permitting
anatomical and hemodynamic assessment of the supercial
and deep venous systems.
26
Overall, these tests have
318 Chapter 31 Clinical presentation and assessment of patients with venous disease
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TABLE 31.2 Differential diagnosis of leg ulceration
Clinical features Arterial ulcer Venous ulcer
Gender Men > women Women > men
Age >60 years 40–60 years, but patients may not present
until much older; multiple recurrences
Risk factors Smoking, diabetes, hyperlipidemia, hyper-
tension
Past medical history Most have a clear history of peripheral,
coronary, and cerebrovascular disease
severe neuropathy. Pain may be relieved by
dependency.
Site Pressure areas (malleoli, heels, metatarsal
heads, fth metatarsal base)
Edge Regular, “punched-out,” indolent Irregular, with neo-epithelium
Base Deep, green (sloughy), or black (necrotic)
with no granulation tissue, exposing major
tendons, bones, and joint
Surrounding skin Features of chronic ischemia (hairless, dry,
pale)
Veins Empty, guttering on elevation Full, usually varicose
Swelling Absent Present
Previous deep venous thrombosis, thrombophilia, varicose veins
>20% clear history of deep venous
thrombosis. History suggestive of occult
deep venous thrombosis is very common
(e.g., leg swelling after childbirth, hip/knee
replacement, or long bone fracture).
Approximately 30% have pain, but it is not
usually severe and may be relieved upon
elevation
Medial (70%) and lateral (20%) or both
malleoli and gaiter area
Pink and granulating, may be covered in a
yellow-green slough
Lipodermatosclerosis (pigmentation, induration, varicose eczema, atrophie blanche)
31.3.6.3.4 Venous leg ulcer assessment
Ulcer assessment (Figure 31.5) should include:
1. Description of the ulcer, concentrating on the features
outlined in Table 31.2
2. Pulse status and ankle-brachial index (ABI)
3. Gait and, in particular, ankle mobility
4. General physical examination
In general, we recommend using the revised Venous Clinical Severity Score (VCSS) for patients with chronic venous
disorders for grading of clinical severity of the disease and
for assessment of post-treatment outcome (see Chapter 78,
Table. 78.2).
31.4 CONCLUSION
Venous disease is common and is often accompanied by
nonspecic symptoms, such as aching and swelling. This
condition may be associated with a signicant risk of morbidity and can present in a variety of modalities depending
on which part of the venous system is affected. A thor-
ough history and clinical examination can provide crucial
information on the underlying pathology and help guide
investigations and management, as recommended and summarized by clinical practice guidelines.
31.5 Ulceration in the gaiter area of the left lower limb.
23–25
References 319
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Best Practice Statements 31.0 of the American Venous Forum on the clinical presentation and assessment of
patients with venous disease
No. Best practice Statements
31.1 In patients with suspected upper extremity venous disease, clinical examination of the upper limb, inspection with comparison with the contralateral limb, palpation, auscultation, and examination of the axilla for adenopathy should be performed. In
patients with adenopathy or swollen arms, we recommend examination of the breast to exclude malignancy.
31.2 In patients with suspected acute deep vein thrombosis (DVT) of the lower extremities, we recommend inspection (edema,
cyanosis, and varicosity), palpation (tenderness and pitting edema), auscultation (arterial bruit, heart and lung examination),
and examination of the deep and supercial veins and calf muscles.
31.3 To predict the pretest probability of DVT, the clinical scoring system of Wells can be used.
31.4 In patients with varicosity and chronic venous insufciency of the lower extremities, clinical examination should include
inspection (varicosity, edema, skin discoloration, corona phlebectatica, ulcer, and lipodermatosclerosis), palpation (cord,
varicosity, tenderness, induration, reux, pulses, and thrill), auscultation (bruit), and examination of the groin and abdomen
(masses, collateral veins, or lymphadenopathy) and ankle mobility.
31.5 Clinical presentation of patients with varicose veins may include symptoms like aching, heaviness and tension, sensation of
swelling, tiredness, restless legs, nocturnal cramps, and itching. There appears to be little or no relationship between these
symptoms and the presence and severity of varicose veins or the pattern and severity of reux.
31.6 For patients with chronic venous disorders, the revised Venous Clinical Severity Score (VCSS) is useful for grading clinical
severity and for assessment of post-treatment outcome.
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31
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Vasc Endovasc Surg. 2012;43(4):
480–484.
15. Van den Oever R., Hepp B., Debbaut B.,
et al. Socioeconomic impact of chronic
venous insufciency. An underestimated
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public health problem. Int Angiol.
1998;17(3):161–167.
16. Decousus H., Quere I., Presles E., Becker
F., Barrellier M.T., Chanut M., et al.
Supercial venous thrombosis and venous
thromboembolism: A large, prospective
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17. Cushman M. Epidemiology and risk
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*18. Dentali F., Ageno W., Becattini C., et
al. Prevalence and clinical history of
incidental, asymptomatic pulmonary
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19. Wells P.S., Anderson D.R., Bormanis
J., et al. Value of assessment of pretest
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1997;350(9094):1795–1798.
20. Jacob A.G., Driscoll D.J., Shaughnessy
W.J., et al. Klippel–Trenaunay syndrome:
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♦21. Eklöf B., Rutherford R.B., Bergan J.J., et
al. Revision of the CEAP classication for
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♦22. Lurie F., Passman M., Meisner M.,
Dalsing M., Masuda E., Welch H.,
Bush R.L., Blebea J., Carpentier P.H.,
De Maeseneer M., Gasparis A., Labropoulos N., Marston W.A., Rafetto J.,
Santiago F., Shortell C., Uhl J.F., Urbanek
T., van Rij A., Eklof B., Gloviczki P.,
Kistner R., Lawrence P., Moneta G.,
Padberg F., Perrin M., Wakeeld T. The
2020 update of the CEAP classication
system and reporting standards. J Vasc
Surg Venous Lymphat Disord. 2020
May;8(3):342–352. doi: 10.1016/j.
jvsv.2019.12.075 (Epub 2020 Feb 27.
Erratum in: J Vasc Surg Venous Lymphat
Disord. 2021 Jan;9(1):288. PMID:
32113854).
♦23. Gloviczki P., Comerota A.J., Dalsing
M.C., 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(5 Suppl.):
2S–48S.
♦24. De Maeseneer M.G., Kakkos S.K., Aherne
T., Baekgaard N., Black S., Blomgren L.,
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ka-Kaczorowska A., Lattimer C.R., Mosti
G., Noppeney T., van Rijn M.J., Stansby
G., Esvs Guidelines Committee, Kolh P.,
Bastos Goncalves F., Chakfé N., Coscas
R., de Borst G.J., Dias N.V., Hinchliffe
R.J., Koncar I.B., Lindholt J.S., Trimarchi
S., Tulamo R., Twine C.P., Vermassen F.,
Wanhainen A., Document Reviewers,
Björck M., Labropoulos N., Lurie F., Mansilha A., Nyamekye I.K., Ramirez Ortega
M., Ulloa J.H., Urbanek T., van Rij A.M.,
Vuylsteke M.E. Editor’s Choice—European
Society for Vascular Surgery (ESVS)
2022 clinical practice guidelines on the
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the lower limbs. Eur J Vasc Endovasc Surg.
2022 Feb;63(2):184–267. doi: 10.1016/j.
ejvs.2021.12.024. Epub 2022 Jan 11.
Erratum in: Eur J Vasc Endovasc Surg.
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35027279.
♦25. National Institute for Health and Care
Excellence. Varicose veins in the legs.
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26. Rautio T., Perala J., Biancari F., et al.
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planning the operation for primary
varicose veins. Eur J Vasc Endovasc Surg.
2002;24(5):450–455.
CHAPTER
32
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Diagnostic algorithm for chronic
venous disorders
Amani D. Politano and Robert B. McLafferty
32.1 INTRODUCTION
Chronic venous disease (CVD) is a common afiction, with
a prevalence of up to 64%,
The diagnosis of telangiectasia, varicose veins, edema with
inammatory changes, and venous ulcers starts with a wellrooted understanding of venous anatomy and pathophysiology, as outlined in previous chapters. While advances
in physiologic testing and duplex and radiologic imaging
continue to be made in the eld of CVD, a thorough and
directed history and physical examination can lead the provider to the proper clinical assessment conrmed by supplementary tests as needed.
This chapter provides a framework for the diagnostic
evaluation of CVD, with a thorough history and physical
examination being the bedrock to guide further evaluation.
These guidelines therefore aim to organize the evaluation
of patients with CVD from the history and physical examination to next steps in physiologic venous testing, duplex
imaging, or more advanced radiologic imaging.
Characterization of CVD should follow the most
recent Clinical, Etiologic, Anatomic, and Pathophysiologic (CEAP) classication system.
described in detail in Chapter 9, the CEAP classication
system is a joint venture between the Society for Vascular
Surgery (SVS), the American Venous Forum (AVF), and the
American Vein and Lymphatic Society (AVLS). The basic
CEAP classication should be used for every patient in the
clinical setting, and the full or advanced CEAP classication for research purposes. This chapter will focus on the
full spectrum of the clinical class continuum in the diagnostic evaluation of CVD. Many clinical practice guidelines
have been published on the diagnosis and treatment of
CVD with the use of GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.
In this chapter, the focus is on providing the clinician with
an integrated diagnostic approach without relying extensively on the specic GRADE recommendations.
1,2
which increases with age.3
4
Revised in 2020 and
5–9
32.2 HISTORY OF THE DISEASE
In taking a complete history for CVD, the use of open-ended
questions remains paramount to retrieving valid information about symptoms. This may be especially pertinent for
patients with lower clinical classications, whereby allowing for uninterrupted answers often can reveal important
symptoms that could be missed with initial closed-ended
questions. Simple questions such as “Can you describe
what bothers you about your legs?” or even “What brings
you to see me today?” provide a launch pad for understanding a patient’s concerns or how their symptoms affect
their daily life. The provider can ask the patient to be more
specic about certain aspects of the history and follow up
with directed questions and pertinent negatives. This technique of open-ended questions with uninterrupted answers
from the patient followed by directed questions should also
provide a framework for thorough documentation, which
often is required for insurance coverage.
Symptoms from CVD, and particularly varicose veins,
can vary from patient to patient and may be vague. While
some patients may be asymptomatic, others have symptoms that can be revealed with a careful history. Some
patients may have difculty articulating their concerns or
may not realize that these vague symptoms are a manifestation of their venous disease. Common symptoms include
dull pain, aching, pressure, throbbing, heaviness, tiredness,
restlessness, itching, burning, tension of the skin, cramping,
and mild edema. Generally, these symptoms are exacerbated with limb dependency and relieved with elevation or
rest. More severe symptoms such as marked edema, dermatitis, hyperpigmentation, corona phlebectatica, atrophie
blanche, lipodermatosclerosis, ulceration, and skin erosion with hemorrhage can be present solely with supercial venous valvular incompetence, but often are seen with
concomitant deep valvular insufciency. On the opposite
end of the CVD spectrum, telangiectasias are often considered cosmetic nuisances and assumed to be asymptomatic,
but they too can illicit symptoms similar to varicose veins.
Furthermore, their presence in association with correlative
symptoms might indicate more severe underlying CVD and
warrant further physiologic testing.
In addition to eliciting the presence of symptoms associated with CVD, it is vital to obtain details regarding both
the severity and duration of these symptoms. A history
of venous complications such as deep venous thrombosis
or supercial thrombophlebitis, major lower extremity
trauma, or prior surgical interventions (for treatment of
venous pathology, orthopedic procedures, or inguinal or
retroperitoneal surgery) should be obtained. Personal risk
9–12
DOI: 10.1201/9781003328971-36
321321
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factors such as hypercoagulable state, obesity (documenting body mass index), occupation with long durations of
standing, history of constipation, or periods of prolonged
bed rest are also important to document. A family history
for diverse types of acute and chronic venous disease as well
as blood clots should be obtained. Other relevant information that should be recorded include the use of venotonic
medications, compression hosiery, leg elevation, exercise,
or weight loss to ameliorate the symptoms. In women, pain
can worsen during the menstrual cycle or pregnancy secondary to increased total body uid volume and/or higher
circulating levels of estrogen. Questions should also assess
for the presence of concomitant inguinal, perineal, vulvar,
and/or vaginal varicosities. For men, a history of varicocele
or scrotal varicosities should be sought.
The differential diagnosis of lower extremity pain
includes claudication secondary to peripheral arterial
disease (calf muscle pain that comes with walking and is
relieved with rest) or venous claudication (a more global
bursting pain in the lower extremity muscles that comes
with walking and is slow to abate with cessation). The differential diagnosis for leg swelling includes primary lymphedema or lipedema, and the overlap between lymphedema
and CVD can be difcult to parse out in terms of which
entity is the primary diagnosis. Other clinical entities that
can overlap or have similar symptoms include restless leg
syndrome, arthritic disorders, neuropathic pain, complex
regional pain syndrome, and other chronic pain syndromes
of the lower extremities. The presence of one or more of
these diagnoses in addition to clear signs of CVD could
cloud the prediction of improvement with treatment of
CVD and may warrant modied expectations for both the
patient and the provider.
For patients presenting with venous ulcers, documentation should include history of prior ulcers, duration of
open ulcers, and current rate of healing (e.g., ulcer growth,
recession, or stagnation). For the current ulcer, the location, size, appearance, and whether there are signs and
symptoms of infection present should be recorded. Past
and current treatment regimens specic to the ulcer are
also important to document.
32.3 PHYSICAL EXAMINATION
phlebectatica, and evidence of healed or active ulceration.
Location, size, depth, color, and number of ulcerations
should be noted. The presence of an underlying congenital arteriovenous or venous malformation may be revealed
by the presence of a well-demarcated, purplish pigmented
area of the skin (port wine stain) or limb hypertrophy.
Inspection should also concentrate on the presence of scars,
particularly in the distribution of previous vein stripping,
harvest, ablation, and/or phlebectomy.
Rarely, auscultation in the vicinity of varicose veins may
reveal a bruit.
14
Patients with a history of lower extremity
10–12
trauma may have an arteriovenous stula as the underlying etiology of varicose veins. Congenital arteriovenous
or venous malformations can appear as a large, isolated,
grapelike cluster of veins or as a moderate-to-large cluster
of smaller vessels appearing with a reddish-bluish hue that
penetrate more deeply into fatty and muscular layers of the
limb. A bruit is not necessary to conrm this etiology.
Palpation to aid in dening the extent and pattern of
CVD is extremely important. With the patient standing,
incompetent dilated veins that are not readily visualized
can be palpated. This may be true when only telangiectasia or venous ulcer is present by inspection. Palpation can
also help dene a more complete outline of varicose veins,
particularly in the thigh region of overweight patients.
Supercial thrombophlebitis can be appreciated as nodules, sometimes tender, within varicose veins, while older
areas of thrombosis are felt as cords that may or may not
be contiguous with other varicosities. A thrill can be palpated in some patients with a traumatic arteriovenous stula. Careful palpation can also help ascertain more serious
signs of infection by detecting the extent of tenderness and
induration. Outlining the extent of lipodermatosclerosis by
palpation may also guide the physician as to which areas to
avoid for phlebectomy or to focus on for perforator treatment.
Patients should also be examined in the supine position.
An abdominal examination may indicate masses causing
venous obstruction. Varicose veins that persist or are slow
to dissipate in the supine position may suggest venous outow obstruction. Pulse examination of the femoral, popliteal, dorsal pedal, and posterior tibial arteries should be
performed.
The physical examination should take place in a warm,
well-illuminated room with the patient in the standing
position. With the patient’s legs completely disrobed, careful inspection is conducted and patterns of telangiectasia,
reticular veins, and varicose veins are noted. Clusters of telangiectasias can appear as skin blemishes or venous lakes
(blue-purple compressible papules ranging from 0.2 mm to
1 mm in size). They are often present in the posterolateral
thigh and popliteal fossa.
ference measurements should be performed to reveal more
subtle edema that may not be detected with simple visual
assessment. Additionally, inspection for other, more serious signs of CVD in the gaiter area (ankle to mid-calf) is
performed. These include dermatitis, hyperpigmentation,
lipodermatosclerosis, cellulitis, atrophie blanche, corona
13
Ankle, calf, and thigh circum-
32.4 LABORATORY EXAMINATION
Patients with CVD should have blood and/or urine testing depending on their history, physical examination, and
treatment plan. Recurrent venous thrombosis, venous
ulcer before age 50, or recurrent or recalcitrant venous
ulcer may require screening for hypercoagulability (see
Chapter
sis ulcers or those with suspected infection may require
a complete blood count, metabolic panel, and inammatory markers. Diabetic patients, especially those presenting with ulcerations, should have their hemoglobin A
checked within the last 3 months as a marker for trends in
glucose control, which may provide an actionable treatment need.
10).
15–18
Patients with long-standing venous sta-
C
1
32.5 Diagnostic vascular laboratory 323
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32.5 DIAGNOSTIC VASCULAR
LABORATORY
In addition to obtaining the history and physical examination, imaging studies are critical to dening the pathophysiology of CVD. Indirect and direct noninvasive
testing for CVD performed in a vascular laboratory by an
experienced technologist allows characterization of the
anatomic and pathologic categories of the CEAP classication. Delineation of venous reux, obstruction, and calf
muscle pump dysfunction are important to the diagnostic
algorithm, particularly in the presence of varicose veins
and venous ulcers. These tests may also be applicable to
patients with telangiectasia, depending on accompanying
leg symptoms.
32.5.1 Indirect noninvasive tests
Several indirect noninvasive vascular laboratory tests dene
the presence and distribution of venous obstruction, reux,
and calf muscle pump dysfunction.
form of plethysmography (see Chapter 13). These various
tests enable most vascular laboratories to measure venous
rell time and/or venous outow. For patients with more
advanced CVD and venous ulcers, selective use of venous
plethysmography is recommended when direct noninvasive
testing with the use of duplex ultrasound does not provide
denitive diagnostic information.
Typically, venous rell times are determined using pho-
toplethysmography (PPG).
21–24
consecutive plantar exions of the ankle to evacuate the
blood from the lower extremity, causing venous pressure
24
to fall.
If the valves are competent, rell to the baseline
pressure through the arterial circuit takes longer than 25
seconds. Reaching the baseline plateau in 20 seconds or
less indicates venous valvular reux. Selective placement of
tourniquets or cuffs inated to approximately 40 mmHg
on the thigh or below the knee during subsequent evaluations to occlude the great saphenous vein and other supercial tributaries allows some delineation of supercial
versus deep venous valve incompetence.
Venous outow can be measured with impedance and/
or strain gauge plethysmography.
the supine position and the legs elevated 15–20 degrees,
thigh cuffs are inated to 50–80 mmHg to occlude venous
outow. When the venous capacitance pressure equalizes
the occluding pressure from the arterial inow of blood,
the cuffs are rapidly deated. Just prior to cuff deation,
total venous capacitance is compared between the limbs.
Limbs with acute or chronic thrombus may have less
venous capacitance. The rate of decline over 3 seconds
compared to the baseline capacitance evaluates for venous
outow obstruction. A leg that is slow to empty could have
thrombus more proximally. The presence of developed collateral venous circulation or venous duplicity can lead to a
false-negative test.
Another use of air plethysmography includes the evaluation of calf muscle pump dysfunction.
air-lled plastic bladder surrounding the lower extremity,
19,20
Many utilize some
7
Seated patients perform
25,26
With the patient in
22,27,28
With an
the system is calibrated with a known volume of air, and
changes in air pressure within the bladder are recorded
as the patient performs specic maneuvers. The changes
in venous capacitance are reected by the changes in calf
diameter. In someone with calf muscle pump failure, minimal blood exits the limb with each ankle dorsiexion,
yielding a markedly reduced ejection fraction and a high
residual volume. Air plethysmography also evaluates other
important physiologic parameters, including venous volume, venous lling index, and residual volume fraction (see
Chapter
13).
32.5.2 Direct noninvasive tests
The criterion standard for the assessment of venous
valvular incompetence remains duplex ultrasound (see
Chapters
11 and 12).
mography techniques described, venous duplex allows for
assessment of occlusive disease as well as reux and further provides information on venous anatomy. Described
by van Bemmelen and colleagues, a complete lower
extremity duplex examination includes visualization of
the common femoral, femoral, popliteal, posterior tibial,
and great and small saphenous veins.
in the standing position, patients use a handrail and dangle the leg in question while the examiner insonates the
aforementioned venous segments with an appropriately
sized cuff placed approximately 5 cm below the probe.
Depending on cuff position, ination pressures from 80
mmHg (thigh) to 120 mmHg (foot) are needed to overcome venous hydrostatic pressure and ensure complete
venous evacuation. After maintaining an ination for 3
seconds, the cuff is rapidly deated within 0.3 seconds or
less. Venous valves with normal function respond rapidly
with cuff deation, with 95% demonstrating complete
cessation of reverse ow within 0.3 seconds. Therefore,
pathophysiologic reversal of ow that is greater than
0.5 seconds in the supercial veins and deep calf veins,
greater than 1 second in the femoropopliteal veins, or
greater than 0.35–0.5 seconds in the perforator veins is
considered abnormal, with 0.5 seconds the recommended
value in the 2022 SVS/AVF/AVLS practice guidelines.
Duplex ultrasonography is also useful in the identication of perforating veins. With the legs in an exaggerated reverse Trendelenburg or sitting position, duplex
can be used to visualize perforating veins along the
medial and lateral calf. Outward ow from the deep to
the supercial venous system with calf compression or
exion may indicate incompetence. Others have looked
at the overall diameter of perforating veins, stating that
incompetence is present if the diameter is greater than
3.5 mm.
33,34
Both the provider and the vascular lab
should be procient in the identication of large perforators of the lower leg that communicate between the
deep and supercial venous systems. In addition, even
after removal of axial supercial veins from the lower
leg, a large perforator may be present and contribute to
continued venous hypertension. This evaluation becomes
increasingly important in the presence of recalcitrant or
recurrent venous ulcers.
7,9
Similar to some of the plethys-
29–31
While examined
9,32
32
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