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315 Clinical Evaluation of Patients with Chronic Lower Extremity Venous Disorder
Conclusion
As in other fi elds of medicine, the history and
physical examination are indispensable to accu-
rate diagnosis and treatment of chronic venous
disorders. While the severity of a patient’s
symptoms do not always correlate closely with
the severity of the physical fi ndings or with the
extent of the disease process, historical clues
and a careful physical examination can aid the
examiner, and ultimately the patient, in the man-
agement of chronic venous disease.
References
1. Carpentier P, Maricq H, Biro C, Ponçot-Makinen C,
Franco A. Prevalence, risk factors, and clinical patterns
of chronic venous disorders of lower limbs: a population-
based study in France. J Vasc Surg. 2004;40:650–9.
2. Criqui M, Denenberg J, Bergan J, Langer R, Fronek A.
Risk factors for chronic venous disease: the San Diego
Population Study. J Vasc Surg. 2007;46:331–7.
3. Lee A, Evans C, Allan P, Ruckley CV, Fowkes FG.
Lifestyle factors and the risk of varicose veins: Edinburgh
Vein Study. J Clin Epidemiol. 2003;56:171–9.
4. Cornu-Thenard A, Boivin P, Baud J-M, et al. Importance
of the familial factor in varicose disease: clinical study of
134 families. J Dermatol Surg Oncol. 1994;20:318–26.
5. Ricci S, Georgiev M, Jawien A, Zamboni P. Sciatic nerve
varices. Eur J Vasc Endovasc Surg. 2005;29:83–7.
6. Eklof B, Rutherford R, Bergan J, Carpentier P,
Gloviczki P, Kistner R, Meissner M, Moneta G, Myers
K, Padberg F, Perrin M, Ruckley CV, Coleridge Smith
P, Wake fi eld T. Revision of the CEAP classi fi cation for
chronic venous disorders: consensus statement. J Vasc
Surg. 2004;40(6):1248–52.
7. Chiesa R, Marone E, Costanzo L, Volonte M, Petrini
O. Chronic venous disorders: correlation between vis-
ible signs, symptoms, and presence of functional dis-
ease. J Vasc Surg. 2007;46:322–30.
8. Uhl JF, Cornu-Thénard A, Carpentier P, Widmer M-T,
Partsch H, Antignani PL. Clinical and hemodynamic
signi fi cance of corona phlebectatica in chronic venous
disorders. J Vasc Surg. 2005;42:1163–8.
9. Cavezzi A, Michelini S, editors. Phlebolymphedema:
from diagnosis to therapy. Bologna: Edizioni P.R.; 1998.
Fig. 5.9 Severe chronic lipodermatosclerotic changes
Fig. 5.8 Acute lipodermatosclerosis
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33
N.S. Sadick et al. (eds.), Practical Approach to the Management and Treatment of Venous Disorders,
DOI 10.1007/978-1-4471-2891-5_6, © Springer-Verlag London 2013
6
Clinical evaluation of the location and extent of
venous disease is an unreliable means of determin-
ing effective and durable treatment plans in a given
limb. This is true as different patterns of incompe-
tence can result in a similar appearance of abnor-
malities, and because several different patterns can
coexist in a single limb. Although several diagnostic
techniques exist, Duplex Ultrasound (DUS) has
evolved to become the primary diagnostic tool used
to evaluate patients with super fi cial venous
insuf fi ciency (SVI). DUS is an inexpensive, portable
and reproducible means of simultaneously assessing
both the venous anatomy and physiology. DUS has
been proven to be invaluable in examining patients
with known or suspected venous disease to identify
the nature, location and extent of the abnormalities.
In this chapter, we will review the techniques
of DUS evaluation in patients with chronic venous
disorders. In patients with suspected acute venous
disease, an ultrasound is indicated to evaluate the
patient for the presence and extent of deep or
super fi cial venous thrombosis. The DUS exami-
nation and imaging fi ndings of patients with acute
venous disease will not be extensively covered in
this chapter. The interested reader is encouraged
to review the papers related to acute venous DUS
diagnosis in the papers [
1 ] .
DUS Indications
It is strongly recommended that all patients being
considered for treatment of lower extremity chronic
venous disorders (CEAP clinical stage 2–6) undergo
an ultrasound of the venous system to determine the
location and pattern(s) of incompetence.
Patients with spider veins (CEAP clinical
stage 1), particularly those in non-saphenous dis-
tributions such as on the lateral thigh area, gener-
ally do not require US evaluation. However, when
the spider veins are found in the distribution of the
great saphenous vein (GSV), it is recommended
that DUS be performed. If truncal (saphenous)
vein re fl ux is identi fi ed and contributory in these
cases, treatment of this re fl ux may be warranted
prior to treatment of the spider veins.
Anatomy as Depicted by DUS
The GSV, small saphenous vein (SSV) and their
primary tributaries are easily examined with
DUS. The GSV and SSV are found deep to the
super fi cial and super fi cial to the deep fascia
within the saphenous sheath. During axial (trans-
verse) imaging, these veins will have the appear-
ance of Cleopatra’s eye or of the Seattle Seahawks
helmet logo (Fig. 6.1a , b ).
Some of the primary named tributaries of the
GSV are also found within the saphenous sheath
and therefore have a similar DUS appearance.
These veins include the anterior and posterior
accessory GSV of the calf and thigh. However
Venous Duplex Ultrasound
in Patients with Chronic
Venous Disorders
Neil M. Khilnani
N. M. Khilnani , M.D.
Weill Cornell Vascular and
the Division of Interventional Radiology,
New York Presbyterian Hospital-Weill
Cornell Medical Center ,
416 East 55th Street, New York , NY 10022 , USA
e-mail: nmkhilna@med.cornell.edu
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34
N.M. Khilnani
the majority of the tributaries of the GSV and
SSV are un-named and exist super fi cial to the
super fi cial fascia in the subcutaneous space on
imaging. Peripheral (caudal) to the joining of a
large tributary vein, the GSV or SSV may dra-
matically decrease in caliber or may not be visi-
ble to DUS. Incompetent saphenous fl ow can
completely spill into a re fl uxing tributary, which
then serves as the source of incompetence to a
lower segment of the same truncal vein if they
join again. If the intervening segment of the trun-
cal vein can be traversed by a catheter, it may be
possible to completely ablate the two incompe-
tent segments of the vein with a single access.
However, if the vein segment between the incom-
petent segments cannot be seen on DUS, com-
plete ablation of the two incompetent segments
would likely require two punctures. In practice,
most vein segments that are visible by ultrasound
can be traversed with a guidewire (Fig.
6.2 ).
Diagnostic DUS Technique
and Findings
The equipment required to perform the examina-
tion is relatively simple by current standards.
Gray scale imaging, pulse wave Doppler (PWD)
and a linear 7.5–10 MHz transducer are neces-
sary elements which are found on most portable
a
b
Fig. 6.1 Axial DUS images
depicting the location of the
GSV ( a ) and SSV ( b ) in the
saphenous space. The deep
fascia surrounding the
muscular compartment splits
to create the saphenous
space. The super fi cial and
deep facial boundaries of the
saphenous space along with
the saphenous vein creates
an appearance that resembles
Cleopatra’s eye
(see Fig.
2.2a, b for
corresponding line drawings)
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356 Venous Duplex Ultrasound in Patients with Chronic Venous Disorders
DUS units available today. Color Doppler (CD)
can expedite the evaluation and PWD is a reliable
and reproducible means of documenting the dura-
tion of the re fl ux.
The goals of the DUS exam are to identify all
incompetent truncal veins and to determine
whether they are responsible for the patient’s
clinical problem. At the end of a DUS exam one
should know whether there is re fl ux, obstruction
or both in the super fi cial and deep venous sys-
tems and which segments are involved. Modern
guidelines for a complete exam have been devel-
oped by both the American College of Phlebology
and the International Union of Phlebology [
2– 4 ] .
Credentialing organizations exist to ensure the
quali fi cations of the operators, appropriateness of
the equipment and techniques used and adequacy
of the documentation (American College of
Radiology {ACR} and Intersocietal Commission
for the Accreditation of Vascular Laboratories
{ICAVAL}). The reader is encouraged to review
the regularly updated guidelines and quali fi cations
supported by these organizations that are avail-
able on their websites.
When evaluating patients for re fl ux, the exam
is commonly performed in the standing position.
The patient is usually positioned on a stand to
elevate the legs, which facilitates the performance
of the exam for the operator. Giving the patient a
handle to hold and lean on helps, particularly with
more elderly patients. The patient is asked to turn
the leg under examination outward to allow scan-
ning of the inner thigh and calf (Fig.
6.3 ).
Performance of the exam in a reverse
Trendelenberg positon is also frequently done.
The advantages of this position are that patient
some patients are more comfortable and the risk
of falling associated with a vagal episode, which
occasionally occurs during DUS, is lessened. No
comparison of the relative ef fi cacy of the two dif-
ferent positions has been performed. However it
A
C
B
Fig. 6.2 Drawing depicting re fl ux in the GSV. In this
example, the re fl ux spills out into a varicose pathway
super fi cial to the saphenous sheath ( Point A ) and then re-
enters the GSV at a lower level ( Point B ). The GSV then
re fl uxes to Point C before spilling into a dilated cluster of
calf varicose tributaries
Fig. 6.3 Photograph of the position used to evaluate the
GSV with DUS
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36
N.M. Khilnani
generally accepted that the ability to detect re fl ux
and the differences in caliber associated with
re fl uxing and non-re fl uxing veins is higher in
these positions relative to a supine exam.
Evaluation of the deep veins can also be per-
formed in the standing or reverse Trendelenberg
position although it is most commonly done
supine. An advantage of the standing exam is that
the vein caliber is much larger making assessment
of the vein size and internal architecture easier.
Generally, the exam begins at the SFJ. The
CFV is evaluated for obstruction and re fl ux. Next,
the GSV is followed from its junction down beyond
the level of any visible varicose veins to the ankle.
The relationship of the GSV to any abnormal veins
is assessed by tracing its course and caliber and
the course of any tributaries that might lead to the
abnormal veins. It is important to be aware of the
standard tributary anatomy of the GSV and to rec-
ognize the frequent variations that are found [
2– 4 ] .
The anterior accessory GSV, which courses ante-
rior to the path of the GSV is very commonly
found with DUS. It has been less precisely
described as a long anterior circum fl ex vein or as a
duplicated GSV. This vein takes usually takes its
origin from the GSV just below the SFJ, initially
passing inferiorly just super fi cial to the super fi cial
femoral artery and femoral vein and then courses
obliquely down the anterior thigh. It is often
responsible for anterior thigh varicose veins. It
may rejoin the GSV in the lower thigh (Fig. 6.4 ).
The caliber of the GSV is then assessed, as
changes in caliber can provide important clues to
physiologic disturbance. Normally, the vein is
approximately 4 mm in diameter. Veins > 7 mm
have a high incidence of re fl ux although clinically
Fig. 6.4 Diagrams of the AAGSV. ( a ) Diagram depicting
re fl ux in the AAGSV leading to varicose veins on the
anterior thigh. ( b ) Diagram of the normal variant when the
AAGSV is the dominant super fi cial vein on the anterior-
medial thigh and is continuous from the GSV near the
knee to the SFJ. ( c ) Diagram of a normal variant when the
AAGSV is the only straight-line intrafacial conduit of
blood from the below knee GSV to the SFJ
a
bGreat saphenous vein
Great saphenous vein
Anterior Accerssory
Great saphenous vein
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376 Venous Duplex Ultrasound in Patients with Chronic Venous Disorders
signi fi cant re fl ux can occur in smaller veins.
Peripheral to the takeoff of incompetent tributary
veins, the caliber of the vein often decreases.
Conversely, the caliber of the GSV will generally
increase at the in fl ow level of a signi fi cant incom-
petent perforator vein or at the in fl ow of an
incompetent tributary as they pass re fl uxing fl ow
into the truncal vein below its in fl ow. A careful
search should be made at points of GSV dilata-
tion to identify such important sources of re fl ux.
Any vein segment suspected of having re fl ux by
size or by relationship to varicose veins is then eval-
uated with CD and PWD to directly visualize the
direction of fl ow. When using Doppler, the operator
needs to angle the probe upward to create an angle
in order to get a Doppler signal. When angling the
probe upward, fl ow toward the probe in a leg vein is
re fl ux that by convention is above the x-axis on
PWD and red on CD. Conversely, fl ow upward is
below the x-axis on PWD and blue on CD.
Re fl ux can be easily documented by looking
for antegrade fl ow followed by retrograde fl ow
after a quick, fi rm compression of a peripheral
segment of the leg. Compression can be gener-
ated by hand or cuff compression by the examin-
ing operator; both are equivalent provocative
maneuvers to identify re fl ux. Generally, when
evaluating the GSV, compression of the calf
should lead to augmentation of antegrade venous
fl ow. When evaluating the AAGSV, compression
of the lower thigh may be more useful. Upon
release of compression, little if any retrograde
fl ow should be noted. Re fl ux is documented when
a signi fi cant amount of retrograde fl ow is found
(Fig. 6.5 ). Although the criteria of 0.5 s of retro-
grade fl ow has been used to identify pathological
re fl ux in the super fi cial veins, several seconds of
retrograde fl ow is often seen in patients with
incompetence (Fig. 6.6 ).
Next the patient is turned away from the exam-
iner and the SSV and the posterior thigh veins are
evaluated (Fig. 6.7 ). The process of evaluation is
similar to that of the GSV. This includes tracing
the course of the SSV vein, assessing its size and
its relationship to any varicose veins and also
assessing the popliteal vein. The anatomy of the
SSV and its thigh extensions are quite variable as
reviewed in Chap. 3 . In ~50–70% of cases, the
SSV has its dominate termination into the
popliteal vein ~2 cm above the popliteal crease.
However, as discussed, more cephalad extension
of this vein is common. Often it will extend sev-
eral cm up the posterior thigh in the saphenous
space to terminate in a perforating vein (PV).
Occasionally it will extend even more cephalad
toward the buttock crease before terminating into
a PV or passing under the gluteal crease toward
the pelvis. A relatively common variant, the Vein
of Giacomini, is a connection between the GSV
and the SSV. This vein runs in the saphenous
space in the posterior thigh connecting directly
with the posterior circum fl ex vein of the thigh.
The Giacomini Vein can transmit re fl uxing fl ow
from the SPJ to the GSV or to posterior thigh
varicose veins if the fl ow re fl uxes into tributary
veins. The Giacomini Vein can be a pathway of
incompetence originating from the GSV leading
to posterior thigh and calf varicose veins.
c
Anterior Accessory
Great saphenous vein
Fig. 6.4. (continued)
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38
N.M. Khilnani
Squceze
b
c
Velocuty
Velocity
Time
Tim
e
a
Fig. 6.5 Diagram of the method and interpretation of pulse
wave Doppler evaluation of re fl ux. ( a ) Diagram depicting
the position of the US probe and hand when evaluating the
popliteal vein for re fl ux. The US probe needs to be angled
toward the head either longitudinally or axially to generate a
Doppler signal. Compression and release of lower vein seg-
ments creates the forward fl ow to evaluate the valve contain-
ing vein segments above the transducer. ( b ) Velocity-time
tracing obtained with the US during the compression and
release of a vein segment below a competent vein. Blood
fl ow away from the transducer is augmented with a squeeze
of a lower vein-muscle segment (by convention, fl ow away
from the transducer is depicted below the x-axis). When the
squeeze is released a short amount of retrograde fl ow toward
the transducer is normally seen before the valves close. ( c )
Velocity-time tracing obtained of a re fl uxing vein with the
US during the compression and release of the calf. After the
squeeze is released, retrograde fl ow occurs via an incompe-
tent vein re fi lling the segment that had been compressed
though the vein being insonated
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396 Venous Duplex Ultrasound in Patients with Chronic Venous Disorders
a
b
c
Fig. 6.6 Doppler DUS
assessment examples: ( a )
Axial image depicting fl ow
toward the transducer ( red )
demonstrating re fl ux in the
thigh GSV immediately after
release of a calf compression.
( b ) Axial image with PWD
evaluation demonstrating
re fl ux in the thigh GSV after
release of calf compression.
( c ) Longitudinal image of the
popliteal vein demonstrating
no re fl ux after release of calf
compression
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40
N.M. Khilnani
An evaluation of the femoral and popliteal
veins for re fl ux and obstruction should be included
in the examination. Evaluation for re fl ux is done
standing using a similar technique to the evalua-
tion of the super fi cial veins. The commonly used
criteria for clinically signi fi cant deep vein re fl ux
is >1 s. Usually the femoral and popliteal veins
can be evaluated in one location each.
Examining the femoral vein waveform over
several breaths should demonstrate normal varia-
tion in spontaneous venous fl ow toward the heart.
Loss of the phasic character to fl ow may infer an
iliac vein obstruction, including extrinsic com-
pression of an iliac vein by an iliac artery or pelvic
mass, narrowing of the vein from a prior thrombo-
sis or acute thrombosis (Fig.
6.8 ). A comparison
with the femoral waveform of the contralateral
extremity may identify asymmetry the would
increase suspicion of an out fl ow obstruction. If
loss of the respiratory variation is found, direct
ultrasound evaluation of the iliac veins can be
performed. If the veins are dif fi cult to see because
of obesity or bowel gas and despite attempts to
visualize them in a decubitus position, they can be
evaluated with contrast enhanced CT or MRI [
5 ] .
The exam to identify evidence of a prior
venous thrombosis of the femoral, popliteal
and tibial veins can be performed standing or
recumbent. The details of this exam are beyond
the focus of this chapter. The reader is referred
to speci fi c works addressing this topic [ 1 ] . As
a brief summary, obstruction from acute or old
thrombosis can be identi fi ed by DUS. A vein
may be considered free of thrombus if the entire
vein segment can be compressed by applying
pressure over the vein with the US transducer
completely approximating the anterior and pos-
terior walls of the vein. This maneuver should
be performed approximately ever 2–3 cm from
the inguinal ligament to the calf. Visualization of
the vein in transverse and longitudinal projects
with gray scale and color can also provide clues
of prior thrombosis. These include narrowed vein
segments with large collateral pathways, intralu-
minal webs, thickened vein segments, and vein
calci fi cations. The femoral and popliteal veins
are usually larger than their corresponding arter-
ies in the standing position although duplication
and occasionally triplications occur. As a normal
variant, the deep femoral vein can be continuous
from the popliteal vein, usually as a continuation
of one of its duplications, to the CFV. In these
cases, the femoral vein may be smaller than typi-
cal but without other evidence to suggest prior
thrombosis. Color fl ow Doppler can be used to
evaluate the lumen of a vein to look for fl ow dis-
turbances that might facilitate detection of throm-
bus, webs and vein wall thickening.
Evaluation of the calf veins for patency and
re fl ux is not essential in most cases of chronic
venous disease. However, in patients with incom-
petent perforating veins in the calf as their primary
problem or with symptoms that are not explained
by the standard exam, calf imaging can be of
value. The gastrocnemius and upper calf tibial
veins usually are super fi cial enough to determine
if they are compressible. However, for the remain
Fig. 6.7 Photograph of the position used to evaluate the
SSV with DUS
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416 Venous Duplex Ultrasound in Patients with Chronic Venous Disorders
der of the calf veins, grey scale imaging with color
Doppler will be necessary to determine patency.
Normal perforating veins should fl ow from
the skin toward the muscular compartment in
the lower extremity except for speci fi c perfo-
rating veins on the plantar surface of the foot
which normally fl ow in the opposite direction.
Re fl ux beyond 0.3 s within a perforating vein
after the release of calf compression is consid-
ered abnormal. Calf perforator diameter cor-
relates with competence. If a calf perforator is
>4 mm, incompetence is likely. Smaller veins are
less likely to re fl ux although Doppler is neces-
sary to determine its presence. Incompetent per-
forating veins (IPV) propagating high muscular
compartment pressures can cause varicose veins
by directly connecting with subcutaneous veins
in the thigh or calf. IPV may directly affect the
health of the skin in some patients. Such IPV are
found in the calf, usually along the inner portion
of the lower one-third of the calf just above the
medial malleolus. Contemporary opinion sug-
gests most enlarged and re fl uxing perforating
calf perforating veins, particularly in patients
with C2-4a SVI, are re-entry perforating veins
that have been subjected to over fl ow. These veins
serve as the deep vein re-entry site for re fl ux fl ow
and as time progresses, these veins dilate and
secondarily become incompetent. However, in
most cases they themselves are not pathologic
and often recover competence after elimination
of the re fl ux that fi lls them. In contrast calf IPV
that are not caused by over fl ow or those that have
persistent re fl ux after other sources are elimi-
nated. Subsets of such veins, when in the vicinity
of an active ulcer, are considered pathologic. This
concept is thoroughly discussed in Chap. 10 on
perforating vein pathology.
In some cases DUS in patients with varicose
veins will not identify truncal vein incompe-
tence. Non-truncal pathways causing varicose
veins are much more common in multiparous
women and include pudendal, lateral venous
system and less commonly gluteal vein incompe-
tence. Occasionally these sources, especially the
pudendal source, can lead to GSV incompetence.
Another important source of non-truncal re fl ux
acusing varicose veins include incompetent per-
forating veins in the medial and lateral thigh and
the popliteal fossa, and can usually be identi fi ed
with DUS.
DUS in Follow-up of Patients Treated
for SVI
DUS is performed periodically to evaluate patients
after treatment. Evaluation goals vary with the
different treatments used, time after treatment
Fig. 6.8 Pulse wave
Doppler assessment of the
longitudinally examined
CFV demonstrating normal
phasic, variable spontaneous
fl ow from the legs toward
the abdomen
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