Review article

Diagnosis and follow-up of varicose veins with

duplex ultrasound: how and why?
R D Malgor and N Labropoulos
Division of Vascular Surgery, Stony Brook Medical Center, HSC T19 Rm90, Stony Brook, NY 11794-8191, USA
Abstract
Chronic venous disease (CVD) is very prevalent and causes a signicant nancial burden
in Western societies. Accurate diagnosis is mandatory to dene the anatomy and
pathophysiology involved in the disease process. Duplex ultrasound (DU) is a well-
established non-invasive tool used for varicose veins work-up that, most recently, has also
been utilized for follow-up after endovenous procedures such as endovenous laser or
radiofrequency ablation and foam sclerotherapy. Insightful information on how DU is
performed during varicose veins work-up and the rationale of DU utilization for
endovenous procedures are discussed.
Keywords: chronic venous disease; pathophysiology; duplex; ultrasound; endovenous
ablation; sclerotherapy
Introduction
About one-third of the adult population presents
with chronic venous disease (CVD) in the Western
world.
1
Reux is the most common cause of
primary CVD generating signs and symptoms of
pain, swelling, itching, burning sensation, skin dis-
colouration and ulceration. Frequently, a positive
family history is found in patients suffering with
primary CVD.
Diagnosis of varicose veins can be accomplished
utilizing several imaging tools. In the past, reux
and patency of lower extremity veins were studied
under uoroscopy in an invasive fashion. Ascend-
ing and descending phlebography were both used
to determine anatomy and reux pathways
between the saphenous vein trunks and their tribu-
taries. However, several complications have been
described and more importantly this is more
expensive, not portable and invasive and therefore
it is utilized only for guiding treatment in the
deep veins.
2
Other imaging modalities such as mag-
netic resonance imaging/magnetic resonance veno-
gram and computerized tomography venography
play a limited role in venous reux work-up being
reserved for the identication of obstruction and
to delineate pelvic and abdominal venous anatomy.
Duplex ultrasound (DU) has changed vascular
surgery practice over the last two decades as the
preferred imaging modality for diagnosis and
endovenous procedures follow-up for varicose
veins treatment.
3
The advent of DU made it possible
to evaluate venous anatomy and its function at the
same time. DU is a non-invasive method that has
other advantages such as lower cost, portability,
reproducibility and it is safe to use. It can be
repeated and utilized for prolonged periods with
no risks to the patient.
Duplex ultrasound for reux and
varicose veins
Technical aspects
A precise technique, attention to detail and under-
standing of the anatomy and physiology of the
venous system is critical during DU when evaluat-
ing venous reux. The examination starts with the
patient in a standing position. A careful assessment
of the limbs is performed to identify the location
and extent of the varicosities and other useful
Correspondence: N Labropoulos, Division of Vascular
Surgery, Stony Brook Medical Center, HSC T19 Rm90,
Stony Brook, NY 11794-8191, USA.
Email: nlabrop@yahoo.com
Accepted 29 December 2011
Phlebology 2012;27 Suppl 1:1015. DOI: 10.1258/phleb.2011.012S05
signs. This helps to guide the DU exam in the areas
of interest. For example, when there are varices
medial to the saphenofemoral junction (SFJ),
pelvic reux is suspected. Very often such veins
are overlooked and the DU exam is inaccurate.
Then the patient is holding onto a frame with the
limb under investigation being relaxed, externally
rotated and exed while the contralateral one is
bearing most of the body weight. Some patients
cannot stand for a long period of time; therefore,
the study should be performed on a at examining
table with the limb in a dependent position.
Multifrequency linear array high-frequency
transducers are used to evaluate the whole lower
limb. For those who have supercial veins within
1 cm from the skin, the upper frequencies are
used and the exam is aided from a thick layer of
gel or a gel pad to be away from the dead zone of
the transducer. Conversely, in patients with larger
limbs when the depth of imaging is .6 cm curvi-
linear lower-frequency transducers are used.
The duplex ultrasound exam starts in the groin
where the SFJ, common femoral, femoral and
deep femoral veins are assessed. A thigh com-
pression with sudden release is used to induce
reux. The Valsalva manoeuvre is used only when
there is no reux with the compression/release
test. Standard pneumatic compression can be used
but it is mandatory only when a more precise
measurement of reux duration is sought.
The great saphenous vein (GSV) is then identied
in the saphenous canal and examined in its entire
length.
4
Notably, if there is a similar vein that is not
located in the saphenous canal, that vein is probably
an accessory saphenous or a tributary of the GSV.
The small saphenous vein (SSV) is then scanned in
the posterior aspect of the popliteal fossa withina tri-
angular fascia between the medial and lateral heads
of the gastrocnemius muscle. Compression distal to
the segment being studied is applied throughout the
exam to induce reux. Foot compression may be
necessary to better evaluate the distal ends of the
GSV and SSV. Other tributaries are also evaluated
for reux pending on the saphenous reux pattern
and the varicose veins location. In the popliteal
fossa the gastrocnemial and popliteal veins are
examined as well.
All the deep veins are not examined routinely in
patients with varicose veins (CEAP [clinical, aetio-
logical, anatomical and pathological elements]
class 2), unless there is history of previous thrombo-
sis or ndings during the exam that indicate
post-thrombotic changes. However, when there is
swelling out of proportion that cannot be explained
by the reux in the supercial vein and in the
presence of skin damage the deep veins are exam-
ined in detail.
Several anatomic variations may be encountered
during DU of both the supercial and deep veins.
Attention to details should be taken in order not
to underestimate those variations. Duplication and
agenesis of some lower-extremity veins is variable.
The popliteal vein is duplicated in up to 40% and
a segmental agenesis of the GSV can be found in
up to 16% of limbs with and without varicose
veins.
5,6
Segmental hypoplasia of GSV and SSV is
very common while duplication (requiring both
veins being inside the canal) is found in 2%.
7
Varic-
osities of the saphenous trunks are also rare and
have small extents while focal dilations are more
common.
7
Such ndings are important in order to
guide the endovenous ablation techniques.
Supercial veins
Reux is most common in the saphenous veins and
their tributaries. Reux in the GSVis found in about
7580% of limbs with CVD, in 1015% in SSV and
in about 10% in non-saphenous veins; however, the
latter can be 20% in patients presenting with recur-
rent varicose veins.
8
The location of the GSV term-
inal valve, its competence at the SFJ and the route
of reux should be traced. As stated above, it is
recommended to test the saphenous veins every
35 cm for compressibility and reux, which is
dened as abnormal if .500 ms.
9
The SSV and its tributaries are evaluated for
reux. Interestingly, a connection between the
popliteal vein and the SSV is highly variable
forming the saphenopopliteal junction (SPJ) in
different levels in the posterior aspect of calf/
lower thigh.
10
However, at least in a quarter of the
patients the SPJ does not exist.
10
Other connections
between the SSV medial gastrocnemius vein, GSV,
muscular veins in the thigh, femoral and pelvic
veins need to be identied prior to any procedure
in order to optimize treatment.
Mapping the diameter of the saphenous trunks
and their routes of reux at several locations is
important to plan procedures that are either
ultrasound-guided such as endovenous ablation
and foam injection or even surgical.
11
The distance
of the saphenous and accessory veins from the
skin is also important in order to avoid skin
damage during endovenous procedures.
Deep veins
Isolated primary axial deep vein reux is rare. Seg-
mental deep vein reux is often seen in the common
R D Malgor and N Labropoulos. Ultrasound with duplex Review article
Phlebology 2012;27 Suppl 1:1015 11
femoral and popliteal veins. This reux is induced
by the longstanding incompetence of the SFJ, SPJ
and the conuence of the gastrocnemius vein with
the popliteal.
12
It is known that treatment of super-
cial venous reux often resolves the deep vein
reux; however, retrograde ow distal to the level
of junctions represents true deep venous reux
and is very common in patients with post-
thrombotic disease.
13,14
The cut-off values for reux have been dened at
.1 second in the common femoral, femoral and
popliteal veins while for the deep femoral and
deep calf veins it is .0.5 seconds.
9
The cause of
axial reux in deep veins is often an episode of
thrombosis. A continuous ow detected in the
common femoral vein (CFV) as opposed to
normal vein phasic ow with normal respiration,
cessation of ow with deep inspiration and ow
during manual compression distally is suggestive
of proximal obstruction that should prompt a scan
of the iliac veins and inferior vena cava. Sub-
sequently, the full length of the femoral vein and
popliteal vein is studied. The latter is examined
above and below the SPJ when this is present in
order to differentiate reux from ow overload of
incompetent supercial veins and true deep
venous reux. The anatomical and haemodynamic
relationship of the popliteal at the SPJ and gastro-
cnemius veins should be established. Last, the
deep calf veins are also investigated for reux.
Perforator veins
By denition, the perforator veins (PVs) are veins
piercing the deep fascia and connect the supercial
veins to the muscular and the deep axial veins.
Despite innumerous PVs found in the lower limb,
only about 20 become incompetent in patients
with CVD. It is recommended that ow direction,
diameter below the fascia defect and the location
of the PV are recorded. The most used criteria to
describe a PV haemodynamic and anatomical
abnormalities are an outward ow (from deep to
supercial veins) .500 ms and a PV diameter of
.3.5 mm.
15,16
Such veins in ulcerated areas have
been recently termed as pathological perforators
(AVF/SVS guidelines). Notably, PVs in the medial
aspect of the leg are most often associated with
skin damage and ulceration.
Non-saphenous veins
Distinct areas of reux are found in veins that are
not part of GSV or SSV system but may connect to
them and are found in about 10% of the patients.
17
Those veins are found in several locations including
the perineum, thigh and knee regions. Non-
saphenous veins of interest comprise the gluteal,
postero-lateral thigh PV, vulvar, lower posterior
thigh, popliteal fossa (a direct tributary of the popli-
teal vein), knee PV and the sciatic nerve veins. A
common risk factor for developing those varicose
veins is female gender and two or more pregnan-
cies. In patients with pelvic congestion syndrome
a careful assessment of gluteal or vulvar varices is
mandatory. Often, those varicose veins are associ-
ated with lower-extremity CVD.
Follow with DU: how and why?
The rationale of DU follow-up after vein surgery,
endovenous ablation or staged foam sclerotherapy
is to assess for venous patency and deep vein
thrombosis (Figure 1). The potential risk of the
latter relies on the fact that, despite maintaining
adequate distance from the saphenous junctions,
thrombus propagation may occur. Treatment is
based on anticoagulation with follow-up pertinent
to deep vein thrombosis protocols.
Anatomic and physiological reux after vein
surgery or endovenous ablation must be investi-
gated. An expert multidisciplinary consensus on
the topic was recently published.
18
According to
that specialists group, an immediate follow-up
appointment with DU is indicated within four
weeks from denitive procedures, which are also
called one-stop treatments, including saphenous
vein endovenous ablation or stripping. This early
follow-up aims to delineate postoperative changes
in the saphenous vein lumen and to dene any seg-
ments of residual, incompetent saphenous vein
trunks (i.e. reux in segments other than those
stripped or ablated).
Frequently, late follow-ups are scheduled mainly
to assess recurrence after a denitive procedure or
continue serial monitoring of staged procedures
such as foam sclerotherapy sessions. Long-term
follow-up also intends to provide information for
research and clinical audit. For the sake of clarity,
timing for surveillance was divided into short-
term comprising one-year DU to monitor for
venous recanalization and new sites of venous
reux, mid-term between two and three years to
continue following early changes, and long-term
at ve years to monitor for clinical recurrence
associated with anatomical and physiological
venous changes that were likely identied during
short- and mid-term surveillance.
A complete and focused DU is performed to
investigate post-procedural recurrence. The study
Review article R D Malgor and N Labropoulos. Ultrasound with duplex
12 Phlebology 2012;27 Suppl 1:1015
starts in the groin checking for residual reux, neo-
vascularization and recurrent reux in veins that
were previously normal. In patients with previous
SFJ ligation the stump is identied and the compe-
tency of all existing connections and surrounding
veins is evaluated. Careful mapping of the area
including stump diameter, reux pattern and its
re-entry point is mandatory to establish a baseline
for future comparison and correction. Residual
stump can be avoided if a ush suture ligation of
the SFJ is performed eliminating the possibility of
a functional residual saphenous vein terminal
valve. However, this does not eliminate the reux
recurrence.
A search for neovascularization, which is dened
as abnormal or newly formed vessels in either an
anatomic or atypical location after the vein surgery
is then carried out. These veins are thin-walled, ser-
pentine and have no valves (Figure 2).
19
Note that
neovascularization can be found in the trajectory of
the GSV, SSV and other non-saphenous trunks. A
thorough scan must track the reux route in those
non-saphenous veins that perhaps communicate
with pelvic, vulvar, gluteal and sciatic nerve veins.
Neovascularization has been demonstrated after
both vein stripping and endovenous ablations but
is rare in the latter.
19,20
Information about location of reux, its origin
and propagation after the procedure is important.
Thus, it is pertinent to assess the saphenous vein
bed after stripping to ensure that the GSV or SSV
were completely removed. Partial or residual GSV
segments are easily demonstrated in the saphenous
canal. If present, those segments must be recorded
for follow-up or procedure completion. In case of
endovenous ablation, multiple channels showing
reux can be captured during the intraoperative
procedure. Notably, patients who undergo CHIVA
(Cure Conservatrice et Hemodynamique de lInsufsance
Veineuse en Ambulatoire) are expected to have patent
GSV with retrograde ow towards the competent
GSV tributaries that will communicate to the
deep veins via perforating veins. However, if
reux in the GSV tributaries is found, prompt
correction with ligation of the offending tributary
is indicated.
21
Perforating veins are also involved in recurrence
post-vein ablation or stripping. The actual impor-
tance of the PV reux post-procedure has been
investigated.
22
However, the impact of incompetent
Figure 1 A 67-year-old woman who presented with mild groin pain and lower-extremity oedema after great saphenous vein (GSV)
radiofrequency ablation (RFA). (a, b) Duplex ultrasound performed within seven days post-procedure showing endovenous heat-induced
thrombosis (EHIT). Thrombus extending into the common femoral vein is noted. (c) Cross-sectional view demonstrating a thrombosed common
femoral vein (CFV). (d, e) DU performed two weeks after RFA demonstrating improvement of thrombosed CFV with phasic ow. Note that the SFJ is
patent with no reux. (f ) Cross-section image of the CFV showing resolution of the thrombosis after treatment
R D Malgor and N Labropoulos. Ultrasound with duplex Review article
Phlebology 2012;27 Suppl 1:1015 13
PV post-procedure on clinical recurrence is still con-
troversial. Due to scarce evidence on the matter,
follow-up with DU seems to be reasonable and
one may proceed to PV ligation or ablation if it is
deemed necessary.
Alternative pathways for reux after stripping or
endovenous ablation procedure can also be traced
in the accessory saphenous veins and posterior
accessory saphenous vein; therefore, it is manda-
tory to establish abolition of reux at the SFJ and
at the level of its stump. Furthermore, it is impor-
tant to consider that usual manoeuvres such as
distal compression or Valsalva may not be accurate
to investigate reux due to occlusion of the GSV. A
persistence and recurrent reux must be interpreted
as abnormal, likely prompting revision of the
procedure.
Conclusion
Duplex ultrasound is an efcient, fast and accurate
tool to diagnose reux and follow the results of vein
interventions. Delineation of the venous anatomy
and the patterns of reux and obstruction should
be recorded in order to optimize the results of treat-
ment. Surveillance with DU appears to be important
after vein stripping and endovenous ablation for
monitoring recurrence and DVT. A careful assess-
ment post-procedure is mandatory in all patients
who underwent vein surgery in order to identify
technical failures and new reux development.
References
1 Robertson L, Evans C, Fowkes FG. Epidemiology of
chronic venous disease. Phlebology 2008;23:10311
2 Lensing AW, Prandoni P, Buller HR, Casara D, Cogo A,
ten Cate JW. Lower extremity venography with iohexol:
results and complications. Radiology 1990;177:5035
3 Ruckley CV, Evans CJ, Allan PL, Lee AJ, Fowkes FG.
Chronic venous insufciency: clinical and duplex corre-
lations. The Edinburgh Vein Study of venous disorders
in the general population. J Vasc Surg 2002;36:5205
4 Caggiati A. Fascial relationships of the long saphenous
vein. Circulation 1999;100:25479
5 Caggiati A, Mendoza E. Segmental hypoplasia of the
great saphenous vein and varicose disease. Eur J Vasc
Endovasc Surg 2004;28:25761
6 Thiery L. [Surgical anatomy of the popliteal fossa]. Phle-
bologie 1986;39:5766
7 Labropoulos N, Kokkosis AA, Spentzouris G, Gasparis
AP, Tassiopoulos AK. The distribution and signicance
of varicosities in the saphenous trunks. J Vasc Surg
2010;51:96103
8 Perrin MR, Labropoulos N, Leon LR Jr. Presentation of
the patient with recurrent varices after surgery
(REVAS). J Vasc Surg 2006;43:32734; discussion 34
9 Labropoulos N, Tiongson J, Pryor L, et al. Denition of
venous reux in lower-extremity veins. J Vasc Surg
2003;38:7938
10 Labropoulos N, Giannoukas AD, Delis K, et al. The
impact of isolated lesser saphenous vein system incom-
Figure 2 A 43-year-old woman who had high ligation and stripping of the GSV presenting with groin and medial thigh recurrent varicose veins.
(a) Thrombosed long GSV stump with small, serpentines vessels. (b) Blood ow in the thrombus favouring the presence of neovascularization. (c)
Pronounced reux in the saphenofemoral junction (SFJ) tracking into the SFJ stump through newly formed small vessel channels. (d) Signicant
reux is clearly noted in the small veins in the neovascularized GSV stump. (e) Multiple varicose veins in groin lymph nodes that are connected with
neovascularized area at the SFJ. (f ) Recurrent dilated, tortuous veins in the groin after GSV stripping that also connect with the new vessels in the
groin
Review article R D Malgor and N Labropoulos. Ultrasound with duplex
14 Phlebology 2012;27 Suppl 1:1015
petence on clinical signs and symptoms of chronic
venous disease. J Vasc Surg 2000;32:95460
11 Pittaluga P, Chastanet S, Locret T, Barbe R. The effect of
isolated phlebectomy on reux and diameter of the great
saphenous vein: a prospective study. Eur J Vasc Endovasc
Surg 2010;40:1228
12 Labropoulos N, Tassiopoulos AK, Kang SS, Mansour
MA, Littooy FN, Baker WH. Prevalence of deep
venous reux in patients with primary supercial vein
incompetence. J Vasc Surg 2000;32:6638
13 Walsh JC, Bergan JJ, Beeman S, Comer TP. Femoral
venous reux abolished by greater saphenous vein strip-
ping. Ann Vasc Surg 1994;8:56670
14 Sales CM, Bilof ML, Petrillo KA, Luka NL. Correction of
lower extremity deep venous incompetence by ablation of
supercial venous reux. Ann Vasc Surg 1996;10:1869
15 Labropoulos N, Mansour MA, Kang SS, Gloviczki P,
Baker WH. New insights into perforator vein incompe-
tence. Eur J Vasc Endovasc Surg 1999;18:22834
16 Sandri JL, Barros FS, Pontes S, Jacques C, Salles-Cunha
SX. Diameter-reux relationship in perforating veins of
patients with varicose veins. J Vasc Surg 1999;30:86774
17 Labropoulos N, Tiongson J, Pryor L, et al. Nonsaphenous
supercial vein reux. J Vasc Surg 2001;34:8727
18 De Maeseneer M, Pichot O, Cavezzi A, et al. Duplex
ultrasound investigation of the veins of the lower
limbs after treatment for varicose veins UIP consensus
document. Eur J Vasc Endovasc Surg 2011;42:89102
19 van Rij AM, Jones GT, Hill GB, Jiang P. Neovasculariza-
tion and recurrent varicose veins: more histologic and
ultrasound evidence. J Vasc Surg 2004;40:296302
20 Theivacumar NS, Darwood R, Gough MJ. Neovascular-
isation and recurrence two years after varicose vein
treatment for sapheno-femoral and great saphenous
vein reux: a comparison of surgery and endovenous
laser ablation. Eur J Vasc Endovasc Surg 2009;38:2037
21 Geier B, Stucker M, Hummel T, et al. Residual stumps
associated with inguinal varicose vein recurrences: a
multicenter study. Eur J Vasc Endovasc Surg 2008;36:
20710
22 van Rij AM, Hill G, Gray C, Christie R, Macfarlane J,
Thomson I. A prospective study of the fate of venous
leg perforators after varicose vein surgery. J Vasc Surg
2005;42:115662
R D Malgor and N Labropoulos. Ultrasound with duplex Review article
Phlebology 2012;27 Suppl 1:1015 15