AJUM November 2010; 13 (4): 37–45

SOUND REFLECTIONS

Duplex ultrasound in the assessment of lower

extremity venous insufficiency
Martin Necas

Waikato Hospital, Vascular Laboratory, Hamilton, Tristram Vascular Ultrasound, Tristram Clinic, Hamilton and
Unitec New Zealand, School of Health, Postgraduate Studies – Ultrasound, Waitakere Campus, Ratanui St, Henderson,
Auckland, New Zealand.
Correspondence to author via ASUM. Email authors@asum.com.au.

Introduction practice, the sonographer usually directly reports to the spe-

The purpose of this paper is to provide a focused overview cialist who is will be treating the patient. The sonographer
of the key concepts in the assessment of lower limb chronic should answer the following questions:
venous insufficiency (CVI) with an emphasis on specific Are the deep veins normal?
techniques which can assist the sonographer or sonologist What is the source (or sources) of reflux?
in achieving an accurate and time-efficient examination. In What is the path of reflux including tributaries affected,
the context of this paper, CVI will pertain to lower extremity their communication and size?
superficial and/or deep venous incompetence of any degree If catheter-based techniques (such as endovenous laser
leading to the classic clinical signs of venous disease includ- ablation) were to be used:
ing: varicose veins, peripheral swelling and skin changes. Is there any obvious problem which would prevent pas-
This paper is by no means a comprehensive review of all sage of a guide wire (such as thrombotic residua or tortu-
issues surrounding CVI and duplex scanning. Interested ous course of any venous segment along the expected wire
readers are directed to the reference section for a selection path)?
of landmark papers and further reading. Is the saphenous vein contained within its fascial envelope?

What the examination includes

Patients presenting for CVI duplex ultrasound Sonographers may be compelled to bring the patient into
The vast majority of patients referred for CVI duplex scan
the scanning laboratory, turn off the lights and start scan-
present with primary superficial varicose veins1. Less com-
ning. This would be a big mistake in CVI assessment. The
monly, lower extremity venous disease is complicated by
sonographer should first obtain detailed history followed
previous thrombotic events (deep or superficial) resulting
by a visual assessment of the leg with the patient standing
in a range of problems in various venous segments includ-
under bright light1,6,7. Having an appreciation for the location
ing: occlusive or non-occlusive chronic thrombotic residua,
of problematic veins, symptomatic areas and skin changes
venous wall fibrosis and incompetence of the affected
can help the sonographer target the examination better and
segments. Another distinct group of patients are those rep-
save valuable scanning time. It also ensures that no varicose
resenting with recurrent varicose veins following past inter-
tributaries are overlooked during scanning. A complete CVI
ventions. The spectrum of clinical presentations in patients
examination therefore contains both indirect and direct
with CVI is broad, ranging from minor asymptomatic tel-
(scanning) components7:
angiectasiae and reticular veins, swelling, itching, venous
Patient’s history
eczema, symptomatic but small varicose veins, asymptom-
Visual assessment
atic but large varicose veins, post-phlebitic leg through to
Duplex ultrasound scan
lipodermatosclerosis and ulceration2,3.
Deep system
Superficial system
What the specialist needs to know Search for perforators
As with other duplex examinations, the information which is Examination extended if required to include
sought on the duplex scan is predominantly dictated by what Iliac veins
the specialist needs to know in order to treat the patient. Ovarian veins.
Duplex ultrasound scan is generally the only imaging test
in these patients. The individual who performs the diag- Interpretation and production of a detailed
nostic duplex scan should have specific training in venous graphical report
hemodynamics, the basics of clinical assessment, high level The role of the sonographer is to gain a thorough under-
of training in vascular duplex ultrasound and should have standing of the venous hemodynamics and varicose vein
completed a minimum of 250–400 supervised CVI examina- distribution in the patient. No questions should remain
tions4,5. The operator is usually a vascular sonographer, but it unanswered and the source of all varicose veins should be
could also be a general sonographer with advanced vascular determined. Finally, the findings of the examination must be
experience or a vascular surgeon, phlebologist, radiologist communicated in a clear graphical report to the specialist.
or interventionalist with sufficient duplex ultrasound exper-
tise to carry out the examination1,6. Any of these operators Time allocation for the examination
will henceforth be referred to as “sonographers”. In clinical CVI examinations need not be lengthy and arduous. On

Australasian Journal of Ultrasound in Medicine November 2010 13 (4) 37

 Martin Necas

occasion, however, these exams can be difficult especially

in patients with non-truncal varicose veins, complex patterns
of recurrence or when the examination needs to be extended
into the abdomen to assess the pelvic veins. The Society for
Vascular Ultrasound7 recommends 65–75 minutes for the
performance of a bilateral lower extremity venous examina-
tion. In our local public and private vascular laboratories
(Hamilton, New Zealand), we allocate 30–45 minutes for a
unilateral study and 60–75 minutes for a bilateral examina-
tion depending on operator experience.

Patient preparation and positioning

The best examination of lower extremity veins is achieved
when the veins are under full distension. The patient should
be instructed not to wear stockings on the day of the exami-
nation, the patient should arrive warm if possible and the Fig. 1: Competent superficial vein. Well optimised duplex image
examination room and gel should also be comfortably warm. of flow in a competent superficial vein. Wide color box was used
The examination should be performed with the patient in a in order for a long segment of the vein to be visualised. Spectral
reverse Trendelenburg position or upright so that hydrostatic waveform is large and clear. Spontaneous venous flow is seen in
pressure in the veins is at its peak to aid venous distension. the left side of the spectral trace, followed by manual augmenta-
If possible, patients with minor varicose veins or cosmetic tion. There is a sharp “click” or “snap” of venous valve closure
concerns should be scheduled in the later parts of the day8. followed by a period of absent flow. Once arterial inflow refills the
If the specialist suspects pelvic venous incompetence on peripheral vascular bed, normal antegrade flow resumes again on
the basis of patient’s history and clinical examination, the the right side of the spectral Doppler trace.
patient should also be fasted for 6–8 hours in order to limit
overlying bowel gas and peristalsis so that ovarian veins and ■ Augmentability: prompt increase in venous flow velocity
internal iliac veins can also be examined. at the sampled location with distal augmentation.
The patient can be positioned for scanning in a variety of ■ Competence: cephalad, unidirectional flow maintained
ways: standing on an elevated platform, combination of stand- by venous valves (Fig. 1).
ing and sitting, recumbent position or lying on a tilt-table in ■ Non-pulsatility: compliance of normal veins results in
reverse-Tredelenburg position at ≥ 30° or ≥ 60° incline. The the effective absorption of cardiac pulsatility which is
leg under examination should be relaxed, slightly flexed at the seen at the level of the right atrium, and upper inferior
knee and externally rotated1,6,7,8,9,10. Which of the above setups vena cava (IVC).
the sonographer employs largely depends on the equipment
available in the laboratory. I strongly recommend a good- Valves, competence, incompetence
quality, hard, narrow tilt-table with hydraulic tilt and up/down In a normal lower extremity vein, venous competence is
movements. The tilt table has two principal advantages: maintained by venous valves. Venous valves act as mechani-
■ The sonographer can remain in an ergonomic position11at cal gates allowing blood to flow centrally, but preventing
a constant height and facing the machine while the table flow from coursing peripherally8,13. Valves come in a thicker
with the patient are maneuvered to the desired tilt and reinforced form or a thin transparent form and usually fea-
height with a push of a button. ture two cusps. Because hydrostatic pressure in the lower
■ Tilt-tables are comfortable for the patients and help pre- extremity increases peripherally, veins are equipped with
vent patient falls. When patients are examined standing, increasing number of valves in the dependent regions of
they have a tendency to get tired and faint. Because the the leg. In the deep system, there is one valve above the
patient’s centre of gravity is invariably above the sonog- CFV level, two to four in the femoral vein and about twelve
rapher, a sudden faint can be dangerous for the patient valves in the deep calf veins. In the superficial system, there
and the sonographer alike10,12. is a terminal and subterminal valve at the top of the great
saphenous vein (GSV), additional one to two valves in the
Characteristics of lower extremity veins thigh section and about 10 to 12 valves in the calf section
Normal deep and superficial veins of the lower extremity of the GSV and small sphenous vein (SSV). Despite their
should meet the following criteria: thin and inconspicuous nature, normal valves are capable
■ Thin, smooth walls. of withstanding tremendous venous pressures without fail-
■ Complete compressibility. ing. Why venous valves sometimes fail resulting in varicose
■ Spontaneity: Flow observed at quiescence. This may be veins without any secondary insult is not entirely under-
difficult to observe in small vessels of the calf. stood. It is likely a combination of endothelial dysfunction,
■ Consistent color fill: Absence of color filling defects. genetic predisposition, hormonal influences as well as other
■ Smooth flow contour: No flow disturbance. factors such as volume-mediated dysfunction, venous hyper-
■ Presence of flow disturbance can signal irregularity of tension and lifestyle factors. When valves do fail, they may
venous wall or thin fibrinous strands which can be over- demonstrate a variety of reflux patterns including a reluctant
looked on 2D examination. tendency “leak” at the cusp tips or profound, obvious and
■ Phasicity: Respiratory variation. Fall in venous flow spontaneousincompetence8. The important observation is
velocity with inspiration, rise with expiration. that normal valves will not fail at high physiologic pres-
Celebrating
38 Australasian Journal of Ultrasound in Medicine November 2010 13 (4) 40 years
1970–2010
 Duplex ultrasound in the assessment of lower extremity venous insufficiency

Fig. 2: Refluxing deep vein. Reflux in the femoral vein elicited with
a sustained valsalva or simulated valsalva manoeuvre lasting three Fig. 4: Refluxing superficial vein. Reflux in the GSV is seen following
seconds. augmentation. The reflux time can be measured or compared to the
time-scale of the spectral Doppler window. In this case, continuous
reflux is seen over a period greater than four seconds.

be achieved using the Valsalva manoeuvre1,13. The patient

should be encouraged to Valsalva forcefully and for a
sustained period of time (two to three seconds is usually
sufficient)8. Unfortunately, some patients (such as older
patients, non-English speakers) find it difficult to perform
the Valsalva manoeuvre adequately. In these patients, a
Fig. 3: Variability of reflux response. The effect of the length of simulated Valsalva can be easier to achieve. The sonogra-
augmentation on the tendency of lower extremity veins to reflux. pher instructs the patient to take a deep breath and hold.
All images are obtained from the same sample site in the popliteal The sonographer then pushes on the patient’s abdomen with
vein of the same patient. Left image: short augmentation resulting the free hand by firmly leaning into the patient. The patient
in reflux time of only 0.7 seconds. Middle image: longer augmenta- should be encouraged to resist (guard against) the pressure,
tion resulting in reflux time of 1.5 seconds. Right image: prolonged hence creating an excellent simulated Valsalva manoeuvre
augmentation resulting in continuous reflux for many seconds. (Fig. 2). Below the level of the SFJ, testing for reflux is
usually performed by using distal manual augmentation1.
sures. It is therefore logical to assess veins for incompetence The augmentation should be gradual, firm, prolonged and
by stressing them as much as possible.This is especially the followed by swift release. This technique ensures that a large
case in patients presenting early in the spectrum of varicose volume of venous blood is emptied out of the calf in order
vein disease or those who present with minor cosmetic prob- to create a high pressure gradient on release. Augmentation
lems and require exclusion of underlying venous incompe- of the ankle or foot is not so effective because little venous
tence. volume is found in these locations.
In case of primary venous reflux of the superficial veins, The techniques described above are clearly patient
the pattern of refluxing veins is always “from top down”. and operator dependent. For instance, the strength of
That is, once the terminal and subterminal saphenous valves the Valsalva manoeuvre and the resultant pressure gradi-
fail, the upper GSV dilates, pressure on the next valve down ent will vary from patient to patient and are basically
increases and this valve will fail also. This domino-effect then unknown. Also, a sonographer with a large strong hand
continues down the lower extremity along the path of least will be able to perform distal augmentation more effec-
resistance. As veins dilate, they also lengthen and their normal tively than a sonographer with a small weaker hand. The
straight course transforms into tortuous varicose vein. strength and duration of distal augmentation as well as
the speed of release can have a significant influence on
Testing for venous incompetence whether reflux is or is not observed and for what duration
Venous incompetence (reflux) can be elicited in several (Fig. 3). Patient’s body position during the scan also plays
ways. It is important that the sonographer achieves a high a role9. In an attempt to introduce at least some level of
pressure gradient across the venous segment under exami- standardisation into the augmentation procedure and to
nation in order to create favourable conditions for reflux to assist the sonographer in performing distal augmenta-
occur. The most common techniques include: tion, some laboratories use an automated cuff applied on
■ Valsalva manoeuvre the lower leg or foot which the operator can inflate with
■ Simulated Valsalva a push of a button. The cuff inflates to a desired peak
■ Manual distal augmentation pressure and then then rapidly deflates. The take-up of
■ Distal augmentation with an automatic pressure cuff this method has been modest. This is partly due to the
■ Activation of the calf muscle pump with plantar-flexion. fact that manual augmentation is very effective and the
Testing of the common femoral vein (CFV), sapheno cuff method may not be suitable for patients with fragile,
femoral junction (SFJ) and upper femoral vein (FV) can sensitive skin or ulcers.

Australasian Journal of Ultrasound in Medicine November 2010 13 (4) 39

 Martin Necas

Fig. 5: Color Doppler survey. High-end ultrasound systems with

multiple beam formers afford acceptable temporal resolution with
large color boxes. Left image: confluence of the PFV and FV. Right
image: femoral vein duplication in the region of the adductor canal.
Closure of normal valves under physiologic conditions
or under provocative manoeuvres is very rapid. Small
amount of retrograde flow can be seen during valve closure
before the valve leaflets snap shut (Fig. 1). The diagnosis Fig. 6: Refluxing flow jets at incompetent SFJs. Refluxing terminal
of reflux is usually made if the retrograde flow exceeds 0.5 valves resulting in incompetent flow jets at a variety of SFJs. Color
seconds1,6 in duration (Fig. 4), although some labs use reflux Doppler should be used first to establish the presence of reflux and
time of > 1 second8,10. Superficial venous reflux is most often the location of the refluxing flow jet. Effective targeted sampling on
continuous over several or many seconds, so both of the spectral Doppler can then be performed.
above criteria are satisfied10. While simple measurement of
reflux time may seem like an unsophisticated way of diag- color Doppler allows the sonographer to observe flow and
nosing venous incompetence, the method is well accepted eye-ball reflux, color does not allow for effective measuring
and highly practical. Some investigators have evaluated of reflux times. For this reason, spectral Doppler recordings
the usefulness of other parameters such as reflux waveform will need to be made in representative sections of the veins.
surface area or adding the parameter of reflux velocity10. Good system optimisation practices are key to an effi-
Ultimately, the discriminatory boundary where reflux is cient CVI examination. Both color and spectral Doppler
diagnosed is a matter of accepted definition and agreement imaging should be performed at favourable Doppler angle
between the specialist and the sonographer. Introducing ≤ 60°. In color Doppler, low scale and high gain settings
more rigid hemodynamic criteria for the definition of reflux should be used. Spectral Doppler should also be well opti-
is difficult given the tremendous anatomical variations in the mised (low scale, low wall filter) in order to display large
venous system, the subjectivity of the ways in which reflux Doppler shifts and clearly interpretable large Doppler wave-
is elicited and the variability of reflux response in different forms. When recording venous waveforms with flow aug-
patients (Fig. 3). mentation in apparently normal vessels, it is a good practice
to wait for the resumption of normal venous flow to ensure
Duplex imaging, system settings and that delayed reflux does not develop (Fig. 1).
optimisation Some sonographers or sonologists have described
Adequate CVI examination can be achieved on most scanning for reflux in transverse section. This approach
medium-level portable ultrasound systems. However, the may work well in the easy patient with gross incompe-
level of diagnostic detail and overall system performance tence. However, transverse color and spectral Doppler
does generally increase with the cost of the system. Ideally, assessment does not allow the operator to ensure there is
a vascular laboratory performing a large volume of CVI a favourable Doppler angle. In small vessels with slow
examinations will feature a high-end ultrasound scanner. reflux, poor Doppler angle will result in dramatic further
Examination of the deep system should be performed with reduction of the already small Doppler shifts making flow
a medium to low frequency linear array transducer in the difficult to detect.
region of 5–8 MHz (centre frequency) whereas superficial
veins should be examined with a high frequency linear Deep vein survey
transducer in the region of 10–12 MHz (centre frequency). For the purposes of a CVI scan, deep vein survey should
Most of the hemodynamic information the sonographer be performed similarly to a standard DVT scan but with
requires to make the diagnosis of reflux can be obtained in the addition of testing for reflux in the distal CFV (below
color Doppler. Color Doppler should be used as an efficient the SFJ), FV and popliteal (POP) vein7. Some labs limit the
surveillance tool. High-end ultrasound systems operate testing for reflux to the FV and POP vein only, recognising
multiple beam formers resulting in faster acquisition of that CFV often refluxes even in normal subjects. If the deep
image frames. This allows the sonographer to comfortably veins reflux to the level of the POP vein, it is worthwhile to
operate with large color boxes, or full-screen color even at assess the distribution of reflux in the calf veins also. The
considerable depth while still achieving acceptable frame sonographer should be mindful of anatomical duplications
rates (Fig. 5). Another advantage of color Doppler is its abil- in the deep veins which are relatively common (20% POP,
ity to pin-point the exact location of refluxing valve jets in 10% FV). When duplications are encountered, both of the
“leaking” but not grossly refluxing valves (Fig. 6). Eccentric duplicated vessels require testing because one may reflux
refluxing jets are commonly encountered at the SFJ and while the other may remain competent (Fig. 7). Spectral
spectral Doppler sampling without careful color Doppler Doppler waveforms obtained in the deep veins can also
guidance can result in a chaotic bidirectional signal or can provide other important diagnostic clues. Absence of respi-
completely miss the presence of a slow valvular leak. While ratory phasicity in the waveform of the CFV should prompt
Celebrating
40 Australasian Journal of Ultrasound in Medicine November 2010 13 (4) 40 years
1970–2010
 Duplex ultrasound in the assessment of lower extremity venous insufficiency

Fig. 7: Duplication of the femoral vein. Duplicated femoral vein

during augmentation (left image) and following augmentation (right
image). Reflux is seen in the more superficial of the two FVs.
Fig. 10: The Saphenous Fascial Envelope. The normal fascial
envelope of the GSV.

Fig. 11: Accessory saphenous and circumflex veins of the thigh.

Fig. 8: Abnormal “flat” aphasic femoral vein waveform. A patient Multiple superficial veins are demonstrated in the right leg. The
presenting for lower extremity venous duplex with clinical signs of anterior accessory saphenous vein (AASV) is typically located
chronic venous insufficiency demonstrates aphasic “flat” femoral directly superficial to the GSV.
waveform due to previously undiagnosed external iliac vein occlu-
sion. On questioning, the patient reported a past history of motor
vehicle accident with significant pelvic trauma.

Fig. 9: Pulsatile venous waveforms in the popliteal (POP) vein in

patients with congestive heart failure. Competent pulsatile POP
vein (left image). Incompetent pulsatile popliteal vein (right image).

investigation of the Iliac system for presence of downstream

venous obstruction which may be due to iliac DVT or iliac
vein compression by a pelvic mass (Fig. 8). On the other
hand, pulsatile peripheral venous waveforms can be found
in individuals with increased central venous pressure most Fig. 12: Superficial veins of the leg. Sapheno-femoral junction (SFJ),
commonly associated with right heart failure. In these great saphenous vein (GSV), AASV, posterior accessory saphenous
patients, increased central venous pressure results in the vein (PASV), anterior thigh circumflex vein (ATCV), posterior thigh
loss of peripheral venous compliance with transmission of circumflex vein (PTCV) sapheno-popliteal junction (SPJ), small
cardiac pulsatility throughout the lower extremity venous saphenous vein (SSV), thigh extension of the small saphenous vein
system (Fig. 9). (TE SSV), intersaphenous vein (Intersaph. V).

Superficial vein anatomy ■ The GSV and its tributaries are found within a well
The greatest number of anatomical variants in the human formed fascial envelope termed the “Saphenous eye,
body is found in the vascular system. No two patients are “Egyptian eye” or “Cleopatra’s eye” (Fig. 10) although
ever exactly alike in terms of the exact location and branch- the veins may escape the fascial envelope into superficial
ing (more precisely convergence) pattern of the venous tree subcutaneous regions anywhere along their course.
of the limbs14,15,16. Some general observations can be made: ■ There may be one or more accessory saphenous veins.
■ The location of the SFJ is relatively constant at the groin The anterior accessory saphenous vein (AASV) is
crease. typically located superficial to the femoral vein. The true

Australasian Journal of Ultrasound in Medicine November 2010 13 (4) 41

 Martin Necas

Fig. 13: Patterns of venous reflux, examples. A: Junctional incom-

petence (SFJ and SPJ); B: Isolated perforator incompetence; C: Fig. 15: Determining the path of reflux. The path of reflux at the con-
Pelvic venous incompetence causing lower extremity varices; D: fluence of GSV and posterior accessory saphenous vein in the calf.
Combination of SFJ reflux contributing to the reflux of the ATCV, The 2D examination already suggests which channel is incompe-
vein of Giacomini and SSV with preservation of the GSV in the thigh. tent (the superficially located vessel is varicose). The varicose vein
does not require testing. The smaller straight vessel (calf section of
the GSV) requires assessment. It is sufficient to use color Doppler
the majority of the time.

Fig. 14: Competent SFJ with GSV reflux supplied by the IEV. Left
image: Normal competent SFJ showing the inferior epigastric vein
(IEV) and great saphenous vein (GSV). Right image: The SFJ is
competent, but flow from the IEV is seen to reflux down the GSV.

GSV lies medial to the AASV. (Figs. 11, 12)

■ Short-course duplications of the GSV and SSV are not
uncommon but full length duplications are rare.
■ The location of the SPJ varies considerably (medial, later-
al, at knee crease, above knee crease, absent, duplicated).
■ The SPJ is often absent and the SSV may drain via a
Thigh Extension (TE SSV) into other vessels. When the
SPJ drains via the TE SSV and posterior thigh circum-
flex vein (PTCV) into the GSV, the vein is called the vein
of Giacomini.
■ The GSV and SSV communicate via intersaphenous
connections especially in the calf. Intersaphenous con-
nections may acts as pathways for reflux.
Detailed diagram of the most common superficial veins
and their accepted international nomenclature14,15 is provided
in Fig. 12. It should be noted that not all the veins demon-
strated in Fig. 12 are present in every patient. Fig. 16: Duplex sampling sites. Assessment for reflux can be eas-
ily targeted so that relatively few locations along the superficial
Common patterns of superficial reflux venous tree require color or spectral Doppler sampling. The patient
Most primary lower extremity varices are caused by reflux below demonstrates primary varicose veins in the GSV territory
at the level of the SFJ or SPJ. Perforator incompetence can with several tributaries. Arrows indicate the few locations which
contribute to CVI or can be the consequence of underlying need to be tested.
CVI17. Isolated primary perforator incompetence leading to
lower extremity varices can occur but is less common. Another easy for sonographers who are new to CVI scanning to
frequent cause of CVI especially in multiparous women is feel overwhelmed by the level of detail, sometimes to the
related to pelvic venous incompetence (Fig. 13). In these patients, point of diagnostic paralysis. While CVI scanning requires
refluxing pelvic veins communicate with lower extremity veins considerable skill and expertise, the examination is not dif-
via pudental, inferior epigastric, gluteal and otherconnections. ficult to perform. There are some general strategies which
For instance, the SFJ can be competent, but an incompetent GSV can help simplify even the most complex examination:
may be supplied by the inferior epigastric (Fig. 14). ■ Reflux always as a source and a path. The most important
task is to locate the source or cause of reflux. The path is
Simplifying the examination easy to follow once the source is determined (Fig. 15).
The superficial venous system can be complex to assess ■ It is best to get a general overview of the extent of the
especially in the presence of convoluted varices. It is CVI first before assessing each individual tributary.
Celebrating
42 Australasian Journal of Ultrasound in Medicine November 2010 13 (4) 40 years
1970–2010
 Duplex ultrasound in the assessment of lower extremity venous insufficiency

Fig. 18: Neovascularity at the site of previous SFJ ligation. The

network of incompetent vessels can be clearly visualised on color
Doppler under forceful Valsalva manoeuvre even though 2D exami-
nation was essentially unremarkable.

Recurrence
Patients presenting with recurrent varices can be
examined using the same methods as first presenters.
Recurrent varicose veins can be caused by primary tech-
nical failure of treatment, neovascularisation,progression
of disease with new onset of primary varices in previ-
ously untreated vessels and perforator incompetence19,20,21.
Fig. 17: Location and nomenclature of lower extremity perforators. Patients may present with failed SFJ or SPJ ligation, double
SFJ or SPJ with past treatment of only one, recanalisation
of previously sclerosed vessels, development of new per-
■ Surveying veins and testing for reflux in color Doppler forator incompetence21, varicose veins related to a pelvic
is far more efficient than testing with spectral Doppler. source, and other complications. A specific type of incom-
Spectral Doppler still needs to be used for recording of petence which may be difficult to visualise is neovasculari-
findings, but not for general survey. sation of the SFJ. With neovascularisation, the region of a
■ Size of the vessel is a good clue to the presence of reflux. past successful SFJ ligation is traversed by a network of
In general, superficial veins > 5 mm nearly always reflux. tiny incompetent veins which trail down peripherally away
Unfortunately it cannot be assumed that a small vessel from the SFJ and converge onto larger, clinically obvious
does not reflux. For example, past superficial venous varices. The vessels involved in neovascularisation may be
thrombosis may have rendered the vessel incompetent. smaller than can be confidently resolved by 2D ultrasound.
■ Varicose veins always reflux and do not require testing. Furthermore, soft tissue scarring related to the past sur-
There is no such thing as a competent varicosity. gery may degrade 2D image quality at the level of the SFJ
■ Normal competent tributaries usually do not require making neovascularisation even harder to appreciate on
further testing unless there are incompetent intercom- 2D ultrasound. When recurrent varicose veins exist in the
municating vessels. GSV territory or when the cause of recurrence cannot be
■ In complex cases, it is a good idea to make notes or a determined, purposeful testing of the SFJ ligation site with
sketch during the examination in order to keep track of vigorous Valsalva using color Doppler on very low scale
what has already been examined. and high gain can reveal neovascularisation as the source
Fig. 16 shows that even in patients with multiple of recurrent lower extremity varices (Fig. 18).
tributaries, the number of sampling sites required to
demonstrate incompetence and determine its path can be Pelvic and ovarian veins
relatively modest. Incompetence of the ovarian and internal iliac veins in
women has been implicated as a contributing factor in the
Perforators formation and recurrence of lower extremity varicose veins.
A complete CVI examination should include a search for It is beyond the scope of this article to discuss pelvic vein
incompetent perforators (Fig. 17). With high-frequency scanning. Suffice it to say that with modern ultrasound
transducers available today, it is relatively easy to see systems, direct assessment of the ovarian and internal iliac
even normal competent perforators. Incompetent perfora- veins can be made very effectively in the vast majority of
tors are generally large (> 3 mm)18. Smaller perforators patients. Where suspicion of pelvic venous incompetence
probably do not require testing. Because the interplay of exists on clinical grounds or on the basis of the findings
venous flow between the perforator and surrounding vari- in the lower extremity veins, pelvic vein assessment incor-
ces can be complex and difficult to predict, the sonogra- porating transabdominal survey of the ovarian and internal
pher should test the perforator several times by applying iliac vein should be performed22,23.
augmentation at over different sites and especially over
local varices in the vicinity of the perforator1. The loca- Reporting of results
tion and diameter of any incompetent perforators should Nearly all patients presenting for CVI duplex are being
be noted on the final report. considered for treatment of varicose veins. The results of
Australasian Journal of Ultrasound in Medicine November 2010 13 (4) 43
 Martin Necas

Fig. 20: Screen capture of a reporting PC. A simple, off-the-shelf,

dual-screen computer set-up such as a laptop connected to an
external monitor or dedicated reporting desktop computer allows
the sonographer to review the images on the one monitor (left in
this case) and compose reports on the other monitor.

Fig. 19: Venous duplex reports. Examples of graphical reports people are often affected. A variety of mechanisms may con-
generated electronically. (Personal details have been changed to tribute to the clinical picture including calf muscle pump
ensure privacy). deficiency, coexisting microvascular arterial disease, increased
the duplex scan have a considerable impact on the choice of central venous pressure from underlying cardiac dysfunction and
treatment. It is therefore imperative that a CVI examination the recently described popliteal vein compression syndrome28.
be accompanied by a high quality graphical report1,6,8,24,25,26,27. Conclusions
The report should include detailed information about both Vascular specialists rely on high-quality duplex examination
superficial and deep veins, identification of refluxing veins in the planning of lower extremity venous interventions. It
and tributaries, the anatomical location of superficial vari- is therefore imperative that the vascular sonographer pro-
ces, superficial vessel sizes and other relevant comments vides a complete indirect and direct assessment of the lower
such as the presence of anatomical variants, thrombus, extremity veins and produces an accurate report. A detailed
fibrin, phleboliths and other incidental findings. Some vas- CVI examination need not be a tedious test. There are a
cular sonographers are excellent artists producing detailed, number of strategies which can make this examination effec-
hand-made, one-off sketches of the venous system on photo- tive and time-efficient. From the sonographer’s standpoint,
copied worksheets6. Another way of producing a more con- CVI scans can be highly satisfying examinations. After all,
sistent and professional report is to use computer software each patient is unique, nearly all examinations will be abnor-
designed for this purpose (Figs. 19, 20)24,25,26. Text reports mal and each patient’s treatment strategies will be guided by
should be avoided as these are tedious to read, difficult to the results of the sonographer’s duplex scan.
interpret and are generally disliked by most vascular special-
ists25,27. While it is important to have sufficient record of the Acknowledgments
CVI examination in frozen images or video recordings, the I am grateful to the following colleagues for their review of this
end product of the examination which the treating specialist manuscript and their constructive feedback: Dr Isabel Wright,
is going to refer to is the graphical sonographer’s report. vascular sonographer; Bridget Boyle, vascular sonographer;
Mai Snelgrove, vascular sonographer; Mr David Ferrar, vas-
Frequently asked questions cular specialist.
How many times should an incompetent vein be tested? References
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Australasian Journal of Ultrasound in Medicine November 2010 13 (4) 45