Review article

Diagnosis of venous disease with duplex ultrasound

R D Malgor and N Labropoulos

Division of Vascular Surgery, Stony Brook Medical Center, Stony Brook, NY, USA

Abstract
The advent of duplex ultrasound (DU) has changed vascular practice over the years. Venous
anatomy, valve function and obstruction can be evaluated in real time using DU. It is a low
cost, portable, non-invasive, safe and operator-friendly device that can be used for diagnosis,
treatment guidance and follow-up. This paper defines the patterns, location and
characteristics of venous reflux and also provides insightful information on acute and
chronic venous obstruction.

Keywords: Duplex ultrasound; venous thrombosis; reflux

Background Evaluation of venous reflux

One-third of the adult population in the Western
world is affected by venous disease (VD).1 Most
patients with VD have reflux, obstruction or the
combination of both while other pathologies such
as aneurysms, malformations and tumours are
uncommon. The most common pathology in
patients with chronic venous disease is reflux, fol-
lowed by a combination of reflux and obstruction
while the latter is rare.2
The advent of duplex ultrasound (DU) has
substantially changed the diagnosis of VD. DU
advantages include non-invasive evaluation of
venous anatomy, valve function and obstruction
in realtime, low cost, portability, safety and
repeatability.3 DU is unable to give an overall
value for the condition of the extremity, identify
the functional effect of the obstruction and evalu-
ate the efficiency of calf muscle pump. However,
it allows accurate diagnosis, instigation of treat-
ment, guide interventions and evaluate the
outcome.
Correspondence: N Labropoulos, Professor of Surgery,
Director of the Vascular Laboratory, Department of Surgery,
HSC T19 Rm90, Stony Brook University Medical Center,
Stony Brook, NY 11794-8191, USA.
Email: nlabrop@yahoo.com
Accepted November 2012
Reflux is most often found in the superficial veins
with the saphenous veins and their tributaries
being the most common location.4 Careful assess-
ment of the distribution and extent of reflux is criti-
cal to tailor the treatment to the patient’s needs.
The investigation of reflux is performed with the
patient in standing position to allow maximum
venous distension. Recently, a multicentre study
has shown that reflux measurements in the super-
ficial veins were more repeatable when performed
in the morning with the patient standing.5 When-
ever the patient is unable to be in a standing pos-
ition, a semierect position or with torso elevation
at 458 is recommended.
Reflux may occur in patients with primary
venous disease, after an episode of venous throm-
bosis, secondary to a traumatic or iatrogenic arterio-
venous fistula or, rarely, due to congenital
malformations including valve hypoplasia or agen-
esis. It has been defined as abnormal when the
retrograde flow lasts .1000 ms in the common
femoral, femoral and popliteal veins and .500 ms
for all other veins in the lower extremity.6,7 Abnor-
mal perforating veins (PVs) are defined as those
with an outward flow of duration of .500 ms,
with a diameter of .3.5 mm.7
Manual cuff compression or automated pneu-
matic cuff inflation/deflation device are used to
assess reflux.7 Recently, a multicentre study com-
pared the automated compression/decompression
device to manual compression. No significant
difference in the duration of reflux was found

Phlebology 2013;28 Suppl 1:158–161. DOI: 10.1177/0268355513476653 # The Author(s), 2013. Reprints and permissions:
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R D Malgor and N Labropoulos. Diagnosis of venous disease with duplex ultrasound
when those two modalities were compared against
each other.5 However, the automated compression/
decompression device may be of assistance if com-
paritive data on the duration of the reflux before
and after a venous procedure are warranted. The
Valsalva manoeuvre is used to test only the compe-
tency of the common femoral vein and sapheno-
femoral junction (SFJ).
The diameter of the saphenous trunks and
routes of reflux must be obtained. Varicose veins
are defined as veins that are .3 mm in diameter
having at least two dilations in continuity.7,8
Dilations of only the valve sinus or of a short
segment (,2 cm in length) must not be considered
varicosities.8 The saphenous trunks rarely are vari-
cose but often have focal dilations. Vein aneurysm
has been defined as vein enlargement of .3 times
of the adjacent normal diameter.8 However, no sig-
nificant work has been done to differentiate vein
aneurysms from varicose veins in patients with
chronic venous disease (CVD).
The patterns and types of reflux must be
recorded. Routinely reflux is first evaluated in
the great saphenous vein (GSV) and small saphe-
nous vein (SSV) and their tributaries. The perforat-
ing veins are then investigated along the saphenous
veins and their tributaries. Evaluation of the
deep vein reflux is critical to complete assessment
of venous reflux particularly in patients with
oedema and skin damage. Primary axial reflux in
the deep veins alone is rare.4 Very often segmental
reflux is found in the common femoral and popli-
teal veins, which is caused by a longstanding saphe-
nous reflux involving their junctions.9 Such deep
reflux is eliminated after treating the saphenous
veins. This is different from the axial deep reflux
often found after deep vein thrombosis. Precise
determination of deep vein reflux is critical in
order to set realistic expectations for the patients
and provide proper management.7
Recurrent varicose veins reflux
Reflux is frequently found after treatment. This
can be residual or recurrent reflux. Its incidence
varies according to the time of the follow-up and
method of treatment.10 Patients who had SFJ lig-
ation or ablation may present with reflux at the
GSV stump level due to tributaries that are con-
nected to the stump or CFV as residual veins.10,11
Tiny vessels with no valves may also be demon-
strated causing reflux at the groin level after GSV
ligation (neovascularization).10,11 An analysis of
170 limbs from the REVAS study participants was
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Review article
performed to assess their presentation, causes and
predisposing factors.10 Most patients were sympto-
matic and three-quarters of the limbs had perforator
reflux. Notably, reflux was mostly found in the SFJ
(47.2%) and leg perforators (54.7%) areas. Another
prospective study of patient with recurrent varicose
veins after surgery demonstrated that reflux is
located at the saphenofemoral or saphenopopliteal
junction in at least a quarter of limbs scanned.12
A progressive valve function deterioration of the
perforators was also shown.12
A standard DU investigation and reporting of
residual and recurrent disease after treatment was
proposed by an UIP document.13 Morphological
and functional characteristics were listed to report
findings after surgical, thermal and chemical abla-
tion. A good record of the pretreatment reflux distri-
bution and extent and the procedure notes was
emphasized in order to give an accurate account
of the post-treatment disease.
Evaluation of venous obstruction
Venous obstruction can be acute and chronic and
it is caused from intraluminal and extraluminal
pathology or a combination of both. Extrinsic
compression can be caused by arteries, tumours,
haematomas, cysts, aneurysms and musculoskele-
tal structures. The most common cause of obstruc-
tion is venous thrombosis. DU is the first imaging
study utilized to rule out deep vein thrombosis
with a sensitivity and specificity of .95%.14
Four pertinent components must be obtained
while performing a DU, visualization, compressi-
bility, flow and augmentation.7 Compressibility
test must be performed every 3 – 5 cm. It is the
most reliable assessment for obstruction and is
carried out with the probe in transverse direction
in all the deep veins of the extremity including
the femoral, deep femoral, popliteal, peroneal,
soleal, gastrocnemial and posterior tibial veins.
The anterior tibial veins are not routinely scanned
due to their low incidence of thrombosis unless
local symptoms or history of trauma to the anterior
compartment is present. The venous flow must
be phasic with respiration especially in central
veins and augmented with distal compression or
stopped with Valsalva manoeuvre at the level of
the common femoral vein. Continuous flow in the
common femoral vein having low or no augmenta-
tion by any manoeuvres is abnormal and requires
an investigation of the iliac veins and vena cava to
rule out venous outflow obstruction. A unilateral
obstruction of the iliac veins can be demonstrated
Phlebology 2013;28 Suppl 1:158–161 159
Review article R D Malgor and N Labropoulos. Diagnosis of venous disease with duplex ultrasound
Table 1 DU criteria to distinguish acute from chronic deep vein thrombosis
Acute (days to weeks)
Size Distended
Echogenicity Echolucent: acute thrombi
containing spongy material
Lumen characteristics The lumen is non- or partially
compressible and often has
spongy feel on compression
Wall characteristics Thin and smooth
Flow pattern Absence of flow/fillings defects
Enhanced flow in
dilated collateral
veins
Thrombus Presence of tail
characteristic
Collateral veins Absent
DU, duplex ultrasound; DUS, duplex ultrasonography
Chronic thrombosis refers to chronic luminal changes, as at a longer stage if the thrombus does not lyse becomes fibrous tissue
by asymmetrical common femoral vein flow com-
pared with the normal phasic flow in the contralat-
eral side. It is important to note that the presence of
a phasic flow does not exclude obstruction.
Patients with acute deep venous thrombosis
(DVT) have dilated veins filled with a hypoechoic,
homogeneous, partially compressible thrombus
(Table 1). Despite absence of confirmatory DU
findings of acute DVT, some patients with high
clinical probability measured by a validated score
(Wells’ score) should be re-imaged in a few days
to confirm or exclude acute DVT. Chronic vein
changes is suggested when a non-dilated vein
with a contracted, organized, hyperechoic, hetero-
geneous, uncompressible thrombus, firmly adher-
ent to the vein wall is found (Table 1). The term
subacute DVT is also used in clinical practice and
it illustrates a venous thrombosis event that
occurred few weeks to months prior to the duplex
scanning. A mixed pattern of hypo and hyperechoic
thrombus with or without signs of recanalization or
wall thickening is often visualized. Such patients
are treated according to their clinical presentation
and DU findings. Typically most of these patients
are placed on anticoagulation.
Venous stenosis is diagnosed by DU using
planimetric measurements of luminal reduction, a
poststenotic/prestenotic velocity ratio (V2/V1) of
.2.5 slow flow, spontaneous echogenity and vein
dilation prior to the stenosis and the presence of col-
lateral veins bypassing the obstruction.15 Whenever
central vein stenosis or occlusion is suspected other
160 Phlebology 2013;28 Suppl 1:158–161
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Subacute (weeks to months) Chronic (months to years)
No longer distended due to lysis Reduced; sometimes unable to be
traced by DUS
Moderate echogenecity: Increased cellular Echogenic: due to fibroblasts and
components showing spongy and collagen deposits in the thrombus
somewhat organized thrombus
Recanalization with adherence of residual Partial recanalization with filling
thrombus to vein wall defects (multiple reflux channels)
and reflux may be present
Thickened Thickening with luminal reduction
due to inflammatory response
from the thrombus
Partial recanalization Partial recanalization with reflux
Decreased linear extension of thrombus
May be present Often found around the obstructed
segments
imaging modalities such as magnetic resonance
venography, computed tomography venography
(CTV) or contrast venography are often used due
to the lack of DU training in these areas. Evaluation
of obstruction with DU is mostly anatomical pro-
viding also some functional information but it is
unable to determine its severity.
Recurrent deep vein thrombosis
Many patients with DVT will present with more
than one episode that may occur in a previous
affected venous segments (acute on chronic) or in
a new location, i.e. the contralateral limb. Risk
factors for recurrent DVT are previous ipsilateral
DVT, age . 65 years, high levels of d-dimer,
residual thrombus or previous iliofemoral involve-
ment.16 Suggested diagnostic criteria for recurrent
DVT are the extension of the thrombus, non-
compressibility of a vein segment that had pre-
viously been compressible or had previously
recanalized and increase in the thrombus thickness
by 4 mm.
Superficial vein thrombosis
Most often superficial vein thrombosis (SVT) affects
the saphenous veins and their tributaries but it can
affect any superficial vein. SVT is not a benign entity
as previously thought. Using DU it is critical to
R D Malgor and N Labropoulos. Diagnosis of venous disease with duplex ultrasound
determine the extent of SVT because propagation
can occur from GSV into the common femoral
vein, SSV into the popliteal vein or even causing
DVT via propagation through perforating veins.
Clinical exam is often inaccurate and underesti-
mates the proximal extension of the thrombus by
5 – 10 cm. It is of clinical relevance to perform DU
to confirm the diagnosis, define the extent of throm-
bosis and provide data for follow-up.
Conclusion
DU is the method of choice for detecting acute
venous disease and CVD, delineating and guiding
the treatment as well as evaluating the outcome of
interventions. In the investigation of the lower
extremity veins the major limitation is the lack of
formal training and standardized examination pro-
tocols, which could allow to maximize the benefits
of using such technology.
Funding
This research received no specific grant from any
funding agency in the public, commercial, or not
for-profit sectors.
Conflict of interest
The authors have no conflicts of interest to declare.
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