Duplex Ultrasound Investigation of the Veins in Chronic Venous Disease of the Lower Limbs—UIP Consensus Document. Part II. Anatomy

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Abstract
Duplex ultrasound investigation has become the reference standard in assessing the morphology and haemodynamics of the lower limb veins. The project described in this paper was an initiative of the Union Internationale de Phlébologie (UIP). The aim was to obtain a consensus of international experts on the methodology to be used for assessment of anatomy of superficial and perforating veins in the lower limb by ultrasound imaging. The authors performed a systematic review of the published literature on duplex anatomy of the superficial and perforating veins of the lower limbs; afterwards they invited a group of experts from a wide range of countries to participate in this project. Electronic submissions from the authors and the experts (text and images) were made available to all participants via the UIP website. The authors prepared a draft document for discussion at the UIP Chapter meeting held in San Diego, USA in August 2003. Following this meeting a revised manuscript was circulated to all participants and further comments were received by the authors and included in subsequent versions of the manuscript. Eventually, all participants agreed the final version of the paper. The experts have made detailed recommendations concerning the methods to be used for duplex ultrasound examination as well as the interpretation of images and measurements obtained. This document provides a detailed methodology for complete ultrasound assessment of the anatomy of the superficial and perforating veins in the lower limbs. The authors and a large group of experts have agreed a methodology for the investigation of the lower limbs venous system by duplex ultrasonography, with specific reference to the anatomy of the main superficial veins and perforators of the lower limbs in healthy and varicose subjects.
Duplex Ultrasound Investigation of the Veins in Chronic
Venous Disease of the Lower Limbs—UIP Consensus
Document. Part I. Basic Principles
P. Coleridge-Smith,
1
*
N. Labropoulos,
2
H. Partsch,
3
K. Myers,
4
A. Nicolaides
5
and A. Cavezzi
6
1
London, UK;
2
Chicago, IL, USA;
3
Vienna, Austria;
4
Melbourne, Australia;
5
Nicosia, Cyprus;
and
6
San Benedetto del Tronto, Italy
Objectives. Duplex ultrasound investigation has become the reference standard in assessing the morphology and
haemodynamics of the lower limb veins. The project described in this paper was an initiative of the Union Internationale de
Phle
´
bologie (UIP). The aim was to obtain a consensus of international experts on the methodology to be used for assessment
of veins in the lower limb by ultrasound imaging.
Design. Consensus conference leading to a consensus document.
Methods. The authors invited a group of experts from a wide range of countries to participate in this project. Electronic
submissions from the experts were made available to all participants via the UIP website. The authors prepared a draft
document for discussion at a UIP Chapter meeting held in San Diego, USA in August 2003. Following this meeting a
revised manuscript was circulated to all participants and further comments were received by the authors and included in
subsequent versions of the manuscript. Eventually all participants agreed the final version of the paper.
Results. The experts have made detailed recommendations concerning the methods to be used for duplex ultrasound
examination as well as the interpretation of images and measurements obtained. This document suggests a methodology for
complete assessment of the superficial and perforating veins of the lower limbs, including recommendations on reporting
results and training of personnel involved in these investigations.
Conclusions. The authors and a large group of experts have agreed a methodology for the investigation of the lower limbs
venous system by duplex ultrasonographpy.
Keywords: Consensus document; Duplex ultrasonography; Venous system; Chronic venous disease.
Introduction
Duplex ultrasonography is probably the most
frequently used investigation to evaluate the venous
system for the management of chronic venous
disease (CVD) of the lower limbs. The results of
many forms of treatment have been evaluated by
duplex ultrasound and published in the medical
literature. However, there is currently no systematic
consensus agreement from phlebology or vascular
societies on how duplex ultrasound for CVD is best
performed. The aim of the document is to summar-
ise best practices for venous duplex ultrasound
examination of the lower limbs agreed upon by a
group of clinicians who regularly use this
technology in their daily practice. Where possible,
this has been based on objective information from
the literature in addition to personal practice.
Methodology
The Union Internationale de Phle
´
bologie (UIP) is an
international organisation to which national societies
of phlebology may subscribe as members. This society
promotes scientific research and good clinical practice
in venous disease through a number of initiatives
including international congresses, sponsored
research grants and consensus development meetings.
Recent consensus publications have included a
nomenclature of the lower limb veins
1
and proposals
for the revision of the CEAP classification
2
which led
to the recent publication of a revised CEAP
classification.
3
Eur J Vasc Endovasc Surg 31, 83–92 (2006)
doi:10.1016/j.ejvs.2005.07.019, available online at http://www.sciencedirect.com on
*
Corresponding author. Philip Coleridge Smith, DM, FRCS, Thames
Valley Nuffield Hospital, Wexham, Bucks SL3 6NH, UK.
E-mail address: p.coleridgesmith@ucl.ac.uk
1078–5884/000083 + 10 $35.00/0 q 2005 Elsevier Ltd. All rights reserved.
TheUIPwishedtopromoteaconsensuson
methods of investigation and interpretation of duplex
ultrasonography in venous disease and invited three
authors (AC, PCS, NL) to gather a group of
international experts on duplex ultrasound in CVD.
The Consensus Group acted individually to provide
personal opinions that did not necessarily reflect
policies of scientific or medical societies to which
they may have been affiliated. The experts were
invited to submit contributions that they felt encapsu-
lated important aspects of clinical practice of duplex
ultrasound examination of the venous system. Elec-
tronic submissions made by the experts were made
available to all participants via the UIP website. The
submissions included references to papers, photo-
graphs, diagrams and suggested text for the consensus
document. The references provided during this
process were not intended to form a systematic review
of the literature but were selected to support
statements made in the final document where
evidence exists. The authors acknowledge that many
of the statements concern subjects, which have not
been the subject of detailed scientific study and reflect
the personal practice of the experts. The organisers
prepared a draft document that was placed on the UIP
website, and this was discussed and further sub-
missions and recommendations were made. Many of
the experts and the organising committee as listed at
the end of this document met at a chapter meeting of
the UIP in San Diego in August 2003 to discuss the
consensus documents and other submissions. A
further draft of the document was then circulated to
all contributors who again added their comments. A
final document was agreed amongst all experts after
further revisions of the manuscript.
The authors consider that the methodology above
achieved a credible consensus process. The references
in the document are intended to support statements
and are not intended to be an exhaustive review. The
Consensus Group gave consideration to using a
formal assessment of every clinical study quoted to
classify it according to clearly defined levels of
evidence. This approach was rejected because few
studies with high levels of evidence have been
published in this area. Recommendations are based
on available evidence and the combined clinical
experience of the Consensus Group.
The authors suggest that implementation of the
recommendations should be performed according to
the facilities available in individual institutions. We
envisage that our this document should form the basis
of local protocols rather than an inflexible set of
instructions.
Aim of the duplex ultrasound examination
The duplex ultrasound examination in patients with
CVD should demonstrate both the anatomical patterns
of veins and abnormalities of venous blood flow in the
limbs. The following data should be established:
(1) Which saphenous junctions are incompetent, their
locations and diameters.
(2) The extent of reflux in the saphenous veins of the
thighs and legs and their diameters. The number,
location, diameter and function of incompetent
perforating veins.
(3) Other relevant veins that show reflux.
(4) The source of filling of all superficial varices if not
from the veins already described.
(5) Veins that are hypoplastic, atretic, absent or have
been removed.
(6) The state of the deep venous system including
competence of valves and evidence of previous
venous thrombosis.
Explanation
Most patients undergoing duplex ultrasound to
investigate the superficial, deep and perforating
veins are being considered for treatment of varicose
veins. Information provided by the investigation will
usually have a significant impact upon whether the
treatment is offered and the type of treatment
considered most appropriate. Patients with incompe-
tent saphenofemoral or saphenopopliteal junctions
may be offered surgery, (duplex-guided) sclerotherapy
or an endovenous procedure (radiofrequency closure
or endovenous laser therapy). Those with isolated
incompetence of saphenous tributaries could be
treated by phlebectomy or sclerotherapy. Failure to
identify and treat all sources of venous filling is likely
to result in early recurrence of varices.
The Duplex Scan
Indications for duplex scanning
Since venous reflux commonly affects both limbs, it is
recommended that both limbs be studied at the initial
investigation, even if only one shows evidence of
venous disease although this is dependant on the
resources of the diagnostic service.
P. Coleridge-Smith et al.84
Eur J Vasc Endovasc Surg Vol 31, 1 2006
Primary uncomplicated great saphenous territory varicose
veins
Whether all patients require scanning is debated.
4,5
Clinical assessment with or without pocket (continu-
ous wave, CW) Doppler will miss up to 30% of
important connections from deep to superficial veins
and information on affected veins when compared to
duplex scanning.
6
Primary uncomplicated small saphenous territory varicose
veins
Duplex scanning is considered to be essential prior to
treatment to determine whether there is a saphenopo-
pliteal junction (SPJ), to record its level, and to show
complex anatomy such as a common insertion with
the gastrocnemius veins.
7–9
Non-saphenous varicose veins
Veins such as those related to pelvic/perineal vein
reflux, varices unrelated to the great or small
saphenous veins, or isolated lateral thigh varicose
veins will be demonstrated to indicate that saphenous
ligation or stripping may not be required.
Recurrent varicose veins
Duplex scanning is considered to be essential to
establish the complex anatomy and haemodynamics
of recurrent varices to show whether surgery or
endovenous treatment is appropriate.
10–12
Chronic venous disease with complications
Duplex scanning is considered to be essential to assess
the relative involvement of the deep and superficial
venous systems to predict the likely outcome after
treating superficial disease alone and to select patients
suitable for consideration of deep venous
reconstruction.
Duplex ultrasound surveillance after treatment
This may be used to assess the outcome of therapy and
for early detection of recurrence.
13
This is likely to be
the only way to obtain level I evidence as to outcome
in the future.
Venous malformations
Duplex ultrasonography may be used to investigate
and provide good management for vascular malfor-
mations (angiomas). The investigation provides ana-
tomical information about the extent of the
malformation and its relationship to other vessels in
the affected limb.
14
It may also be used to guide
treatment of malformations by sclerotherapy.
15
It is
frequently a prelude to further investigation by
magnetic resonance imaging.
Explanation
Duplex ultrasonography can localise and specify the
source of the venous problem to provide a map to help
select best treatment and evaluate outcome for the
venous problems discussed above.
Machine requirements and settings
A colour duplex ultrasound machine is recommended
for this investigation.
A high-frequency linear array transducer of 7.5–
13 MHz is appropriate for most lower limbs to obtain
good quality images of superficial veins. A curvilinear
array transducer of 3.5–5 MHz can be useful for very
large or oedematous limbs.
B-mode machine settings
Superficial veins normally lie 1–3 cm below the skin.
They are usually imaged in the longitudinal view with
the proximal end of the veins to the left of the screen,
and in the transverse view with the lateral aspect of the
right limb and medial aspect of the left limb shown to
the left of the screen. The focal zone for the transducer
should be set at an appropriate level to obtain the best
B-mode image of the vein under investigation. Gain
and dynamic gain control (DGC) should be set to
optimise the image so that the lumen of the vein
should be dark in the absence of acute or chronic
thrombosis and very slow flow (for cell aggregates can
give spontaneous contrast), but to allow echoes from
thrombus to be seen from within the lumen.
Pulsed-wave spectral or colour Doppler settings
The use of ‘low flow’ settings is recommended to
optimise the machine for low flow velocities encoun-
tered within veins. Set the Doppler range to 5–10 cm/s
with the wall filter at its lowest setting. It is best to
increase the Doppler gain to show a small amount of
‘noise’ in the colour or pulsed Doppler signal to ensure
maximum sensitivity of the system. It is advisable to
increase the Doppler range and decrease the colour gain
in patients with high venous flow to avoid significant
colour artefact. It is conventional to use blue to represent
orthograde venous flow towards the heart in the colour
mode and red for the reverse (venous reflux) direction.
Position of the patient and probe
In order to standardise measurements of venous
diameter and reflux, it is recommended that examin-
ation of the superficial veins is performed with the
patient standing. The horizontal position is inap-
propriate for detection of reflux and measurement of
vein diameters. However, both the lying and standing
Venous Duplex Consensus. Part I: Basic Principles 85
Eur J Vasc Endovasc Surg Vol 31, 1 2006
positions have been reported in the published
literature.
Examination of calf veins is usually best performed
with the patient in either the sitting or standing position,
according to the structures that are to be scanned (Fig. 1).
Transverse and longitudinal views of the veins should
be employed in duplex ultrasound scanning of the lower
limbs. The transverse view gives more precise general
information regarding morphology and possible
presence of endoluminal thrombus through the com-
pression manoeuvre, while a longitudinal view helps to
assess orthograde flow and venous reflux more accu-
rately. An angle of insonation of 45–608 between the
transducer and vein should be used to achieve the
optimum colour or spectral Doppler signal.
Examination for reflux
Definition of venous reflux
Venous reflux is considered to be retrograde flow in
the reverse direction to physiological flow lasting for
more than 0.5 s,
16,17
though a definitive cut-off for all
vein segments has not been agreed in the published
literature.
Several methods are used to elicit reflux:
Release after a calf squeeze for proximal veins or
foot squeeze for calf veins.
Manual compression of vein clusters.
Pneumatic calf cuff deflation.
18
Active foot dorsiflexion and relaxation.
The Valsalva manoeuvre— this may be the pre-
ferred technique to demonstrate saphenofemoral
incompetence.
Venous reflux is elicited by imaging the vein under
investigation whilst applying compression to the limb
using one of the methods described above. The
compression is abuptly removed and the presence
and duration of reflux observed. Pneumatic cuff
deflation has been used to permit quantitative
assessment of reflux.
18
This may be the most
reproducible although some find it technically more
difficult. Some experts consider that a Valsalva
manoeuvreismoreappropriatetotestvalvular
competence at the sapheno–femoral junction.
Prepare the patient
The patient is examined in a room with sufficient
lighting to enable thorough evaluation of the lower
limbs and establish the distribution of varices.
The lower limbs are inspected for varicosities and
scars from surgery to help predict the source of reflux
and facilitate the examination. It is necessary to
explain to the patient what is going to be done,
particularly the Valsalva manoeuvre.
Fig. 1. Position of patient and probe during duplex ultrasound examination of the lower limb (Courtesy by K. Jaeger, Basle).
P. Coleridge-Smith et al.86
Eur J Vasc Endovasc Surg Vol 31, 1 2006
Reflux is more likely to develop later in the day,
especially for non-dilated vein segments. A warm
environment helps to make veins dilate, while a cold
environment can cause them to constrict making them
difficult to see so that borderline venous reflux may
disappear. The lower limb under investigation must be
relaxed during imaging to allow good venous filling in
the calf veins.
Fig. 2 shows the approximate surface positions of
the major superficial veins which will be examined.
Protocols for scanning the great saphenous vein (GSV), deep
veins above knee and thigh perforators
Position of the patient
The patient should stand facing towards the examiner
with the leg rotated outwards, heel on the ground and
weight taken on the opposite limb.
The great saphenous vein (GSV) and accessory saphenous
veins
Start the scan in the groin of the first limb to be
examined. Use a transverse view to identify the GSV
and the common femoral vein, both lying medial to the
common femoral artery, using the ‘Mickey Mouse’
sign (Fig. 3). If the junction is not present after surgery
to remove the GSV, then ‘Mickey’s’ medial ear is
missing. Several veins can be visualised in the region
of the saphenofemoral junction (SFJ) and two GSV
valves (terminal and pre-terminal) can be imaged near
the SFJ. It is important to assess these tributaries and
GSV valves as several haemodynamic patterns can be
seen.
19
Assess possible sources of reflux or proximal points
of insufficiency including SFJ incompetence, veins
from the lower abdomen or pelvis, thigh or calf
perforators, or the vein of Giacomini.
In the transverse view, determine whether the
destination for reflux is into: (a) the GSV within the
saphenous compartment, (b) into the accessory
anterior saphenous vein (AASV) which is slightly
external to GSV and aligned with the femoral vessels
below, or (c) to major thigh tributaries superficial to the
saphenous fascia. A connection between the GSV and
pelvic sources of venous reflux is suspected if there is
sudden increase in the GSV diameter, whereas the
diameter may decrease distal to a major incompetent
tributary. It is also recommended to scan within the
inguinal lymph node area distal to the SFJ where
normal and varicose veins may lie.
20
Follow the full length of the GSV or tributaries to the
ankle. This vein lies within a fascial compartment
which can easily be identified on the B-mode
ultrasound image (Fig. 4). This appearance is widely
Fig. 2. Surface distribution of major superficial veins. AASV, anterior accessory saphenous vein; GSV, great saphenous vein;
TE, thigh extension of the small saphenous vein; SPJ, sapheno–popliteal junction; SSV, small saphenous vein.
Venous Duplex Consensus. Part I: Basic Principles 87
Eur J Vasc Endovasc Surg Vol 31, 1 2006
known as the ‘saphenous eye’. Test every few
centimetres for compressibility and reflux.
Measure diameters at the junction and along the
GSV if there is reflux. Many authors measure GSV
diameter three centimetres below the SFJ. Further
useful sites of measurement are at the mid-thigh and at
the knee. The measurement should be made of the
saphenous trunk vein and not of any varix or dilated
segment with an incompetent valve. Measurement of
the diameter can be used to help decide between
different types of treatment, for example between
(duplex-guided) sclerotherapy, radiofrequency, endo-
venous laser and surgery. The depth of the saphenous
trunk beneath the skin may also be important in
patients where radiofrequency closure or endovenous
laser therapy is being considered. These measure-
ments can be used as a baseline for follow up after
endovenous procedures.
Deep veins in the thigh
The common femoral vein (CFV) should be tested in
the longitudinal view for phasic flow with normal
respiration, cessation of flow with deep inspiration,
possible reflux with the Valsalva manoeuvre, and flow
during manual compression of the thigh or calf. This
may be better demonstrated with the patient in the
supine position. If continuous flow is detected in the
CFV, which can indicate a proximal obstruction, it is
recommended to extend duplex scanning to the iliac
veins and inferior vena cava.
The CFV should be examined above and below the
SFJ as retrograde flow in CFV is seen at the SFJ level or
higher in the presence of SFJ reflux whereas retrograde
flow distal to this level represents true deep venous
reflux. It is then necessary to follow the full length of
the femoral vein (FV—formerly termed the superficial
femoral vein)
1
to the popliteal vein. If necessary, the FV
may be better seen by moving the probe to an anterior
window through the vastus medialis at the adductor
hiatus.
Fig. 3. Transverse view of common femoral vein and artery
in the right groin: ‘Mickey Mouse’ view; CFA, common
femoral artery; CFV, common femoral vein; SFJ, sapheno–
femoral junction (from the archive of PCS).
Fig. 4. The ‘saphenous eye’—a transverse ultrasound image of the GSV in the thigh showing the fascial components which
constitute the saphenous compartment. Other superficial lower limb veins including the AASV and SSValso lie within fascial
compartments.
P. Coleridge-Smith et al.88
Eur J Vasc Endovasc Surg Vol 31, 1 2006
Thigh perforators
It is recommended to look for perforators on the
medial aspect of the thigh during the examination of
the GSV and the deep veins. Not all thigh perforators,
competent or incompetent, will be detected. These are
usually found in the middle and lower thirds of the
thigh, but can also occur in the proximal thigh near the
SFJ. It is necessary to look for lateral and posterior
thigh perforators if clinical assessment shows varices
in these regions.
Use spectral and/or colour Doppler to test for inward
and outward flow in perforators by calf or thigh muscle
contraction.Perforatingveins which allowbi-directional
flow are probably abnormal, although a few non-
varicose subjects may have a similar pattern.
21,22
If an
incompetent thigh perforating vein is found then it may
be useful to record its diameter measured at the muscle
fascia and its location with reference to the knee joint to
help decide the best management for this vein.
Protocols for scanning the popliteal vein (PV)
The popliteal fossa is a complex site for investigation,
both from the anatomical point of view and for
assessment of venous haemodynamics. Multiple
longitudinal and transverse views are required. PV is
properly scanned with the patient lying in prone
position when phasicity o flow with respiration has to
be elicited, though some patients may not show this
finding also in absence of any abnormality; it is usual
to assess flow augmentation with the calf squeezing
manoeuvre for the Valsalva manoeuvre is of limited
utility at this level. The PV should be examined above
and below the SPJ when this is present, as retrograde
PV flow is present above the SPJ when the SPJ terminal
valve is incompetent, and only retrograde flow distal
to this level represents true deep venous reflux. The
anatomical and haemodynamic relationship of the PV,
SPJ and gastrocnemius veins should be established.
Protocols for scanning the small saphenous vein (SSV),
thigh extension of the SSV and vein of Giacomini
Position of the patient
Scan the SSV, thigh extension of SSV and vein of
Giacomini with the patient standing and facing away,
with the knee slightly bent, heel on the ground and
weight taken on the opposite limb.
Scanning techniques
Start at the back of the knee. Use a transverse view
to identify the major veins of the popliteal fossa.
Determine whether the SPJ is present. If so, show
the junction in a longitudinal view. Test the
popliteal vein proximal and distal to the SPJ, the
gastrocnemius vein insertion and the SPJ for reflux
or thrombosis. Determine if there is SPJ incompe-
tence with SSV reflux. SSV reflux may occur during
calf muscle contraction or manual calf compression
(systolic phase) in some patients suggesting possible
popliteal and/or femoral vein obstruction,
23
whereas typically reflux is most obvious during
calf release (diastolic phase). If there is reflux,
measure the diameter of the SSV 3 cm distal to the
SPJ (or at the popliteal crease) and at mid-calf,
avoiding any varix in the vein. Measure the level of
the SPJ in relation to the popliteal skin crease. The
SSV may join the popliteal vein medially, posteriorly
or laterally so that it is advisable to record its
position in relation to the popliteal vein circumfer-
ence. Ascertain the presence or absence of an artery
accompanying the SSV or the gastrocnemius veins.
This is of importance when duplex-guided scler-
otherapy is to be undertaken. Look for alternative
sources of reflux including communication of the
SSV with a popliteal fossa perforator, GSV tribu-
taries, pelvic veins traced to the buttock or
perineum, the thigh extension of SSV, or the vein
of Giacomini. Look for alternative destinations for
GSV reflux including tributaries, the thigh extension
of SSV, or the vein of Giacomini.
Scan the thigh extension of the SSV and its
connections with deep thigh veins or pelvic veins.
The vein of Giacomini is deep to the fascia in most of
its course.
24
Determine its distal SSV connection and
proximal connection into the GSV. Demonstrate the
flow direction and show whether there is reflux down
from saphenofemoral incompetence to pass to the SSV
or up from saphenopopliteal incompetence to pass to
the GSV.
Protocols for scanning veins below the knee
Position of the patient
Scan for below-knee veins with the patient standing
(preferable for superficial veins), or sitting with the
foot hanging down resting on the examiner’s knee or
on a step.
Deep crural veins
With experience, all deep crural veins can be
identified. Reflux in the posterior tibial veins (PTVs)
best reflects clinical features. Examine PTVs from a
medial or posteromedial view and peroneal veins
from a posteromedial or posterior view.
Venous Duplex Consensus. Part I: Basic Principles 89
Eur J Vasc Endovasc Surg Vol 31, 1 2006
These veins should be examined in patients with
past or present deep vein thrombosis, and in patients
with incompetent perforating veins in the calf.
Peroneal veins are the most frequently affected calf
veins following previous venous thrombosis.
25
Exam-
ination of soleal and gastrocnemius veins deep in their
muscle groups completes the basic investigation of
deep veins in the leg.
Superficial veins of the calf
Examine the GSV in the calf for venous reflux. The
GSV in the middle to lower third of the leg is
competent in up to 97% of limbs with GSV trunk
incompetence
26
but the GSV below knee may be
incompetent where more proximal parts of the vein
are competent and should be investigated. Following
varicose vein surgery, incompetence of the GSV below
knee may fill varices at the ankle and in the foot.
Examine the posterior arch vein (vein of Leonardo)
which is a major tributary of the GSV in the leg, search
for calf perforating veins that join this vein in the
medial calf region, and test for reflux in the vein that
may result in medial calf varices.
Calf perforators
Perforators pass through the deep fascia which is a
distinct band on the B-mode image. Look for
perforators around the circumference of the calf. Not
all calf perforators, competent or incompetent, will be
detected. If they show outward flow then measure
their diameters at the deep fascia and their level from
the medial or lateral malleolus. However, diameter
measurement alone cannot distinguish competent
from incompetent perforators.
27
Test for bidirectional
flow by colour Doppler or spectral analysis after a
distal muscle squeeze or isometric calf muscle
contraction. However, no consensus has been reached
on the pathological significance of bidirectional flow.
Bidirectional flow in a perforator indicates its
incompetence, but some authors argue that true
pathological incompetence is present only if reflux is
elicited during the diastolic phase of calf muscle
relaxation or release of compression. Accordingly,
some authors suggest testing for inward and outward
flow separately during calf muscle contraction or
compression and calf muscle relaxation or release to
help distinguish pathological from re-entry perfora-
tors.
28
Assessing approximate duration of inward and
outward flow may provide an estimate of the net
flow.
29,30
Organisation and reporting of tests
The emphasis of an investigation for the morphology
and haemodynamic changes in patients with chronic
venous disease in the lower limbs is quite different
from a test for suspected deep vein thrombosis. The
request for the investigation should be made by a
physician who has taken a history and undertaken
clinical examination to provide valid reasons for the
investigation and guidance as to what to look for.
Indications for investigation include:
Primary varicose veins.
Recurrent varicose veins.
Skin changes or leg ulceration.
Other manifestations such as leg swelling or aching.
Venous malformations.
Suspected acute deep vein thrombosis.
Reports of results of duplex ultrasound examinations
of lower limb veins
The report should state the reason for undertaking the
investigation. Inclusion of ultrasound images from the
report may be useful to demonstrate the findings but
the dynamic nature of the investigation limits the
value of still images in most patients. Diagrammatic
representation as well as a textual report is far more
helpful to express the findings. Video recordings are
useful for quality control purposes but video record-
ings would not normally form part of the report of the
investigation.
Reports should detail information regarding
venous reflux and development of varices or other
aspects of venous disease. This should include the
presence of incompetence at each saphenous junction
and extent of reflux in each saphenous trunk
describing the GSV in the thigh and calf separately
where appropriate. The morphology and haemody-
namic abnormalities relating to varices and location of
diseased veins should be indicated on a diagram. In
cases of recurrent varices it is useful to know whether
a recurrence has occurred at a previously ligated
junction or whether a previously treated saphenous
trunk has recanalised. Inclusion of the diameters of
diseased veins including saphenous trunks and
perforating veins is useful since this may influence
the treatment selected for that vein. The report should
also include information regarding the morphology of
the veins which are hypoplastic, atretic or have been
removed at a previous operation.
Deep or superficial veins that have suffered recent
or previous venous thrombosis should be described,
including the current patency of the vein, indicating
P. Coleridge-Smith et al.90
Eur J Vasc Endovasc Surg Vol 31, 1 2006
whether the vein remained occluded or has recana-
lised and whether the recanalised vein has become
incompetent and to what extent.
Explanation
The aim of the report should be to convey the full
information obtained by the investigator to the
clinicians responsible for the patient’s treatment. This
should greatly influence the management of the
patient so that the report should be as unambiguous
as possible. This informative process is obviously
facilitated if the investigator and clinician responsible
for treatment are the same person, but an exhaustive
report with a diagram is always suggested for
treatment and subsequent follow-up.
Training of personnel conducting venous duplex ultrasound
examinations
There is considerable variation between countries as to
who actually undertakes the investigation. Registered
vascular technologists usually perform these tests in
USA and Australia, vascular scientists in UK, and
radiologists in many other countries. However, it is
common for surgeons, angiologists and phlebologists
to perform their own investigations. It is highly
desirable that all those personnel involved in perform-
ing the investigations undergo systematic training that
should include theoretical information, practical
training and clinical experience of the investigation
recorded in a log book.
Explanation
Reliable information can only be obtained from duplex
ultrasound examinations by staff who have a detailed
knowledge of the pathological conditions for which
they are searching. These will require a comprehensive
theoretical knowledge of the subject as well as
practical experience for interpreting ultrasound
images in such cases.
Acknowledgements
List of the experts who were invited to review this document
in San Diego during the Consensus Meeting, or via the
internet:
Allegra Claudio (ITA), Antignani P.Luigi (ITA), Bergan John
(USA), Bradbury Andrew (GBR), Caggiati Alberto (ITA),
Cappelli Massimo (ITA), Cavezzi Attilio (ITA), Chunga
Chunga Juan (PER), Clough A. (AUS), Coleridge-Smith
Philip (GBR), Creton Denis (FRA), De Simone Juan (ARG),
Franceschi Claude (FRA), Gallenkemper Georg (GER),
Georgiev Mihael (ITA), Grondin Louis (CAN), Guex J.Jerome
(FRA), Jaeger Kurt (SWI), Jeanneret Christina (SWI), Kabnick
Lowell (USA), Labropoulos Nicos (USA), Lindhagen Anders
(SWE), Marshall Markward (GER), Morrison Nick (USA),
Myers Ken (AUS), Nelzen Olle (SWE), Nicolaides Andrew
(CYP), Partsch Hugo (AUT), Pereira Alves Carlos (POR),
Pichot Olivier (FRA), Pieri Alessandro (ITA), Rabe Eberhard
(GER), Raymond- Martimbeau Pauline (CAN), Ricci Stefano
(ITA), Rilantono Lily I (Indonesia), Schadeck Michel (FRA),
Scuderi Angelo (BRA), Somjen George M (AUS), Staelens
Ivan (BEL), Strejcek Jaroslav (CZR), Tessari Lorenzo (ITA),
Thibault Paul (AUS), Uhl J.Francois (FRA), Van Rij Andre
(NZL), Von Planta Irene (SWI), Weiss Robert (USA),
Zamboni Paolo (ITA).
The authors express their gratitude to Pierluigi Antignani
(webmaster of the UIP website) and to Bernhard Partsch
(secretary of the working group) for their collaboration.
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Available online 14 October 2005
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    • "Patients expressing an interest in participation will be offered an appointment for a screening visit with a study investigator. At the screening appointment, the medical history and examination will be reviewed, followed by a detailed duplex ultrasound examination according to a set protocol based upon international consensus [39, 40] . If the potential participant meets the required inclusion criteria without any exclusion criteria, subsequent discussion of the study will take place in full (Fig. 1 ). "
    [Show abstract] [Hide abstract] ABSTRACT: Background Endovenous thermal techniques, such as endovenous laser ablation (EVLA), are the recommended treatment for truncal varicose veins. However, a disadvantage of thermal techniques is that it requires the administration of tumescent anaesthesia, which can be uncomfortable. Non-thermal, non-tumescent techniques, such as mechanochemical ablation (MOCA) have potential benefits. MOCA combines physical damage to endothelium using a rotating wire, with the infusion of a liquid sclerosant. Preliminary experiences with MOCA showed good results and less post-procedural pain. Methods/DesignThe Laser Ablation versus Mechanochemical Ablation (LAMA) trial is a single-centre randomised controlled trial in which 140 patients will be randomly allocated to EVLA or MOCA. All patients with primary truncal superficial venous insufficiency (SVI) who meet the eligibility criteria will be invited to participate in this trial. The primary outcomes are intra-procedural pain and technical efficacy at 1 year, defined as complete occlusion of target vein segment and assessed using duplex ultrasound. Secondary outcomes are post-procedural pain, analgesia use, procedure time, clinical severity, generic and disease-specific quality of life, bruising, complications, satisfaction, cosmesis, time taken to return to daily activities and/or work, and cost-effectiveness analysis following EVLA or MOCA. Both groups will be evaluated on an intention-to-treat basis. DiscussionThe aim of the LAMA trial is to establish whether MOCA is superior to the current first-line treatment, EVLA. The two main hypotheses are that MOCA may cause less initial pain and disability allowing a more acceptable treatment with an enhanced recovery. The second hypothesis is that this may come at a cost of decreased efficacy, which may lead to increased recurrence and affect longer term quality of life, increasing the requirement for secondary procedures. Trial registrationClinicalTrials.gov identifier: NCT02627846, registered 8 December 2015EudraCT number: 2015-000730-30REC ref: 15/YH/0207R&D ref: R1788
    Full-text · Article · Aug 2016
    • "When no abnormalities are detected, venous disease is often excluded, although this does not exclude the possibility of venous pump deficiency. Duplex scanning is recommended as the first diagnostic test for all patients with suspected CVD [97] . The test is safe, costeffective , noninvasive and reliable. "
    [Show abstract] [Hide abstract] ABSTRACT: Venous diseases and lower limb pain are common problems in physiatry clinics. Because of having different treatment modalities, it is necessary to distinguish whether they are associated or not. Learning more about venous diseases is crucial for physiatrists, so we tried to review the literature for overview our knowledge. A PubMed search was performed for studies relating to venous diseases and lower limb pain from 2005 to 2015. Publications were retrieved by using search terms for venous diseases and lower limb pain. Relevant references from these studies were also retrieved. No filters were applied to limit the retrieval by study type. Patients with lower limb pain should be asked for symptoms of venous diseases which may include burning, tingling, muscle cramp, swelling, sensation of heaviness, itching skin, restless leg, leg tiredness and fatigue, as well as pain. Because venous diseases are frequently the cause of pain, discomfort, loss of working days, deterioration of health-related quality of life and disability. As physiatrists, we should know the nature of venous diseases. At least, we should gain adequacy to diagnose lower limb pain related to venous diseases for referring cardiovascular surgery clinics. Physiatrists should provide complementary treatment modalities to reduce edema and pain, and to improve joint mobility and muscle strength in patients with venous diseases.
    Full-text · Article · Nov 2015 · Trials
    • "ents and it is the third common cause of the chronic venous insufficiency. [5] In physical examination and Duplex US investigation findings excluding the presence of the AASV may cause misdiagnosis, undertreatment, and possible recurrences. [13] Detailed preoperative Duplex US imaging is, therefore, necessary to figure out any anatomic description. [7] In conclusion, we suggest that the isolated AASV insufficiencies should be treated together with the GSV. When they have a connection with each other, the endovenous thermal ablation procedure is effective in this treatment."
    [Show abstract] [Hide abstract] ABSTRACT: Venous disorders of the lower limb are frequently seen in the general population. As the endovenous treatment of the venous disorders has evolved in the last two decades, our understanding on venous system anatomy has extended. Accessory saphenous vein is present in nearly half of the patients with lower limb venous insufficiency and should be taken into consideration before planning the treatment. In this article, we report a rare case of isolated reflux in an anterior accessory saphenous vein in the absence of a great saphenous vein insufficiency.
    Full-text · Article · Jul 2015 · Trials
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