Diagnosing Venous Insufficiency

Clinical Presentation

• The American Academy of Family Physicians notes that patients with venous insufficiency may present with localized symptoms including pain, burning, itching, and tingling at the site of varicose veins 1
• The American Academy of Family Physicians also reports that generalized symptoms include aching, heaviness, cramping, throbbing, restlessness, and swelling in the legs, typically worse at the end of the day and after prolonged standing 2
• Symptoms often resolve when patients sit and elevate their legs, as noted by the American Academy of Family Physicians 2
• The American Academy of Family Physicians identifies signs of more serious vascular insufficiency, including skin pigmentation changes, eczema, infection, superficial thrombophlebitis, venous ulceration, loss of subcutaneous tissue, and lipodermatosclerosis 1
• Women are significantly more likely than men to report lower limb symptoms, according to the American Academy of Family Physicians 2

Risk Factors

• The American Academy of Family Physicians lists family history of venous disease as a risk factor for venous insufficiency 1
• Female sex is also a risk factor, as reported by the American Academy of Family Physicians 1
• Older age is a risk factor, according to the American Academy of Family Physicians 2
• Chronically increased intra-abdominal pressure, such as obesity, pregnancy, chronic constipation, or tumors, is a risk factor, as noted by the American Academy of Family Physicians 1
• Prolonged standing is a risk factor, according to the American Academy of Family Physicians 2
• Deep venous thrombosis causing valve damage is a risk factor, as reported by the American Academy of Family Physicians 1
• Arteriovenous shunting is a risk factor, according to the American Academy of Family Physicians 2

Diagnostic Algorithm

• The American College of Radiology recommends documenting clinical severity using the CEAP classification system, which includes:
  • C0: No visible or palpable signs of venous disease 2
  • C1: Telangiectasias or reticular veins 1
  • C2: Varicose veins 2
  • C3: Edema 2
  • C4: Skin changes (pigmentation, eczema) 2
  • C5: Healed venous ulcer 1
  • C6: Active venous ulcer [1] [3]
• The American Academy of Family Physicians notes that duplex ultrasonography should be performed when venous disease is severe or interventional therapy is being considered 1
• The American College of Radiology recommends that the examination include assessment of direction of blood flow, evaluation for venous reflux, and assessment for venous obstruction 4
• The American Academy of Family Physicians recommends examining the deep venous system, great saphenous vein (GSV), small saphenous vein (SSV), and accessory saphenous veins 1
• The American College of Radiology suggests identifying perforating veins and alternative refluxing superficial venous pathways 4

Diagnostic Techniques

• The American College of Radiology recommends positioning the patient standing or semi-standing with weight on the contralateral leg during duplex ultrasonography 5
• The American College of Radiology suggests performing the Valsalva maneuver to assess for reflux 5
• The American College of Radiology identifies three key sonographic criteria for diagnosis of venous insufficiency:
  • Dilated, tortuous veins >4 mm 5
  • Slow or reversed blood flow (3 cm/s) 1
  • Dilated arcuate veins that communicate with varicosities 5

Additional Imaging

• The American College of Radiology recommends considering contrast-enhanced CT venography or magnetic resonance venography (MRV) for pelvic or iliac vein involvement 4
• The American College of Chest Physicians suggests considering D-dimer testing (though limited utility in cancer patients) or contrast venography (rarely used now due to invasiveness) for cases with suspected deep vein thrombosis 6

Key Diagnostic Findings

• The American Academy of Family Physicians notes that incompetent valves allowing blood to flow in reverse direction are a key diagnostic finding 1
• The American Academy of Family Physicians reports that elongated and tortuous veins due to increased pressure are a key diagnostic finding 1
• The American College of Radiology recommends assessing for reflux during Valsalva maneuver or compression/release testing 4
• The American College of Radiology suggests that a peak systolic velocity ratio >2.5 across stenosis indicates hemodynamically significant obstruction 5

Diagnosing Venous Insufficiency with Imaging

Diagnostic Imaging

• The American College of Radiology recommends considering contrast-enhanced CT venography or magnetic resonance venography (MRV) for suspected pelvic or iliac vein involvement, as MRV can identify stenosis, occlusion, venous atresia, collaterals, edema, webs, trabeculations, and vein wall thickening 7
• Gadolinium-enhanced MRV with contrast is preferred for high intravascular enhancement and high spatial resolution, and three-dimensional volumetric imaging is preferred over MR direct thrombus or time-of-flight subtraction angiography 7
• Ultrasound Doppler examination of IVC and iliac veins can determine patency; if visualization is limited, spectral waveforms can indirectly assess patency, and loss of respiratory phase variation and monophasic physiology in common femoral veins indicate severe iliac vein occlusive disease (high specificity but low sensitivity) 7
• Invasive venography may be necessary before intervention to clarify the nature of disease and guide therapy in complex cases 7