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Varicose Veins and Spider Veins Workup

  • Author: Robert Weiss, MD; Chief Editor: William D James, MD  more...
Updated: Dec 08, 2015

Laboratory Studies

Laboratory tests are not useful for patients with varicose veins.


Imaging Studies

The goal of imaging studies is to identify and map all areas of acute or chronic obstruction and all areas of reflux within the deep and superficial venous systems. Successful imaging of the deep venous system requires a thorough knowledge of venous anatomy and physiology and a meticulous attention to detail. The most useful modalities available for venous imaging are contrast venography, magnetic resonance imaging (MRI), and color-flow duplex ultrasonography.

Duplex ultrasonography

Duplex ultrasonography is the standard imaging modality for diagnosis of varicose insufficiency syndromes and for treatment planning and preoperative mapping.

Two-dimensional ultrasonography forms an anatomic picture based on the time delay of ultrasonic pulses reflected from deep structures. Structures that absorb, transmit, or scatter ultrasonic waves appear as dark areas; structures that reflect the waves back to the transducer appear as white areas in the image. Vessel walls reflect ultrasound; blood flowing in a vessel absorbs and scatters ultrasound in all directions. The normal vessel appears as a dark-filled white-walled structure.

Duplex ultrasonography is a combination of anatomic imaging by 2-dimensional ultrasound and flow detection by Doppler-shift. With duplex ultrasonography, after the 2-dimensional anatomic image is displayed, a particular spot in the image can be selected for Doppler-shift measurement of flow direction and velocity.

Color-flow imaging (sometimes called triplex ultrasonography) is a special type of 2-dimensional ultrasonography that uses Doppler flow information to colorize areas of the image in which flow has been detected. Vessels in which blood is flowing are colored red for flow in one direction and blue for flow in the other, with a graduated color scale to reflect the speed of the flow. Modern color-flow duplex ultrasonography equipment can provide flow information in conjunction with surprisingly high-resolution views of both deep and superficial venous systems. Structural details that can be observed include the most delicate venous valves, small perforating veins, reticular veins as small as 1 mm in diameter, and (using special 13-MHz probes) even tiny lymphatic channels.

Magnetic resonance venography (MRV)

Magnetic resonance venography (MRV) is the most sensitive and most specific test for deep and superficial venous disease in the lower legs and in the pelvis, where other modalities cannot reach. MRV is particularly useful because unsuspected nonvascular causes for leg pain and edema may often be observed on the MRV scan when the clinical presentation erroneously suggests venous insufficiency or venous obstruction.

Direct contrast venography

Direct contrast venography is the most labor-intensive and invasive imaging technique. In most centers, it has been replaced by duplex ultrasonography for routine evaluation of venous disease, but the technique remains extremely useful for difficult or confusing cases.[5]

An intravenous catheter is placed in a dorsal vein of the foot, and radiographic contrast material is infused into the vein. If deep vein imaging is desired, a superficial tourniquet is placed around the leg to occlude the superficial veins and force contrast into the deep veins more quickly.

Assessment of reflux by direct contrast venography is a difficult procedure that requires passing a catheter from ankle to groin with selective introduction of contrast material into each vein segment.

Nearly 15% of patients undergoing venography for detection of deep venous thrombosis (DVT) develop new thrombosis after contrast venography. The incidence of contrast-induced DVT in patients who undergo venography for diagnosis and mapping of varicose veins is not known.


Other Tests

Color-flow ultrasound imaging has become accepted as the standard for evaluation of venous anatomy and gross physiology. For many patients, color-flow imaging alone may be sufficient. For complex cases, however, physiologic tests of venous function may reveal more information. Physiologic parameters most often measured are the venous refilling time (VRT), the maximum venous outflow (MVO), and the calf muscle pump ejection fraction (MPEF). The availability of small, relatively inexpensive Duplex ultrasound imaging has reduced the need for physiologic testing.

Venous refilling time

The venous refilling time is the time necessary for the lower leg to become suffused with blood after the calf muscle pump has emptied the lower leg as thoroughly as possible.

When perfectly healthy patients are in a sitting position, venous refilling of the lower leg occurs only through arterial inflow and requires at least 2 minutes.

In patients with mild and asymptomatic venous insufficiency, some venous refilling occurs by means of reflux across leaky valves. These asymptomatic patients have a VRT that is 40-120 seconds.

In patients with significant venous insufficiency, venous refilling occurs through high-volume reflux and is fairly rapid. These patients have an abnormally fast VRT of 20-40 seconds, reflecting retrograde venous flow through failed valves in superficial and/or perforating veins. This degree of reflux may or may not be associated with the typical symptoms of venous insufficiency. Such patients often report nocturnal leg cramps, restless legs, leg soreness, burning leg pain, and premature leg fatigue.

A venous refilling time of less than 20 seconds is markedly abnormal and is due to high volumes of retrograde venous flow. High-volume reflux may occur via the superficial veins, the large perforators, or the deep veins. This degree of reflux is nearly always symptomatic. If the refilling time is shorter than 10 seconds, venous ulcerations are so common as to be considered virtually inevitable.

MVO measurement

The MVO measurement is used to detect obstruction to venous outflow from the lower leg, regardless of cause. It is a measure of the speed with which blood can flow out of a maximally congested lower leg when an occluding thigh tourniquet is suddenly removed.

The advantage of MVO testing is that it is a functional test rather than an anatomic one, and it is sensitive to significant intrinsic or extrinsic venous obstruction from any cause at almost any level. It can detect obstructing thrombus in the calf veins, the iliac veins, and the vena cava, where ultrasonography and venography are insensitive. It also detects venous obstruction due to extravascular hematomas, tumors, and other extrinsic disease processes.

The disadvantage of the test is that it is sensitive only for significant venous obstruction and does not detect partially obstructing thrombus. It is not useful for detection of venous insufficiency states. A normal MVO absolutely does not rule out deep vein thrombosis.

MPEF test

The MPEF test is used to detect failure of the calf muscle pump to expel blood from the lower leg.

MPEF results are highly repeatable but require a skilled operator to obtain clean meaningful tracings. The patient is asked to perform 10-20 tiptoes or dorsiflexions at the ankle, and the change in some physical parameter that reflects calf blood volume is recorded as the calf muscle is pumped.

In patients without varicose veins, 10-20 tiptoes or ankle dorsiflexions cause the venous capacitance circuit of the calf to be emptied.

In patients with muscle pump failure, severe proximal obstruction, or severe deep vein insufficiency, tiptoes or ankle dorsiflexions have little or no effect on the amount of blood remaining within the calf.

Contributor Information and Disclosures

Robert Weiss, MD Associate Professor, Department of Dermatology, Johns Hopkins University School of Medicine

Robert Weiss, MD is a member of the following medical societies: American Academy of Cosmetic Surgery, American Academy of Dermatology, American College of Phlebology, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, MedChi The Maryland State Medical Society

Disclosure: Received honoraria from Angiodynamics for speaking and teaching; Received intellectual property rights from CoolTouch Corp for consulting; Received grant/research funds from Cynosure for independent contractor; Received grant/research funds from Palomar for independent contractor.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

John G Albertini, MD Private Practice, The Skin Surgery Center; Clinical Associate Professor (Volunteer), Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine; President-Elect, American College of Mohs Surgery

John G Albertini, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery

Disclosure: Received grant/research funds from Genentech for investigator.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Kelly M Cordoro, MD Assistant Professor of Clinical Dermatology and Pediatrics, Department of Dermatology, University of California, San Francisco School of Medicine

Kelly M Cordoro, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Medical Society of Virginia, Society for Pediatric Dermatology, Women's Dermatologic Society, Association of Professors of Dermatology, National Psoriasis Foundation, Dermatology Foundation

Disclosure: Nothing to disclose.


Craig F Feied, MD, FACEP, FAAEM, FACPh Professor of Emergency Medicine, Georgetown University School of Medicine; General Manager, Microsoft Enterprise Health Solutions Group

Craig F Feied, MD, FACEP, FAAEM, FACPh is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Phlebology, American College of Physicians, American Medical Association, American Medical Informatics Association, American Venous Forum, Medical Society of the District of Columbia, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

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Patient with large tortuous varicose veins, high-volume venous reflux, and early stasis changes of the medial ankle.
Typical chronic medial leg ulceration associated with long-standing venous insufficiency. The ulcer had been present for 12 years and was refractory to every treatment approach until treatment of the refluxing superficial varices was performed. Treatment consists of endovenous ablation, foam sclerotherapy, or ambulatory phlebectomy.
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