Varicose Vein Surgery Workup

No currently available lab test is useful in the diagnosis or therapy of varicose veins.

Patients with varicose veins may have a spuriously positive D-dimer test result because of chronic low-level thrombosis within varices. See the eMedicine topic Deep Venous Thrombosis and Thrombophlebitis for more information.

The duplex ultrasound (US) has become the most useful tool for workup and has replaced many of the physical examination maneuvers and physiological tests once used for diagnosis.

Tests used to rule out deep vein thrombosis obstruction as a cause of varicose veins

• Duplex US: This is noninvasive imaging with good sensitivity and selectivity. See the DVT section for more discussion.
• Perthes maneuver/Linton test: This is a physical examination technique in which a tourniquet is placed over the proximal part of the leg to compress any superficial varicose veins while leaving deep veins unaffected. The patient walks or performs toe-stands to activate the calf-muscle pump which normally causes varicose veins to be emptied. However, if obstruction of the deep system exists, then activation of the calf-muscle pump causes a paradoxical congestion of the superficial venous system and engorgement of varicose veins resulting in a positive test. To verify, the patient is then placed supine, and the leg is then elevated (Linton test). If varices distal to the tourniquet fail to drain after a few seconds, again deep venous obstruction must be considered. This test is rarely performed in practice today with the advent of duplex imaging and assessment of the superficial and deep venous systems.
• Maximum venous outflow (MVO): The MVO is a functional test to help detect obstruction to venous outflow. It can help detect more proximal occlusion of the iliac veins and IVC, as well as extrinsic causes of obstruction in addition to DVTs. MVO uses plethysmography (technique to measure volume changes of the leg) to measure the speed at with which blood can flow out of a maximally congested lower leg when an occluding thigh tourniquet is suddenly removed.^[11]
• Magnetic resonance venography (MRV): The most sensitive and most specific test to find causes of anatomic obstruction. MRV is particularly useful because unsuspected nonvascular causes for leg pain and edema may often be seen on the scan image when the clinical presentation erroneously suggests venous insufficiency or venous obstruction. However, this is an expensive test used only as an adjuvant when doubt still exists.^[11]

Tests used to demonstrate reflux

• Duplex US with color-flow imaging (sometimes called triplex ultrasound): This is a special type of 2-dimensional ultrasound that uses Doppler-flow information to add color for blood flow in the image. Vessels in the blood 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. Venous valvular reflux is defined as regurgitant flow with Valsalva that lasts great than 2 seconds.
• Trendelenburg test: This physical examination technique distinguish patients with reflux at the SFJ from those with incompetent deep venous valves. The leg is elevated until the congested superficial veins have all collapsed. Direct pressure is used to occlude the GSV just below the SFJ. The patient stands with the occlusion still in place. If the distal superficial varicosities remains empty or fills very slowly, the principal entry point of high pressure into the superficial system is at the SFJ. Rapid filling despite manual occlusion means that some other reflux pathway is involved.
• Doppler auscultation: A Doppler transducer is positioned along the axis of a vein with the probe at an angle of 45° to the skin. When the distal vein is compressed, audible forward flow exists. If the valves are competent, no audible backward flow is heard with the release of compression. If the valves are incompetent, an audible backflow exists. These compression-decompression maneuvers are repeated while gradually ascending the limb to a level at which the reflux can no longer be appreciated.
• Venous refilling time (VRT): This is a physiologic test, again using plethysmography. The VRT is the time necessary for the lower leg to become infused with blood after the calf-muscle pump has emptied the lower leg as thoroughly as possible. In healthy subjects, venous refilling is greater than 120 seconds. In patients with mild and asymptomatic venous insufficiency, VRT is between 40 and 120 seconds. In patients with significant venous insufficiency, VRT is abnormally fast at 20-40 seconds. Such patients often complain of nocturnal leg cramps, restless legs, leg soreness, burning leg pain, and premature leg fatigue. A VRT of less than 20 seconds is markedly abnormal, and is nearly always symptomatic. If the VRT is less than 10 seconds, venous ulcerations are likely.^[11]
• Muscle pump ejection fraction (MPEF): 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. The patient performs ankle dorsiflexion 10-20 times, and plethysmography is used to record the change in­­­­­­­­­­­ calf blood volume. In healthy patients, the venous systems will drain, but in patients with muscle pump failure, severe proximal obstruction, or severe deep vein insufficiency, the amount of blood remaining within the calf has little or no change.^[11]

Tests used to define anatomy

• Duplex US

  • Two-dimensional ultrasound 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 waves; blood flowing in a vessel absorbs and scatters ultrasound waves in all directions. The normal vessel appears as a dark-filled, white-walled structure.
  • Duplex ultrasound is a combination of anatomic imaging by 2-dimensional ultrasound and flow detection by Doppler shift. With duplex ultrasound, 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.
  • 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.
• Direct contrast venogram: An intravenous catheter is placed in a dorsal vein of the foot, and radiographic contrast material is infused into the vein. X-rays are then used to obtain an image of the superficial venous anatomy. If deep vein imaging is desired, a superficial tourniquet is placed around the leg to occlude the superficial veins and contrast is forced into the deep veins. Assessment of reflux can be difficult because it requires passing a catheter from ankle to groin, with selective introduction of contrast material into each vein segment. This is a labor-intensive and invasive venous imaging technique with a 15% chance of developing new venous thrombosis from the procedure itself. It is rarely used, and has been replaced by duplex ultrasound. Its use is reserved for difficult or confusing cases.

This classification is based on the clinical, etiological, anatomic, pathophysiological (CEAP) classification from the American Venous Forum, last revised 2004.^[12] It is used to standardize recording of venous disease, as follows:

• Clinical

  • C₀ - No visible or palpable signs of venous disease
  • C₁ - Telangiectases or reticular veins
  • C₂ - Varicose veins
  • C₃ - Edema
  • C_4a - Pigmentation or eczema
  • C_4b - Lipodermatosclerosis or atrophie blanche
  • C₅ - Healed venous ulcer
  • C₆ - Active venous ulcer
  • S – Symptomatic, includes: ache, pain, tightness, skin irritation, heaviness, and muscle cramps, and other complaints attributable to venous dysfunction
  • A - Asymptomatic
• Etiologic classification

  • Ec - Congenital
  • Ep - Primary
  • Es - Secondary (post-thrombotic)
  • En - No venous cause identified
• Anatomic classification

  • As - Superficial veins
  • Ap - Perforator veins
  • Ad - Deep veins
  • An - No venous location identified
• Pathophysiologic classification

  • Basic CEAP
    • Pr - Reflux
    • Po - Obstruction
    • Pr,o – Reflux and obstruction
    • Pn - No venous pathophysiology identifiable
  • Advanced CEAP: Same as basic CEAP, with addition that any of 18 named venous segments can be used as locators for venous pathology
    • Superficial veins: (1) telangiectasias or reticular veins, GSV (2) above knee or (3) below knee, (4) small saphenous vein, or (5) nonsaphenous veins
    • Deep veins: (6) Inferior vena cava, (7) common iliac vein, (8) internal iliac vein, (9) external iliac vein, (10) pelvic veins - gonadal, broad ligament veins, other, (11) common femoral vein, (12) deep femoral vein, (13) femoral vein, (14) popliteal vein, (15) crural veins (anterior tibial, posterior tibial, peroneal veins (all paired)), or (16) muscular veins - gastrocnemial, soleal veins, other.
    • Perforating veins: (17) Thigh or (18) calf

Example: A patient has painful swelling of the leg, and varicose veins, lipodermatosclerosis, and active ulceration. Duplex scanning on May 17, 2004, showed axial reflux of the great saphenous vein above and below the knee, incompetent calf perforator veins, and axial reflux in the femoral and popliteal veins. No signs of post-thrombotic obstruction are present.

• Classification according to basic CEAP: C_6,S, E_p,A_s,p,d, P_r.
• Classification according to advanced CEAP: C_2,3,4b,6,S, E_p,A_s,p,d, P_{r2,3,18,13,14} (2004-05-17, L II).^[12]