Varicose Vein Surgery Workup

No currently available laboratory 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. For more information, see Deep Venous Thrombosis.

Duplex ultrasonography (DUS) has become the most useful tool for workup and has replaced many of the physical examination maneuvers and physiologic tests once used for diagnosis (see below).

Duplex ultrasonography

DUS is a noninvasive imaging modality with good sensitivity and selectivity for ruling out deep venous thrombosis (DVT) in this setting. (See Deep Venous Thrombosis.)

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 paradoxic 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. Currently, with the advent of duplex imaging and assessment of the superficial and deep venous systems, this test is rarely performed in practice.

Maximum venous outflow

Maximum venous outflow (MVO) is a functional test to help detect obstruction of venous outflow. It can help detect more proximal occlusion of the iliac veins and the inferior vena cava (IVC), as well as extrinsic causes of obstruction in addition to DVT. MVO uses plethysmography (a technique for measuring 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. ^[24]

Magnetic resonance venography

Magnetic resonance venography (MRV) is the most sensitive and most specific test for finding 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 that is used only as an adjuvant when doubt still exists. ^[24]

Duplex ultrasonography with color-flow imaging

DUS with color-flow imaging (sometimes called triplex ultrasonography [US]) is a special type of two-dimensional (2D) US 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 longer than 2 seconds.

Trendelenburg test

The Trendelenburg test is a physical examination technique that is used to distinguish patients with reflux at the saphenofemoral junction (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 great saphenous vein (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 the limb gradually ascends to a level at which the reflux can no longer be appreciated.

Venous refilling time

The venous refilling time (VRT) is a physiologic test that uses 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, the VRT is longer than 120 s. In patients with mild and asymptomatic venous insufficiency, the VRT is 40-120 s. In patients with significant venous insufficiency, the VRT is abnormally fast, 20-40 s. Such patients often complain of nocturnal leg cramps, restless legs, leg soreness, burning leg pain, and premature leg fatigue. A VRT shorter than 20 s is markedly abnormal and is nearly always symptomatic. If the VRT is shorter than 10 s, venous ulcerations are likely. ^[24]

Muscle pump ejection fraction

The muscle pump ejection fraction (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 shows little or no change. ^[24]

Duplex ultrasonography

With 2D US, an anatomic picture is generated on the basis of the time delay of ultrasonic pulses reflected from deep structures. Structures that absorb, transmit, or scatter ultrasonic waves appear as dark areas in the image; structures that reflect the waves back to the transducer appear as white areas. 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.

DUS is a combination of anatomic imaging by 2D US and flow detection by Doppler shift. With DUS, after the 2D 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 (with special 13-MHz probes) even tiny lymphatic channels.

Direct-contrast venography

In direct-contrast venography, 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 material 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.

Direct-contrast venography is a labor-intensive and invasive venous imaging technique that carries a 15% risk of new venous thrombosis developing from the procedure itself. It is rarely used in current practice and has largely been supplanted by DUS. Its use is reserved for difficult or confusing cases.

The clinical-etiologic-anatomic-pathophysiologic (CEAP) classification formulated by the American Venous Forum in 1993, revised in 2004 ^[25] and subsequently updated in 2020, ^[26] is used to standardize recording of venous disease. Each of the four components of this classification is assessed individually, and the components are combined to determine the CEAP classification.

The clinical component of the CEAP classification is assessed as follows:

• C0 - No visible or palpable signs of venous disease
• C1 - Telangiectases or reticular veins
• C2 - Varicose veins
• C2r - Recurrent varicose veins
• C3 - Edema
• C4 - Changes in skin and subcutaneous tissue secondary to chronic venous disease
• C4a - Pigmentation or eczema
• C4b - Lipodermatosclerosis or atrophie blanche
• C4c - Corona phlebectatica
• C5 - Healed
• C6 - Active venous ulcer
• C6r - Recurrent active venous ulcer
• S - Symptomatic
• A - Asymptomatic

The etiologic component of the CEAP classification is assessed as follows:

• Ec - Congenital
• Ep - Primary
• Es - Secondary
• Esi - Intravenous secondary
• Ese - Extravenous secondary
• En - No venous cause identified

The anatomic component of the CEAP classification is assessed as follows:

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

The pathophysiologic component of the CEAP classification is assessed in two ways, basic and advanced. The basic approach to this component includes the following:

• Pr - Reflux
• Po - Obstruction
• Pr,o – Reflux and obstruction
• Pn - No venous pathophysiology identifiable

The advanced approach is the same as the basic one, with the additional option that any of 18 named superficial, deep, or perforating venous segments can be used as locators for venous pathology. In the 2004 version of the CEAP classification, ^[25] each of these venous segments had an assigned numeric descriptor (see below); in the 2020 update, ^[26] these descriptors were replaced by their common abbreviations.

The superficial veins that can be used are as follows:

• Telangiectasias or reticular veins (1)
• GSV above the knee (2)
• GSV below the knee (3)
• Small saphenous vein (SSV) (4)
• Nonsaphenous veins (5)

The deep veins that can be used are as follows:

• IVC (6)
• Common iliac vein (7)
• Internal iliac vein (8)
• External iliac vein (9)
• Pelvic veins - Gonadal, broad ligament veins, other (10)
• Common femoral vein (11)
• Deep femoral vein (12)
• Femoral vein (13)
• Popliteal vein (14)
• Crural veins - Anterior tibial, posterior tibial, peroneal veins (all paired) (15)
• Muscular veins - Gastrocnemial, soleal veins, other (16)

The perforating veins that can be used are as follows:

• Thigh (17)
• Calf (18)

The following example illustrates the difference between the two approaches. ^[25] A patient has painful swelling of the leg, and varicose veins, lipodermatosclerosis, and active ulceration. DUS on May 17, 2004, shows axial reflux of the GSV above and below the knee, incompetent calf perforator veins, and axial reflux in the femoral and popliteal veins. No signs of postthrombotic obstruction are present. The basic and advanced CEAP classifications for this patient are as follows:

• Basic CEAP - C6,S, Ep, As,p,d, Pr
• Advanced CEAP - C2,3,4b,6,S, Ep, As,p,d, Pr2,3,18,13,14 (2004-05-17, L II)