Should I Order Imaging for Suspected Chronic Venous Insufficiency?
Case: a 38-year-old female presents with a 6-month history of bilateral lower leg aching with dry skin and occasional muscle cramps. She works 12-hour shifts as a nurse and thinks her left ankle is a bit swollen by the end of the day. She denies worsening leg pain with exercise and has not noticed any lower leg wounds. She takes no medications. She has no significant past medical history aside from 3 healthy pregnancies. She otherwise feels well, and her last menstrual period was 1 week ago.
What is the most likely diagnosis, even before your physical exam?
Lower limb chronic venous insufficiency.
What is Lower Limb Chronic Venous Insufficiency?
It encompasses a spectrum of abnormalities of the venous system, secondary to venous hypertension and in most cases is caused by venous wall valvular incompetence or obstruction of venous blood flow (1). Superficial valvular incompetence is due to weakened or abnormally shaped valves causing “leaky valves.” Most commonly, the leaky valve is located near the termination of the greater saphenous vein into the common femoral vein (1). Deep vein dysfunction is usually due to a previous DVT which results in inflammation, adhesion, valve scarring, and luminal narrowing – this prevents the proper closure of the valve cusps in the superficial veins. Regardless of the cause, the outcome is the same. Elevated venous hydrostatic pressure = lower extremity aching and edema.
Risk factors: female gender, obesity, smoking, pregnancy, prolonged standing, history of deep venous thrombosis, non-thrombotic iliac vein obstruction (May-Thurner syndrome), and venous injury (1, 2).
Back to the case: Her vitals are stable, and BMI is 27. There are telangiectasias notes around her ankles, and spider veins on the medial aspects of her thighs. There are small varicose veins on her left calf. There is no pitting edema of the lower limbs. Her skin is warm, dry, with normal capillary refill and skin turgor. There is no skin erythema and calf circumference sizes are equal. There is no skin ulceration or wounds. Peripheral pulses are easily palpated bilaterally. Cardiac and respiratory exams are normal.
These findings help confirm the suspicion of chronic lower limb venous insufficiency. Staging of chronic venous insufficiency is classified with the CEAP classification , which can help stratify mild versus moderate to severe disease and can influence testing and treatment decisions.
Signs and symptoms of lower limb chronic venous insufficiency
Differential Diagnosis: Lower Limb Edema
This can be broken down into two major mechanisms of lower limb edema: increased capillary hydrostatic pressure and decreased capillary oncotic pressure (3).
Capillary hydrostatic pressure: the pressure that blood exerts in the capillaries – as blood moves along the capillary, fluid moves out through its pores into the interstitial space. Hydrostatic pressure forces fluid out of the capillary.
Capillary oncotic pressure: driven by plasma proteins (especially albumin) in the blood that draws fluid back into the capillary.
Differential diagnosis of lower limb edema (3).
Is Diagnostic Imaging Needed to Confirm Chronic Venous Insufficiency?
Chronic venous insufficiency is a generally clinical diagnosis, therefore imaging with duplex ultrasonography (DUS) is not required to confirm the diagnosis. However, DUS is very helpful to inform treatment decisions in specific circumstances and can help with diagnostic clarification if diagnostic uncertainty exists.
BOTTOM LINE: Chronic venous insufficiency can be diagnosed clinically.
Venous duplex ultrasound is not required to make the diagnosis, but is helpful to guide treatment recommendations depending on disease severity and symptom burden.
If a patient is asymptomatic or mildly symptomatic and does not want invasive testing like sclerotherapy, you might not need to order any more tests. Start with conservative management and monitor.
As a general overview, DUS evaluates the great saphenous vein and the small saphenous vein and their primary tributaries (4). The goal of DUS is to identify all incompetent truncal veins and to determine whether they are responsible for the patient’s clinical problem (4).
The radiologist will try to answer the following questions:
1) Are the deep veins normal?
2) What is the source or source(s) of reflux or obstruction?
3) What is the path of reflux including tributaries affected, their communication, and size? (5)
Consider Duplex Ultrasonography in the Following Circumstances
1. There are moderate-severe signs and symptoms of chronic venous insufficiency and more intensive treatments are being considered (e.g. sclerotherapy). If a patient is moderately or severely symptomatic, or very bothered by cosmesis of spider veins or varicose veins and is requesting more invasive treatment, DUS is helpful to characterize the patterns of venous incompetence or obstruction (4). Further, it guides treatment for venous insufficiency, including sclerotherapy and endovenous thermal ablation. Precise anatomic and flow mapping is required prior to planning this treatment and DUS is needed for monitoring post-treatment (4).
Source: see link attached
2. The patient wants more intensive treatment for cosmetic reasons. Location of spider veins is important to determine the need for DUS. If a patient has superficial spider veins in typical distributions like the lateral thigh, DUS is generally not required. If spider veins are found in the distribution of a large truncal vein like the great saphenous vein, DUS is recommended. If truncal vein reflux is identified on DUS, treatment of this reflux may be warranted prior to treatment of the spider veins. (4). In general, DUS is not necessary prior to treating telangiectasias, reticular veins or small varicose veins that are not associated with other limb symptoms like swelling, aching, heaviness (6). In other words, if a patient does not have any lower leg symptoms, but is bothered by the appearance of telangiectasias and spider veins, DUS is generally not necessary.
3. If venous leg ulcers are present: DUS can assess the source and severity of chronic venous insufficiency to better inform treatment decisions (6).
4. For patients with a history of DVT who present with persistent leg symptoms (e.g. post-thrombotic syndrome). DUS can assess the source and severity of venous reflux and/or obstruction to better inform treatment decisions (6).
5. If there is diagnostic uncertainty, consider DUS. If findings are normal, revisit your differential diagnosis.
BOTTOM LINE: Consider duplex ultrasonography if:
1. There is diagnostic uncertainty.
2. If patients have moderate to severe symptoms of chronic venous insufficiency and more intensive treatments are being considered.
3. Patients with a history of DVT with persistent leg symptoms.
4. If venous ulcers are present to better inform treatment decisions.
What about ankle brachial index (ABI)? This test is used to assess peripheral arterial disease. Patients with chronic venous insufficiency may have concurrent arterial disease. If you suspect PAD, this is the test of choice to rule in or rule out the diagnosis. If a person is high risk for PAD, an ABI should be completed, especially if compression stockings are being considered as part of venous insufficiency treatment. This can be done in the clinic setting with basic materials (6).
Advanced venous imaging: CT venography, MR venography, or catheter-based venography may be obtained when there is suspicion for iliocaval venous obstruction or compression. Consider this possibility in patients with recurrent VTE, prior VTE with post-thrombotic syndrome, history and physical that support a diagnosis of May-Thurner syndrome, or possible compression from a pelvic or retroperitoneal tumour (6). DUS is still the initial imaging modality of choice.
Back to the case: After discussing the most likely diagnosis of mild lower limb chronic venous insufficiency, your patient tells you she is not bothered by the cosmetic appearance of telangiectasias or spider veins. She is not overly bothered by the aching, but wanted to ensure it wasn’t something “more serious.” With this information, it is decided to forego further testing, and will manage symptoms conservatively with follow up.
References
1. Patel SK, Surowiec SM. Venous Insufficiency. [Updated 2023 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430975/
2. Mathes BM, Kabnich LS. Clinical manifestations of lower extremity chronic venous disease. In: UpToDate, Eidt JF, Mills JL Collins KA (Ed), Wolters Kluwer. (Accessed March 23, 2024).
3. Kittleson, M, Panjrath, G, Amancherla, K. et al. 2023 ACC Expert Consensus Decision Pathway on Management of Heart Failure With Preserved Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2023 May, 81 (18) 1835–1878. https://doi.org/10.1016/j.jacc.2023.03.393
4. Khilnani NM, Min RJ. Imaging of venous insufficiency. Semin Intervent Radiol. 2005 Sep;22(3):178-84. doi: 10.1055/s-2005-921950. PMID: 21326691; PMCID: PMC3036278.
5. Necas M. Duplex ultrasound in the assessment of lower extremity venous insufficiency. Australas J Ultrasound Med. 2010 Nov;13(4):37-45. doi: 10.1002/j.2205-0140.2010.tb00178.x. Epub 2015 Dec 31. PMID: 28191096; PMCID: PMC5024873.
6. Mathes BM, Fukaya E. Diagnostic evaluation of lower extremity chronic venous insufficiency. In UpToDate, Eidt JF, Mills JL, Collins KA (Ed), Wolters Kluwer. (Accessed March 23, 2024).