Venous Duplex Is Essential in Confirming Venous Insufficiency

Hello, and welcome to the May 2018 issue of Vascular Disease Management. In this issue, there are several outstanding case reports that will be of clinical benefit to our readers. I have chosen to deviate from my standard practice of commenting on one of these articles and have instead decided to comment on the diagnosis of venous insufficiency and discuss the new device options available for the treatment of superficial venous insufficiency.

In this decade, there has been dramatic progress made in the diagnosis and interventional treatment of symptomatic superficial venous insufficiency. Interventional therapy has replaced surgical ligation and stripping as the primary mode of treatment, as it has been demonstrated to have excellent rates of venous closure and less morbidity. Superficial venous insufficiency has become recognized as far more than a cosmetic problem. In its most severe manifestation, venous insufficiency may present as venous ulcers. Typically, prior to ulceration patients experience leg edema, pain, restless legs, and ultimately skin changes. Visible varicose veins are not always noted. Symptoms are typically more pronounced when the patient is upright and somewhat relieved with recumbent position.

The diagnosis of venous insufficiency is confirmed by venous duplex, ideally performed with the patient standing. Duplex examinations performed in supine position without provocation are useful in evaluating deep venous thrombosis (which may of course be a cause of leg pain and edema) but will typically miss the diagnosis of venous insufficiency (deep or superficial.) The ultrasound examination should include a description of the deep and superficial veins with recorded vein size, presence or absence of thrombus, and tortuosity noted. Venous insufficiency is typically considered to be significant when it is greater than 500 milliseconds.

It is imperative that the healthcare provider ordering a venous duplex study indicate that the study is being performed to evaluate for deep venous thrombosis and venous insufficiency or one might receive a report only mentioning that there is or is not deep venous thrombus. Knowledge of venous insufficiency may help the physician correlate the patient’s symptoms and may be helpful when treating conditions such as congestive heart failure, as the edema related to venous insufficiency may render daily weights far less effective in determining intravascular volume overload leading to overuse of diuretics. It
is important to note that the nomenclature has changed in the past decade to more accurately reflect pathology. Previous nomenclature was confusing and has been changed. The superficial femoral vein (now called femoral vein) is actually a deep vein.

Once the diagnosis of symptomatic venous insufficiency has been made, compression hose may provide symptomatic relief but do not treat the underlying venous valvular pathology. Compression hose often provide additional benefit after definitive veno-ablative therapies but may be uncomfortable, particularly in hot climates. Patients may obtain symptomatic relief with leg elevation to facilitate venous drainage.

Definitive therapy of superficial venous insufficiency typically consists of venous sclerotherapy by heat (radiofrequency or laser catheters), mechanical/chemical energy (Clarivein), foam sclerotherapy (Varithena), cyanoacrylate adhesives (Venoseal), or surgery. The most commonly used interventional venous ablative procedures historically utilized thermal ablation. Occasionally, several treatment modalities are used in combination. Thermal treatments typically require tumescent anesthesia to avoid pain and thermal damage to surrounding tissues. Thermal ablation is associated with excellent long-term closure of the insufficient veins. Therapies utilizing foam or cyanoacrylate are more recently approved therapies that do not require tumescent anesthesia. Venous ablative procedures are typically office based, utilizing only local anesthesia at the catheter entry sites (and tumescent anesthesia where required). There is low risk of deep venous thrombosis secondary to superficial venous ablation.

Clinicians must assess for venous insufficiency when there are clinical signs or symptoms such as leg edema, leg pain, restless leg syndrome, venous stasis skin changes, and venous ulceration. Caregivers must diagnose superficial and deep venous insufficiency to properly treat patients. Verification by properly performed venous duplex is essential.