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JOURNAL OF VASCULAR SURGERY

May Supplement 2011

tiate from diabetic neuropathy or any underlying neurologic problem. An abdominal mass or lymphadenopathy may be a clue to venous compression and outflow obstruction.

Corona phlebectatica (ankle flare or malleolar flare) is a fan-shaped pattern of small intradermal veins located around the ankle or the dorsum of the foot. This is considered an early sign of advanced venous disease. The pattern of the varicose veins should be established, because perineal, vulvar, or groin varicosity can be a sign of iliac vein obstruction or internal iliac vein or gonadal vein incompetence causing pelvic congestion syndrome. Scrotal varicosity may be a sign of gonadal vein incompetence, left renal vein compression between the superior mesenteric artery and the aorta (nutcracker syndrome), or occasionally, even IVC lesions or renal carcinoma. Varicose veins of the upper thigh can be caused by inferior gluteal vein reflux.72,73

Classic tourniquet tests for saphenous or perforator incompetence or deep venous occlusion (Trendelenburg test, Ochsner-Mahorner test, Perthes test)71 are rarely used today; they are mostly of historic interest and should be used in rare instances, when duplex scanning or Doppler studies are not available. Distal palpation and proximal percussion of the saphenous vein, however, are useful tests to suggest valvular incompetence.

Skin lesions, such as capillary malformations, tumors, onychomycosis, or excoriations, should be noted and a complete pulse examination performed to exclude underlying peripheral arterial disease. An aneurysmal saphenous vein can be misdiagnosed as a femoral hernia or vice versa. The presence of a longer limb, lateral varicosity noted soon after birth, and associated capillary malformations are tip-offs for congenital venous malformation (Klippel-Trénaunay syndrome),74,75 whereas edema of the dorsum of the foot, squaring of the toes, thick skin, and nonpitting edema are signs of chronic lymphedema. The physical examination can be complemented by a handheld Doppler examination, although the latter does not replace evaluation of the venous circulation with color duplex scanning.

The Guideline Committee recommends using the basic CEAP classification76,77 (see Classification of chronic venous disorders later in the Guidelines) to document the clinical class, etiology, anatomy, and pathophysiology (CEAP) of CVD (Tables II and III). We also recommend use of the revised Venous Clinical Severity Score (VCSS)78 to grade the severity of CVD (see Outcome assessment; Table IV).

The aim of the clinical evaluation is not only to determine the presenting signs and symptoms and the type of venous disease (primary, secondary, congenital) but also to exclude other etiologies, including peripheral arterial disease, rheumatoid disease, infection, tumor, or allergies. The physician should also establish the degree of disability caused by the venous disease and its impact on the patient’s QOL.

Table II. The CEAP classification

Adapted from Eklöf et al.77 Used with permission.

Duplex scanning

Duplex scanning is recommended as the first diagnostic test for all patients with suspected CVD.5,79 The test is safe, noninvasive, cost-effective, and reliable. It has much better diagnostic accuracy in the assessment of venous insufficiency than continuous-wave Doppler ultrasonography.80 B-mode imaging permits accurate placement of the pulsed Doppler sample volume, and the addition of color makes it easier to establish obstruction, turbulence, and the direction of venous and arterial flow.44 Duplex scanning is excellent for the evaluation of infrainguinal venous obstruction and valvular incompetence.81 It also differentiates between acute venous thrombosis and chronic venous changes.82,83

Technique of the examination. The technique of venous duplex scanning has been described in detail previously by several authors.80,83-88 The pulsed-wave Doppler of 4 to 7-MHz linear array tranducers are used most frequently for the deeper veins, with the higher-frequency probes used more to assess the superficial veins. Evaluation of reflux in the deep and superficial veins with duplex scanning should be performed with the patient upright,