Thread by @CameronAdlerMD

Varicose Veins are a significant cause of morbidity and healthcare expenditure. Follow along to learn more about the sonographic evaluation of venous insufficiency in the lower extremity!

@CameronAdlerMD
@MaitrayPatelMD
@cookyscan1
@RadioGraphics
@RadG_Editor

Understanding venous anatomy is critical to performing a complete and accurate exam. Deep venous anatomy is less variable than superficial venous anatomy.
#RGphx

Superficial venous anatomy is more variable. Understanding the anatomy, drainage into the deep venous system, and common anatomic variants, are important.
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In addition to the larger drainage pathways from the superficial venous system into the deep venous system (SFJ and SPJ), there are numerous tiny perforator veins which are typically not visible unless abnormal.
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Understanding the 4 primary mechanisms of varicose vein formation can improve your understanding and reporting of the exam.
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Some specific patterns of findings on the exam can help determine the etiology of varices, extra evaluation which may be necessary, and whether treatment is appropriate.
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There are many treatment options for varicose veins, but endovenous laser ablation is typically the preferred treatment method when appropriate and feasible.
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It is important to have a thorough protocol with appropriate patient positioning and adequate provocative maneuvers. Complete protocol discussion is too detailed for a tweetorial, please see the full article.
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Insufficiency is most often defined as reflux of at least 500 milliseconds with provocative maneuvers, although some have advocated for a threshold of 1000 milliseconds.
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There are numerous potential pitfalls in the sonographic evaluation of lower extremity varicose veins. Missing deep venous reflux often leads to failed treatment of superficial veins.
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Misidentification of CFV reflux as true deep venous reflux in the setting of GSV insufficiency and no other deep venous insufficiency is a common pitfall. This is actually due to terminal valve insufficiency in the GSV.
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Failure to recognize AAGSV involvement in saphenofemoral insufficiency will lead often lead to incomplete treatment and treatment failure. AAGSV involvement can be easily missed as it is an accessory vein which is not present in a majority of the population.
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Not reporting a very superficial course of the AAGSV or GSV. If not recognized before treatment and appropriate countermeasures are not performed, endovenous laser ablation may result in skin burns.
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Central venous obstruction is hard to recognize, as it can result in lower extremity venous insufficiency and signs are secondary and may not be routinely included in the exam.
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Ineffective provocative maneuvers can result in a false negative study.
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In summary, US is an excellent method for evaluating venous insufficiency in the lower extremities, but is complex and there are many pitfalls to avoid in interpretation.
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I hope you enjoyed this summary! Please check out the complete manuscript for an in-depth overview of the topic, as these exams are complex and may frequently require imaging beyond your standard protocol. Happy new year!