Initial Evaluation

History

A thorough history is very important. Common symptoms include pain, heaviness, restless legs, itching, swelling, bleeding from skin erosions, superficial thrombophlebitis and cosmetic concerns. A family history of venous disease is frequently obtained, and this may alert to the possibility of a familial thrombophilia which may have treatment implications. Vulval varicosities occurring during pregnancy and menstruation suggest incompetence of pelvic and ovarian veins as the underlying pathology. Previous thromboembolic events suggest a secondary cause rather than the more common primary varicose veins. Any benefit perceived from the use of compression stockings should be noted. General health, ability to ambulate and individual patient preference or capacity to tolerate available procedures should be assessed.

Physical Examination

A detailed physical examination is essential and may reveal telangiectasia, reticular veins, varicosities or the presence of more advanced changes associated with chronic venous stasis such as lower extremity oedema, pigmentation, lipodermatosclerosis, thrombophlebitis, cellulitis and ulceration. The distribution of varicosities should also be noted because the pattern may have implications for treatment; for example a high anterior accessory thigh vein is not adequately treated by endovenous saphenous ablation alone and vulval varicosities feeding into medial or posterior thigh varicosities suggest ovarian vein incompetence.

Ultrasound Scan

Ultrasound scanning provides all the information required to understand the pathophysiological abnormalities and indicate the best treatment options. Dr Alan Bray’s vascular laboratory in Newcastle was the first centre in Australia to recognise and promote the value of this investigation for venous disorders.

It can also be important to evaluate the peripheral pulses because of the coexistence of arterial and venous disease and its potential treatment implications. If there is any difficulty in feeling peripheral pulses, especially in the elderly, then a full vascular ultrasound arterial assessment should be obtained.

Table 1
Features evaluated on ultrasound scanning include:

• Great saphenous vein reflux
• Great saphenous vein anatomy (eg duplicated system)
• Diameter of the great saphenous vein
• Distance of the great saphenous vein from the skin
• Small saphenous vein reflux
• Anatomy of the sapheno-popliteal junction
• Perforator incompetence and location
• Presence and extent of superficial thrombophlebitis
• Patency of the deep venous system
• Evidence of prior deep vein thrombosis
• Deep venous system reflux

Ultrasound scanning is the gold standard for evaluating venous disease and assesses all three venous components of the lower extremity – superficial, deep and perforators. It provides accurate information about vein patency, wall characteristics, valve morphology and competence as well as qualitative information about the presence of reflux and obstruction. In most patients, ultrasound scanning is the only diagnostic investigation necessary. Plethysmography and venography are seldom required.