Venous Insufficiency Case/Protocol

Authors: Henry Suarez RDMS, RVT; Richard Garay R.T. (S), RDMS, RVT


Today we have a case to evaluate for the presence of “ venous reflux”.
“Venous reflux” is a common abnormality due to valvular incompetence leading to the condition
known as venous insufficiency.

Venous insufficiency is caused by the backwards flow of blood in the veins returning downward
towards the lower extremities causing an increased intravascular pressure in the veins known
as venous hypertension. The symptoms caused by venous hypertension can range depending on the severity of the
patient’s condition and can include

  • Varicose Veins (with and without pain)
  • Spider Veins
  • Edema (leg swelling)
  • Brawny leg discoloration
  • Ulcers seen in the ankles

Understanding the patient’s history is important information:
Do they have a history of DVT?
A history of cancer or chemotherapy/radiation treatment?
Do varicose veins run in the family?

Our purpose now is to identify and evaluate the presence of reflux in the deep and superficial
venous system (including the perforators).


Prep the patient on the bed in reverse Trendelenburg to increase the hydrostatic pressure in the

Preform a venous duplex exam protocol, while evaluating for reflux.

Begin by evaluating for reflux in the sapheno-femoral junction located in the groin.

Sapheno-Femoral Junction

Ask the patient to perform the valsalva technique by having them bare down and strain.
This should elicit retrograde flow if the SFJ is incompetent. Positive reflux is >0.5 seconds for all superficial veins.
This patient demonstrates a considerably severe reflux in the SFJ (up to 4 seconds) performed w/ valsalva.

Measure the sapheno-femoral junction. In this case it is 8.4mm.

Check For Deep Vein Reflux

Reflux in the deep veins is considered spectral reversal >1 second. Venous reflux (Valvular incompetence) was then demonstrated in the CFV, the femoral vein, and
posterior tibial veins along with an incompetent perforator vein in the right leg.
Measure the wall diameter (varicose >3mm) of the incompetent perforator vein.

You can elicit retrograde flow in the incompentent vein by distal augmentation and/or asking the
patient to perform the valsalva technique (this works best from the going to mid to distal thigh

Great Saphenous Vein

Ask if there’s a history of GSV harvesting. The Great Saphenous Vein (GSV) is evaluated next for incompetence.
This patient demonstrated severe venous reflux in the GSV from the groin to ankle.

Great saphenous vein

Measure the diameter of the incompetent GSV areas in transverse.
In this case we measure the entire length (proximal to distal thigh and proximal to distal calf).
Identify an accessory vein (tributaries of the GSV) for incompetence.

Note: these are often seen as the “varicose veins” in the calves.
This incompetent accessory vein was seen as tortuous vessel from the distal thigh to the ankle
measuring approximately 4.4mm in A/P diameter w/ approximately over 3 seconds of reflux
(flow seen above the baseline)

Small Saphenous Vein

The Small Saphenous Vein (SSV) did not elicit an incompetent response to distal augmentation.
Repeat the protocol now in the left leg
(Venous insufficiency was noted within the same deep veins and GSV groin to ankle.
SSV was patent and competent.
No incompetent perforators were visualized)

Giacomini Vein

When at the SSV check if the Giacomini vein is present and check at mid
thigh for reflux. Note if reflux is coming down from GSV to SSV or from SSV to GSV.
(Giacomini vein cranial extension of SSV that communicates with the GSV via the
posterior thigh circumflex vein.)

If patient has anterior, lateral or posterior medial accessory GSVs assess competence.
If accessory GSV is incompetent then measure the diameter and the straight length. Positive for reflux if >0.5 second
reverse flow with spectral Doppler.

Asses for edema, calcifications, phleoboliths etc.

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