Podiatric Vein Care
Performing Diagnostic Doppler Ultrasound on the Venous Patient

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Jodi Schoenhaus, DPM

Clinical Insights April 25, 2019

The diagnostic ultrasound is to be performed on patients with a suspicion of venous insufficiency and reflux. The deep system, superficial system and perforating veins are to be examined. You can refer the patient to a diagnostic center or perform the study in your office. It is common to have a Registered Venous Technician do the study. However, as a doctor, you can become certified through the Registered Phlebology Sonographer program.  A common pitfall with getting a standard prescription for ultrasound evaluation filled correctly is that the ultrasound on the superficial system is often improperly performed with the patient supine. For evaluation of superficial venous insufficiency and reflux, the patient must be standing.

The patient should be wearing loose fitted shorts and the ultrasound is performed in a stepwise approach, being consistent every time.

Diagnostic imaging on the deep system is performed with the patient supine. Common femoral, popliteal, and the posterior tibial veins should all be evaluated for color flow change, complete filling on color Doppler, compressibility of the vessel and any change in echogenicity within the vessel lumen or wall.  This is performed from the groin to the ankle moving distally and taking recordings every few inches.

Next the patient stands and the examination is started at the common femoral junction. Evaluation of reflux is performed by measuring the vein diameter and performing a squeeze test to observe color flow direction changes on Doppler and measurement of duration of reflux. Evaluation for reflux of the common femoral vein and the greater saphenous vein (GSV) are performed at the saphenofemoral junction. The GSV is evaluated midthigh, below the knee and distal leg. Next, the saphenopopliteal junction is identified and the popliteal, small saphenous vein (SSV), perforating veins medially and the perforating peroneal vein anterolateral are tested. Other tributaries such as the Accessory Saphenous Vein should also be tested. If you are uncertain where the reflux is stemming from, you can always trace a cluster of varicosities back to its main branch origin.  In the presence of a venous ulceration, it is recommended to directly scan over the ulcer (with a probe cover) and visualize the perforating vein leading to the surface wound. 

Physicians who are interested in performing the ultrasound Doppler evaluation have a benefit in being able to truly visualize the vein map that requires treatment. When an outside ultrasonographer performs the venous ultrasound, it has been shown that there is a significant amount of missed pathology, mostly in the perforating system This is a critical point, as it is normally the perforating system of the lower leg that leads directly to the venous ulceration.

If there is no reflux or vein insufficiency, cosmetic treatments can be initiated. If reflux is identified, this underlying insufficiency is addressed first and foremost.