Ultrasound Diagnostics in CVD: Reflux Criteria and Venous Mapping ESVS 2022
The Role of Duplex Ultrasound in the ESVS 2022 Algorithm
In the clinical guidelines of the ESVS 2022 for chronic venous disease of the lower limbs, duplex scanning is considered the main method of primary imaging. Its task is broader than confirming varicose transformation: the study should establish the source of reflux, the anatomical path of discharge, involvement of the superficial, deep, and perforating systems, as well as signs of post-thrombotic changes or obstruction.
The practical result of duplex ultrasound is a clinico-anatomical model of the disease suitable for choosing a strategy: conservative treatment, endovenous ablation, sclerotherapy, surgical intervention, correction of tributaries, or additional assessment of the deep venous system.
How to Perform the Study
The examination of veins in CVD is performed under conditions that allow provoking and recording reflux. For superficial veins, this is usually a vertical position or a dependent limb position. Reflux is provoked by the Valsalva maneuver for proximal segments and distal compression with subsequent rapid release for more distal sections.
In the protocol, it is important to record not only the fact of reverse flow but also the segment where it begins, its extent, involved tributaries, the diameter of target trunks in the planned access zone, and features affecting the intervention: tortuosity, superficial location, aneurysmal dilation, thrombosis, post-thrombotic changes.
Criteria for Pathological Reflux
The key measurable parameter is the duration of retrograde blood flow after provocation. ESVS 2022 provides different thresholds for different venous basins; they cannot be mechanically transferred from superficial veins to deep or perforating veins.
| Venous Segment | Pathological Reflux Threshold by Duration | Practical Comment |
|---|---|---|
| Superficial veins, including saphenous trunks | More than 0.5 s | Assess the source, extent along the trunk, and connection with tributaries. |
| Deep veins of the femoropopliteal segment | More than 1.0 s | It is important to distinguish primary deep reflux from post-thrombotic disease and combined lesions. |
| Perforating veins | More than 0.35 s | Significant when associated with varicose tributaries, trophic changes, or ulcer zone. |
In the conclusion, it is undesirable to write only "reflux present." It is necessary to specify the segment, duration, direction of pathological discharge, and hemodynamic connection with the clinical picture.
CEAP and What Ultrasound Provides
ESVS uses CEAP as a common language for describing CVD. Clinical class C reflects visible and clinical manifestations, while ultrasound helps clarify the anatomical component A and the pathophysiological component P: reflux, obstruction, or their combination.
| Class C | Clinical Manifestation | What to Check on Ultrasound |
|---|---|---|
| C0 | No visible or palpable signs | If symptoms are present, exclude hidden reflux or another cause of complaints. |
| C1 | Telangiectasias or reticular veins | Exclude proximal source of discharge before aesthetic treatment. |
| C2 | Varicose veins | Map saphenous trunks, tributaries, perforators. |
| C3 | Edema | Assess superficial and deep reflux, signs of obstruction. |
| C4 | Skin changes of venous origin | Look for combined reflux, perforators in the area of changes, post-thrombotic signs. |
| C5 | Healed venous ulcer | Map reflux sources associated with the area of the former ulcer. |
| C6 | Active venous ulcer | Determine treatable reflux sources and the condition of deep veins. |
Preoperative Mapping of Superficial Veins
Before intervention, the map should answer the operator's questions: where does the pathological discharge begin, which trunk is affected, where does it become competent, which tributaries feed varicose nodes, and are there alternative drainage paths. For the great saphenous vein, describe the saphenofemoral zone, trunk on the thigh and calf, anterior accessory saphenous vein, posterior and medial tributaries. For the small saphenous vein, indicate the saphenopopliteal junction, variant of entry, cranial continuation, and connection with intersaphenous tributaries.
The diameter of the trunk is useful to measure in segments significant for access and method choice. However, the decision should not be based solely on diameter: reflux, clinical presentation, anatomical course, distance to skin, and neurovascular structures are important.
Deep Veins: Reflux, Patency, Post-thrombotic Changes
Assessment of deep veins is mandatory when planning treatment of superficial reflux. It is necessary to confirm patency, compressibility, phasicity of blood flow, presence or absence of post-thrombotic changes, deep valve reflux, and signs of proximal obstruction.
If the clinical presentation is disproportionately expressed compared to data on superficial veins, there is edema, trophic changes, a history of thrombosis, or suspicion of iliac-femoral obstruction, a standard examination of the calf and thigh may not be sufficient. In the logic of ESVS, further imaging is chosen based on the clinical task and method availability.
Perforating Veins
Perforating veins are described not in isolation but in the context of the hemodynamic chain. Important are localization, connection with varicose tributaries, flow direction, and duration of outward discharge. In C4-C6, perforators located in the area of skin changes or ulcers are of particular importance.
The conclusion "incompetent perforators of the calf" without coordinates is of little use for intervention. It is optimal to specify the surface of the calf, level relative to anatomical landmarks, and connection with the superficial varicose reservoir.
Minimum Data Set in the Protocol
- CEAP clinical class, if known from referral or examination.
- Patency of deep veins and presence of post-thrombotic changes.
- Presence of deep reflux with indication of segment and duration.
- Source of superficial reflux: saphenofemoral, saphenopopliteal junction, accessory veins, tributaries, perforators.
- Extent of reflux along each affected trunk.
- Target veins for treatment: course, diameter at significant points, access features.
- Recurrent varicose veins: source of recurrence, neovascularization, residual trunk, tributaries, or perforators.
Typical Errors
The first error is examining only in a lying position: reflux may be underestimated. The second is describing varicose nodes without searching for the proximal source. The third is ignoring deep veins before ablating the superficial trunk. The fourth is the absence of a map of tributaries and perforators, due to which technically successful ablation does not eliminate a clinically significant reservoir.
The ESVS 2022 standard effectively translates duplex ultrasound from a "presence/absence of reflux" format to a navigational study format. This makes the protocol suitable for interdisciplinary decision-making and intervention planning.
Frequently asked questions
What reflux threshold should be used for the great saphenous vein?
For superficial veins, including saphenous trunks, ESVS 2022 uses a pathological reflux threshold of more than 0.5 s.
Is it necessary to examine deep veins if only varicose treatment is planned?
Yes. Before intervention, it is important to confirm the patency of deep veins and assess deep reflux or signs of post-thrombotic changes, as this affects strategy and prognosis.
What must be indicated in the preoperative venous map?
The source of reflux, affected trunk or tributary, extent of discharge, condition of the saphenofemoral and saphenopopliteal zones, significant perforators, patency of deep veins, and anatomical access features.