Doppler Ultrasound of Lower Limb Veins: Point Protocol and Ready-Made Report Template
Documentation Principles
According to the principles of vascular ultrasound documentation (Society for Vascular Surgery / IAC), the report must meet the requirements of completeness, reproducibility, indicating the conditions and phase of measurement [Blagodir, 2026]. Venous diagnostics rely on precise anatomy and unified nomenclature: the correct naming and localization of the vessel determine both the diagnosis and the phlebologist's strategy.
Report Structure (Rule 2)
The report is structured according to the scheme and must directly answer the clinical question of the referral, rather than repeat the description:
| Element | Content |
|---|---|
| Status | Positive / negative / indeterminate |
| Diagnosis and localization | Nosology with precise attachment to the vein segment |
| Key diameter | Indicating the measurement method |
| Dynamics | Relative to the previous study |
| Recommendation | Control interval or referral |
Description for CVD according to CEAP 2020
CVD is proven insufficiency (reflux/obstruction) with clinical symptoms, not just any varicose veins. The description is conducted according to the CEAP 2020 classification with letter abbreviations of veins (PrSSV, division Esi/Ese, C4c corona phlebectatica, recurrence C2r/C6r). Example formula: “C3,s; Ep; As, Ap; Pr” [Blagodir, 2026].
The report documents:
- duration of reflux with segmental testing;
- diameters and source of reflux;
- perforators;
- depth <5 mm for thermal ablation;
- CEAP formula.
A vein map is mandatory: blue — competent veins, red — incompetent/tortuous tributaries/varicose veins (with leakage and re-entry points) — as a plan for the phlebologist.
Report for Thrombus Description
For a mobile thrombus, mandatory report anchors include: variant (e.g., fixed with a mobile end), fixation point (e.g., posterior wall of the femoral vein), length of the free part, occlusiveness (occlusive/non-occlusive), and proximal boundary. Additionally, the ultrasound physician's strategy is recorded: urgent data transfer to the clinician on the same day, refusal of compression in the thrombus zone; urgent decision on anticoagulation and strategy determination is recommended [Blagodir, 2026].
Report After Venous Intervention
The report after venous intervention must document:
- type and date of intervention;
- treated trunk;
- condition of the stump at the junction;
- presence and extent of thrombus, its relation to the junction and percentage of deep vein lumen coverage;
- AVF-EHIT class (for EHIT/EGIT);
- condition of deep veins and tributaries;
- recommendations.
Example conditions: 52-year-old female patient, scheduled follow-up 4 days after EVLA of the great saphenous vein on the left, linear probe 7–12 MHz, study in the upright position [Blagodir, 2026].
Download Template
The format of the report fields is illustrative; specific fields are adjusted to the institution's template [clarify: file for download].
Frequently asked questions
What is the scheme for structuring a Doppler ultrasound report of veins?
Status (positive/negative/indeterminate) — diagnosis and localization — key diameter with method — dynamics relative to previous — recommendation. The report must directly answer the clinical question of the referral.
Which classification should be used for CVD?
CEAP 2020 with letter abbreviations of veins (PrSSV, division Esi/Ese, C4c corona phlebectatica, recurrence C2r/C6r). Example formula: “C3,s; Ep; As, Ap; Pr”.
What must be indicated when a mobile thrombus is detected?
Variant, fixation point, length of the free part, occlusiveness, and proximal boundary. Data is urgently transferred to the clinician on the day of the study, and the thrombus zone is not compressed.
What vein depth is important for planning thermal ablation?
The report notes a depth of <5 mm for thermal ablation — as a parameter for the phlebologist.
What should be documented in the report after venous intervention?
Type and date of intervention, treated trunk, condition of the stump at the junction, presence and extent of thrombus with percentage of deep vein lumen coverage, AVF-EHIT class, condition of deep veins and tributaries, recommendations.