Clinical features
Nandhitha.M.V 14/7/2025
Symptoms
• Aching or heaviness in legs
• Leg swelling(worse by evening)
• Night cramps, restless legs
• Itching, burning, tingling
• Bleeding from varices (advanced)
Signs
• Dilated tortuous veins
• Ankle edema
• Lipodermatosclerosis
• Hyperpigmentation
• Eczema
• Atrophie blanche
• Venous ulcers (medial malleolus )
CEAP Classification
Clinical , etiological , anatomical, pathological
Hardened painful discoloured plaques
Dilation of the small vessels of
due to subcutaneous fibrosis and
the skin or mucous membranes
inflammation
• C0: no signs of venous disease;
• C1: telangiectasia or reticular veins;
• C2: varicose veins;
• C3: oedema;
• C4a: pigmentation or eczema
painful, recurring ulcers on the lower legs, abnormally dilated blood vessels, typically spider veins
ankles, or feet, which often heal to leave and small varicose veins, around the ankle and foot
• C4b: LDS or atrophie blanche; white, atrophic scars
• C4c Corona phlebectatica
• C5: healed venous ulcer;
• C6: active venous ulcer.
• Ec: congenital;
• Ep: primary;
• Es: secondary (post-thrombotic);
• En: no venous cause identifed
• As: superfcial veins;
• Ap: perforator veins;
• Ad: deep veins;
• An: no venous location identifed.
• Pr: refux;
• Po: obstruction;
• Pr,o: refux and obstruction;
• Pn: no venous pathophysiology identifable.
Investigations of venous
disorders of lower limb
Investigations
Handheld Doppler Ultrasound
Mechanism/Procedure:
A continuous wave 8 MHz Doppler probe is placed at sites like the saphenofemoral junction (SFJ).
Audible signals (e.g., “whoosh” > 0.5 sec during Valsalva manoeuvre) suggest venous reflux.
Biphasic flow = reflux; uniphasic = normal.
Uses :
Varicose veins
Perforator incompetence
Saphenofemoral and saphenopopliteal incompetence
Duplex Ultrasonography (Duplex Scan)
Mechanism/Procedure:
Combines B-mode imaging (anatomy) with Doppler (flow).
Used in standing, lying down, and during Valsalva.
Detects thrombus, reflux, and gives color-coded maps.
“Mickey Mouse Sign” on transverse scan = Femoral artery (lateral) + GSV & FV (medial).
Uses:
Varicose veins
Deep vein thrombosis (DVT)
Venous reflux
Venous Hemodynamic Mapping (VHM / Cartography)
Mechanism/Procedure:
Performed via Duplex US.
Identifies anatomical landmarks like “Saphenous eye” and extent of reflux.
Uses:
Varicose veins
Surgical planning for superficial venous ablation
Recurrent varicose veins
Radioactive fibrinogen test
• Thyroid gland is blocked by sodium iodide 100 mg orally
• IV injection of 100 microcuries of I125 labelled fibrinogen
• Scintillation counter placed over precordium - 100%
• Counting at the lower extremity at 2 inches interval
• Increase > 20% indicates thrombus formation
Plethysmography
Mechanism/Procedure:
Measures volume changes in the leg non-invasively.
Evaluates calf pump function and venous reflux.
Photoplethysmography
Mechanism/Procedure:
Infrared light measures venous filling time after exercise.
Faster filling = venous reflux.
Uses:
Chronic venous insufficiency
Venous reflux (especially superficial veins)
Air Plethysmography
Mechanism/Procedure:
Uses an air-filled cuff on calf to measure volume changes when standing.
Calculates Venous Filling Index (VFI) and Ejection Fraction.
Uses:
Quantifying reflux
Evaluating calf muscle pump
Surgical decision-making in varicose veins
Ambulatory Venous Pressure (AVP)
Mechanism/Procedure:
Invasive test: needle in dorsal foot vein, connected to pressure transducer.
After toe-tip exercises, fall and rise of pressure is measured.
Uses:
Advanced venous hypertension
Predicting ulcer formation
Intravenous Ultrasound (IVUS)
Mechanism/Procedure:
Catheter-based US inside the vein to directly visualize lumen and valves.
Uses:
Complex venous obstruction
Iliac vein compression (May-Thurner syndrome)
