Throughout each examination, the sonographer or examiner should:

• Observe sonographic characteristics of normal and abnormal tissues, structures, and blood flow, allowing necessary adjustments to optimize exam quality.
• Assess and monitor the patient’s physical and mental status, allowing modifications to the procedure plan according to the patient’s clinical status.
• Analyze sonographic findings to ensure that sufficient data is provided to the physician to direct patient management and render a final diagnosis.

Follow a standard imaging protocol per department specific/facility specific anatomic algorithm. A complete venous insufficiency evaluation incorporates B-mode and spectral Doppler with color and/or power Doppler imaging.

• Studies may be unilateral with the use of an appropriate algorithm. However, it is required to compare the common femoral spectral waveform from the contralateral limb, in this event.
• Transverse transducer compressions (when anatomically possible and not contraindicated) should be performed every 2cm to ensure entire vein is assessed.
• Representative images are obtained per lab protocol.

Direct Testing: Duplex Evaluation for Venous Reflux

Interrogation and documentation of compression of the following veins is the minimum requirement:

• Common femoral
• Sapheno-femoral junction (SFJ)
• Proximal femoral
• Mid femoral
• Distal femoral
• Popliteal
• Posterior tibial
• Peroneal
• Great saphenous (GSV)
• Small saphenous (SSV)
• Additional images to document areas of suspected thrombosis

The following veins are included if indicated or required by the facility specific-protocol:

• Inferior vena cava
• Common iliac
• External iliac
• Proximal deep femoral
• Gastrocnemius
• Soleal
• Anterior tibial
• Perforators

When pathology (thrombus or intraluminal echoes) is present:

• B-mode image should demonstrate the degree of compressibility
• Differentiate between partially or totally non-compressible segments
• Appearance, presence of intraluminal echoes
• Document location, extent and echogenicity of thrombus
• Differentiate between unattached proximal tips and attached thrombi.
• Note dilatation or contraction of vein to assist in describing characteristic of aging the thrombus
• Any other pathologies documented

Proper measurements usually include the following or as determined by facility protocol, and should be taken under the following conditions:

• Vein diameter measurements are acquired with the extremity(s) in a dependent position
• Be acquired anterior wall to posterior wall, consistently, as defined by the protocol
• Assure that no external pressure is applied to the vein.
  • GSV at the SFJ
  • GSV just beyond the SFJ
  • GSV at the knee
  • SSV at the sapheno-popliteal junction or level of the sapheno-popliteal junction (40% of the time the SSV does not connect to the popliteal vein)
• Diameter measurements of all accessory saphenous veins, perforator veins ≥ 3.5 mm or other requirements by protocol

Spectral Doppler waveform assessment is performed in the sagittal plane. It is not required to angle correct unless measuring velocities. If angle correction is utilized, 45-60 degree angles should be maintained and aligned with the vessel wall.

Spectral Doppler waveforms for assessing venous reflux showing baseline and response to physiologic maneuvers is documented as required by the protocol and include at a minimum:

• Proximal common femoral vein, bilaterally
• Sapheno-femoral junction (SFJ)
• Mid femoral vein
• Great saphenous vein (GSV) above the knee and below the knee
• Popliteal vein
• Sapheno-popliteal junction (SPJ)
• Small saphenous vein (SSV)
• Suspected areas of venous valvular reflux, including representative spectral Doppler waveforms
• Documented reflux time measured in milliseconds
• Representative color Doppler image is documented as required by the facility protocol
• Any additional sites indicated or required by the facility-specific protocol (e.g., anterior accessory saphenous vein, posterior accessory saphenous vein, extension of the small saphenous vein, varicosities, posterior tibial, peroneal, gastrocnemius veins, etc.
• The order of vessel assessment is dependent upon patient positioning. It is important to identify the presence and define the location of perforating veins. Size and incompetence should be documented when discovered.