Physical Examination, Doppler Ultrasound and Colour Flow Duplex Scanning: Guides to Therapy for Primary Varicose Veins

Abstract

Objective: To compare physical examination (PE) and continuous-wave hand-held Doppler (CWD) examination with colour flow duplex scanning as a gold standard for greater saphenous vein (GSV) reflux. Design: Prospective performance of PE and CWD by two clinical examiners and subsequent duplex scanning by two vascular laboratory technicians unaware of the results of the PE and CWD examinations. Tapes were then reviewed; results of the duplex scanning were compared with physical and CWD findings. Patients: Thirty-one women and nine men, aged 27–64 years, with symptomatic class I primary varicosities in distribution of the GSV. Eighty limbs were evaluated Prospectively in 40 consecutive patients, including 22 limbs in 14 patients with a history of prior GSV stripping. Interventions: GSV ligation and stripping in 50 limbs when duplex demonstrated saphenofemoral or truncal reflux; 30 limbs were treated by stab avulsion, cluster excision and sclerotherapy. Main outcome measures: Demonstration of saphenofemoral reflux by duplex was confirmed by operative findings. Sensitivity, specificity and positive and negative predictive values of PE and CWD were calculated in comparison to duplex scans. Results: For PE, sensitivity ad specificity were 48% and 73%; positive predictive and negative predictive values were 75% and 46%. For CWD, sensitivity and specificity were 48% and 83%; positive predictive and negative predictive values were 83% and 44%. CWD was falsely positive for saphenofemoral reflux in 10 instances. The GSV was spared in these 10 limbs and in 20 other limbs based on negative colour flow duplex examinations. At 12–18 months clinical results were similar in 50 limbs treated by ligation and GSV stripping as compared with 30 treated by stab avulsion, cluster and sclerotherapy. Conclusion: Sensitivity and negative predictive values for PE and CWD were low while specificity and postitive predictive values were high. CWD false postitives were due to insonation of veins close to the bulb or upper superficial femoral vein reflux subsequently detected by duplex scans. Colour flow duplex scanning is recommended prior to intervention for primary saphenous varicosities; exceptions occur in slender subjects where PE and CWD are more specific and predictive for reflux.

Venous Reflux at the Sapheno-Femoral Junction

“…It demonstrates incompetence at the saphenofemoral junction but not incompetence through the sapheno-femoral junction. The limitations of continuous-wave Doppler are well know; assumptions based on Doppler findings may be inaccurate to a certain extent, because of lack of visualization and localization [16][17][18].…”

The Preoperative Duplex Examination

“…Should preoperative duplex be a routine examination, or is it more conveniently limited only to cases the surgeon believes are not adequately diagnosed by clinical and CW Doppler examinations? In a well‐designed study duplex has been shown to correct clinical and CW Doppler diagnosis and modify the surgical procedure in more than 50% of cases 4 . But even if that figure were much lower, there are hardly arguments for operating one's veins without first looking at them.…”

“…Duplex evaluation of varicose veins was first reported in 1986, 2 and by 1991 it replaced phlebography completely in some leading centers 3 . Although later reports also suggested that varicose vein surgery “appears best guided by color flow duplex scanning,” 4 routine use of duplex prior to surgery seems not yet to be a well‐established practice. In a 1994 survey in the US, 18% of vascular technologists did not use duplex for vein mapping, and another 37% did so only occasionally, 5 while in a 1995 British survey only 33% of vascular and 15% of general surgeons used duplex for preoperative evaluation 6 …”

<I>Response to paper by SP Smith</I> Olecranon fractures – a reliable technique for accurate positioning of the tension band wire

“…The most accurate test was the tourniquet + HHD (sensitivity, 0.90; specificity, 0.45). More recently, DePalma et al 3 looked at the accuracy of clinical tests (cough test, tap test) and HHD for diagnosing saphenofemoral incompetence. Reflux was identified by duplex scanning, and subsequently confirmed operatively.…”