Lower

Extremity Venous Incompetence Protocol

• First part of study would be a complete venous study to rule out thrombus. If DVT is present, inform the
ordering physician before proceeding with examination. With acute DVT, the exam should be terminated. With
chronic DVT, the exam may be completed. If thrombus is noted in the superficial system, inform the ordering
physician before proceeding with examination. The exam may be terminated or completed depending on the
location of the SVT.

• The optimal exam is performed with the patient standing. Have the patient shift their weight to one side and
evaluate the non-weight bearing leg. If the patient cannot safely stand, perform exam with the patient in
reverse Trendelenburg position (head and body elevated above legs) or sitting with leg hanging off the side of
bed.

• This is a basic protocol to determine the presence and severity of valvular insufficiency. It may need to be
altered due to patient’s anatomy (i.e. duplicated/ accessory veins or SSV not emptying into Pop V). Additional
images may also be needed if pathologies are seen (i.e. varicosities, large perforators, or suspicion of deep calf
vein insufficiency).

Structure Scan Plane Label Images Stored

Identify RT or LT
Common Femoral Vein Sagittal CFV W/ VALSALVA Color & Spectral Doppler with Valsalva
o If reflux is seen, include measurement of
reflux time on spectral waveform
Transverse GSV AT SFJ Measure anterior outer wall to posterior outer wall
Great Saphenous Vein
Junction with Common
Sagittal GSV AT SFJ W/ AUG Color & Spectral Doppler with augmentation
Femoral Vein
o If reflux is seen, include measurement of
(saphenofemoral
reflux time on spectral waveform
junction)
Transverse GSV MID THIGH Measure anterior outer wall to posterior outer wall
Great Saphenous Vein
Mid Thigh Sagittal GSV MID THIGH Color & Spectral Doppler with augmentation
W/AUG o If reflux is seen, include measurement of
reflux time on spectral waveform
Transverse GSV LOWER THIGH Measure anterior outer wall to posterior outer wall
Great Saphenous Vein
Lower Thigh Sagittal GSV LOWER THIGH Color & Spectral Doppler with augmentation
W/AUG o If reflux is seen, include measurement of
reflux time on spectral waveform
Transverse GSV MID CALF Measure anterior outer wall to posterior outer wall
Great Saphenous Vein
Mid Calf Sagittal GSV MID CALF Color & Spectral Doppler with augmentation
W/AUG o If reflux is seen, include measurement of
reflux time on spectral waveform
Transverse GSV LOWER CALF Measure anterior outer wall to posterior outer wall
Great Saphenous Vein
Lower Calf Sagittal GSV LOWER CALF Color & Spectral Doppler with augmentation
W/AUG o If reflux is seen, include measurement of
reflux time on spectral waveform

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 Lower Extremity Venous Incompetence Protocol

Sagittal FV MID W/AUG Color & Spectral Doppler with augmentation

Femoral Vein Mid o If reflux is seen, include measurement of
reflux time on spectral waveform
Sagittal POP V W/AUG Color & Spectral Doppler with augmentation
Popliteal Vein o If reflux is seen, include measurement of
reflux time on spectral waveform
Small Saphenous Vein Transverse SSV AT SPJ Measure anterior outer wall to posterior outer wall
Junction with Popliteal
Vein (saphenopopliteal Sagittal SSV AT SPJ W/AUG Color & Spectral Doppler with augmentation
junction) o If reflux is seen, include measurement of
reflux time on spectral waveform
Transverse SSV MID CALF Measure anterior outer wall to posterior outer wall
Small Saphenous Vein
Mid Calf Sagittal SSV MID CALF Color & Spectral Doppler with augmentation
W/AUG o If reflux is seen, include measurement of
reflux time on spectral waveform
Transverse SSV LOWER CALF Measure anterior outer wall to posterior outer wall
Small Saphenous Vein
Lower Calf Sagittal SSV LOWER CALF Color & Spectral Doppler with augmentation
W/AUG o If reflux is seen, include measurement of
reflux time on spectral waveform

Tips

• An LEV exam is recommended first to clear the leg of thrombus. This may have been done prior to the
insufficiency study being ordered.
• This exam should NOT be done with patient supine. Standing, sitting, or reverse Trendelenburg is required.
Standing is recommended if patient’s condition allows.
• Use something for the patient to stand on and something to help them stay balanced. Patient safety must
always be considered.
• Have patient turn and rotate during exam to make the veins more accessible.
• Work in pairs for this study if possible. One person can work the machine, one can scan.
• Augmentation may be necessary in the small vessels to verify location with color Doppler.
• Take breaks during this exam as needed. The patient will tire quickly and so will you.
• If an automated cuff system with foot pedal is available, use it!! This will free up a hand.
• After augmenting for one image, you must wait a minimum of 30 seconds before evaluating the next segment
of vessel to allow flow to normalize.
• Keep in mind that the strength and duration of compression will affect the amount of blood that is augmented
and therefore the amount of reflux if valves are insufficient/ incompetent.

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 Lower Extremity Venous Incompetence Protocol

Spectral Doppler

• No angle correct is needed

• Gate should be placed in center of vessel. Use reflux seen on color Doppler to aid in placement of the spectral
gate.
• Make sure PRF and filters are set low for slow flow evaluation
• To ensure that the entire amount of retrograde flow is measured, you must show the return to normal,
antegrade flow in your waveform. (There should be a visible beginning and end to the reflux).
• Sweep speeds may need to be adjusted so that each waveform shows:
• Normal flow
• Valsalva or augmentation with or without reflux
• Return of flow or end of reflux
• You will need to decrease the sweep speed in cases of severe reflux.
• Retrograde flow is measured to determine reflux time

Abnormal Reflux Times

• > 1.0 seconds in a deep vein

• > 0.5 seconds in a superficial vein (> 2.0 seconds is severe)
• > 0.35 seconds in a perforating vein

Venous Diameter Measurements

• In the transverse plane, measure the Anterior/Posterior (AP) diameter of the saphenous veins from outer wall to
outer wall being careful not to compress the vein at all
• Keep in mind that vein diameter will vary from patient to patient
• Established abnormal diameter measurements which are highly predictive of reflux include:
• GSV at SFJ exceeding 9 mm
• GSV mid thigh exceeding 7.5 mm
• GSV calf exceeding 5 mm
• Perforator vein exceeding 3-4 mm

Incidental Findings

• Incidental findings should be noted as these may explain patient’s symptoms.

• Examples include edema, significant arterial disease (stenosis or aneurysm), and masses.

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