Diagnosis

Non-invasive Diagnosis Methods

Non-invasive diagnostic methods for venous disease were developed for screening, for quantifying lesions, and for hemodynamic studies. Both the general practitioner and the specialist must, at their different levels, know the significance of the various vascular tests, their indications and limitations, so they can avoid having to prescribe unnecessarily invasive and costly tests.

Because venous disease is so manifold it is somewhat more difficult to evaluate than arterial disease and requires experience and closer evaluation. This means venous tests are much more operator-dependent and require specific clinical skills, particularly in the evaluation of CVI. CVI can be the result of obstruction to venous outflow or reflux, or to a combination of the two. Clinical examination and diagnostic techniques therefore aim to establish which conditions are present. The anatomical location of the alterations must be found and the reflux and/or obstruction must be identified.

There are many simple, rapid and efficient tests available, with good cost-benefit ratios. The diagnostic procedures listed summarily below reflect those set out in the Procedure Operative per Indagini Diagnostiche Vascolari (Operating Procedures for Vascular Diagnostic Investigations) published by the Italian Society for Vascular Investigation, and accepted by the Italian College of Phlebology.

Main investigational techniques

Ultrasound	Continuous-wave (CW) Doppler Duplex scan Echo(color) Doppler (ECD)
Radiographic imaging	angio-computed tomography (CT) scans angio-magnetic resonance (MR) scans
Plethysmography	Quantitative photoplethysmography Phlebography (venography)

Diagnostic process

The aim of the investigation is to check whether there is venous reflux or superficial and/or deep venous thrombosis. Depending on the findings, the diagnostic pathways divide. The deep venous circulation should always be examined.

Ultrasound examination	Ultrasound examination is useful to demonstrate reflux, identify its origin and follow its axis cranio-caudally. After clinical examination, the main screening method for CVI should be CW Doppler.
Echo-Doppler and Echo-color-Doppler	Echo- Doppler and echo color-Doppler should be used to establish the location and the morphology of the problem, and preoperatively.
Phlebography	Phlebography is only needed for a small number of patients who have anatomical anomalies or malformations, or when surgery or endovascular therapy on the deep venous system is indicated.
Grade B Plethysmography	Grade B Plethysmography should be considered as an additional quantitative test. Grade B Investigations of the microcirculation are only indicated in selected patients, mainly for research purposes.
Other Tests	Physiologic tests of venous function are important adjuncts to anatomic imaging of venous disease. The physiologic parameters most often measured are the Venous Refilling Time (VRT) , the Maximum Venous Outflow (MVO) , and the Muscle Pump Ejection Fraction (MPEF) .