A comparison between descending phlebography and duplex Doppler investigation in the evaluation of reflux in chronic venous insufficiency: a challenge to phlebography as the "gold standard".

To evaluate venous reflux in 56 lower limbs of 32 consecutive patients, hemodynamic tests, ascending and descending phlebography, and supine and erect quantitative duplex scanning were performed and the clinical severity was classified (class 0 = 15, class 1 = 19, class 2 = 8, and class 3 = 14). Of the 56 lower limbs, 22 (40%) had severe swelling and hyperpigmentation with or without ulcer (classes 2 and 3). Adequacy of the clinical severity classification was supported by the hemodynamic results. Radiologic and ultrasound findings were described by axial grading, multilevel/multisystem point, and multisegment scoring systems. Applying these evaluation systems, the phlebographic and scan results correlated poorly. There was no relationship between the radiologically obtained average reflux grade or points and the clinical severity. An erect quantitative duplex Doppler test assessed by the multisegment scoring system correlated best with the severity classification. The predictive value of this test to diagnose severe reflux leading to severe symptoms (classes 2 and 3) was 77% compared with 35% to 44% for descending phlebography. The study suggests that erect quantitative segmental duplex Doppler reflects the degree and distribution of venous reflux more accurately than does descending venography.