Diagnosis of chronic venous insufficiency.

An orderly diagnostic approach is needed to establish specific anatomic and etiologic diagnoses in patients with chronic venous insufficiency. It begins with the history and physical examination, including Doppler examination of the veins, in the office. When the severity of the problem warrants further investigation, the vascular laboratory can be used to assess the degree of physiologic change via pressure, volume, and flow studies. Diagnosis of obstructive and incompetent states can be established, and the one distinguished from the other. Ascending phlebography is used to demonstrate the anatomy of the veins, competence of the perforators, and the presence of postthrombotic deep vein changes. Descending phlebography is used in selected cases to diagnose specific incompetence of the valves in the superficial femoral, deep femoral, and greater saphenous veins. A complete venous evaluation defines which veins are patent, where the valves are located and if they are competent, and provides physiologic pressure and volume studies to correlate with the clinical state. Problems caused by primary valve incompetence are separated from those caused by postthrombotic recanalization or occlusion. On the basis of these findings, specific therapy can be tailored to the problem at hand.