With suspected venous disease, ultrasound is the first step to explore whether further diagnostics are warranted. If so, venography via computed tomography (CT) or magnetic resonance imaging (MRI) can be used to help design therapeutic or surgical strategies to treat the abnormality. Although oral contrast is sometimes used, venography usually requires the injection of contrast material which itself can cause deep vein thrombosis. This risk is small and is much less hazardous than allowing venous disease to remain undiagnosed.

Veins anywhere in the cardiovascular system can present with chronic venous disorders that interfere with functional return of deoxygenated blood to the heart and threaten the tissue affected by the compromise of venous drainage. When venous drainage is not optimal, the normal gaseous exchange between arterial and venous interaction at the tissues (oxygen and carbon dioxide) can fail, leading to injury of the tissues involved in this failure.

Age and immobility are two frequent causes of venous disorders. The valves within veins, which keep blood from backing up, can deteriorate with age in some people. They can also be destroyed by clots (thrombi), which leads to venous insufficiency and to increased pressure from the pooled blood (venous hypertension).  Immobility prevents the pumping action of the legs from contributing to the flow upwards toward the heart.

Chronic Venous Disorders are classified by a system based on:

• Clinical signs.

• Etiology.

• Anatomy.

• Pathophysiology.

Chronic Venous Disease

Chronic venous disease refers to abnormalities in venous structure or function that present symptoms or signs requiring further investigation or treatment:

• Extremity tingling.

• Pain, aching, or burning.

• Skin irritation or changes.

• Dilated veins (telangiectasias, varicosities).

• Clinical edema.

• Ulceration.

Chronic Venous Insufficiency

Chronic venous insufficiency refers to chronic venous disease with more serious clinical signs, such as significant edema and changes in the skin, including ulceration.

Diagnosis using Venous Venography

Duplex Ultrasound

Venous venography is used to identify and plan therapeutic protocols for venous insufficiency, venous hypertension, thrombosis, and varicose developments. Prior to that, the accuracy, affordability, and non-invasive nature of ultrasound is used as a both a screen and as a first step when signs and symptoms of a venous disorder present.

Duplex ultrasound is the combination of two ultrasonic technologies:

• B (brightness) mode: To reflect sound waves off of tissues of different densities to render an image of structure.

• Doppler flow ultrasonography: To evaluate motion of blood flow and to identify venous stasis and sluggishness or obstruction to this flow.

Venous Venography

For patients who have venous insufficiency but uncertain ultrasound findings, a catheter can be used to enhance the imaging used in multidetector computed tomography (MDCT) or magnetic resonance (MR) venography. These techniques are used for confirming inconclusive venous disease, imaging difficult areas to visualize ultrasonographically, or for planning surgical interventions.

For suspicion of thrombosis in deep venous systems, such as the hepatic portal system or the intestinal mesenteric veins, MDCT and MR venography are needed to make a definitive diagnosis. These venous channels and their tributaries are simply too deep for ultrasound accuracy in conditions for which accuracy is crucial to prevent disastrous events such as bowel ischemia or liver complications (portal hypertension and other liver-related illness).

Arteriography

In some circumstances, arterial disease is either the precursor or the cause of venous disease, and persons with risk factors for peripheral arterial disease (smokers, diabetics, hypertensive, hyperlipidemia) should have arterial imaging included in the venous diagnostic approach.

Blood Tests

When thrombosis within veins is diagnosed, blood tests for coagulation problems (hypercoagulability) are done which will both identify predisposing clotting disorders as well as serve to monitor the levels of anticoagulation medications used to dissolve the clot(s) or prevent their extension.

Medical management and treatment of Venous Disorders

The presence of venous insufficiency without thrombotic complications can initially be treated very conservatively:

• Leg elevation.

• Compression stockings.

• Scrupulous management of any ulcerations.

• Mobility.

Leg elevation prevents up to 40% of blood volume to pool in the leg’s veins. Compression stockings keep fragile veins at minimal diameter, reducing the amount of blood retained in them. Mobility helps re-establish the compression/decompression of leg muscles that act as a pump for upward propelling of blood back to the heart.

If there are ulcers, management and treatment involve cultures to identify or rule out infections that can be treated with antibiotics and debridement of any necrotic tissue that can jeopardize adjacent tissue and promote spread of the ulceration. Proper dressing is required to keep the ulcer bed moist for its best healing prospects.

Invasive management and treatment of Venous Insufficiency

When medical management fails, addressing the veins directly may be indicated by ablating (destroying) them chemically with sclerosing agents or surgically removing them. Vein destruction or removal reduces the amount of blood in the failing venous system, which helps prevent progression of varicosities and other chronic venous disease.

Management and treatment of Thrombosis

Thrombosis (clot formation) is a much more serious development. It can cause venous disease or be a result of it. Regardless, thrombi represent imminent dangers:

• Obstruction to venous flow.

• Risk of separation and migration to the lung circulation. Resulting in dyspnea or death from pulmonary emboli, or right ventricular disease (“cor pulmonale“) which is heart disease due to pathological lung conditions.

Thrombosis requires anticoagulation, using anticoagulants such as warfarin or clopidogrel (Plavix); in thrombosis of crucial venous channels that risk organ damage, surgery or interventional catheterization techniques may be required in conjunction with reversing any therapeutic anticoagulation beforehand. If emboli are frequent and originating from deep vein thrombosis (DVT) in the legs, a filter can be placed in the vena cava as a weir to prevent life-threatening pulmonary emboli.