Color Doppler ultrasound should be performed with the patient standing
COLOR DOPPLER ULTRASOUND
Color Doppler ultrasound is a special ultrasound device that shows the flow, velocity and direction of blood in the vessel in color, in addition to the gray tones of classic ultrasound . By means of this device, the doctor can determine whether a vessel is occluded, narrowed, dilated or incompetent (reflux). In venous insufficiency, color Doppler ultrasound shows not the valves themselves but their function. If the blood flows upward on Doppler ultrasound, the valves are normal, if the blood flows back to the foot, the valves are deformed and thus, there is venous insufficiency. In Doppler ultrasound, the flow direction can be represented in different colors; in general, the upstream flow is shown in blue and the backward flow is shown in red.
In varicose veins, color Doppler ultrasound also provides an idea of the degree of venous insufficiency by showing the severity and duration of reflux. Varicose veins that are not close to the skin and therefore cannot be seen are easily detected by ultrasound. Color Doppler ultrasound also shows the presence or absence of obstruction in the deep veins, as well as the presence of occlusion of the arteries. All this information allows us to determine whether the patient is suitable for treatment and, if appropriate, which treatment should be administered to which vein.
Unfortunately, color Doppler examination, which provides such valuable information about varicose veins and underlying venous problems, is generally not performed sufficiently or accurately. Personally, speaking, I generally find a 50-60% discrepancy between the patient's color Doppler reports and my own Doppler examination results. This is very important because in some countries, ultrasound is usually performed by radiologists and based on this ultrasound report, other physicians such as surgeons perform the treatment. Therefore, errors and omissions in color Doppler ultrasound examination are directly affect the result of the treatment.
One of the most common mistakes in color Doppler is to perform the examination with the patient lying instead of standing. It must be remembered that reflux in the vein is the flow of venous blood backwards under the influence of gravity, and naturally, the patient must be standing to evaluate the effect of gravity. If the patient is lying during color Doppler ultrasound, the examination may sometimes show reflux in the deep veins besides the superficial veins. This is important because when the ultrasound report states that there is reflux in the deep veins, surgeons think that the patient cannot be treated and recommend only medication and compression stockings. However, when a "good" color Doppler ultrasound is performed in these patients, the deep veins are seen to be normal and can be easily treated. During my professional life, I have seen many patients who were told to have reflux in their deep veins due to incorrect ultrasound examination, and therefore remained untreated. After I performed the ultrasound by myself, I saw that the deep veins were normal in these patients and safely treated the incompetent superficial veins and varicosities.
In color Doppler examination, another common mistake is incomplete investigation. Some physicians search venous insufficiency only in the great saphenous veins and terminate the examination. However, reflux may also originate from the small saphenous vein, perforating veins and pelvics veins, and these regions need to be examined individually. Pelvic vein insufficiency is often overlooked, especially if not carefully searched. For this, the inguinal region should be examined in color mode and the presence of varices around the genital region should be investigated. Pelvic vein insufficiency and genital varices are a common problem in many countries. In a significant proportion of patients thought to have great saphenous vein insufficiency, the problem is in fact pelvic vein insufficiency which induced "secondary" saphenous vein insufficiency. In such patients, if pelvic vein insufficiency is left untreated, it may cause varicose veins to recur in a short time even if the great saphenous vein insufficiency is eliminated.
Color Doppler ultrasound is very important not only in the diagnosis but also in the treatment of varicose veins. Today, all varicose veins treatments except spider veins are performed under the guidance of ultrasound. Therefore, ultrasound knowledge, experience and familiarity of the performing physician is one of the most important factors affecting the success of the procedure. Unfortunately, most of the physicians performing varicose veins treatment do not have formal ultrasound training.
In conclusion, color Doppler ultrasound has dramatically changed the diagnosis, treatment and follow-up of varicose veins. Therefore, physicians who do not have sufficient knowledge and experience on color Doppler ultrasound are not likely to be beneficial to the patients with varicose veins.
In color Doppler ultrasound, normal and reverse flow are shown in different colors and it can be easily understood which vessels are incompetent (reflux).
Color Doppler ultrasound should be performed with the patient standing, not only large saphenous vein, but small saphenous and perforating veins should also be examined, pelvic vein insufficiency and secondary saphenous vein insufficiency should be carefully evaluated and all sections of both legs should be scanned with ultrasound.