PRACTICE GUIDELINES

advancing vein care

Duplex Ultrasound Imaging

Duplex Ultrasound Imaging Of Lower Extremity Veins in

Chronic Venous Disease, Exclusive of Deep Venous Thrombosis:
Guidelines for Performance and Interpretation of Studies

These American College of Phlebology Indications for Duplex Doppler

guidelines for lower extremity ultrasound Ultrasound Studies in Chronic
venous imaging describe minimum standards Venous Disorders:
for imaging protocols and reporting as Duplex ultrasound imaging is the most
well as qualifications for those individuals commonly used investigation to evaluate
performing and interpreting these studies. the venous system prior to management of
The accuracy of the non-invasive venous chronic venous disorders (CVD) of the lower
study depends on the knowledge, skill and extremities. After a focused history and a
experience of the technologist or physician physical examination, a request should be
made for a duplex ultrasound exam. Duplex
performing the studies, and the knowledge,
ultrasonographic imaging is indicated in
skill and experience of the physician patients seeking treatment for primary or
interpreting the studies. recurrent venous insufficiency (varicose veins)
and in patients with lower extremity symptoms
The ultrasound investigation in patients with or signs suggestive of venous disorders.
chronic venous disease (CVD) is very different
from examinations to rule out deep vein The duplex ultrasound examination in CVD
thrombosis. Most examinations for CVD are for patients should demonstrate both venous
diagnosis and planning for treatment of venous anatomy and function. The following facts
insufficiency. The information gathered by the should be determined during the standing
duplex investigation has a significant impact on examination:
what type of treatment will be most appropriate
and therefore recommended. Failure to identify 1. The location, competency and diameter
and treat all sources of reflux may result in of the saphenous junctions.
outright treatment failure. Duplex ultrasound 2. The distal extent of reflux in the
is essential to the performance of endovenous saphenous veins in the thighs and legs.
ablative procedures including endovenous laser, Recording the saphenous diameter
radiofrequency occlusion, and ultrasound- at the mid-thigh and at the knee is
guided sclerotherapy. The examination may be desirable.
used for outcome assessment after treatment. 3. The location of incompetent perforating
veins as measured from the floor.

1 Practice Guidelines: Duplex Ultrasound Imaging rev61312

 4. Other named and unnamed veins Evaluation of the deep venous system of the
that show reflux or are varicose thigh may be carried out with the patient supine
should be noted. or in a reverse Trendelenburg position. The
5. The source of venous hypertension flexed leg may be externally rotated for better
in varices if not from the veins access to the deep venous circulation. Access
described above. to the popliteal vein or posterior calf veins may
6. Saphenous veins that are absent, be performed by way of a posterior approach
totally occluded, hypoplastic or atretic with the patient in a lateral decubitus position.
should be noted.
7. The state of the deep venous system, Reporting of Results
including valvular competence and The report should clearly state the reason for
evidence of current or previous the ultrasound examination. A diagrammatic
venous thrombosis. representation of the findings is highly
desirable. A textual report is required. The
Qualification to perform and/or interpret report should include information about the
duplex ultrasound imaging does not constitute location of sources of venous reflux, status
qualification to perform endovenous ablation of the saphenous junctions, function of the
procedures. Additional training in those saphenous veins and the deep venous system.
techniques is mandatory. Inclusion of selected images from the study is
recommended. A video recording does not
Equipment usually form part of the report.
Use of appropriate duplex instrumentation,
which uses both B-mode imaging and real Qualifications
time Doppler ultrasound, is required. A color The appropriate use and interpretation of non-
duplex ultrasound instrument is recommended. invasive venous studies requires knowledge of
Imaging probes of 7-15 MHz are appropriate venous anatomy, physiology, hemodynamics,
for obtaining good quality images of the venous and the clinical manifestations of venous
system of the legs. Doppler frequencies of disease. In addition, knowledge of ultrasound
at least 3 MHz and hardcopy documentation physics, indications for testing, criteria for
of the examination are recommended. Static diagnosis of venous reflux and thrombosis,
images must be archived. technical limitations of the study and an
understanding of the skills necessary to perform
Patient Positioning the studies.
Evaluation of the superficial system is best
performed on the non-weight bearing extremity Suggested minimum qualifications for the
with the patient standing. The supine position physician performing and/or interpreting
is inappropriate for detection of reflux and studies include the following, which relate
measurement of vein diameters. chiefly to interpretation of examinations:

Examination of calf veins may be performed A. Hold an active medical license.

with the patient in either the sitting or standing B. Clinical experience in phlebology or
position. For examination of the tibial and calf related vascular specialty.
vessels, the patient may need to be tilted or the leg C. Training and understanding of
dangled over the side of the examination table. venous anatomy, physiology and
hemodynamics, ultrasound physics and

2 Practice Guidelines: Duplex Ultrasound Imaging

 instrumentation. Evidence of training in performing the examinations is required. The
residency, fellowship, or postgraduate physician should perform a minimum of 100
CME course work that includes these examinations per year in order to maintain
items is required. This should include: performance skills. 
supervised experience in an approved
training program in which non-invasive Suggested minimum qualifications for the
venous studies are an integral part of sonographer performing studies include the
the experience with a minimum of 50 following:
cases. Or, in the absence of the formal
training during residency or fellowship, A. Training in venous anatomy, physiology,
the physician should have experience hemodynamics, ultrasound physics and
with at least 100 documented cases. instrumentation. Evidence of formal
D. CME with specific reference to venous training in a supervised setting and
disease including imaging should be continuing CME course work, which
maintained at a minimum of 15 credit includes these principles, is required.
hours every 3 years. B. Qualification to perform these studies
E. Continuing experience is important to is best demonstrated by certification or
maintaining competence; a minimum eligibility for certification by a nationally
of 100 examinations per year is recognized certifying body, such as
recommended to maintain a physician’s the Registered Vascular Technologist
interpretation skills. (RVT) credential offered by American
F. Regular interaction with a sonographer, Registry of Diagnostic Medical
if applicable, to ensure continuous Sonographers (ARDMS) or the
quality control and improvement is Registered Vascular Specialist (RVS)
desirable. credential offered by Cardiovascular
Credentialing International (CCI).
The clinical experience and training above C. CME minimum requirements should be
relate primarily to interpretation of studies. 30 hours every 3 years.
Additional skills training by the physician in

Practice Guidelines: Duplex Ultrasound Imaging 3

References
The American College of Phlebology guidelines are largely based on the International Union of Phlebology’s
Consensus Documents on Duplex Ultrasound Investigation of Veins in Chronic Venous Disease of the Lower
Limbs. These consensus documents, as well as other materials reviewed in forming the ACP guidelines
included but were not limited to:

1. Cavezzi et al. Duplex Ultrasound Investigation of the Veins in Chronic Venous Disease of the Lower Limbs – UIP
Consensus Document. Part II Basic Principles. Eur J Vasc Endovasc Surg 2006;31:288-99.
2. Coleridge-Smith et al. Duplex Ultrasound Investigation of the Veins in Chronic Venous Disease of the Lower
Limbs – UIP Consensus Document. Part I Anatomy. Eur J Vasc Endovasc Surg 2006;31:83-92.
3. MedPAC recommendations of imaging services, statement of executive director March 2005
4. ACC/ACP/SCAI/SVMB/SVS Clinical Competence Statement on Vascular Medicine and Catheter-Based
Peripheral Vascular Interventions – J Am Coll Cardiol 2004;44(4):941-57.
5. ACR practice guideline for performing and interpreting diagnostic ultrasound examinations, as revised and
amended 2000, effective January 2001
6. Suggested Minimum Qualification for Physicians Interpreting Noninvasive Vascular Diagnostic Studies, Society
of Vascular Technology, March 1996
7. Foldes, M et al: Standing Versus Supine Positioning in Venous Reflux Evaluation: J Vasc Tech 1991;15(6):321-24.
8. Registered Physician in Vascular Interpretation examination requirements
9. Clinical Privilege White Paper, the Credentialing Resource Center, Marblehead Mass

Disclaimer
Adherence to these guidelines will not ensure successful performance. Furthermore these guidelines should not be
deemed inclusive of all proper methods of treatment or exclusive of other protocols reasonably directed to obtain the
same results. The physician and patient must make the ultimate judgment regarding the propriety of any performance and
interpretation of studies in light of all the circumstances presented by the individual patient.

These guidelines reflect the best available data at the time it was prepared; the results of future research or technology
may require alteration of the minimum standards and reporting as set forth in this guideline.

4 Practice Guidelines: Duplex Ultrasound Imaging