Why We Draw a 'Vein Map' on Your Leg Before Varicose Vein Treatment

How da Re-Fit Clinic decides which veins to treat, and how far

"The bulging vein is here. Why are you scanning all the way up my thigh?"

"I have already had an ultrasound. Why are you marking my leg before the procedure?"

During a varicose vein consultation you may notice that the scan covers a wider area than the veins you can see, or that lines and marks are drawn on your leg before treatment.

From the patient's side, it can seem that treating the sore spot or the bulging vein should be enough. But a treatment plan needs more than what shows on the skin. We need to see where blood is flowing backwards and which veins that reflux runs into.

At da Re-Fit Clinic we describe this as making a "vein map" for your own leg.

1. The vein you can see and the place where reflux starts may be different

Leg veins are connected in many branches. A twisted vein close to the skin may be fed by reflux in another vein, or the problem may be limited to one tributary.

So even when the bulging vein is on the calf, the scan does not stop at the calf. We follow the connected veins to find where the reflux is and how far it extends. Only then can we say specifically what needs treatment. This is why the scan runs from the groin to the ankle and, when needed, behind the knee.

The opposite also holds. A visible vein is not a reason to treat every vein around it. Working out which veins relate to your symptoms, and how far treatment needs to go, comes first.

2. The scan looks at much more than "is there reflux?"

A venous duplex ultrasound shows the shape of the veins and the flow of blood at the same time. The guidelines of the European Society for Vascular Surgery (ESVS) and of the US societies (SVS/AVF/AVLS) both recommend it as the basic test for assessing varicose veins.

When planning treatment we check:

• where reflux is seen and how far it continues
• the diameter, depth and course of the vein
• how bulging tributaries connect to other veins
• the condition of the deep veins, including any clot
• how the scan findings relate to the symptoms you describe

Reflux is usually tested with you standing. Lying down lowers the pressure in the veins, so reflux can look smaller than it is or not appear at all. The time threshold used to call a flow "reflux" is explained in our column on the 0.5-second standard.

These conditions differ from patient to patient, even with the same diagnosis. When both legs are affected, the plan for the right leg and the left leg may not be the same.

Finding reflux on a scan also does not mean that every ache or discomfort in the leg comes from the veins. We look at where and how the symptoms appear, together with the examination, and consider other causes such as the back, joints, nerves or arteries.

3. Marks on the skin are a way of confirming the plan

Using ultrasound to trace where the veins are and how they connect is called vein mapping. Based on the scan and on the varicose veins that can be seen, we may mark the relevant areas on the skin.

Bulging veins can look different when you stand and when you lie down. A vein that is obvious while standing may be hard to see once you are on the procedure table. Checking and marking the position beforehand helps us find it during treatment.

The lines on the skin do not show the whole extent of the procedure, and they do not mean that every marked vein will be removed. Marking is an aid to carrying out the plan. In procedures that need ultrasound guidance, we also watch the vein and the instruments on the screen during treatment.

4. Ask "where, and why" as well as "which procedure"

Before treatment, patients usually hear the names of methods first: laser, radiofrequency, medical adhesive and so on. But the veins treated and the extent of treatment can differ even with the same method.

For example, a plan to treat the main refluxing vein and a plan for bulging tributaries near the skin have to be considered separately. Whether to treat the tributaries at the same session, or to treat the main vein first and decide on further treatment after follow-up, depends on the individual patient. The research behind this choice is summarised in our column on concomitant phlebectomy.

The purpose of a vein map is not to widen the treatment. It is to separate what should be treated now from what should be observed, and to explain why.

5. We explain the scan findings together with the treatment plan

At da Re-Fit Clinic we decide the direction of treatment by looking at the veins seen on ultrasound together with the discomfort you feel.

In consultation we think it is important to explain which vein shows reflux, which areas we consider for treatment, and why a particular method is being considered. We also tell you which areas may need further treatment or follow-up. How we choose between methods is covered in Same Diagnosis, Different Treatment.

If you have had a scan in another country, bring the report. It helps the consultation, and the mapping is checked again here before treatment. Consultations for international patients are supported through our interpretation system.

If treatment is ahead of you, these questions are worth asking:

• "Which veins in my leg need treatment?"
• "How are those veins related to the symptoms I have now?"
• "What will be treated together, and what will be observed?"
• "Are there symptoms that may remain after treatment, or anything to check later?"

Hearing the answers helps you understand the treatment and decide.

Varicose vein treatment starts with understanding the state of your own veins. What matters more than a few lines on the leg is the examination and judgement that led to them.

We aim for a consultation that explains not only how we will treat, but which vein we treat and why.

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References

• De Maeseneer MG, Kakkos SK, Aherne T, et al. European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. Eur J Vasc Endovasc Surg. 2022;63(2):184-267. (PMID: 35027279) — duplex ultrasound recommended as the basic test in chronic venous disease.
• Gloviczki P, Lawrence PF, Wasan SM, et al. The 2022 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex Scanning and Treatment of Superficial Truncal Reflux. J Vasc Surg Venous Lymphat Disord. 2023;11(2):231-261. (PMID: 36326210) — recommendations on duplex evaluation and on concomitant versus staged treatment of tributaries.
• Coleridge-Smith P, Labropoulos N, Partsch H, Myers K, Nicolaides A, Cavezzi A. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs — UIP consensus document. Part I. Basic principles. Vasa. 2007;36(1):53-61. (PMID: 17323300) — International Union of Phlebology consensus on how to perform the examination.

This article provides general medical information. The extent of the scan and the treatment plan depend on your veins and symptoms and need to be confirmed in consultation.