Venous Doppler and mapping

Venous Doppler and mapping — limbs, jugular and subclavian veins — Reference values: Lower limbs — thrombosis assessment, Venous mapping for varicose veins — technique.

Integrates deep and superficial venous thrombosis assessment, reflux/varicose-vein mapping, pre-procedure planning, saphenous mapping for graft, jugular/subclavian veins and indirect signs of central venous obstruction. Green means technically complete and consensually normal findings; yellow means limitation, post-thrombotic change, borderline reflux, variable anatomy or guideline divergence; red means thrombosis, obstruction, consensual pathologic reflux or urgent sign.

Measurements and reference values

Measurement	Usual value	Note
Lower limbs — thrombosis assessment	serial compression	Document common femoral vein, saphenofemoral junction, proximal/mid/distal femoral vein, popliteal vein, posterior tibial and peroneal veins; add gastrocnemius, soleal and superficial veins when symptomatic.consensus normal: compressible, patent, phasic and without intraluminal materialincomplete or indeterminate: segment not seen, limited calf or post-thrombotic changeconsensus abnormal: noncompressible vein, thrombus or absent flow after technical optimizationSource: ACR-AIUM-SPR-SRU 2026 / IAC Vascular Testing / CBR-SBACV-SP 2020
Venous mapping for varicose veins — technique	standing + standardized maneuvers	Assess reflux preferably standing. Use Valsalva at the common femoral vein and saphenofemoral junction; use distal compression/release for the other segments. Record position, maneuver and reflux time on spectral Doppler.adequate technique: standing or dependent position, documented maneuvertechnical limitation: not standing, pain, dressing, obesity or poor maneuverdo not interpret as complete mapping: reflux assessed only supine without justificationSource: CBR-SBACV-SP 2020 / SVS-AVF-AVLS 2023 / ESVS 2022
Great saphenous vein — minimum mapping points	junction + thigh + calf	Document the saphenofemoral junction, anteroposterior great saphenous caliber in thigh and calf, reflux extent, source, drainage, tributaries, accessory saphenous veins and any subdermal or hypoplastic course.complete map: calibers + reflux + source/drainage by segmentincomplete map: no calibers, no source/drainage or no accessory-vein descriptionassociated critical finding: thrombosis, stump ascending to deep junction or suspected deep extensionSource: CBR-SBACV-SP 2020 / CBR documentação mínima / SVS-AVF-AVLS 2023
Small saphenous vein — minimum mapping points	junction + knee distance + calf	The saphenopopliteal junction is variable; record distance to the knee joint line/crease, small saphenous caliber by segment, cranial extension, Giacomini vein and reflux drainage.useful description: junction, knee distance, caliber and cranial extension describedvariable anatomy: no typical junction, cranial extension/Giacomini or complex drainagecomplication: superficial thrombosis near deep junction or extension into deep systemSource: CBR-SBACV-SP 2020 / Caggiati nomenclature / ESVS 2022
Saphenous vein mapping for graft	caliber + continuity + compressibility	Describe by segment: diameter, compressibility, continuity, varicosities, thrombosis, bifurcations, superficial course and usable length. Acceptable caliber varies by service; as a teaching safety rule, less than 2 mm is red, 2-2.9 mm yellow and 3 mm or more green if wall and course are suitable.favorable: ≥3 mm, compressible, continuous and without varicosity/thrombosisborderline: 2-2.9 mm or short usable segmentunfavorable: <2 mm, thrombosed, markedly varicose or discontinuousSource: CBR-SBACV-SP 2020 / vascular lab vein mapping protocols
Superficial reflux — saphenous, accessory and tributary veins	> 0,5 s	Preferably assess standing or in dependent position, with standardized provocation and reflux time measured on spectral Doppler.normal: up to 0.5 sborderline/technical: 0.45-0.50 s or inadequate maneuver/positionpathologic reflux: greater than 0.5 sSource: CBR-SBACV-SP 2020 / SVS-AVF-AVLS 2023 / CMS LCD
Deep reflux — femoropopliteal segment	> 1,0 s	For common femoral, femoral and popliteal veins, many consensus documents use greater than 1.0 s; other deep segments use greater than 0.5 s.normal: up to 1.0 s in the femoropopliteal segmentgray zone: 0.8-1.0 s or inconsistent techniquedeep reflux: greater than 1.0 s in the femoropopliteal segmentSource: CBR-SBACV-SP 2020 / SVS-AVF / CMS LCD
Perforator veins	> 0,35–0,50 s	There is divergence between 0.35 s and 0.50 s. Brazilian consensus accepts greater than 0.35 s; international treatment criteria often require greater than 0.5 s and diameter greater than 3.5 mm, especially beneath ulcerated or damaged skin.consensus normal: less than 0.35 sguideline divergence: 0.35-0.50 s or without diameter/contextmore accepted abnormal: greater than 0.50 s with diameter above 3.5 mm or related skin/ulcer changeSource: CBR-SBACV-SP 2020 / SVS-AVF / CMS LCD
Upper limbs, jugular and subclavian veins	compression when possible + Doppler	Internal jugular, axillary, brachial, basilic and cephalic veins should be compressed when possible; the subclavian vein is partly limited by the clavicle and relies more on color, spectral waveform, phasicity and contralateral comparison.normal: compressible where possible, spontaneous, phasic and symmetric flowanatomic limitation: subclavian vein not fully compressible but normal Dopplerobstruction/thrombosis: noncompressible, absent filling, collaterals or asymmetric continuous waveformSource: SVU 2019 / ACR Appropriateness Criteria 2020 / AVF 2026
Superficial venous thrombosis	noncompressibility + thrombus	Describe extent, distance from the deep junction, involved vein and inflammatory signs. Proximity to the saphenofemoral/saphenopopliteal junction or extension into the deep system increases severity.absent: compressible and patent superficial veinlocalized superficial: superficial thrombus away from deep systemhigh risk: near deep junction, extensive, ascending or with associated deep thrombosisSource: ACR-AIUM-SPR-SRU / CBR-SBACV-SP

Classifications and calculators

Interactive assistant — thrombosis, reflux and venous obstruction

Output	Color	Practical use
Patent/normal	Green	Preserved compressibility, phasic/symmetric flow and reflux below accepted cutoffs.
Indeterminate, limited or post-thrombotic	Yellow	Use when there is technical limitation, anatomically noncompressible subclavian vein, borderline reflux or post-thrombotic scarring.
Thrombosis, obstruction or pathologic reflux	Red	Noncompressible vein, thrombus, absent flow, central collaterals, asymmetric continuous waveform or reflux clearly above cutoffs.

The calculator does not replace clinical probability, D-dimer, serial follow-up or venography/CT/MR venography when central suspicion remains high.

Source: SRU 2018 / ACR-AIUM-SPR-SRU / IAC / AVF 2026

Varicose-vein mapping — technical checklist

Step	What to document	Teaching color
Deep system first	Compressibility, patency, phasicity and deep reflux when the study is for venous insufficiency.	Green if complete and normal
Great saphenous vein	Saphenofemoral junction, thigh and calf caliber, terminal/preterminal/segmental reflux, source and drainage.	Green if no reflux and well documented
Small saphenous vein	Saphenopopliteal junction, distance to knee, caliber, cranial extension, Giacomini vein and drainage.	Yellow when anatomy is variable
Tributaries and accessory veins	Map the source and drainage of reflux; do not call every channel saphenous without identifying the involved trunk.	Yellow if topography is missing
Perforator veins	Site, distance from knee or sole, diameter, reflux and relationship to skin/ulcer.	Yellow/red according to reflux and diameter
Thrombosis or deep extension	Noncompressible vein, saphenous thrombus near deep junction, extension into the deep system or phlegmasia.	Red

The map should be anatomic and functional: where reflux starts, where it travels, where it drains and which segments are treatable.

Source: CBR-SBACV-SP 2020 / SVS-AVF-AVLS 2023 / ESVS 2022

Saphenous veins — reflux patterns for reporting

Pattern	How to recognize	How to report
Terminal reflux	Incompetent terminal valve/junction with reflux entering the saphenous trunk.	State junction, cranio-caudal extent and drainage into tributaries/perforators.
Preterminal reflux	Competent terminal valve, but reflux below the junction through tributary, accessory vein or perforator.	Differentiate from junction incompetence to avoid overtreatment.
Segmental reflux	Limited saphenous segment with reflux and normal segments above/below.	Describe start, end and connections.
Tributary or accessory-vein reflux	The saphenous trunk may be competent, but reflux is present in an anterior/posterior accessory or tributary vein.	Name the vein and its relationship to the saphenous compartment.
Giacomini vein or cranial extension of the small saphenous	Connection of the small saphenous vein with thigh veins/great saphenous vein.	Record course and drainage direction.
Post-surgical or recurrent varices	Stump, neovascularization, residual saphenous vein, incompetent accessory vein or incompetent perforator.	Report recurrence source instead of only “varices”.

Source: CBR-SBACV-SP 2020 / Caggiati nomenclature / local report corpus

Perforators — color reading

Color	Criterion	Interpretation
Green	No reflux or reflux less than 0.35 s.	Do not call it an incompetent perforator by diameter alone.
Yellow	Reflux 0.35-0.50 s, isolated diameter greater than 3.5 mm or incomplete topography.	Divergence zone: document and correlate with skin, ulcer and varices.
Red	Reflux greater than 0.50 s with diameter greater than 3.5 mm, especially beneath skin change or ulcer.	More accepted criterion for pathologic/treatable perforator.

Brazilian consensus accepts greater than 0.35 s as perforator reflux; international treatment criteria more often use reflux greater than 0.5 s plus diameter greater than 3.5 mm.

Source: CBR-SBACV-SP 2020 / SVS-AVF-AVLS 2023 / ESVS 2022 / CMS LCD

Saphenous graft mapping — practical table

Color	Finding	Report action
Green	Continuous, compressible saphenous vein without thrombosis/marked varicosity and generally 3 mm or larger.	Report usable length and segmental calibers.
Yellow	Caliber 2-2.9 mm, bifurcations, short segment, superficial course or irregular wall.	Describe limitations without universally rejecting; decision is surgical.
Red	Caliber less than 2 mm, thrombosis, marked varicosity, discontinuity or post-ablation.	Flag as unfavorable and look for an alternative if requested.

Source: vascular lab vein mapping protocols / CBR-SBACV-SP 2020

Venous thrombosis assessment — color reading

Color	Finding	Interpretation
Green	Compressible vein, no intraluminal material, color flow and phasic waveform.	Normal in the assessed segment if the study was complete.
Yellow	Equivocal partial compression, unseen segment, limited calf or chronic wall-adherent change.	Report limitation and consider serial follow-up or complementary imaging according to clinical risk.
Red	Noncompressible vein, intraluminal material, absent filling, free-floating thrombus or proximal extension.	Compatible with thrombosis/occlusion until proven otherwise; communicate according to local protocol.

Source: SRU 2018 / ACR-AIUM-SPR-SRU / IAC

Venous reflux — teaching cutoffs by segment

Segment	Green	Yellow	Red
Saphenous, accessory and tributary veins	up to 0.5 s	0.45-0.50 s or poor technique	greater than 0.5 s
Common femoral, femoral and popliteal veins	up to 1.0 s	0.8-1.0 s or inadequate maneuver	greater than 1.0 s
Perforator veins	less than 0.35 s	0.35-0.50 s or no clinical context	greater than 0.50 s, especially if diameter greater than 3.5 mm
Deep veins below the knee	up to 0.5 s in many references	technique-dependent	greater than 0.5 s when reproducible

Always record patient position, maneuver and reflux source/drainage. Reversed flow from proximal obstruction should not be called valvular reflux.

Source: CBR-SBACV-SP 2020 / SVS-AVF / ESVS 2022 / CMS LCD

Jugular, subclavian and suspected central obstruction

Site	Practical assessment	Warning sign
Internal jugular vein	Direct compression, color and spectral Doppler.	Noncompressibility or thrombus.
Subclavian vein	Compression limited by clavicle; use color filling, phasicity, pulsatility and comparison with the opposite side.	Asymmetric continuous/monophasic waveform, little respiratory variation or collaterals.
Brachiocephalic veins and superior vena cava	Usually indirect assessment; consider CT, MRI or venography if suspicion remains high.	Face/arm edema, chest-wall collaterals, catheter or pacemaker with abnormal central waveform.

Source: ACR Appropriateness Criteria 2020 / SVU 2019 / AVF 2026

CEAP clinical classification — chronic venous disease

Class	Clinical finding	Teaching color
C0	No visible or palpable signs	Green
C1	Telangiectasias or reticular veins	Yellow if symptomatic
C2	Varicose veins	Yellow
C3	Venous edema	Yellow
C4	Skin changes from venous disease	Red
C5	Healed venous ulcer	Red
C6	Active venous ulcer	Red

CEAP is a clinical classification; color here is educational and does not replace the complete clinical category with etiology, anatomy and pathophysiology.

Source: AVF CEAP 2020 / ESVS 2022

Useful differentials when it is not thrombosis

Scenario	Possibilities	Ultrasound clue
Calf pain and swelling	Ruptured popliteal cyst, muscle injury, hematoma, cellulitis, lymphedema.	Compressible veins and explanatory extravascular finding.
Bilateral edema	Cardiac, renal, hepatic, medication-related or lymphatic cause.	Patent venous flow; assess symmetry and systemic context.
Arm/face edema or chest-wall collaterals	Central venous obstruction from catheter, pacemaker, mass or central thrombosis.	Asymmetric continuous waveform, loss of phasicity or collaterals.
Severe pain with very swollen limb	Extensive thrombosis, phlegmasia, compartment syndrome or severe infection.	Urgent communication even before completing broad mapping.

Source: SRU 2018 / ACR-AIUM-SPR-SRU / CBR-SBACV-SP

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