Acute Respiratory Illness in Immunocompetent Patients. MRI Chest Our search failed to identify any studies evaluating the role of MRI in this clinical scenario. The study population examined by Syrjala et al [14] did not include any patients with parapneumonic effusion or empyema. However, MRI has been shown to be at least as sensitive as CT for detecting pleural effusions in immunocompromised patients and is superior to CT for detecting pleural adhesions/loculations [16].


Acute Respiratory Illness in Immunocompetent Patients. Variant 5: Acute asthma exacerbation in immunocompetent patients, uncomplicated (no suspicion of pneumonia or pneumothorax). Initial imaging. Radiography Chest The incidence of PNA is exceedingly low in patients presenting with an uncomplicated asthma exacerbation. Heckerling [22] reported <2% of asthmatic patients as having pneumonic opacities. Findley and Sahn [37] observed that 99% of their patients either had normal chest radiograph examinations or showed only slightly prominent markings or hyperinflation.


Acute Respiratory Illness in Immunocompetent Patients. CT Chest Our literature search failed to identify any data that suggest that CT serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with an acute asthma exacerbation.


Acute Respiratory Illness in Immunocompetent Patients. US Chest Our literature search failed to identify any data that suggest that US serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with an acute asthma exacerbation.


Acute Respiratory Illness in Immunocompetent Patients. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with an acute asthma exacerbation.


Acute Respiratory Illness in Immunocompetent Patients. Variant 6: Acute asthma exacerbation in immunocompetent patients, complicated (suspected pneumonia or pneumothorax). Initial imaging. Radiography Chest Use of chest radiographs in patients with asthma exacerbation is controversial. Petheram et al [38] found clinically important radiographic findings in 9% of their patients and concluded that a chest radiograph is indicated. However, the incidence of PNA in patients presenting with an asthma exacerbation is low [22,37]. Findley and Sahn [37] recommended chest radiographs only when PNA or pneumothorax is suspected. White et al [39] found significant chest radiograph abnormalities in 34% of adults whose asthma exacerbation warranted hospital admission.


Acute Respiratory Illness in Immunocompetent Patients. CT Chest Although our literature search failed to identify any data that suggest that CT serves any significant role in the initial imaging of patients with a high pretest probability of PNA presenting with an acute asthma exacerbation, patients who cannot reliably follow-up or for whom any delay in diagnosis of PNA could be life-threatening may warrant a CT if the chest radiograph is negative or equivocal. Chest radiographs are usually sufficient to diagnose pneumothorax. CT should be reserved for patients who require additional evaluation of their pneumothorax to look for an underlying cause.


Acute Respiratory Illness in Immunocompetent Patients. US Chest US may be a reasonable alternative to chest radiographs to identify PNA [8-12] and pneumothorax [13].


Acute Respiratory Illness in Immunocompetent Patients. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a high pretest probability of PNA presenting with an acute asthma exacerbation.


Acute Respiratory Illness in Immunocompetent Patients. Acute Respiratory Illness in Immunocompetent Patients Variant 7: Acute COPD exacerbation in immunocompetent patients, uncomplicated (no chest pain, fever, or leukocytosis, no history of coronary artery disease, or heart failure). Initial imaging. Radiography Chest The ATS defines a chronic obstructive pulmonary disease (COPD) flare as an acute worsening of COPD symptoms. Sherman et al [40] studied the usefulness of chest radiographs in 242 patients with acute exacerbations of COPD. Of this group, 135 patients (56%) had asthma, and 107 (44%) had emphysema and chronic bronchitis. Chest radiographs were abnormal in 14% but resulted in significant change in management in only 4.5%.


Acute Respiratory Illness in Immunocompetent Patients. CT Chest Our literature search failed to identify any data that suggest that CT serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with a COPD exacerbation.


Acute Respiratory Illness in Immunocompetent Patients. US Chest Our literature search failed to identify any data that suggest that US serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with a COPD exacerbation.


Acute Respiratory Illness in Immunocompetent Patients. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with a COPD exacerbation.


Acute Respiratory Illness in Immunocompetent Patients. Variant 8: Acute COPD exacerbation in immunocompetent patients with accompanying chest pain, fever, or leukocytosis, or a history of coronary artery disease, or heart failure. Initial imaging. Radiography Chest Chest radiographs seem warranted in COPD patients with significant comorbidities or a higher pretest probability of PNA (such as those who are elderly or who have abnormal vital signs or physical examination findings). Sherman et al [40] suggested that a chest radiograph is indicated if a COPD exacerbation is accompanied by leukocytosis, chest pain, or edema, or by a history of coronary artery disease or congestive heart failure.


Acute Respiratory Illness in Immunocompetent Patients. US Chest Studies by Reissig et al [11] and Nazerian et al [10] included patients with COPD. There was no mention of how the presence of COPD might affect the ability of US to diagnose PNA. The presence of COPD did not appear to be a contraindication to US.


Acute Respiratory Illness in Immunocompetent Patients. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a high pretest probability of PNA presenting with a COPD exacerbation.


Acute Respiratory Illness in Immunocompetent Patients. Summary of Recommendations Variant 1: A chest radiograph is usually appropriate for the initial imaging of immunocompetent patients presenting with ARI and a negative physical examination, normal vital signs, and no other risk factors. Variant 2: A chest radiograph is usually appropriate for the initial imaging of immunocompetent patients presenting with ARI and positive physical examination, abnormal vital signs, organic brain disease, or other risk factors. Variant 3: Chest CT without IV contrast is usually appropriate for imaging immunocompetent patients with ARI and positive physical examination, abnormal vital signs, organic brain disease or other risk factors and a negative or equivocal initial chest radiograph.


Acute Respiratory Illness in Immunocompetent Patients. 10 Variant 4: Chest CT, with or without IV contrast, is usually appropriate for imaging immunocompetent patients with PNA complicated by suspected parapneumonic effusion or abscess on initial chest radiograph and MRI may be appropriate in this scenario. Variant 5: Imaging is usually not appropriate for the initial workup of immunocompetent patients presenting with an uncomplicated acute asthma exacerbation (no suspicion of PNA or pneumothorax) but a chest radiograph may be appropriate. Variant 6: A chest radiograph is usually appropriate for the initial imaging of immunocompetent patients presenting with a complicated acute asthma exacerbation (suspected PNA or pneumothorax). Variant 7: A chest radiograph is usually appropriate for the initial imaging of an uncomplicated acute COPD exacerbation in immunocompetent patients (no chest pain, fever, or leukocytosis, no history of coronary artery disease, or heart failure). Variant 8: A chest radiograph is usually appropriate for the initial imaging of complicated acute COPD exacerbation in immunocompetent patients (chest pain, fever, leukocytosis, or a history of coronary artery disease, or heart failure).


Acute Respiratory Illness in Immunocompetent Patients. Although there are references that report on studies with design limitations, 12 well-designed or good-quality studies provide good evidence.


Acute Respiratory Illness in Immunocompetent Patients. Appropriateness Category Names and Definitions Relative Radiation Level Information Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate


Acute Respiratory Illness in Immunocompetent Patients. Supporting Documents For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Introduction/Background Ankle injuries are the most common injury presenting to primary care and emergency rooms [1,2], accounting for 4.4% of United States emergency room visits [3]. Acute ankle sprains (pain, swelling, limited mobility) make up the majority of these injuries, with an estimated incidence of 2 million per year [4]. Diagnosis of presence and degree of sprain, fracture, subluxation, dislocation, cartilage abnormalities, foreign bodies, or neurovascular involvement are critical in determining appropriate and timely orthopedic fixation/treatment planning [1,5] and to avoid chronic pain and immobility. Appropriate use of ankle imaging guidelines and clinical decision support mechanisms is paramount [6,7].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. The current standard clinical imaging guidelines to determine if radiographs are necessary are the Ottawa Ankle Rules (OAR), instituted in 1992. The OAR have been validated for adults and children >5 years of age [8] and recommend ankle radiographs in patients with the following clinical criteria in the acute setting: 1) inability to bear weight, 2) point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, or 3) inability to ambulate for 4 steps. For the purposes of this paper, the OAR will still apply during the first 1- to 3-week interval following initial injury. Multiple validation studies have confirmed OAR effectiveness and utility in obtaining appropriate imaging, reducing unnecessary radiographs and costs, and improving clinical outcomes [8-13].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Exclusionary Criteria OAR should not be used in children <5 years of age or in those patients with a neurologic abnormality affecting the lower leg with decreased sensation (eg, diabetic), altered sensorium, or inability to communicate [8,25,26]. Other


Acute Trauma to the Ankle

Acute Trauma to the Ankle. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Reprint requests to: publications@acr.org


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Acute Trauma to the Ankle possible cautionary or exclusionary scenarios include pregnancy, penetrating trauma, or presence of prior recent outside radiographs on transfer.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Special Imaging Considerations Avoidance of manipulation of the ankle prior to radiographs in the absence of neurovascular deficit or critical skin injury is recommended in order to avoid remanipulation or complication in this setting [27]. Advances in MRI technology have facilitated short dedicated extremity MRI protocols in some centers that may be used as an emergent adjunct to radiographs [28].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. OR Discussion of Procedures by Variant Variant 1: Adult or child 5 years of age or older. Acute trauma to the ankle or acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial imaging. Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are positive: 1. Inability to bear weight immediately after the injury, OR 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, OR 3. Inability to ambulate for 4 steps in the emergency department. Bone Scan Ankle Bone scan is not routinely used as the first imaging study for the evaluation of acute trauma to the ankle with positive OAR.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. talus, or calcaneus, OR CT Ankle Although CT may be used in polytrauma patients to determine the extent of injury in complex fractures, CT is not routinely used as the first imaging study of acute trauma to the ankle with positive OAR when exclusionary criteria do not apply.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. MRI Ankle Although MRI may be used for occult injuries or suspicion for ligamentous tears in inversion injuries [29], it is not the first imaging study for the evaluation of acute trauma to the ankle with positive OAR.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Radiography Ankle Radiographs are indicated in patients who meet OAR criteria as the initial imaging study. Studies demonstrate between 92% and 99% sensitivity for detecting ankle fracture using these guidelines, with <2% of those who are negative for fracture using the OAR actually having a fracture [13-15,30]. The OAR are validated in children >5 years of age and should not be used in patients meeting the exclusionary criteria listed above [8]. Typical radiographic protocols should include 3 standard views: anteroposterior, lateral, and mortise views to include the base of the fifth metatarsal bone distal to the tuberosity [31]. Although foot and ankle radiographs have been performed together in clinical settings in the past, in a retrospective study of 243 patients with both radiographs performed, no foot fractures other than the base of the fifth metatarsal were noted. In the presence of inversion injury or fracture of the ankle, foot or knee radiographs should not be performed owing to low yield [32,33].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Weight-bearing radiographs, if possible, provide important information, particularly with fractures of uncertain stability, because the most important criterion in treatment of malleolar fractures is stability. A medial clear space of <4 mm should confirm stability. Increased incidence of fracture and instability is noted with medial tenderness, bruising or swelling, fibular fracture above the syndesmosis, bi- or trimalleolar fractures, open fracture, or high- energy fracture injury [34]. Special scenarios that warrant special mention and additional views include:


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Acute Trauma to the Ankle US Ankle Ultrasound (US) may be useful but is not typically considered the first line of imaging for the evaluation of acute trauma to the ankle with positive OAR [41].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Variant 2: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present (eg, neurologically intact (including no peripheral neuropathy)). Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are negative: No point tenderness over the malleoli, talus, or calcaneus on physical examination. Able to walk. Initial imaging. Bone Scan Ankle Bone scan is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. CT Ankle CT is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. MRI Ankle MRI is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Radiography Ankle Radiography is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. US Ankle US is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Variant 3: Adult or child 5 years of age or older. Acute trauma to the ankle. Exclusionary criteria are present (eg, neurologic disorder, neuropathy, or other). Patient does not meet requirements for evaluation by the Ottawa Ankle Rules. Initial imaging. OAR should not be used in patients with neurologic abnormality involving the lower leg or those with decreased sensation (eg, diabetics), altered sensorium, or inability to communicate [25,26]. Other possible cautionary or exclusionary scenarios include pregnancy, penetrating trauma, or presence of prior recent outside radiographs on transfer.


Acute Trauma to the Ankle

Acute Trauma to the Ankle

Acute Trauma to the Ankle. Acute Trauma to the Ankle


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Bone Scan Ankle Bone scan is not routinely used as the first imaging study for the evaluation of acute trauma to the ankle in the setting of peripheral neuropathy or other exclusionary criteria.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. CT Ankle The imaging pathway is dependent on the severity of the trauma in patients within this particular clinical scenario. In the high-energy trauma patient or polytrauma patient, fractures and dislocations may be more difficult to identify clinically in the neurologically impaired or neuropathy patient. Occasionally, multidetector CT can be useful as first-line imaging study, particularly for complex injuries such as posterior malleolar fracture and posterior pilon variant fractures, which fall outside the typical classification systems. In a study of 270 patients by Switaj et al [41], the frequency of posterior malleolus fractures and posterior pilon variants was 50% and 20%, respectively; both were found more commonly in older females and diabetic patients. Recent studies of use and implementation of low-dose weight-bearing cone beam CT, particularly in the pediatric population, may be a viable alternative to standard CT studies [42].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. MRI Ankle MRI is not routinely used as the first imaging study for the evaluation of acute trauma to the ankle in the setting of peripheral neuropathy or neurological disorder or other exclusionary criteria.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Radiography Ankle In patients with diabetic neuropathy, neurologic compromise of the lower leg, or other exclusionary criteria in which application of the OAR is not possible and fracture is suspected, ankle radiographs are considered the initial imaging study. These patients may have no pain or point tenderness and may walk without discomfort despite fracture because of poor pain proprioception [25]. If there is high suspicion for foreign body, radiographs may also be useful for identification if the foreign body is radiopaque in nature.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Radiography Ankle Stress Views Ankle stress views are not the first imaging study for the evaluation of acute trauma to the ankle in the setting of peripheral neuropathy or other exclusionary criteria.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. US Ankle US is not routinely used as the first imaging study for the evaluation of acute trauma to the ankle in the setting of peripheral neuropathy or other exclusionary criteria. US may be useful as a secondary step in evaluation of foreign bodies or focal fluid collections.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Variant 4: Adult or child 5 years of age or older. Acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial radiographs negative. Next study. Acute trauma includes immediate time of injury to <3 weeks, whereas subacute trauma includes 3 weeks to <6 months. The timeframe of this clinical scenario is at the intersection of the late acute and subacute phases, and the OAR criteria can still apply for acute ankle trauma in this setting. Persistent pain may be associated with a radiographically occult fracture, bone contusion, subtle cartilage injury, soft-tissue injury, or foreign body not visible on radiographic examination. Diagnosis is critical in determining appropriate and timely orthopedic fixation/treatment planning [1,5].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Bone Scan Ankle Bone scan is typically not used as the next step in this clinical scenario.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. CT Ankle CT of the ankle without intravenous (IV) contrast is useful in the trauma setting as the next study to evaluate for radiographically occult fractures and soft-tissue abnormalities. It is rare (<1%) for patients with a large joint effusion but no discernible fracture on radiographic examination, however, CT proved useful in demonstrating a fracture in one-third of cases in one large study [43,44]. Talar fractures (lateral process or comminuted talar body/dome fractures) and fractures associated with the subtalar joint can be difficult to detect on radiographs but are well identified on CT [45,46]. In patients with spiral fractures of the tibia, there is a higher incidence of nondisplaced posterior malleolar fractures that may be missed on radiographic examination [47].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. A comparison of multidetector CT versus radiography for ankle fracture detection demonstrated only 87% and 78% sensitivity, respectively, for calcaneal fracture and talar fractures by radiography as compared with CT [48]. Occult osteochondral fractures of the subtalar joint may only be visualized on CT, particularly in patients without


Acute Trauma to the Ankle

Acute Trauma to the Ankle


Acute Trauma to the Ankle

Acute Trauma to the Ankle. dislocation, with fractures involving the posterior facet, with associated massive swelling, or with failure to regain subtalar motion after a period of immobilization [49].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. CT with IV contrast is not indicated in this scenario because soft-tissue abnormalities and fluid collections can be identified on noncontrast high-resolution CT studies.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. MRI Ankle MRI of the ankle without IV contrast is most sensitive for evaluation of occult fractures with associated bone marrow edema patterns, particularly in inversion injuries and persistent lateral ankle pain, as well as presence and extent of soft-tissue injuries [29]. Stress injuries of bone, including those of the weekend warrior, are best depicted by MRI [50].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. MRI is the reference standard for ligamentous injury and assessment of stability, which is particularly important in athletes, in whom determination of grade (1, 2, or 3) of syndesmotic ligament, anterior tibiofibular ligament, and deltoid injuries is critical for treatment planning and return to sport assessment [51]. High-resolution evaluation of the tendons and ligaments allows distinction between tendinopathy, sprain, and partial or complete tears.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Ligament and tendon injuries can occur without fracture on radiography. Grossterlinden et al [52] compared MRI and radiography and showed that 15% of ligamentous injuries (including sprains, partial tears, and complete tears) at the syndesmosis in acute ankle injuries on MRI demonstrated no fracture on radiography. Presence of bone bruise and adjacent soft-tissue edema have shown a higher association with acute ligamentous injuries (anterior talofibular ligament most common) and tendon abnormalities [53,54] in patients with negative radiographs. MRI can also help exclude Salter 1 fractures in the pediatric population [55].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Radiography Ankle Repeat radiographs are not typically the next study but may be of use to identify early callous formation at an occult fracture line or possible mineralization at a site of intramuscular hematoma if contusion occurred during trauma. Radiographs with better technique may assist in diagnosis of subtle injuries such as the lateral talar process avulsion, which may erroneously be diagnosed as a lateral ankle sprain [37].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Radiography Ankle Stress Views Although ankle stress views are not the typical next best study for this patient group, if there is clinical evidence of instability on physician maneuvers, ankle stress views may be of benefit for identification of occult avulsion injury at ligamentous attachments that may contribute to widening of the joint space on radiographic stress views.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. US Ankle US is not typically the next imaging study. US may be useful as a secondary evaluation modality for focused evaluation of underlying soft-tissue injuries and ligaments, with the added benefit of dynamic imaging. This includes focused high-resolution US of the peroneal tendons and the superior peroneal retinaculum [56], stress US (during anterior drawer) to assess joint laxity or chondral avulsion fractures associated with lateral ligament injury in children with negative radiographs [57,58], and potential detection of superficial occult fractures at the base of the fifth metatarsal, lateral malleolus, and malleolus [41].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Variant 5: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present. Radiographs demonstrate fracture or potential osteochondral injury. Next study. Bone Scan Ankle Osteochondral lesions Bone scan is not the next imaging study in this clinical scenario.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Fractures Bone scan is not the next imaging study in this clinical scenario. Bone scan may be used in rare setting in polytrauma cases for evaluation of multiple fractures.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. CT Ankle Osteochondral lesions Although MRI is the reference standard, CT is also of utility to identify, locate, and quantify cortical and subcortical involvement or loss as well as presence of intra-articular ossific bodies or associated fractures. In a prospective study of 399 patients, uncontained osteochondral lesion of the talus shoulder, as determined arthroscopically, had a more complicated clinical outcome than those with nonshoulder lesions, confirming the importance of imaging localization for clinical outcome [59]. An inverted osteochondral fracture of the lateral talus (lateral, inverted,


Acute Trauma to the Ankle

Acute Trauma to the Ankle

Acute Trauma to the Ankle. Acute Trauma to the Ankle


Acute Trauma to the Ankle

Acute Trauma to the Ankle. fracture talus, also known as the LIFT lesion) can occur after twisting injury to the ankle. Initial radiographs should be followed by CT and MRI [60,61]. These lesions are treated successfully with combined open approach and arthroscopy.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Fractures CT is the first-line imaging study after radiographs to determine extent, displacement, comminution, intra-articular extension, associated injuries, and potential classification of fractures [48]. This is particularly important in subtalar, calcaneal, and talar fractures because of the complex anatomy and in high-impact polytrauma or complex comminuted injuries in which multiplanar CT imaging is recommended to help direct the preoperative planning evaluation process [62].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. MRI Ankle Osteochondral lesions MRI without IV contrast is considered the study of choice for assessment of cartilage abnormalities and bone contusions related to acquired osteochondral lesion, particularly in patients with symptoms of persistent pain, stiffness, locking, clicking, and ankle swelling [22,55-57,63]. Although radiographs and CT depict ossific fragments and fracture lines, cartilage abnormalities and bone contusions related to osteochondral lesion are best seen on MRI. Seventy percent of ankle fractures and 50% of ankle sprains have been shown to result in some variation of cartilage injury [57,58,61,64].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Fractures Although CT is more commonly used as the next step in fracture assessment in known fractures, MRI can be useful as a follow-up imaging modality for assessment of associated bone marrow contusions, stress injuries, or fractures [65]. MRI is especially important in fracture sites such as the talus, which are at higher risk for osteonecrosis. MRI is highly accurate for associated soft-tissue abnormalities including tendon entrapment/dislocation and for ligamentous injuries [66].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. US Ankle Osteochondral lesion US is not the next step in this clinical scenario.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Fractures US has been shown to be useful for identification of lateral malleolar, medial malleolar, and fifth metatarsal fractures [41] but is not considered a first-line assessment tool or next imaging study in this clinical scenario.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Variant 6: Adult or child 5 years of age or older. Acute trauma to the ankle. Radiographs negative for osseous injury and physical examination or radiographs demonstrate alignment abnormality suggesting syndesmotic/ligamentous injury or dislocation. Next study. Lateral sprain is more common than medial strain, with the anterior talofibular ligament most commonly torn. High sprain and fractures are more common in high-collision sport injuries [60], with higher incidence of ankle injuries during winter months [67] and increased incidence in military recruits [68]. Inversion injuries of the ankle account for 25% of musculoskeletal system injuries and 50% of all sports-related injuries [1].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Bone Scan Ankle Bone scan is not routinely the next line of imaging in this clinical scenario.


Acute Trauma to the Ankle

Acute Trauma to the Ankle


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Rare pantalar dislocations without associated talar or other fracture can be assessed on CT or MRI and have high rates of osteonecrosis, osteoarthritis, and infection [71].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. MRI Ankle MRI is the reference standard for ligamentous injury and assessment of stability, which is particularly important in athletes, in whom determination of grade (1, 2, or 3) of syndesmotic ligament, anterior tibiofibular ligament, and deltoid injuries is critical for treatment planning and return to sport assessment [51].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Ligamentous injuries can occur without fracture on radiography. Grossterlinden et al [52] compared MRI and radiography and showed that 15% of ligamentous injuries (including sprains, partial tears, and complete tears) at the syndesmosis in acute ankle injuries on MRI demonstrated no fracture on radiography.


Acute Trauma to the Ankle


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Radiography Ankle Stress Views Stress radiographs may be useful in assessing syndesmotic instability, particularly in supination external rotation ankle injuries according to the Lauge-Hansen classification. Lee et al [72] noted that tibiotalar tilt angle and anterior tibiofibular space measurements were affected when the anterior tibiofibular and posterior talofibular ligaments were injured (confirmed on MRI) in 299 patients. Lateral stress testing with widening of the tibiofibular clear space has been shown to be an indicator of syndesmotic injury, with the traditional external rotation stress test shown to be a poor indicator when the deltoid ligament is injured [73].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Radiography Leg Maisonneuve fracture (syndesmotic injury of the ankle in combination with a proximal fibular fracture) may be overlooked as a result of lack of pain at the fibula. Careful palpation of the proximal fibula should be performed with radiographic evaluation of the entire tibia and fibular if focal tenderness is present [74].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. US Ankle US is not typically the next line of evaluation of syndesmotic injuries. Although some studies have suggested focused US could be beneficial for ligamentous evaluation, others have shown limited utility in lateral ankle ligament sprains [75].


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Summary of Recommendations Variant 1: Ankle radiographs are usually appropriate for the initial imaging of patients 5 years of age or older with acute trauma to the ankle or acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks with no exclusionary criteria present and the OAR are positive: 1. Inability to bear weight immediately after the injury, OR 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, OR 3. Inability to ambulate for 4 steps in the emergency department.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Variant 2: Imaging is usually not appropriate for patients 5 years of age or older with acute trauma to the ankle when the patient is able to walk and there are no exclusionary criteria present (eg, neurologically intact (including no peripheral neuropathy)) and the OAR are negative: No point tenderness over the malleoli, talus, or calcaneus on physical examination.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Variant 3: Ankle radiographs are usually appropriate for the initial imaging of patients 5 years of age or older with acute trauma to the ankle when exclusionary criteria are present (eg, neurologic disorder, neuropathy, or other) and the patient does not meet requirements for evaluation by the OAR.


Acute Trauma to the Ankle

Acute Trauma to the Ankle

Acute Trauma to the Ankle. Acute Trauma to the Ankle


Acute Trauma to the Ankle

Acute Trauma to the Ankle. ankle without IV contrast is more likely to be performed for known fracture evaluation with MRI ankle without IV contrast more likely to be performed for potential osteochondral injury evaluation.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.


Acute Trauma to the Ankle

Acute Trauma to the Ankle. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Introduction/Background Lower extremity venous insufficiency is a common chronic medical condition resulting from primary valvular incompetence or, less commonly, prior deep venous thrombosis (DVT) or extrinsic venous obstruction. Venous insufficiency may cause varicosities that vary in presentation from cosmetic concern to chronic lower extremity discomfort, swelling, induration, dermatitis, and ulceration [1].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Varicose veins are dilated and usually tortuous subcutaneous veins measuring at least 3 mm in diameter in an upright position, larger than reticular veins (subdermal veins, 1-3 mm in diameter) and telangiectasia (intradermal veins, <1 mm in diameter) [1].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Venous disease of the legs can be categorized according to the severity, cause, site, and specific abnormality using the Clinical Etiologic Anatomic Pathophysiologic (CEAP) classification system [1,2]. The elements of the CEAP classification include, 1) Clinical severity (grade 0-6, asymptomatic, symptomatic), 2) Etiology (congenital, primary, secondary), 3) Anatomical distribution (superficial, deep, perforator veins), and 4) Pathophysiological dysfunction (reflux, obstruction).


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Lower extremity chronic venous disease has a high prevalence with a related socioeconomic burden. In the United States, over 11 million men and 22 million women 40 to 80 years of age have varicose veins, with over 2 million adults having advanced chronic venous disease [3]. Approximate total prevalence of C2 to C3 disease is 25% and 5% for stages C4 to C6 [1,3]. Additionally, most chronic leg ulcers are venous in origin, with prevalence of nearly 1% [4,5]. The high cost to the health care system is related to the recurrent nature of venous ulcerative disease, with total treatment costs estimated >$2.5 billion per year in the United States, with at least 20,556 individuals with newly diagnosed venous ulcers yearly [4].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Treatment of superficial venous insufficiency is intended to alleviate symptoms and reduce the risk of complications. Conventional management targeted at reducing reflux has been surgical removal of the great saphenous vein (GSV) from the level of the saphenofemoral junction to the level of the knee or ankle (along with saphenous vein branch ligation in the groin). Alternatives to saphenous vein stripping and ligation include vein ablation using laser energy, radiofrequency-generated thermal energy, or chemical sclerosing agents [6-8].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Discussion of Procedures by Variant Variant 1: Varicose veins. Initial diagnosis. Catheter Venography Iliac Veins Catheter venography of the iliac veins can aid in evaluating proximal occlusions or significant stenosis when proximal varicosities are present. Adjunctive usage of intravascular ultrasound (IVUS) can improve the specificity


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. aModern Vascular of Denver, Thornton, Colorado. bResearch Author, University of Colorado Denver, Denver, Colorado. cPanel Chair, University of Michigan, Ann Arbor, Michigan. dPanel Chair, Massachusetts General Hospital, Boston, Massachusetts. ePanel Vice-Chair, University of California San Francisco, San Francisco, California. fPanel Vice-Chair, University of Vermont Medical Center, Burlington, Vermont. gDetroit Medical Center, Tenet Healthcare and Envision Radiology Physician Services, Detroit, Michigan. hZucker School of Medicine at Hofstra Northwell, Hempstead, New York. iTufts University School of Medicine, Boston, Massachusetts; Society for Vascular Surgery. jOregon Health and Science University, Portland, Oregon. kMedical University of South Carolina, Charleston, South Carolina. lRenaissance School of Medicine at Stony Brook University, Stony Brook, New York. mBoston University School of Medicine, Boston, Massachusetts. nMayo Clinic, Rochester, Minnesota; Commission on Nuclear Medicine and Molecular Imaging. oWeill Cornell Medicine- New York Presbyterian Hospital, New York, New York; American Vein & Lymphatic Society. pFroedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin. qSpecialty Chair, Emory University Hospital, Atlanta, Georgia. rSpecialty Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Reprint requests to: publications@acr.org


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Lower Extremity Chronic Venous Disease of such lesions. However, there is no relevant literature regarding the use of catheter-directed venography of the iliac veins when evaluating for varicose veins.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Catheter Venography Lower Extremity Catheter venography is ideal in performing descending venography of the lower extremity to evaluate for deep vein reflux [9]. However, there is no relevant literature regarding the use of catheter-directed lower extremity venography in the evaluation of bilateral GSV insufficiency with visible varicose veins.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. CTV Lower Extremity CT venography (CTV) of the lower extremity has not been cited as a first-line examination. However, given the high rate of recurrence 2 years postintervention (15%-35%), it has been suggested that further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Understanding the anatomy could aid in the appropriate selection of treatment, plan interventions, reduce recurrence, and decrease complication rates. In a study, a retrospective evaluation of a prospectively acquired database, out of 810 studied limbs, there were numerous anatomic variations, including 1 anatomic variant that had not been described in the literature [11]. Limitations of this study include retrospective nature and possible selection bias given that it was a single center and consecutively acquired data.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. US has been championed as a best initial test. However, there are rare cases in which US imaging is limited, such as obesity. In these cases, where characterization of lower extremity veins is suboptimal, CTV can be used adjunctively [9].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. CTV Pelvis There is no relevant literature regarding the use of CTV of the pelvis in the evaluation of bilateral GSV insufficiency with visible varicose veins. However, a comprehensive understanding of the anatomy could aid in the appropriate selection of treatment, planning interventions, and decreasing complication rates.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. US Intravascular Iliac Veins There is no relevant literature regarding the use of iliac vein IVUS in the evaluation of bilateral GSV insufficiency with visible varicose veins.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. MRV Lower Extremity MR venography (MRV) of the lower extremity has not been cited as a first-line examination. However, given the high rate of recurrence 2 years postintervention (15%-35%), it has been suggested that further anatomic characterization before therapy may be useful and could result in selecting more effective treatment [10-13].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. In rare cases in which US imaging is limited, characterization of lower extremity veins is suboptimal, or the goal is to avoid iodinated contrast, MRV can be used adjunctively [9].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. MRV Pelvis There is no relevant literature regarding the use of MRV of the pelvis in the evaluation of asymptomatic bilateral GSV insufficiency with visible varicose veins. However, a comprehensive understanding of the anatomy could aid in the appropriate selection of treatment, planning interventions, and decreasing complication rates.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. US Duplex Doppler Lower Extremity It is widely agreed upon that duplex US should be the first assessment of the lower extremity venous system [1,9,14]. Duplex US evaluation should include condition of the deep venous system, GSV, small saphenous vein (SSV), and accessory saphenous veins. Presence and location of clinically relevant perforating veins and extent of possible alternative refluxing superficial venous pathways should also be included in any duplex US evaluation. Evaluation of venous structures should be accomplished via both transverse and longitudinal planes. Respiratory variation and cardiac pulsations are normally present and indicate a patent pathway to the heart [1].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. The association between reflux and clinical manifestations of chronic venous disease is well established. Reflux, defined as retrograde venous flow >500 ms is almost always the result of primary degenerative changes within the venous wall and valves or as sequela of acute DVT causing destruction of venous valves [15]. Duplex Doppler US recordings should thus document presence, absence, and location of reflux. At a base level, abnormal reflux times should be measured and reported [16].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Variant 2: Varicose veins. Treatment. Compression Therapy Compression therapy has been widely described as the best initial treatment for varicose veins [18-20]. Compression therapy involves the use of a wide varying degree of devices to provide extrinsic compression on the lower extremity. As a group, they reduce venous stasis in various ways. Edema is contained by reduction of capillary filtration, fluid shift into noncompressed regions, and improved lymphatic drainage. Veins are directly affected by increasing venous blood flow velocity, reducing blood pooling, and improving venous pumping function. Lastly, microcirculation is influenced by transient increases in sheer stress, which in turn causes the release of anti- inflammatory, vasodilating, and antithrombotic mediators [19,21].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. When using compression therapy, a minimum pressure of 20 to 30 mm Hg is recommended. Pressures of 30 to 40 mm Hg are advised for more severe disease [20]. Of note, improved ejection fraction in refluxing vessels and higher extrinsic pressures were achieved when higher pressures were exerted at the calf over the distal ankle (negative graduated compression bandage). Improved pressures and ejection fractions were also observed when placing the compression bandage over the calf versus the distal leg [18].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Until recently, it had been widely accepted that treatment failure typically results from noncompliance [16,17]. However, 2 high-quality systematic reviews have concluded that the current published data are inadequate. The weakness in the data relates to the reliance on surrogate outcomes and subjective clinical improvement. Though present, few data demonstrate correlation with quality of life (QoL) improvement with routine use of compression alone [15]. Adherence should nonetheless be encouraged with proper fitting, education, and detailed instructions [19,20].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Despite the minimal evidence regarding C2 to C4 disease, there is evidence that compression therapy has value in C5 (preventing ulcer recurrence) and C6 disease (healing ulcers) [15]. Mosti and Partsch [18] demonstrated that 30 to 40 mm Hg inelastic compression is better than elastic bandaging for wound healing. They also showed that for ankle-brachial indices between 0.9 and 0.6, reduced compression to 20 to 30 mm Hg is successful and safe for venous leg ulcers (VLU) healing. Velcro inelastic compression was noted to be as good as 3- or 4-layer inelastic bandages. Caution is advised, however, when the ankle-brachial index is <0.6 because it indicates an arterial anomaly needing revascularization [21].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Saphenous Vein Ablation Endovenous ablation has largely supplanted surgical ligation and stripping as the main invasive method to treat varicose veins with similar efficacy, improved early QoL, and reduced hospital recovery [7,22,23].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. The 2 types of endovenous ablation are radiofrequency ablation (RFA) and endovenous laser ablation (EVLA). RFA is a minimally invasive procedure in which a catheter is inserted into a target vein lumen. Intense, local heat- based energy through the catheter then obliterates the vein lumen and destroys the wall. EVLA uses laser energy that is absorbed by the target tissue and converted to heat. Both treatments use tumescent anesthesia, a method by which diluted local anesthetic with or without epinephrine and/or sodium bicarbonate are injected around the target vessel. This adjuvant protects the surrounding tissue and collapses the vein wall extrinsically to further ensure the target tissue is ablated in its entirety [7]. By 3 months post-treatment, endothelium is absent and organized thrombus is formed. Occlusion rates for these types of endovenous ablation vary from 91% to 100% within 1-year post- treatment [7,22].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Multiple recent meta-analyses confirm that EVLA and RFA are at least as efficacious, if not slightly more so, than surgery [12,24-26]. When compared to surgery, EVLA had fewer rates of bleeding, hematoma, and wound infection [24]. EVLA and RFA were also noted to have reduced rates of paresthesia compared to surgery [27]. A meta- analysis pooling 52 studies of both RFA and EVLA demonstrated postprocedural thrombotic events infrequently; DVT occurred in 0.3% of cases, and pulmonary embolism occurred in 0.1% of cases [28]. Rates of recurrence between surgery and EVLA had conflicting data, with Paravastu et al [25] noting improved recurrence rates with EVLA at 6 weeks and 1 year and Pan et al [24] noting no significant difference.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. So far, little difference is seen when comparing the various endovenous treatments in terms of QoL, benefit, and durability [15]. Current data on RFA versus EVLA is rather limited, although there have been some recent


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Lower Extremity Chronic Venous Disease developments. Gale et al [29] randomized 48 patients into EVLA and 46 patients into RFA, with 11 RFA patients demonstrating recurrence compared with 2 cases of recurrence in the EVLA arm. A meta-analysis showed not only no statistically significant difference in long-term outcomes between conventional surgery and endovenous therapy but also no statistically significant difference in long-term outcomes between RFA and EVLA or conventional surgery [30]. An additional meta-analysis including 792 EVLA-treated and 785 RFA-treated patients demonstrated the same safety and efficacy between the 2 treatment cohorts. Outcomes included 3-day and 10-day pain scores, 1 month and 1 year QoL, occlusion, thrombophlebitis, hematoma, and recanalization. Though limited, data from this meta-analysis suggest RFA seems to have a lower overall risk of complication when compared to EVLA [31].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. We can conclude that the aggregate of evidence supports that ablation of saphenous veins provides significant benefits compared with compression [15].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Compression Sclerotherapy Compression sclerotherapy has been used effectively in the treatment of varicose veins, reticular veins, and telangiectasias [7,14]. In sclerotherapy, a liquid or foamed sclerosing drug is injected into the lumen of the varicose vein. This sclerosant is a chemical that damages the vein wall and ultimately occludes it secondary to fibrotic transformation of the vessel. Foamed sclerosant is used to increase the surface area by which the luminal wall can be treated. Doppler US of the GSV ablated with foam at 1-year post-treatment demonstrated occlusion rates vary from 72% to 89%, which is lower compared to EVLA at 1 year [7,32]. Sclerosant can also be administered over a rotating wire, which causes local trauma to the vessel. This form of mechanochemical ablation has closure rates that vary from 88% to 94% in the literature [7].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Advantages of these chemical ablative techniques include a lack of potential thermal injury that could injure the skin, nerves, muscles, and nontarget blood vessels, which is rarely seen with endovenous ablation. Additionally, because of a lack of thermal energy, tumescent anesthesia is not needed. Potential complications include phlebitis, new telangiectasias, and residual pigmentations. Exceedingly rare complications include DVT [7]. Other nontumescent techniques that are used are cyanoacrylate glue. Risk factors would be allergies to adhesives.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Multiple studies have shown that, compared with conventional open surgery and EVLA, chemical sclerotherapy has worse outcomes at 1-, 5-, and 8-year follow-ups, with higher rates of recurrent GSV reflux and saphenofemoral junction failure [33-36]. There are conflicting data on QoL, however, with equivalent improvement reported per the Aberdeen Varicose Vein Severity Score [36] and inferior improvement reported per the Chronic Venous Insufficiency Quality of Life Questionnaire [35].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Ligation and Stripping Higher rates of GSV reflux recurrence are identified with EVLA compared with high ligation and stripping. Both EVLA and high ligation and stripping, however, were noted to have similar metrics on disease specific QoL [37- 39]. Another study comparing high ligation and stripping versus EVLA in patients with GSV incompetence showed no significant difference between the 2 groups in recurrent GSV reflux, recurrent varicose veins, frequency of reoperations, Venous Clinical Severity Score, and QoL scores in a 5-year follow-up [40]. The RELACS study demonstrated, specifically, that high ligation and stripping was superior to EVLA in recurrence rates 5 years post- treatment [38].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. There are conflicting data regarding procedural complications. Pan et al [24] affirms that there is no significant difference in postprocedural phlebitis and bruising and concludes that there are fewer complications regarding bleeding, hematoma, wound infection, and paresthesia with EVLA. Rass et al [39], on the other hand, affirms that higher rates of phlebitis, tightness, and dyspigmentation were noted with EVLA.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Microphlebectomy Microphlebectomy involves the surgical excision of pathologic vessels. This method is used in combination with sclerotherapy ablation for best results. The most common complication involves skin blistering from dressing abrasions and adhesive tape. Wound infections may occur. Less commonly, small sensory nerves can be injured leading to areas of anesthesia and less commonly hyperesthesia. A rare injury could result from common peroneal nerve injury. The common peroneal nerve is commonly located just medial to the biceps femoris tendon and near the fibular head. Injury to this nerve can cause sensory loss or foot drop. When planning microphlebectomy, care or avoidance of this region is recommended [2].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Lower Extremity Chronic Venous Disease Variant 3: Venous leg ulcer. Initial diagnosis. Catheter Venography Iliac Veins Catheter-directed venography of the iliac veins has been described as the next step in diagnosis after CTV/MRV has characterized an occlusion or stenosis [9]. Venography has been criticized for low sensitivity for identifying critical lesions in the iliac vein [41]. Venographic findings can be grouped into normal, stenosis, and occlusion [8].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Catheter Venography Lower Extremity Digital subtraction ascending venography has been described as the next step in diagnosis after CTV or MRV has characterized an occlusion or stenosis [9]. Catheter-directed venography of the lower extremity is used mainly as part of a procedure in which treatment is planned for post-thrombotic and nonthrombotic obstruction of the iliac veins and much less often for post-thrombotic femoral veins.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. CTV Lower Extremity CTV of the lower extremity has not been cited as a first-line examination. However, it is helpful after duplex US in evaluation for occlusion, stenosis, collaterals, post-thrombotic changes, and axial transformation of the profunda vein [8]. Further highlighting the importance of CTV before intervention is the high rate of recurrence 2 years postintervention (15%-35%). Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Understanding the anatomy could aid in the appropriate selection of treatment and reduce recurrence and complication rates.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. CTV Abdomen and Pelvis CTV of the abdomen and pelvis has been suggested in the literature in cases with signs of iliac or inferior vena cava (IVC) involvement [9]. Further anatomic characterization before therapy can ensure appropriate and effective treatment, thus reducing the frequency for reintervention [10-13]. Understanding the anatomy could aid in the selection of an appropriate treatment modality and reduce recurrence and complication rates.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. US Intravascular Iliac Veins IVUS has been cited as the most sensitive and specific imaging modality for detecting deep vein obstructive disease. Compared to multiplanar venography, IVUS has been found to be more sensitive for detecting significant stenosis. One study found that, in 26.3% of patients, significant lesions were detected with IVUS not initially seen with 3- view venography [42]. Up to 10% of significant stenotic lesions, however, could not be seen via IVUS and required trial balloon angioplasty to unmask stenosis [8].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. IVUS has also shown utility at predicting when stenting for iliofemoral vein stenosis will result in symptomatic improvement. One study involving CEAP C4 to C6 study population has shown significant improvement symptomatology in stenting >50% iliofemoral vein stenosis (50% area reduction chosen by authors) [41].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. MRV Lower Extremity MRV of the lower extremity has not been cited as a first-line examination. As with CTV, MRV identifies stenosis, occlusion, venous atresia, collaterals, and edema. In addition, MRV can show webs, trabeculations, and vein wall thickening [9]. Furthermore, understanding unique patient anatomy [10] could aid in the selection of the appropriate treatment modality and reduce recurrence and complication rates.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. In cases in which characterization of lower extremity veins is suboptimal, MRV can be used adjunctively [9].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. MRV Abdomen and Pelvis MRV of the abdomen and pelvis has not been cited as a first-line examination. As with CTV, MRV identifies stenosis, occlusion, venous atresia, collaterals, and edema. In addition, MRV can show webs, trabeculations, and vein wall thickening [9]. Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Characterization of these potential variants is important for treatment planning purposes.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. US Duplex Doppler Lower Extremity It is widely agreed upon that duplex US should be the first assessment of the lower extremity venous system [1,9,14]. Duplex US is currently the most common imaging technique because it is noninvasive. Evaluation should include direction of blood flow, assessment for venous reflux, and venous obstruction [20].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Additionally, duplex US evaluation should include the condition of the deep venous system, GSV, SSV and its thigh extension (Giacomini Vein), and accessory saphenous veins. Presence and location of perforating veins near a VLU should also be included in any duplex US evaluation [1].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Lower Extremity Chronic Venous Disease If after treatment an ulcer recurs, repeat duplex US should assess for recanalization of treated GSV or reflux into the Giacomini vein, transmitting to the short saphenous vein [8].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Arterial vascular characterization may also prove useful because it has been noted that 16% of patients with VLU have concomitant arterial occlusive disease, which is frequently not recognized [19,43].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. US Duplex Doppler IVC and Iliac Veins As in arterial vasculature, critical stenosis is defined by a sharp reduction in forward flow; in venous vasculature, critical stenosis is related to venous hypertension. In fact, the beneficial effects of venous stenting are related to peripheral venous decompression [44]. This is an important distinction to make because Doppler US can be used to evaluate for this metric via peak systolic velocities. Labropoulos et al [45] and Metzger et al [46] agree that a peak systolic velocity ratio >2.5 across the stenosis (poststenotic velocity to prestenotic velocity) as an accurate criterion to use for the presence of a pressure gradient of 3 mm Hg. Doppler US can thus be used to determine candidacy for intervention and also monitor success of treatment on follow-up.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Variant 4: Venous leg ulcer. Treatment. Compression Therapy Compression therapy has been widely described as a helpful initial treatment for VLU [18-20]. Compression therapy involves the use of a wide varying degree of devices to provide extrinsic compression on the lower extremity. As a group, they reduce venous stasis in various ways. Edema is contained by reduction of capillary filtration, fluid shift into noncompressed regions, and improved lymphatic drainage. Veins are directly affected by increasing venous blood flow velocity, reducing blood pooling, and improving venous pumping function. Lastly, microcirculation is influenced by transient increases in sheer stress, which in turn causes the release of anti- inflammatory, vasodilating, and antithrombotic mediators [19,47].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. When using compression therapy, a minimum pressure of 20 to 30 mm Hg is recommended. Pressures of 30 to 40 mm Hg are advised for more severe disease [20]. Of note, improved ejection fraction in refluxing vessels and higher extrinsic pressures were achieved when higher pressures were exerted at the calf over the distal ankle (negative graduated compression bandage). The alternative, graduated compression bandage, in which more force is generated at the distal ankle over the calf, demonstrated inferior ejection fraction in refluxing vessels and lower extrinsic pressures compared with their negative graduated compression bandage counterparts. Improved pressures and ejection fractions were also observed when placing the compression bandage over the calf versus the distal leg [18].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Until recently, it had been widely accepted that treatment failure typically results from noncompliance [16,17]. However, 2 high-quality systematic reviews have concluded that the current published data are inadequate. The weakness in the data relates to the reliance on surrogate outcomes and subjective clinical improvement. Though present, few data demonstrate correlation with QoL improvement with routine use of compression alone [15]. Adherence should nonetheless be encouraged with proper fitting, education, and detailed instructions [19,20].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Despite the minimal evidence regarding C2 to C4 disease, there is evidence that compression therapy has value in C5 (preventing ulcer recurrence) and C6 disease (healing ulcers) [15]. Mosti and Partsch [18] demonstrated that 30 to 40 mm Hg inelastic compression is better than elastic bandaging for wound healing. They also showed that for ankle-brachial indices between 0.9 to 0.6, reduced compression to 20 to 30 mm Hg is successful and safe for VLU healing. Velcro inelastic compression was noted to be as good as 3- or 4-layer inelastic bandages. Caution is advised, however, when the ankle-brachial index is <0.6 because it indicates an arterial anomaly needing revascularization [21].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Saphenous Vein Ablation Multiple recent meta-analyses confirm that EVLA and RFA are at least as efficacious, if not slightly more so, than surgery [12,24-26]. When compared to surgery, EVLA had fewer rates of bleeding, hematoma, and wound infection [24]. EVLA and RFA were also noted to have reduced rates of paresthesia compared to surgery [27]. A meta- analysis pooling 52 studies of both RFA and EVLA demonstrated postprocedural thrombotic events infrequently; DVT occurred in 0.3% of cases, and pulmonary embolism occurred in 0.1% of cases [28]. Rates of recurrence between surgery and EVLA had conflicting data, with Paravastu et al [25] noting improved recurrence rates with EVLA at 6 weeks and 1 year and Pan et al [24] noting no significant difference.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Lower Extremity Chronic Venous Disease Gohel et al [48] compared timing of EVLA, either immediately (within 2 weeks) or deferred (after 6 months or resolution of ulcer) and determined that early EVLA resulted in faster healing of venous ulcers and more ulcer-free time.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Current data on RFA versus EVLA is rather limited, although there have been some recent developments. Gale et al [29] randomized 48 patients into EVLA and 46 patients into RFA, with 11 RFA patients demonstrating recurrence compared with 2 cases of recurrence in the EVLA arm. A meta-analysis showed not only no statistically significant difference in long-term outcomes between conventional surgery and endovenous therapy but also no statistically significant difference in long-term outcomes between RFA and EVLA or conventional surgery [30]. An additional meta-analysis including 792 EVLA-treated and 785 RFA-treated patients demonstrated the same safety and efficacy between the 2 treatment cohorts. Outcomes included 3-day and 10-day pain scores, 1-month and 1-year QoL, occlusion, thrombophlebitis, hematoma, and recanalization. Although limited, data from this meta-analysis suggest RFA seems to have a lower overall risk of complication compared to EVLA [31].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Compression Sclerotherapy Compression sclerotherapy has been used effectively in the treatment of varicose veins, reticular veins, and telangiectasias [7,14]. In foam sclerotherapy, a liquid or foamed sclerosing drug is injected into the lumen of the varicose vein. This sclerosant is a chemical that damages the vessel wall and occludes the affecting vasculature secondary to fibrotic transformation of the vessel. Foamed sclerosant is used to increase the surface area by which the luminal wall can be treated. At 1-year post-treatment, occlusion rates vary from 72% to 89%, which is lower when compared to EVLA at 1 year [7,32]. Sclerosant can also be administered over a rotating wire, which causes local trauma to the vessel. This form of mechanochemical ablation has closure rates that vary from 88% to 94% in the literature [7].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Advantages of these chemical ablative techniques include a lack of potential thermal injury that could injure the skin, nerves, muscles, and nontarget blood vessels, which is rarely seen with endovenous ablation. Additionally, because of a lack of thermal energy, tumescent anesthesia is not needed. Potential complications include phlebitis, new telangiectasias, and residual pigmentations. Exceedingly rare complications include DVT [7]. Other nontumescent techniques that are used are cyanoacrylate glue. Risk factors would be allergies to adhesives.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Multiple studies have shown that, compared with conventional open surgery and EVLA, chemical sclerotherapy has worse outcomes at 1-, 5-, and 8-year follow-ups, with higher rates of recurrent GSV reflux and saphenofemoral junction failure [33-36]. There are conflicting data on QoL, however, with equivalent improvement reported per the Aberdeen Varicose Vein Severity Score [36] and inferior improvement reported per the Chronic Venous Insufficiency Quality of Life Questionnaire [35].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Iliac Vein Stenting If venography has characterized a central occlusive vascular insult as a culprit for disease that involves the iliocaval segments, angioplasty with possible stenting should be performed. Cases with large ulcers that have decreased in size from prior superficial vein ablation usually require iliac vein stenting to complete ulcer healing [8].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Post-thrombotic iliac vein obstruction can lead to many QoL affecting symptoms including pain, swelling, and VLU. Multiple studies have shown iliac vein stenting to be advantageous with iliac vein stenosis >50%. Rossi et al [49] attests that compared with medial therapy alone, QoL and symptomatology are dramatically improved in both the short and long term with iliac vein stenting and medial therapy. A meta-analysis of available studies demonstrated that iliac vein stenting improved pain, swelling, and venous ulcer healing with secondary patency rates acceptable given relatively low overall risk [15].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Microphlebectomy There is no relevant literature regarding the use of microphlebectomy in the treatment of venous ulcers.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Ligation and Stripping Higher rates of GSV reflux recurrence are identified with EVLA compared with high ligation and stripping. Both EVLA and high ligation and stripping, however, were noted to have similar metrics on disease specific QoL [37- 39]. Another study comparing high ligation and stripping versus EVLA in patients with GSV incompetence showed no significant difference between the 2 groups in recurrent GSV reflux, recurrent varicose veins, frequency of reoperations, Venous Clinical Severity Score, and QoL scores in a 5-year follow-up [40]. The RELACS study demonstrated, specifically, that high ligation and stripping was superior to EVLA in recurrence rates 5 years post- treatment [38].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Lower Extremity Chronic Venous Disease There are conflicting data regarding procedural complications. Pan et al [24] affirms that there is no significant difference in postprocedural phlebitis and bruising and concludes that there are fewer complications regarding bleeding, hematoma, wound infection, and paresthesia with EVLA. Rass et al [39], on the other hand, affirms that higher rates of phlebitis, tightness, and dyspigmentation were noted with EVLA.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Wound Care Although literature has shown benefit in ulcer debridement in improving venous ulcer, the optimal protocol for wound care is yet to be elucidated. Beyond debridement, wound exudate control and surface bacteria management are additional important goals in wound care. Antibiotic dressings, however, have shown no benefit. Adjuncts such as topical dressings to control wound exudate and maintain moisture as well as skin protectants are also important [6,21].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Variant 5: Suspected pelvic-origin lower extremity varicose veins in females. Initial diagnosis. Catheter Venography Pelvis Catheter-directed venography of the iliac veins has been described as the next step in diagnosis after US of the iliac veins, ovarian veins, renal veins, and IVC, CTV/MRV has characterized an occlusion or stenosis [9]. Venographic findings can be grouped into normal, stenosis, and occlusion [8]. Pelvic varices can sometimes be demonstrated with direct catheterization plus or minus balloon occlusion.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. CTV Abdomen and Pelvis There is no relevant literature regarding the use of CTV abdomen and pelvis in the evaluation of pelvic-derived lower extremity varicose veins in women. This examination can be useful in evaluating the anatomy of dilated ovarian veins and nutcracker phenomenon, which can explain connections to pelvic-origin lower extremity varicose veins.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. CTV of the abdomen and pelvis has been suggested in the literature in cases with signs of iliac or IVC involvement [9]. Further anatomic characterization before therapy can ensure appropriate and effective treatment thus reducing the frequency for reintervention [10-13]. Understanding the anatomy could aid in the selection of an appropriate treatment modality and reduce recurrence and complication rates.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. US Intravascular Iliac Veins IVUS has been cited as the most sensitive and specific imaging modality for detecting deep vein obstructive disease. Compared to multiplanar venography, IVUS has been found to be more sensitive for detecting significant stenosis. One study found that in 26.3% of patients, significant lesions were detected with IVUS not initially seen with 3- view venography [42]. Up to 10% of significant stenotic lesions, however, could not be seen via IVUS and required trial balloon angioplasty to unmask stenosis [8].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. US Intravascular Renal Veins There is no relevant literature regarding the use of IVUS for renal veins in the evaluation of pelvic-derived lower extremity varicose veins in women, although it can accurately characterize the severity of a stenosis of a renal vein but compression over the adjacent aorta and superior mesenteric artery.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. MRV Abdomen and Pelvis MRV of the abdomen and pelvis can identify stenosis, occlusion, venous atresia, collaterals, and edema. In addition, MRV can show webs, trabeculations, and vein wall thickening [9]. MRV can also demonstrate the diameters of pelvic veins and ovarian veins to identify those that are varicose (>5 mm periuterine and periovarian veins and >6- 8 mm in diameter ovarian veins) [50]. Further highlighting the importance of MRV before intervention is a high


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Lower Extremity Chronic Venous Disease rate of recurrence 2 years postintervention (15%-35%). Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Characterization of these potential variants is important for treatment planning purposes.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. US Duplex Doppler Lower Extremity It is widely agreed upon that duplex US should be the first assessment of the lower extremity venous system [1,9,14]. Duplex US is currently the most common imaging technique because it is noninvasive. Evaluation should include direction of blood flow, assessment for venous reflux, and venous obstruction [20].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Duplex US evaluation should additionally include condition of the deep venous system, GSV, SSV, and accessory saphenous veins. Presence and location of clinically relevant perforating veins and extent of possible alternative refluxing superficial venous pathways should also be included in any duplex US evaluation [1].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. In a study of 56 women with pelvic varicose veins, 44 patients demonstrated varying degrees of venous insufficiency. This information suggests a connection between pelvic varicose veins and venous insufficiency. Duplex US of the lower extremities may then be a very reasonable evaluation in patients with known pelvic varicose veins [51].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. In addition, Khilnani et al [52] notes that duplex US in patients with varicose veins in the posterior thigh, vulva, and inguinal regions (nonsaphenous pelvic origin varicose veins) can help identify venous escape points from reflux in the internal iliac venous system.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. US Duplex Doppler Pelvis It is widely agreed upon that duplex US should be the first assessment of the lower extremity venous system [1,9,14]. Duplex US is currently the most common imaging technique because it is noninvasive. Evaluation should include direction of blood flow, assessment for venous reflux, and venous obstruction [20].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. If there are vulvar varicose veins, operators are rarely able to trace these vessels to a pelvic origin. These examinations require a very experienced sonographer to acquire relevant information. Most often, it is necessary to characterize with advanced imaging [1].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. US Duplex Doppler IVC and Iliac Veins There is no relevant literature regarding the use of US for evaluation of the IVC and iliac veins in the treatment of pelvic-origin lower extremity varicose veins. As in arterial vasculature, critical stenosis is defined by a sharp reduction in forward flow; in venous vasculature, critical stenosis is related to venous hypertension. In fact, the beneficial effects of venous stenting are related to peripheral venous decompression [44]. This is an important distinction to make because Doppler US can be used to evaluate for this metric via peak systolic velocities. Labropoulos et al [45] and Metzger et al [46] agree that a peak systolic velocity ratio >2.5 across the stenosis (poststenotic velocity to prestenotic velocity) as an accurate criterion to use for the presence of a pressure gradient of 3 mm Hg. Doppler US can thus be used to determine candidacy for intervention and monitor success of treatment on follow-up.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Variant 6: Pelvic-origin lower extremity varicose veins in females. Treatment. Saphenous Vein Ablation Patients commonly present with lower extremity symptoms related to pelvic venous insufficiency. Typically after embolization and sclerotherapy of gonadal veins and pelvic varices, respectively, they may then have endovenous venous ablation of their saphenous veins for definitive treatment [56].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Compression Sclerotherapy Foam sclerotherapy is an option to treat chronic pelvic pain and pelvic-origin lower extremity varicose veins in women caused by a pelvic venous disorder, often in conjunction with embolization. Most of the current literature involves therapy of pelvic venous disease.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Lower Extremity Chronic Venous Disease The commonly used substances reported in the literature for sclerotherapy are sodium tetradecyl sulfate and polidocanol. In high-flow pelvic varicoceles, there is a small risk of systemic dispersion of the sclerosant. In order to optimize the quantity and efficacy of the sclerosant, stop-flow foam sclerotherapy techniques have been described. This technique involves the use of balloon occlusion of high-outflow collaterals to achieve the complete filling of pelvic varices and exclusion of collaterals, thereby embolizing the entire length of incompetent vessels, including tributaries [57].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. In a retrospective study of 26 patients involving the use of 3% sodium tetradecyl sulfate foam, significant improvement in symptoms was observed at 1, 3, 6, and 12 months. Of note, all patients had colic-like pain that spontaneously resolved after 5 minutes [58].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. In a meta-analysis of 21 prospective case series involving a total of 1,308 women, early substantial pain relief was observed in 75% of women undergoing embolization (including combinations of coil, glue, and sclerotherapy), generally increasing and sustained over time. Repeat interventions were generally low, and, although there were few data on post-treatment impact on menstruation, ovarian reserve, and fertility, no concerns were noted. Overall, transient pain was common following foam embolization, and there was <2% risk of coil migration. Overall, data from studies that used a sclerosant suggest significant symptomatic improvement of approximately 75% [59].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Foam sclerotherapy has also shown good results as an alternative to embolization in patients with leg, vulvar, and pudendal varicosities of pelvic origin without pelvic venous disease [60].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Iliac Vein Stenting There is no relevant literature regarding the use of iliac stenting in the treatment of pelvic-origin lower extremity varicose veins in women, although it is postulated that stenting may relieve the congestion in the pelvis. However, there is no high-quality data.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Iliac Vein Embolization Internal iliac vein embolization (in addition to ovarian vein embolization) has been shown to be safe and effective in treating pelvic venous insufficiency and reducing pelvic pain in most women undergoing treatment for pelvic congestion syndrome [61]. However, there is no high-quality data demonstrating the value of pelvic embolization or iliac or renal vein stenting to improve pelvic origin varicose veins and their related symptoms.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Iliac Vein Surgery There is no relevant literature regarding the use of iliac vein surgery in the treatment of pelvic-origin lower extremity varicose veins in women.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Left Renal Vein Stenting The treatment of pelvic venous disease due to nutcracker syndrome has been primarily surgical in the past, employing left renal vein bypass, transposition, and external stent placement. However, because of the morbidity associated with surgical techniques, percutaneous endoluminal left renal vein stenting is now performed [62]. No studies have demonstrated benefit of renal vein stenting on pelvic origin lower extremity varicose veins. A limited number of studies have demonstrated remission of pelvic venous symptoms with stenting of the left renal vein as an alternative to open surgery [63], although none have demonstrated improvement in lower extremity varicose veins or symptoms.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Left Renal Vein Surgery Though no literature has focused on nutcracker syndrome causing pelvic-derived varicose veins, the treatment of pelvic venous disease due to nutcracker syndrome has been primarily surgical in the past, employing left renal vein bypass, transposition, and external stent placement. However, because of the morbidity associated with surgical techniques, percutaneous endoluminal left renal vein stenting is increasingly performed [62].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Rundqvist et al [64] described the first open surgical removal of the left ovarian vein in patients with pelvic congestion syndrome. Symptomatic improvement was described in two-thirds of this studied cohort. Laparoscopic left ovarian vein surgical ligation in patients with pelvic congestion syndrome was described in 2003 by Gargiulo et al [65]; 23 out of 23 patients reported complete resolution of symptoms in the 1-year follow-up. No studies have demonstrated benefit of renal vein surgery on pelvic origin lower extremity varicose veins. Surgery should be considered in patients with lifestyle-limiting chronic pelvic pain that have recurred despite embolotherapy [63,66].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Lower Extremity Chronic Venous Disease Microphlebectomy There is no relevant literature regarding the use of microphlebectomy in the treatment of isolated pelvic-derived lower extremity varicose veins. However, it is well established as an effective tool at eliminating varicose veins in general and may be helpful in the correct clinical setting.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Ovarian Vein Embolization Ovarian vein embolization is the most frequently cited treatment for pelvic venous disease, often in conjunction with sclerotherapy. In a meta-analysis of 21 prospective case series involving a total of 1,308 women, early substantial pain relief was observed in 75% of women undergoing embolization (including combinations of coil, glue, and sclerotherapy), generally increasing, and sustained over time. Repeat interventions were generally low, and, although there were few data on post-treatment impact on menstruation, ovarian reserve, and fertility, no concerns were noted. Overall, transient pain was common following foam embolization, and there was <2% risk of coil migration. Overall, data from studies that used a sclerosant suggest significant symptomatic improvement of approximately 75% [59].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Immediate success rates for the endovascular treatment of pelvic venous disease have been favorable with the low complication rate. In a study, most patients reported pain relief in symptoms for up to 5 years post-treatment [67]. In a study involving 11 embolization procedures for 10 women (1 patient had an additional embolization procedure), 3 women (30%) had mild recurrence of pain at midterm follow-up. Of 8 patients who complained of dyspareunia, 6 were cured [68].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Evidence of efficacy in a second embolization procedure is contradictory. One study notes that embolization of pelvic varices may be an effective treatment in a well-selected group; however, if there is no improvement after the initial embolization, a second procedure is unlikely to be effective [69]. In a second study, 4 patients required second embolization, 3 of whom reported improved symptoms [70]. In another study involving retreatment after pregnancy-related recurrence, repeat embolization was shown to eliminate recurrent reflux [71].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Complications of embolization procedures have been noted in up to 9% of patients. These include thrombophlebitis, embolization of nontarget vessels, recurrence varices, and stroke-related paradoxical emboli. Postembolization abdominal discomfort was reported in up to 14.8% of patients and is usually self-limited or treated with analgesic or anti-inflammatory medications [57].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Although success rates are favorable, excluding other causes such as nutcracker syndrome are important. Additionally, no randomized or high-quality controlled trials have been recorded, which limits the provided evidence. Though no gynecological complications were noted in the above literature, they have not been explicitly studied.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. No current prospective studies or randomized control trials demonstrating benefit of embolization for patients with pelvic-origin lower extremity varicose veins have been published. Current literature is limited to single-center case series which have failed to demonstrate significant improvement after pelvic venous embolization or stenting [52].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Overall, in distinction to ovarian vein embolization for patients with chronic pelvic pain, there is little evidence to support the use of embolization or stenting to aid in lower extremity pelvic origin varicose veins [52].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Conservative Management There is no relevant literature regarding the use of compression therapy in the treatment of pelvic-origin lower extremity varicose veins in women. Conservative therapies to manage symptoms of pelvic origin lower extremity varicose veins include compression therapy, nonsteroidal anti-inflammatory drugs, hormonal agents, ergot alkaloid derivatives, and venoactive agents [72].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Variant 7: Suspected iliocaval or lower extremity disease with severe post-thrombotic changes. Initial diagnosis. Catheter Venography Iliac Veins Catheter-directed venography of the iliac veins has been described as a diagnostic technique but is often now only performed as part of procedure with the intent to treat an iliocaval lesion. It is invasive, and in patients with post- thrombotic iliac and caval lesions, it is typically done after US/CTV/MRV has characterized an occlusion or stenosis [9].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Catheter venography with IVUS is usually performed in those with an indication for venous intervention, such as iliac vein stenting typically after CTV or MRV has characterized an occlusion or stenosis [6,9].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Lower Extremity Chronic Venous Disease Catheter Venography Lower Extremity Venography is performed mostly during procedures with the intent on treating an iliac or IVC obstructive lesion. Collaterals and post thrombotic changes from stenoses and/or occlusions are typically noted.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. CTV Lower Extremity CTV of the lower extremity has not been cited as a first-line examination. However, it is very rarely used after duplex US in evaluation for occlusion, stenosis, collaterals, post-thrombotic changes, and axial transformation of the profunda vein [8]. Further highlighting the importance of CTV before intervention is the high rate of recurrence 2 years postintervention (15%-35%). Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Understanding anatomy could aid in the selection of appropriate treatment modality and reduce recurrence and complication rates. In a study, retrospective evaluation of a prospectively acquired database, out of 810 studied limbs, there were numerous anatomic variations, including 1 anatomic variant that had not been described in the literature [11]. Characterization of these potential variants is important for treatment planning purposes.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. CTV Abdomen and Pelvis There are 2 scenarios described in the literature characterizing pelvic venous obstruction. Primary chronic venous disease describes a phenomenon in which there is obstruction in the pelvic or abdominal veins (eg, May-Thurner) without a prior DVT. Imaging can then be used to identify the cause of obstruction. Secondary chronic venous disease describes a phenomenon in which primary thrombotic events cause a post-thrombotic syndrome. In addition to an occlusive IVC or iliac vein lesion, these cases also show signs of delayed or incomplete recanalization of the pelvic and lower extremity deep veins with extensive intraluminal changes. In both of the above types, primary focus should be on anatomy to accurately identify stenosis and occlusion related to outflow obstruction [9].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. CTV of the abdomen and pelvis has been suggested in the literature in cases in which there are signs of iliac vein or IVC involvement, and in cases with fast recurrence of varicose veins after adequate treatment, CTV clearly identifies stenosis, occlusion, venous atresia, collaterals, and edema [9]. Further highlighting the importance of CTV before intervention is the high rate of recurrence 2 years postintervention (15%-35%). Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Understanding anatomy could aid in the selection of appropriate treatment modality and reduce recurrence and complication rates. In this study, retrospective evaluation of a prospectively acquired database, out of 810 studied limbs, there were numerous anatomic variations, including 1 anatomic variant that had not been described in the literature [11]. Characterization of these potential variants is important for treatment planning purposes.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. US Intravascular Iliac Veins IVUS has been cited as the most sensitive and specific modality for deep vein obstructive disease. Up to 10% of significant stenotic lesions, however, could not be seen via IVUS and required trial balloon angioplasty to unmask stenosis [8]. Catheter venography with IVUS should be performed in those with an indication for venous intervention such as iliac vein stenting [6].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. MRV Lower Extremity MRV of the lower extremity has not been cited as a first-line examination. As with CTV, MRV identifies stenosis, occlusion, venous atresia, collaterals, and edema. In addition, MRV can show webs, trabeculations, and vein wall thickening [9]. Furthermore, understanding unique patient anatomy could aid in the selection of appropriate treatment modality and reduction of recurrence and complication rates. In a study, a retrospective evaluation of a prospectively acquired database, out of 810 studied limbs, there were numerous anatomic variations, including 1 anatomic variant that had not been described in the literature [11]. Further highlighting the importance of MRV before intervention is the high rate of recurrence 2 years postintervention (15%-35%). Appropriate anatomic characterization before therapy can thus ensure appropriate and effective treatment [11-13].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. MRV Abdomen and Pelvis MRV of the abdomen and pelvis has not been cited as a first-line examination. As with CTV, MRV identifies stenosis, occlusion, venous atresia, collaterals, and edema. In addition, MRV can show webs, trabeculations, and vein wall thickening [9]. Further highlighting the importance of MRV before intervention is a high rate of recurrence 2 years postintervention (15%-35%). Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Characterization of these potential variants is important for treatment planning purposes.