Diagnosis Of Venous Disorders

Clinical Semiotics

Clinical semiotics started in 1806 when the Swiss surgeon Tommaso Rima described a simple test for the diagnosis of saphenous reflux. In 1846, Sir Benjamin Brodie described a method of testing for incompetent valves by constriction of the limb and palpation. These two tests were reproposed by Friedrich Trendelenburg in 1890. In 1896, Georg Perthes of Bonn described the famous test to verify the patency of the deep veins. Finally, in 1938, John Homans described a test for detection of deep venous obstruction based upon foot dorsiflexion. Surprisingly, these tests and maneuvers still appear in modern texts of vascular medicine and venous surgery.

FIGURE 1.7 Post-thrombotic varicose veins (Cruveilhier, 1857).


The history of phlebography started in 1923, when Berberich and Hirsch described the technique to demonstrate the venous system in living humans by infusion of strontium bromide. One year later, Sicard and Forestier performed the first phlebography in humans using Lipiodol. In 1929, McPheeters and Rice performed the first dynamic varicography and described the movement of blood in the varicose veins. Further developments were due to Ratschow (who in 1930 introduced water soluble contrast media for angiography), Dos Santos (who demonstrated in 1938 the utility of direct ascending contrast venography to detect deep venous thrombosis), and Farinas (who performed the first pelvic venography in 1947). Intraosseus phlebography was then proposed by Schobinger in 1960 and refined by Lea Thomas in 1970. Finally, Dow described in 1973 the technique to perform retrograde phlebography.

Traditional venography is even less used in daily practice due to the achievement of duplex sonography. However, radiologic venous imaging recently improved due to the introduction of computed tomography (CT) and magnetic resonance (MR) techniques. CT was introduced in 1980 to demonstrate venous thrombosis by Zerhouni. Multislice CT, proposed first in 1994 by Stehling to evaluate the venous

FIGURE 1.8 The first contrastless 3D venography by multislice CT (Caggiati, 1999).

bed of the lower limb, also is indicated for the contemporary evaluation of the pulmonary vessels. More recently, multislice CT has been proposed to obtain 3D images (see Figure 1.8) of superficial veins3 with special reference to the preoperative evaluation of varicose limbs.4 MR was introduced in the field of the diagnosis of DVT in 1986 by Erdman. MR venous imaging improved since 2001, when the group of Jorge Debatin proposed the technique called "low-dose, direct-contrast-injection 3D MR venography."5

Ultrasonic Venous Flow Evaluation and Imaging

The history of ultrasounds in venous medicine started in 1961 when Stegall and Rushmer described the first Doppler instrument and the basis for its practical use. A refinement of the Doppler techniques for venous investigations was made in 1967 by Sigel and coworkers. One year later, fundamentals of Doppler investigation of deep venous thrombosis were furnished separately by Evans and Cockett, and Sumner and Strandness. The technique to evaluate valvular competence was deeply investigated in 1970 by Folse and Alexander.

The history of venous echotomography started in 1976, when Day focused the possible role of B-mode imaging of venous thrombi. Duplex scanning was proposed for the diagnosis of venous disorders in 1986 by the group of Szendro, Nicolaides, Myers, Malouf et al.6 and by that of Luizy, Franceschi, and Franco.7

TABLE 1.2 Proposals for Evaluation of Venous Disorders
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