Truncal varicosis, a common manifestation of chronic venous insufficiency (CVI), affects millions of people worldwide and is one of the main causes of venous complaints. Diagnosis of this condition is mainly based on clinical examination and duplex ultrasonography, which is considered the gold standard. However, despite its reliability, results can vary under different conditions and due to several influencing factors. Such variations can cause uncertainty for both patients and treating physicians, especially when findings in a second opinion differ from the original results.
Differences in diagnoses are often due to a combination of external and internal factors. This article examines these factors in detail, presents scientific explanations and references, and offers practical approaches to improve diagnosis. The aim is to promote understanding of the variability of findings and to identify ways to ensure accurate diagnosis.
Factors influencing the diagnosis of truncal varicosis:
1. temperature and seasonal fluctuations
Physiology of vein diameters
The function of the veins is strongly influenced by external temperature changes. At higher temperatures, vasodilation causes the veins to dilate, which increases the reflux phenomena. This adaptation serves thermoregulation and is controlled by the influence of the autonomic nervous system. Conversely, cold causes vasoconstriction, which reduces the vein cross-section and may make insufficient valves appear less conspicuous on ultrasound.
Seasonal effects on venous insufficiency
Studies have shown that patients complain more frequently of symptoms such as swelling, heaviness and pain in warmer months. These complaints correlate with the physiological dilation of the veins in warm climates. Studies in different seasons show an increased prevalence of reflux phenomena in summer compared to winter.
Scientific evidence:
- Schmid-Schönbein, G.W., & Zweifach, B.W. (1975). Microcirculatory effects of temperature and posture.Circulation Research, 36(5), 652-661.
- Szendro, G., Nicolaides, A.N., et al. (1992). Seasonal variation in venous insufficiency symptoms. Journal of Vascular Surgery, 15(1), 111-117.
- Allegra, C., et al. (2008). Chronobiological aspects of venous insufficiency. Phlebology, 23(4), 178-185.
Practical recommendations
- Ideally, tests should be carried out under constant temperature conditions.
- If this is not possible, seasonal effects should be included in the interpretation of the findings.
2. influence of compression stockings
Change in venous hemodynamics
Compression stockings are an essential component of conservative therapy for varicosis. They exert gradual pressure on the veins, promote venous return and reduce the hydrostatic pressure in the lower extremities. This mechanical effect leads to a reduction in the venous lumen and can distort sonographic findings if the examination is performed immediately after the stockings have been worn.
Temporal dimensions of the stocking effect
Studies show that the recovery time after wearing compression stockings can vary. While in some patients a normal vein cross-section can be measured again after just a few hours, others need several days. This variability depends on individual factors such as the elasticity of the vein walls and the duration of compression use.
The time it takes for the veins to return to normal after wearing compression stockings varies from person to person. Some patients show unchanged vein cross-sections after just a few hours, while others need several days.
Scientific evidence:
- Partsch, H. (2003). Compression therapy of the legs. Journal of Vascular Surgery, 37(5), 930-936.
- Nicolaides, A.N., et al. (2000). The investigation of chronic venous insufficiency: A consensus statement. Circulation, 102(20), 126-163.
- Zamboni, P., et al. (2010). Effects of graduated compression stockings on venous hemodynamics.European Journal of Vascular and Endovascular Surgery, 39(4), 487-492.
Practical recommendations
- Patients should not wear compression stockings for at least 24 hours before the examination.
- Documentation of compression use is important for diagnosis.
3. posture during the examination
Standing vs. lying down
The patient’s posture during the examination has a significant influence on the results. Examinations in a standing position often show stronger reflux phenomena, as the hydrostatic pressure in the veins is highest in this position. When lying down, this pressure is reduced, which can lead to an attenuation or masking of reflux.
Scientific evidence:
- Labropoulos, N., et al. (1996). Effect of venous outflow and standing on venous reflux in lower-limb varicose veins. Journal of Vascular Surgery, 24(5), 782-789.
- Christopoulos, D., et al. (1988). Pathophysiological mechanisms of venous ulceration in chronic venous insufficiency. European Journal of Vascular Surgery, 2(4), 245-252.
Practical recommendations
- Examinations should preferably be carried out in a standing position in order to obtain a realistic picture of the venous insufficiency.
4. diurnal fluctuations
Chronobiological aspects
Venous function shows diurnal fluctuations, which are influenced by activity and strain on the legs. After an active day, veins may appear dilated due to fluid retention and venous stasis.
Scientific evidence:
- Zamboni, P., et al. (1999). Circadian variation in the diameter of leg veins. Phlebology, 14(2), 58-63.
- Allegra, C., et al. (2008). Chronobiological aspects of venous insufficiency. Phlebology, 23(4), 178-185.
Practical recommendations
- Diagnostic examinations should be carried out in the morning if possible to minimize diurnal variability.
5 Technical and methodological variables
Influence of ultrasound devices
The quality and sensitivity of the devices used have a significant impact on diagnostics. High-resolution devices enable more precise identification of reflux phenomena, while older devices may overlook them.
Investigator dependency
The experience and expertise of the examiner play a key role. Studies show that the diagnostic accuracy of experienced phlebologists is significantly higher than that of less experienced examiners.
Scientific evidence:
- van den Bos, R., et al. (2009). Influence of experience on the accuracy of duplex ultrasound examination. Journal of Vascular Surgery, 50(5), 1102-1109.
- Rabe, E., et al. (2013). Technical standards for duplex ultrasound in chronic venous disorders.Phlebology, 28(S1), 63-67.
Practical recommendations
- The devices should be serviced and calibrated regularly.
- Investigators should regularly participate in training and further education.
6 Subjective complaints and their significance
Discrepancy between clinical findings and symptoms
Patients’ subjective complaints – such as a feeling of heaviness, pain, cramps and visible swelling – do not always correlate directly with the anatomical findings. For example, patients with only minimal changes in the duplex ultrasound may have severe symptoms, while others with pronounced reflux are virtually symptom-free.
Influence of lifestyle and psychological factors
The perception of symptoms is highly individual and is influenced by factors such as age, gender, occupation, lifestyle and psychological well-being. Women tend to report symptoms more frequently than men, regardless of the objective severity of the illness.
Scientific evidence:
- Rabe, E., Guex, J.J., et al. (2012). Epidemiology of chronic venous disorders. International Angiology, 31(2), 105-115.
- Marsden, G., Perry, M., et al. (2015). The relationship between venous reflux, clinical symptoms, and quality of life. Phlebology, 30(10), 661-667.
- Kahn, S.R., & Shrier, I. (2002). Relationship between symptoms and venous disease severity in chronic venous disorders. Journal of Vascular Surgery, 36(5), 820-825.
Practical relevance
A holistic diagnosis should include both objective findings and subjective complaints in order to obtain a complete picture of the disease.
7. Variability of findings in second opinions
Technical and methodological influences
The diagnosis of truncal varicosis is often based on duplex ultrasonography, which, despite its high standard, depends on the experience and technique of the examiner. Differences in the examination method – e.g. standing vs. lying down – or in the pressure exerted by the transducer can influence the results. Even under identical conditions, individual variations in interpretation can occur.
Importance of standard protocols
The use of standardized examination protocols can help to reduce variability.
These include:
- Uniform patient preparation (e.g. no wearing of compression garments before the examination).
- Determination of a specific position for the examination (standing preferred for reflux measurements).
- Use of calibrated devices and regular training of medical staff.
Scientific evidence:
- Lurie, F., et al. (2012). Mechanisms of recurrent varicose veins: a new look at an old problem.Phlebology, 27(1), 2-9.
- Nicolaides, A.N., et al. (2000). Consensus on venous investigations. Circulation, 102(20), 126-163.
- van den Bos, R., et al. (2009). Technical aspects of duplex ultrasound examinations in chronic venous disease. Journal of Vascular Surgery, 50(1), 168-173.
Practical relevance
Second opinions are an important part of modern patient care. Transparent communication about possible variations in the findings strengthens patients’ trust in diagnostics and treatment.
Recommendations for improving diagnostics
- Standardization of the methodology:
Uniform examination protocols with regard to posture, timing and preparation of patients. - Consideration of external factors:
Documentation of temperature, time of day and compression stocking application. - Integration of subjective complaints:
Complementing the diagnosis with a detailed medical history. - Use of modern technology:
Use of high-resolution equipment and regular maintenance. - Further training for examiners:
Promotion of specializations and regular training.
Conclusion and recommendations
The diagnosis of truncal varicosis is a dynamic process that is influenced by numerous internal and external factors. Variations in the findings are not uncommon and reflect the complexity of venous insufficiency. Precise diagnosis therefore requires not only the use of modern technology, but also a holistic view of individual patient factors.
Recommended measures:
- Standardized diagnostic protocols:
- Uniform conditions and standardized procedures for ultrasound diagnostics.
- Consideration of external factors:
- Documentation of temperature, season and the use of compression stockings.
- Integration of subjective complaints:
- Complement imaging diagnostics with a detailed medical history.
- Patient education:
- Transparent communication about possible variabilities and their significance.
Such an approach can improve the quality of diagnostics and increase patient confidence.
Ethical handling and professional communication in the event of diagnostic discrepancies
Discrepancies in the findings in the diagnosis of truncal varicosis are not uncommon in medicine and can be influenced by numerous factors, as explained in this article. This makes it all the more important that medical professionals deal with such discrepancies professionally and ethically. It is neither collegial nor ethical to deliberately set patients against other colleagues. Such an approach exploits the uncertainty of patients, who generally do not have the professional expertise to understand the reasons for different findings. Instead of stirring up uncertainty, doctors should explain to their patients openly and objectively which influencing factors can lead to varying diagnoses. Patient education plays a central role here: medical professionals should emphasize that discrepancies in diagnosis, for example due to seasonal fluctuations, the use of compression stockings or methodological differences, are perfectly normal and do not affect the overall quality of the diagnosis. Respectful interaction between colleagues and transparent communication with patients help to strengthen trust in medical care. Only uniform standards, a holistic view of the findings and an ethical attitude can ensure high-quality patient care. The team at VenaZiel Venenzentrum Berlin will be happy to provide you with further information or an individual consultation. Our experts combine state-of-the-art technology with extensive experience to offer you the best possible care.
