Improving Detection and Quantification of Saphenofemoral Junction Reflux Using an Additional Transverse Coronal Duplex View: A Quality Improvement Study

Objective: The aim of this quality improvement study was to determine whether adding a transverse coronal (TC) duplex Doppler view to the conventional long-axis sagittal (SAG) approach improves the detection and quantification of reflux at the saphenofemoral junction (SFJ) in patients with clinical evidence of chronic superficial venous insufficiency. Materials and Methods: This quality improvement study evaluated 64 limbs from 33 patients undergoing lower extremity venous duplex examinations at 4 private cardiovascular practice offices. All patients had a documented history and clinical signs or symptoms of superficial venous insufficiency and an SFJ diameter greater than 5 mm. Each limb was examined in reverse Trendelenburg using both the conventional SAG approach and an additional TC approach. Color and spectral Doppler were used to evaluate reflux direction, intraluminal flow pattern, and reflux duration during a Valsalva maneuver. Pathologic reflux was defined as retrograde flow lasting at least 500 ms. Reflux detection rates were compared using McNemar exact test, and paired reflux-duration measurements were compared using a paired Student t test. Results: Reflux was detected in 63 of 64 limbs (98.4%) using the TC approach and in 44 of 64 limbs (68.8%) using the SAG approach. Among the 63 TC-positive limbs, the SAG approach failed to detect reflux in 19 limbs, corresponding to a relative false-negative rate of 30.2%. The difference in paired detection rates was statistically significant ( P = .0000038). Mean reflux duration was 2417.3 ms with the TC approach compared with 1605.1 ms with the SAG approach. The mean paired increase was 812.2 ms, representing a 50.6% increase in measured reflux duration with the TC approach ( P < .001). The TC view facilitated visualization and sampling of eccentric reflux jets that were incompletely demonstrated in the sagittal plane. Conclusion: There may be value to adding a TC duplex Doppler view to the conventional SAG examination for chronic venous insufficiency significantly increased SFJ reflux detection and produced longer reflux-duration measurements in this patient population. The conventional sagittal approach may underestimate or fail to detect clinically relevant venous reflux when the reflux jet is eccentric, low flow, or poorly aligned with the Doppler beam. The TC view may be a useful adjunct when sagittal findings are negative, borderline, or discordant with the clinical presentation.