Chronic venous insufficiency (CVI) is a common vascular disorder resulting from impaired venous return due to valvular incompetence, venous obstruction, or both. This condition leads to persistent venous hypertension, which contributes to progressive structural and functional changes in the venous system of the lower limbs. Clinically, CVI manifests as a spectrum ranging from telangiectasia and varicose veins to edema, skin pigmentation, lipodermatosclerosis, and venous ulceration. ¹

Varicose veins are among the most frequent manifestations of chronic venous disease and are characterized by dilated, tortuous superficial veins, most commonly involving the great saphenous vein and its tributaries. Epidemiological studies indicate that chronic venous disease affects approximately 10–30% of the adult population, with prevalence increasing with age. ² The condition represents a significant public health concern because of its impact on quality of life, work productivity, and healthcare costs. ³

The pathophysiology of chronic venous insufficiency primarily involves venous valve incompetence, which allows retrograde blood flow and leads to venous hypertension. Over time, this increased pressure causes venous dilation, endothelial dysfunction, and inflammatory changes in the microcirculation. These mechanisms contribute to the development of edema, skin changes, and eventually venous ulceration in advanced stages of disease. ⁴

Several risk factors have been associated with the development of venous insufficiency. These include advancing age, obesity, pregnancy, family history, previous episodes of deep vein thrombosis, and occupations that involve prolonged standing or sedentary posture. Occupational factors are particularly important in individuals who remain standing for long periods, as this leads to increased hydrostatic pressure in the lower limb veins and contributes to venous valve failure. ⁵

Accurate diagnosis of venous insufficiency is essential for appropriate treatment planning. Clinical examination alone is often insufficient to determine the anatomical location of venous reflux or obstruction. Traditionally, contrast venography was considered the reference standard for evaluating venous disease; however, it is invasive and associated with potential complications. ⁶

With advances in vascular imaging, color duplex ultrasonography (CDUS) has become the primary diagnostic modality for evaluating venous insufficiency. Duplex ultrasonography combines B-mode imaging with Doppler flow analysis, enabling visualization of venous anatomy and assessment of venous hemodynamic in real time. This technique allows accurate detection of venous reflux, identification of incompetent perforator veins, and evaluation of both superficial and deep venous systems. ⁷

The superficial venous system of the lower limb primarily includes the great saphenous vein and small saphenous vein, which communicate with the deep venous system through perforator veins. Reflux in these veins is considered the major underlying mechanism responsible for primary varicose veins. Duplex ultrasonography plays an essential role in identifying the anatomical site and extent of reflux, which is critical for treatment planning. ⁸

The Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification provides a standardized method for describing chronic venous disease. This classification system categorizes venous disorders based on clinical severity, etiology, anatomical distribution, and pathophysiological mechanisms.⁹

Given the increasing prevalence of venous insufficiency and the importance of accurate diagnosis, the present study was conducted to evaluate the clinical profile and duplex ultrasound findings in patients with lower limb venous insufficiency presenting to a tertiary care hospital.

This study was conducted as a prospective observational study in the Department of Radio‑diagnosis at a tertiary care hospital.

The study aimed to evaluate patients presenting with clinical features suggestive of lower limb venous insufficiency using color duplex ultrasonography. The study was carried out over a period of 18 months. Ethical clearance for the study was obtained from the Institutional Ethics Committee and the study was conducted in accordance with the principles outlined in the Declaration of Helsinki. Written informed consent was obtained from all participants prior to their inclusion in the study. A simple random sampling technique was used for the recruitment of study participants. Patients attending the hospital

outpatient department or referred from other departments with clinical suspicion of varicose veins, venous ulcers, or lower limb swelling suggestive of chronic venous insufficiency were considered for inclusion.
The sample size was calculated using the standard prevalence formula: -

n = (Z² × P × (1 − P)) / E², Where Z = 1.96 corresponding to a 95% confidence interval, P = 0.37 representing the expected prevalence of great saphenous vein (GSV) varicosities reported in previous literature, and E = 0.07 representing the acceptable margin of error.

Based on this calculation, the estimated sample size was approximately 165 patients. To account for variability and to enhance statistical reliability, the final sample size was increased to 200 participants.

Eligible patients were enrolled until the required sample size was achieved. The inclusion criteria consisted of patients aged 18 years and above, individuals presenting with clinically suspected varicose veins referred for color Doppler sonography, and patients with symptoms such as lower limb swelling, venous ulcers, or other signs suggestive of chronic venous insufficiency who were willing to participate and provide informed consent.

The exclusion criteria included pregnant women, patients with severe obesity, individuals with severe chronic systemic diseases, patients with uncertain diagnosis, and those who refused to provide consent for participation. Data collection was performed using a validated pre‑structured questionnaire. Information regarding demographic details, occupation, medical history, comorbidities, history of trauma, surgery, prolonged immobilization, addiction history, and duration and progression of symptoms was recorded. Clinical examination findings including limb pain, swelling, skin changes, and ulceration were documented.

All enrolled patients underwent color duplex ultrasonography of the lower limb venous system using standard imaging protocols. Both superficial and deep venous systems were evaluated. Particular emphasis was placed on assessing the great saphenous vein (GSV), small saphenous vein (SSV), perforator veins, and deep veins to identify venous reflux or obstruction.Color duplex ultrasonography provided real‑time visualization of venous blood flow and helped detect valvular incompetence,

incompetent perforator veins, deep vein thrombosis, and other structural abnormalities. The examination was performed in appropriate patient positions to facilitate venous filling and reflux assessment. The location of reflux, the venous segment involved, and associated abnormalities were recorded systematically. Clinical findings were correlated with duplex ultrasonography results, and patients were further categorized according to the clinical‑etiology‑anatomy‑pathophysiology (CEAP) classification system for chronic venous disease. All collected data were compiled and analysed to determine the distribution of venous reflux patterns, associated predisposing factors, and clinical severity of venous insufficiency among the study population.

Table 1: Age Distribution of Patients

Table 2: Gender Distribution of Patients

Table 3: Predisposing Factors Associated with Venous Insufficiency

Table 4: Distribution of Patients According to Reflux Site on Color Duplex

Table 5: CEAP Clinical Classification of Patients

Chronic venous insufficiency is a progressive vascular disorder that affects a considerable proportion of the adult population. The present study evaluated the clinical characteristics and duplex ultrasonography findings among patients with lower limb venous insufficiency.

In the present study, the majority of patients belonged to the 41–60 year age group, indicating that venous insufficiency is more prevalent among middle-aged individuals. Similar findings have been reported in epidemiological studies which demonstrate that the prevalence of chronic venous disease increases with age due to progressive degeneration of venous valves and reduced elasticity of venous walls. ¹⁰

Gender distribution in venous disease varies across different populations. In the current study, males constituted a larger proportion of the study population. While several studies have reported higher prevalence among females, particularly due to hormonal factors and pregnancy-related changes in venous pressure, other studies have demonstrated male predominance depending on occupational exposure and lifestyle factors. ¹¹

Occupational factors were identified as an important predisposing factor in the present study. Prolonged standing was observed to be associated with the development of venous insufficiency. Continuous standing results in increased hydrostatic pressure in the lower limb veins, which may lead to venous dilation and valve incompetence. Previous studies have also highlighted prolonged standing as a significant occupational risk factor for varicose veins. ¹²

Color duplex ultrasonography plays a central role in the diagnosis and evaluation of venous insufficiency. In the present study, the great saphenous vein was the most common site of venous reflux. This observation is consistent with previous studies that have reported incompetence of the great saphenous vein as the most frequent cause of primary varicose veins.¹³

The small saphenous vein was the second most commonly involved vein in the present study. Reflux in the small saphenous vein contributes to posterior calf varicosities and may also be associated with perforator vein incompetence. Duplex ultrasonography allows accurate identification of these venous segments and helps determine the extent of disease. ¹⁴

Perforator vein incompetence was observed in a smaller proportion of cases in the present study. Incompetent perforator veins allow reverse blood flow from the deep venous system to the superficial veins, resulting in increased venous pressure and progression of chronic venous disease.¹⁵

Deep venous reflux was identified in a minority of patients in the present study. Deep venous incompetence is often associated with previous deep vein thrombosis and post-thrombotic syndrome. Although less common than superficial venous reflux, deep venous disease may lead to more severe manifestations such as venous ulceration.

The CEAP classification system was used to assess the clinical severity of venous disease. Most patients in the present study were classified as C2 stage, indicating visible varicose veins without significant skin changes. However, a proportion of patients presented with advanced stages including skin changes and venous ulceration. These findings emphasize the importance of early diagnosis and treatment to prevent disease progression.

Color duplex ultrasonography has become the gold standard diagnostic modality for evaluating venous insufficiency because it is non-invasive, accurate, and widely available. It allows detailed assessment of venous anatomy and hemodynamic, thereby facilitating appropriate treatment planning and improving patient outcomes.

Chronic venous insufficiency is a common vascular disorder affecting the lower limbs and is frequently associated with significant morbidity. The present study demonstrated that middle-aged individuals were most commonly affected, with occupational factors playing an important role in disease development.

Color duplex ultrasonography proved to be an effective, non-invasive, and reliable diagnostic modality for identifying venous reflux and evaluating both superficial and deep venous systems. The great saphenous vein was the most common site of reflux, and most patients presented in the C2 stage of CEAP classification.

Early diagnosis using duplex ultrasonography allows timely management and helps prevent complications such as venous ulceration. Therefore, duplex ultrasound should be considered the investigation of choice in the evaluation of lower limb venous insufficiency.

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