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Recurrent Lower-Limb Varicose Veins: Effect of Direct Contrast-enhanced Three-dimensional MR Venographic Findings on Diagnostic Thinking and Therapeutic Decisions¹

¹ From the Institute of Diagnostic Radiology (M.A.M., B.M., J.K.W.) and Division of Cardiovascular Surgery (D.M.), University Hospital Zurich, Zurich, Switzerland; and Biostatistics Unit, Institute of Social and Preventive Medicine, University of Zurich, Zurich, Switzerland (B.S.). Received June 8, 2007; revision requested August 10; revision received August 31; accepted September 28; final version accepted October 29. J.K.W. supported in part by the Swiss Foundation of Medical-Biological Grants, the Novartis Research Foundation, and the Swiss Society of Radiology. Address correspondence to J.K.W., Molecular Imaging Program at Stanford, Department of Radiology and Bio-X Program, Stanford University School of Medicine, E 150 Clark Center, 318 Campus Dr, Palo Alto, CA 94305-5427 (e-mail: willmann{at}stanford.edu).

	ABSTRACT

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Purpose: To assess the effect of direct three-dimensional (3D) magnetic resonance (MR) venographic findings on diagnostic thinking and therapeutic decisions in patients with complex recurrent varicose vein anatomy who were being evaluated for surgical treatment.

Materials and Methods: The study was approved by the Institutional Review Board; informed consent was obtained from patients. MR venography was performed before surgery in 22 legs of 14 patients (seven women: mean age, 53 years; seven men: mean age, 59 years) thought to have recurrent varicose veins. Two radiologists assessed image quality and evaluated sites and sources of varicose veins on MR venograms. One vascular surgeon completed a questionnaire before and after MR venography and noted diagnosis and therapeutic decisions. Diagnoses at MR venography were compared with surgical results in 19 legs that underwent surgery. Differences between diagnosed and treated varicose veins per leg before and after MR venography were analyzed with logistic regression for survey data. Values were calculated to illustrate interobserver agreement for grading image quality of venous segments and for diagnosing recurrent varicose veins.

Results: Mean graded image quality of the deep venous system and the recurrent varicose veins was good or excellent in 89% of segments. There was good agreement between readers regarding grading of image quality of venous segments ( = 0.80). After MR venography, diagnosis of the sites and sources of recurrent varicose veins changed in 17 of 22 legs of nine of 14 patients. In one of 14 patients, the preoperative diagnosis of recurrent varicose veins was withdrawn. A change in treatment plan occurred in 17 of 22 legs after MR venography. The number of diagnosed and treated sources of reflux increased significantly after MR venography. MR venographic diagnoses were confirmed at surgery in all 19 legs.

Conclusion: MR venographic results have a substantial effect on diagnostic thinking and therapeutic decisions when recurrent lower-limb varicose veins are suspected.

© RSNA, 2008

	INTRODUCTION

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Recurrence rates for varicose veins have been reported to be between 5% and 49% after surgery (1). Therefore, accurate preoperative detection of all sources of venous reflux is of paramount importance to decrease the recurrence rate of varicose veins after surgical revision. According to a publication of the American Venous Forum (2), duplex ultrasonography (US) is advocated as the primary noninvasive imaging modality, after medical history has been obtained and clinical examination has been performed, for preoperative assessment of patients with varicose veins. Duplex US enables rapid access, has a high level of accuracy and a low cost, and allows preoperative marking of the sites of incompetent vessels directly on the skin of the patient. However, in patients with complex recurrent varicose vein anatomy, further work-up with additional imaging modalities, including conventional venography, computed tomography, or magnetic resonance (MR) venography, has been recommended (2). These imaging modalities allow a two- or three-dimensional (3D) visualization of the entire venous system of the lower limbs and help facilitate preoperative planning in patients with complex varicose vein anatomy (3,4).

Three-dimensional MR venography has the advantage of a noninvasive and accurate 3D visualization of the deep and superficial venous system of the lower limbs without patient exposure to ionizing radiation. Several studies (5,6) have addressed the value of MR venography for the diagnosis of deep venous thrombosis. Experience with 3D MR venography in patients with lower extremity varicose veins is limited (7–9), and, to our knowledge, there is no report on the value of 3D MR venography in patients with recurrent varicose veins. Our clinical experience suggests that 3D MR venography may be valuable for surgical planning in selected cases of patients with complex recurrent varicose vein anatomy. Thus, the purpose of our study was to assess the effect of direct 3D MR venographic findings on diagnostic thinking and therapeutic decisions in patients with complex recurrent varicose vein anatomy who were being evaluated for surgical treatment.

	MATERIALS AND METHODS

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Patients
The study was approved by the Institutional Review Board of the University Hospital Zurich; informed consent was obtained from all patients. From January 2003 to April 2006, 308 consecutive patients were referred to undergo varicose vein surgery of the lower extremities in the department of vascular surgery in our hospital. Of these 308 patients, 38 (12%) patients suspected of having recurrent varicose veins of the lower limbs were admitted. In our hospital, every patient suspected of having recurrent varicose veins undergoes a standardized preoperative evaluation according to the American Venous Forum (3): a thorough medical history is obtained; a physical examination is performed; and standard duplex US of the superficial, tributary, perforator, and deep veins of the lower extremities of the patient is performed.

For the purpose of our study, one vascular surgeon (D.M., 11 years of experience in varicose vein surgery) obtained the medical history and performed the physical examination in all 38 patients suspected of having recurrent varicose veins. Duplex US was performed by one of two experienced technologists (one with 15 and one with 18 years of experience in duplex US) with previously described techniques (2). On the basis of this standardized preoperative evaluation, the sites and sources of incompetent vessels could be defined in 24 (63%) of 38 patients without additional work-up, and the patients were directly scheduled for surgery. In 14 (37%) of 38 patients, additional preoperative work-up was indicated at clinical examination (ie, sites and sources of incompetent veins could not be thoroughly assessed or there was a mismatch between the findings from medical history, physical examination, and duplex US). These 14 patients were referred to undergo direct contrast material–enhanced 3D MR venography for further evaluation (Fig 1).

View larger version (16K): [in this window] [in a new window] [Download PPT slide]   Figure 1: Flowchart shows selection of patients suspected of having recurrent varicose veins who were included in the study and evaluated with direct 3D MR venography.

First Clinical Evaluation
For each of the 22 legs under consideration, the vascular surgeon separately completed a standardized questionnaire in the form of a check-off sheet. On the questionnaire, the most probable sites and sources of recurrence, as well as the most likely therapeutic decisions, were noted on the basis of medical history, physical examination, and duplex US examination results. According to the classification of patients with recurrent varices after surgery (10), the sites (groin, thigh, popliteal fossa, lower leg including ankle and foot, or other site) and sources (pelvis or abdomen, saphenofemoral junction, thigh perforator, saphenopopliteal junction, popliteal perforator, gastrocnemius veins, lower leg perforator, or no source of reflux) of the varicose veins were defined in each patient. The following therapeutic options were offered: (a) no therapy, (b) conservative treatment (compressive stockings, wound and skin care, pharmacologic therapy) (4), and (c) surgery. Surgical approaches included treatment of the different sources and sites of reflux (eg, ligation and/or excision of incompetent saphenofemoral and saphenopopliteal junctions or incompetent thigh and lower leg perforators). In case of surgery, the vascular surgeon noted one or a combination of the surgical approaches on the questionnaire.

Because the results of preoperative work-up was judged incomplete by the vascular surgeon in all 14 patients, which was the inclusion criterion for the study, the diagnostic and therapeutic decisions at the first clinical evaluation were based on the "best clinical guess."

Direct Contrast-enhanced 3D MR Venography
Direct contrast-enhanced 3D MR venography was performed by using a previously reported protocol with slight modifications (7). In all 14 patients, MR imaging was performed with a 1.5-T MR imager (Signa EchoSpeed Plus or Signa Excite HD; GE Healthcare, Milwaukee, Wis) with a maximum gradient amplitude of 33 mT/m and a slew rate of 120 mT/m/msec. The patients were positioned supine and feet first on the imaging table with their arms placed above their head. For signal reception, all patients were covered with a three-station phased-array peripheral vascular surface coil (Four-Channel Phased-Array Peripheral Vascular Coil; GE Medical Systems, Milwaukee, Wis). Each station of the coil received signals from a maximum distance of 48 cm. The coil was placed on the patient to ensure that all veins from the ankles to the distal inferior vena cava were covered.

A two-dimensional spin-echo scout-view sequence in the transverse plane was performed in the lower legs, thighs, and pelvis (repetition time msec/echo time msec, 1.0/1.4; flip angle, 60°; bandwidth, 31.25 kHz; section thickness, 5 mm; matrix, 256 x 162; number of signals acquired, 1.0). On the basis of these images, 3D data acquisitions in the coronal plane were prescribed for all three stations. For 3D data acquisition, a 3D spoiled gradient-recalled-echo sequence was used (2.7/0.7; flip angle, 30°; bandwidth, 83 kHz; field of view, 48 x 48 cm; section thickness, 3 mm; matrix, 256 x 192; number of signals acquired, 1.0; zero interpolation).

For contrast medium application, a medial superficial metatarsal vein was selected. First, a single rubber-tube tourniquet (diameter, 6 mm; length, 80 cm) (Sanor Stauschlauch; Lamprecht, Dielsdorf, Switzerland) was put around the ankle tight enough to ensure congestion of the dorsal superficial venous system of the foot for needle placement and to avoid contrast-media filling of the superficial venous system of the leg during the first MR data acquisition (estimated pressure between 70–90 mm Hg). Second, a 22-gauge plastic cannula (Venflon; Becton Dickinson, Franklin Lakes, NJ) was placed into the medial vein of the dorsal superficial venous system of the foot. In all patients, the contrast medium was then injected continuously at a flow rate of 1 mL/sec up to a total volume of 300 mL per leg, which corresponds to 20 mL of gadoterate meglumine in each leg. Data acquisition was started after the administration of 40 mL of diluted (1:15) gadoterate meglumine (0.5 mol/L Dotarem; Guerbet, Roissy, France) in each leg (which corresponded to a delay time of 40 seconds between the start of contrast media administration and the start of MR imaging data acquisition). The value of diluted contrast media has been previously demonstrated (7).

Each image for each station was acquired in 40 seconds. After this data acquisition, the tourniquet was removed from the ankle to ensure filling of the superficial veins, and a second set of images was acquired for assessment of the superficial veins. In the cases of a bilateral MR venography, both legs were infused and imaged simultaneously.

Image Analysis of MR Venography
Images were analyzed on a dedicated interactive workstation (Advantage Windows Workstation, version 4.2; GE Healthcare, Buc, France).

For the purpose of the study, the deep venous system was divided into nine segments, including the anterior and posterior tibial veins, the fibular veins, the popliteal vein, the femoral vein, the common femoral vein, the external and common iliac vein, and the distal inferior vena cava. Varicose veins were divided into three parts (proximal, middle, and distal). The image quality of 238 venous segments (190 deep venous segments and 48 varicose veins) was evaluated. Two readers (reader 1 [M.A.M.] and 2 [J.K.W.], with 1 and 5 years of experience, respectively, in the interpretation of MR venograms) independently assessed subjective image quality of all nine segments of the deep venous system and image quality of varicose veins on all MR venograms in all 22 legs (data from the first MR imaging acquisition with the tourniquet placed around the ankle). The readers were blinded to the names of the patients, the clinical data, and findings at duplex US. All MR venograms were analyzed in random order. Both readers were allowed to individually adjust window centers and level settings of the MR data sets for image analysis on the workstation, and a cine mode was available for rapid interactive interpretation. In addition, both readers were allowed to use maximum intensity projections of the MR data sets in different planes if considered useful.

The image quality of each vessel was graded with a four-point scale: grade 1 indicated poor visibility (diagnostic information cannot be obtained from the image); grade 2, moderate visibility (image quality of the vessel is degraded because of inhomogeneous distribution of the contrast medium in the vessel, but is still diagnostic for delineation of varicose veins and measurement of vessel diameter); grade 3, good visibility (slightly inhomogeneous distribution of the contrast medium in the vessel); and grade 4, excellent visibility (homogeneous distribution of the contrast medium in the vessel).

Both readers independently evaluated all MR venograms with regard to the presence of recurrent varicose veins. According to the recurrent varices after surgery classification, which was also used for the clinical evaluations in our study, varicose veins were classified according to the sites (groin, thigh, popliteal fossa, lower leg including ankle and foot, or other site) and sources (pelvis or abdomen, saphenofemoral junction, thigh perforators, saphenopopliteal junction, popliteal perforator, gastrocnemius veins, lower leg perforators, or no source of reflux) of the varicose veins. Varicose veins with a diameter more than 3 mm were considered significant (11).

Diameters were measured by using an electronic caliper on the workstation by reader 1. The diagnoses from the separate analysis of reader 1 and 2 were compared, and disagreements between readers were resolved with a consensus analysis. The results from the consensus reading were used for the second clinical evaluation.

Second Clinical Evaluation
The second clinical evaluation was performed during the next consultation by the same vascular surgeon who performed the first clinical evaluation (mean interval between clinical evaluations, 63 days; range, 12–152 days). For this second evaluation, the vascular surgeon considered both the MR imaging results (diagnosis from the consensus reading of readers 1 and 2) and the findings from medical history, physical examination, and duplex US for making both the diagnosis and the therapeutic decisions. After the second clinical evaluation, the vascular surgeon completed the same standardized questionnaire used for the first clinical evaluation.

All patients were followed up by the same vascular surgeon during a period of 6 months to 2 years after surgery or MR venography (mean follow-up period, 17 months). Medical history was obtained and physical examinations were performed at these checkups. Doppler US was only performed if recurrent varicose veins were suspected at clinical examination.

Statistical Analysis
The questionnaires obtained before and after MR venography were compared with regard to sites and sources of recurrent varicose veins, as well as with regard to therapeutic decisions. Diagnostic thinking and therapeutic decisions before and after MR venography were analyzed on a per–venous segment basis. Differences between diagnosed varicose veins and treated varicose veins per leg before and after MR venography were analyzed by using logistic regression for survey data (Intercooled Stata, version 9.2 for Macintosh; Stata, College Station, Tex) with the leg as the primary sample unit. With this analysis, correlations and clustering between segments within the same leg are taken into account. The positive predictive value, including 95% confidence interval, of MR venography was determined on the basis of findings in the 19 legs that had undergone surgery before the end of the study. To illustrate the interobserver agreement between reader 1 and 2 for grading image quality of the different venous segments and for diagnosing recurrent varicose veins, a value was determined. Poor agreement was indicated by of 0; slight agreement, of 0.01–0.2; fair agreement, of 0.21–0.40; moderate agreement, of 0.41–0.60; good agreement, of 0.61–0.80; and excellent agreement, of 0.81–1.00 (12). Mann-Whitney U test results (for calculation of the difference between women and men with regard to age), the value, and the Wilcoxon signed rank test results were obtained by using software (SPSS, version 13.0 for Mac OS X; SPSS, Chicago, Ill). Differences were considered significant at a P value of less than .05.

	RESULTS

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Image Quality at MR Venography
The qualitative values of subjective image quality showed a small decrease from the lower leg to the pelvic region (Table 1, Fig 2).There was good agreement between reader 1 and 2 with regard to the grading of image quality of venous segments ( = 0.80). There was no relevant arterial enhancement.

View larger version (62K): [in this window] [in a new window] [Download PPT slide]   Figure 2: Coronal direct MR venographic maximum intensity projection (2.7/0.7) in 32-year-old woman with possible recurrent varicose veins of both lower legs who was referred for surgery. Both readers graded image quality of lower leg veins (anterior tibial [large arrowheads], fibular [small arrows], posterior tibial [large arrows]), popliteal (small arrowheads) and femoral (C-shaped arrows), and common femoral (five-point solid stars) veins as excellent (grade 4). Because of slightly inhomogeneous distribution of contrast media, image quality of external iliac veins (five-point open stars), common iliac veins (eight-point solid stars), and inferior vena cava (eight-point open star) was graded as moderate by both readers. Note bilateral varicose veins (bent arrows) and slight enhancement of lower leg arteries.

Overall, diagnostic thinking changed for 17 (77%) of 22 legs of nine (64%) of 14 patients after MR venography. The number of diagnosed incompetent varicose veins increased significantly after MR venography (P = .045). On the basis of a per–venous segment analysis, MR venography depicted 21 additional incompetent lower leg perforator veins that were not diagnosed at first clinical examination without MR venography (Table 2; Figs 3, 4), and three lower leg perforator veins suspected of being incompetent at clinical examination were excluded at MR venography. Two thigh perforator veins suspected of being incompetent (Fig 5) and six saphenofemoral junctions (Fig 6) suspected of being incompetent were confirmed at MR venography. In one leg of one (7%) of 14 patients, MR venographic results demonstrated no source of reflux.

View larger version (44K): [in this window] [in a new window] [Download PPT slide]   Figure 3: Oblique maximum intensity projection of direct MR venographic data set (2.7/0.7) in 52-year-old woman suspected of having recurrent varicose veins of right leg and who was referred for surgery. A 4-mm incompetent posterior tibial perforator vein (arrow) that was missed before MR venography was detected. The therapeutic decision changed by means of an additional ligation of incompetent posterior tibial perforator vein. Level of tourniquet (arrowhead) can be seen.

View larger version (45K): [in this window] [in a new window] [Download PPT slide]   Figure 4: Coronal maximum intensity projection of direct MR venographic data set (2.7/0.7) in 45-year-old man suspected of having recurrent varicose veins of left leg and with mismatch between physical examination and duplex US results and who was referred for surgery. At physical examination, an incompetent lower leg perforator vein was suspected; however, source of reflux could not be identified at duplex US. A 5-mm incompetent perforator vein (large arrow) was diagnosed arising from posterior tibial vein (small arrow), with subsequent contrast material filling of a superficial varicose vein (arrowhead). The treatment plan changed by means of an additional ligation of this incompetent posterior tibial perforator vein.

View larger version (47K): [in this window] [in a new window] [Download PPT slide]   Figure 5: Coronal maximum intensity projection of direct MR venographic data set (2.7/0.7) in 41-year-old woman suspected of having an incompetent thigh perforator vein in right leg on the basis of standard preoperative diagnostic approach. Both readers confirmed a 4-mm incompetent thigh perforator vein (arrow) at the level of the distal thigh, which feeds a large varicose vein on medial site of thigh (arrowheads). Diagnostic thinking and therapeutic decision were not changed after MR venography in this patient.

View larger version (33K): [in this window] [in a new window] [Download PPT slide]   Figure 6: Coronal direct MR venographic maximum intensity projection (2.7/0.7) in 55-year-old man with possible recurrent varicose veins at level of saphenofemoral junction (arrow) in right leg who was referred for surgery. Varicose veins were confirmed on coronal maximum intensity projection by both readers. Diagnostic thinking and therapeutic decision were not changed after MR venography. Arrowhead = tourniquet level.

View larger version (49K): [in this window] [in a new window] [Download PPT slide]   Figure 7: Coronal maximum intensity projection of direct MR venographic data set (2.7/0.7) in 59-year-old man suspected of having recurrent varicose veins in left leg. On image, a chronic short postthrombotic occlusion (arrowhead) of popliteal vein was diagnosed by both readers. Note incompetent lower leg perforator veins originating from posterior tibial veins at two levels (large arrows) and from anterior tibial veins at two levels (small arrows) in lower leg. After MR venography, treatment plan changed from surgery to conservative treatment in this patient.

	DISCUSSION

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Direct contrast-enhanced 3D MR venography has been proved valuable for assessment of patients with lower-limb venous disease (7–9,13,14). Ruehm et al (7) demonstrated high accuracy of direct 3D MR venography in the detection of varicose and postthrombotic changes compared with that at conventional venography. In that study, postthrombotic changes were diagnosed with a sensitivity and specificity of 100% and 98%, respectively, and varicose changes were detected with a sensitivity and specificity of 94% and 96%, respectively, at direct MR venography.

To our knowledge, our study is the first to address the value of direct contrast-enhanced 3D MR venography in the preoperative assessment of patients with recurrent varicose veins. In conjunction with a peripheral vascular coil, direct injection of contrast material into pedal veins, and application of a tourniquet, MR venography resulted in a display of the entire deep and superficial venous system of the lower limbs in our study. Both readers graded image quality as good or excellent in 89% of the venous segments in our study. In particular for pelvic veins, moderate image quality was observed. This may be explained by dilution of the contrast material when traveling from the lower leg to the pelvic region during data acquisition. However, in none of the venous segments was image quality judged to be nondiagnostic by either reader.

The results of our study show that MR venographic results changed the diagnosis in 64% of patients. MR venography was of value in particular for the diagnosis of additional incompetent lower leg perforators and saphenofemoral junctions. A total of 21 incompetent lower leg perforator veins that were not depicted with the standard preoperative diagnostic approach were diagnosed at MR venography in our study. Additional incompetent saphenofemoral junctions were detected at MR venography in three legs and were excluded as being incompetent in four legs. In one of 14 patients, the diagnosis of recurrent varicose veins was withdrawn in synopsis with the clinical presentation, and in two other patients, the therapeutic approach changed from surgical to conservative treatment due to the diagnosis at MR venography of chronic thromboses of the popliteal vein. During the follow-up period between 6 months and 2 years, there were no recurrent varicosities diagnosed in any patients. Therefore, the results of our study suggest that MR venography may improve the clinical outcome in patients with recurrent varicose veins and with inconclusive clinical and duplex US evaluation by enabling the visualization of additional incompetent veins. However, the follow-up time of only up to 2 years may have been too short to definitively exclude missed varicose veins at MR venography in our study.

The technique of direct 3D MR venography described in our study follows with slight modifications from a protocol first introduced by Ruehm et al (7) and could be accomplished, on average, in about 25 minutes in our study. The technique is now used on a routine clinical basis at our institution as a problem-solving preoperative tool in patients with recurrent varicose veins and inconclusive findings with the standard preoperative evaluation protocol. One drawback of the technique, however, is that a needle must be placed into a pedal vein for contrast-media application. This may be difficult in some patients and may cause some discomfort for patients.

Our study had limitations. The number of patients with recurrent varicose veins was small. Because inclusion of patients in the study was determined by using the clinical diagnostic approach in patients with recurrent varicose veins at our hospital, patients were scheduled for additional imaging work-up only if indicated at clinical examination. Therefore, further studies with larger study samples are warranted to confirm our findings. Moreover, because only patients suspected of having recurrent varicose veins were included, this may have resulted in a systematic bias when we evaluated MR venograms for the presence of varicose veins. Furthermore, because surgery was performed only on those sites of reflux that were detected at direct MR venography, we cannot comment on the number of sites of reflux that may have been missed at direct MR venography in our study (ie, lack of standard of reference for nonoperated sites of the venous system).

An inherent limitation of our MR imaging technique, which was without the use of a Valsalva maneuver and with acquisition only in a supine position, was the lack of functional information (in contrast to that at Doppler US or conventional venography). The diagnosis of an incompetent varicose vein in our study was based on morphologic criteria only (diameter >3 mm), which was useful in this study because the diameter of incompetent perforator veins is usually larger than that of perforator veins without reflux (15,16). Therefore, further comparative studies between MR venography and duplex US are warranted. However, the results of our study have shown that these further studies need to be performed in patients without a complex postoperative venous anatomy because duplex US may not be considered a standard of reference in that subset of patients.

In addition, in our study we assumed that MR venographic results may directly influence diagnostic thinking and therapeutic decisions. However, other parameters unrelated to MR venography may have influenced the decision process in our study, such as a change in clinical symptoms between the first and second clinical evaluation or a change of patients' expectations of the surgical approach. However, this limitation is an inherent drawback of this kind of study in which the influence of imaging on the clinician's diagnostic and therapeutic thinking is investigated. Finally, the influence of MR venography on diagnostic thinking and therapeutic decisions was only assessed for one vascular surgeon specialized in varicose vein surgery in our hospital. The diagnostic approach in patients suspected of having recurrent varicose veins may vary at different institutions.

In conclusion, results of this study have shown that direct contrast-enhanced 3D MR venographic results have an effect on diagnostic thinking and therapeutic decisions involving patients suspected of having complex varicose vein anatomy. This effect may be explained by the visualization of the venous system on MR venograms, which facilitates assessment of the sites and sources of reflux of recurrent varicose veins. Therefore, we believe direct 3D MR venography is a valuable complementary imaging modality after performance of duplex US to help vascular surgeons plan further treatment in patients with complex varicose vein anatomy.

	ADVANCES IN KNOWLEDGE

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• In patients with complex recurrent lower-limb varicose vein anatomy, direct three-dimensional (3D) MR venography allows good to excellent image quality and visualization of the deep venous system and of varicose veins in 89% of venous segments.
  
• Direct 3D MR venographic results influenced diagnostic thinking in 64% of patients with complex recurrent varicose vein anatomy.
  

	IMPLICATION FOR PATIENT CARE

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCES IN KNOWLEDGE IMPLICATION FOR PATIENT CARE References

 

• Direct 3D MR venographic findings can change therapeutic decisions in patients with complex recurrent varicose vein anatomy.
  

	FOOTNOTES

 

Abbreviations: 3D = three dimensional

Author contributions: Guarantors of integrity of entire study, M.A.M., D.M., J.K.W.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; manuscript final version approval, all authors; literature research, M.A.M., J.K.W.; clinical studies, M.A.M., D.M., J.K.W.; statistical analysis, B.S., J.K.W.; and manuscript editing, J.K.W.

Authors stated no financial relationship to disclose.

	References

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCES IN KNOWLEDGE IMPLICATION FOR PATIENT CARE References

 

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