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16 Varicose Veins KCE Reports 164 3.1.2 Quality appraisal of diagnostic studies Quality appraisal was carried out using the QUADAS tool 38 as discussed in section 2.2.1. Figure 2 shows the range of quality rating per question of the QUADAS tool. The two studies were judged to have a low risk of bias as they studied patients representative of usual practice, used an acceptable reference test (duplex ultrasound) and patients underwent this test regardless of the results of the index test. Figure 2 Quality appraisal results using QUADAS 38 tool Blomgren Lee pts representative of normal practice? selection criteria defined? acceptable ref standard? acceptable delay between tests? partial verification avoided? differential verification avoided? ref standard independent of index test? index test described in detail? ref standard described in detail? index tests blinded? ref test blinded? relevant clinical information? uninterpretable results reported? withdrawals explained? Key yes unclear no NA: not applicable 3.2 OVERVIEW OF INCLUDED DIAGNOSTIC STUDIES The two studies included compared a reference test, duplex ultrasound scan before varicose vein surgery, with: • no duplex ultrasound 47 , • duplex ultrasound with CT venography 48 . No studies were found for the diagnostic procedures of preoperative arterial Doppler, phlebography, magnetic resonance imaging and intravascular ultrasound. 3.3 PRE-OPERATIVE DUPLEX ULTRASOUND COMPARED WITH NO SCAN Blomgren (2005) compared duplex with no duplex (clinical examination) and as such evaluated the clinical outcomes associated with a patient undergoing a duplex scan prior to varicose vein surgery. Patients (343 legs) were randomised to either duplex imaging or no duplex before varicose vein surgery and followed up at two months and two years with a duplex assessment. Duplex imaging conducted before surgery resulted in a different clinical plan compared with clinical examination in 26.5% of legs. At two years, two legs had recurrence compared with 14 legs in the in the non-duplex scan group (p=0.002) 47 . NA
KCE Reports 164 Varicose Veins 17 3.4 COMPUTED TOMOGRAPHY VERSUS DUPLEX A study by Lee et al. (2008) used multidetector computed tomography (MDCT) to evaluate 100 patients (151 limbs) with varicose veins. They performed a comparative analysis with duplex in 50 patients only (61 limbs) 48 . The authors concluded that CT images provide a good 3D overview of the deep venous system. The sensitivity of CT venography in the prediction of GSV insufficiency was 98.2% (56 of 57 cases) and the specificity was 83.3% (14 of 17 cases). MDCT was less accurate in the prediction of insufficiency in the SSV with a sensitivity of 53.3% (eight of 15 cases) and a specificity of 94.9% (56 of 59 cases) 48 . However, this test did not demonstrate any functional information of reflux or valve insufficiency. Given this lack of functional information as well as the disadvantage of the invasive procedure with the use of ionizing radiation there is no evidence that this technique is superior to duplex ultrasound to improve the outcomes of patients with varicose veins. • Duplex ultrasound is considered to be the ‘gold standard’ for the assessment of venous haemodynamics and anatomy (duplex anatomy) to determine the appropriate treatment for each patient; • There is no evidence to recommend multidetector computed tomography or other diagnostic tests for the diagnosis and treatment planning of varicose veins.
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118. Advantages, disadvantages and
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