Preoperative planning is the key to successful treatment of varicose veins using any of the ablation techniques. Patients first undergo a thorough history and physical examination. They are queried regarding any previous vein procedures (sclerotherapy, ablation, or stripping), history of deep venous thrombosis (DVT), superficial thrombophlebitis, or personal or family history of thrombophilia. This information is passed on to the vascular laboratory prior to duplex scanning and can guide the vascular technologist on what to look out for while scanning. Patients with recurrent varicose veins after procedures such as stripping often do not have straightforward venous anatomy and may require additional time for their study. Because care must also be taken in performing venous procedures on patients with peripheral arterial disease, pedal pulses should always be palpated during the initial physical examination. If these pulses are abnormal, the vascular laboratory may be called upon to perform a concomitant arterial evaluation.

A meticulous duplex ultrasound examination is the next step in preprocedure planning. A detailed “roadmap” of incompetent saphenous trunks and other sources of varicose veins is important. Failure to address nonsaphenous sources of varicosities such as perforators, accessory branches, and pelvic veins can lead to immediate or early treatment failure and patient dissatisfaction (see Chapter 25). In our practice, along with the formal report, the vascular technologist draws a “map” of the varicose veins including the diameters of the GSV and the SSV and the presence of any relevant accessory branches and perforator veins (Fig. 29.1). Incompetent anterolateral and posteromedial branches from the GSV are common, and if untreated, these may be associated with an unsatisfactory clinical result. It is not uncommon for the GSV or the SSV to terminate in the distal thigh or calf, with continuation as a branch above the superficial fascia. Such a branch is referred to not as the GSV or the SSV but as a tributary.¹⁸ Incompetent tributaries above the fascial layer in any part of the limb should be noted. Depth of the veins under the skin has potential ramifications for endovenous treatment. “Shallow” veins require more local anesthetic, and patients often have more discomfort after the procedure. Some suprafascial veins are close enough to the skin to preclude thermal ablation, and other techniques such as ambulatory phlebectomy or UGFS can be considered
on these veins. An assessment of the deep system is particularly important in patients with a history of DVT, edema, skin changes, or ulceration or in young patients with severe varicosities and suspicion for Klippel-Trenaunay syndrome.

In patients presenting with groin, medial thigh, and upper posterior thigh varicose veins, a pelvic source from an incompetent internal iliac vein branch should be considered (Fig. 29.2). This varicose vein pattern is almost invariably seen only in female patients, and it is most often present during or after pregnancy. It is common in these cases that the terminal valve of the GSV is competent, and the GSV becomes incompetent when a varicose vein branch from the pelvic veins empties into it. When performing a varicose vein study, if the GSV is incompetent and yet the terminal valve is competent, an alternative source for the reflux should be investigated such as a perforator vein, a pelvic branch, or a branch from an incompetent accessory vein.

Precise near-field resolution is the most important feature for diagnostic imaging and treatment of varicose veins. In our practice, we use a GE Logic 9 machine with a 12-MHz “hockey stick” probe and a 10-MHz linear probe for preoperative mapping. Documentation of deep and superficial venous incompetence, as well as the presence of any clinically significant refluxing perforator veins, is noted.