Lower Extremity Venous Duplex Imaging: Why the Details Matter More Than Ever

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At ISET 2026, interventional radiologist Alexander Misono, MD, MBA, RPVI, challenged attendees to rethink how lower extremity venous duplex imaging fits into the modern deep vein thrombosis (DVT) care pathway. He framed venous ultrasound not as a routine checkbox but as a pivotal decision point that can dramatically alter patient outcomes.

Dr Misono began his presentation describing how missed or under-recognized proximal DVT carries a significant risk of pulmonary embolism, higher short-term mortality, and a greater likelihood of debilitating post-thrombotic syndrome (PTS). For patients who progress to severe PTS, quality of life can be comparable to that seen in congestive heart failure or cancer. Dr. Misono emphasized that accurate diagnosis is no longer just about anticoagulation decisions but about identifying patients who may benefit from timely intervention.

He then provided a review of how dramatically the treatment landscape has evolved. With the rapid expansion of thrombectomy technologies over the past 5 years, clinicians now have the ability to remove large clot burdens quickly, restore venous flow, and achieve durable clinical improvements. Yet, despite these advances, Dr. Misono argued that the “clinical value chain” remains incomplete if imaging interpretation fails to keep pace.

Much of the presentation focused on where breakdowns occur. Referring providers, sonographers, interpreting physicians, and interventionalists all play essential roles, but gaps in communication and reporting can derail care. Dr. Misono highlighted 3 recurring frustrations: venous ultrasound reports that underemphasize proximal DVT, a lack of recommendations for additional imaging when findings suggest central obstruction, and the near absence of suggestions for interventional consultation, even when patients may clearly benefit.

Through case examples, he illustrated how subtle clues such as abnormal venous waveforms or asymmetric findings can point to iliocaval disease, contralateral obstruction, in-stent thrombosis, or even underlying malignancy. In several cases, failure to recognize or clearly report these findings nearly resulted in missed interventions or delayed diagnoses, reinforcing the idea that careful, anatomy-driven interpretation can be a true game changer.

Dr. Misono advocated for simpler, more intentional imaging practices: always consider proximal disease, even when it isn’t directly visualized; use waveform abnormalities as diagnostic signals; be willing to recommend further workup, such as computed tomography or magnetic resonance venography; and don’t hesitate to suggest interventional consultation when appropriate. These small shifts can meaningfully improve downstream care.