The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders

As the importance of pelvic venous disorders (PeVD) has been increasingly recognized, progress in the field has been limited by the lack of a valid and reliable classification instrument. Misleading historical nomenclature, such as the May-Thurner, pelvic congestion, and nutcracker syndromes, often fails to recognize the interrelationship of many pelvic symptoms and their underlying pathophysiology. Based on a perceived need, the American Vein and Lymphatic Society convened an international, multidisciplinary panel charged with the development of a discriminative classification instrument for PeVD. This instrument, the Symptoms-Varices-Pathophysiology ("SVP") classification for PeVD, includes three domains-Symptoms (S), Varices (V), and Pathophysiology (P), with the pathophysiology domain encompassing the Anatomic (A), Hemodynamic (H), and Etiologic (E) features of the patient's disease. An individual patient's classification is designated as SVP_A,H,E. For patients with pelvic origin lower extremity signs or symptoms, the SVP instrument is complementary to and should be used in conjunction with the Clinical-Etiologic-Anatomic-Physiologic (CEAP) classification. The SVP instrument accurately defines the diverse patient populations with PeVD, an important step in improving clinical decision making, developing disease-specific outcome measures and identifying homogenous patient populations for clinical trials.

[Endoluminal Treatment of Varicose Veins: Value of Duplex Ultrasound (Part 2)]

Part one addressed the value of duplex ultrasound in the diagnostic workup of varicosis. The present article discusses the use of preinterventional, intrainterventional and postinterventional duplex ultrasound in endoluminal methods for the treatment of varices. It is a prerequisite for the planning, implementation, and follow-up of this form of therapy.

The importance of small saphenous vein reflux on chronic venous disease clinic

AIM

It is estimated that between 5% to 20% of the adult population in developed countries is affected by chronic venous insufficiency (CVI), thus being the most frequent vascular disorder. Recent studies show that, in most CVI patients, their junctions are competent and the correlated superficial reflux is present along the saphenous vein. Objective of the study was to correlate the presence and distribution of reflux in the saphenous vein with the signs and symptoms of CVI, through CEAP, in female patients.

METHODS

Record review of patients with CVI signs and symptoms who underwent clinical and ultrasound examinations in order to classify them according to CEAP. The sample was divided into three groups according to the presence of saphenous vein insufficiency: Group I-SSV, Group II-GSV, and Group III-SSV and GSV.

RESULTS

A total of 312 lower limbs of 259 female patients aged between 15 and 85 years were examined. The most prevalent clinical classes in the three groups were C2 (44.55%) and C3 (46.48%). Four patterns of reflux were identified in isolated SSV, with the highest incidence of proximal reflux (69.23%). SPJ impairment was most likely to occur in clinical cases of greater severity. Five patterns of reflux were identified in GSV, with the proximal one the most prevalent (64.42%).

CONCLUSION

There is a correlation between the clinical severity of CVI and the reflux along the SSV in association with GSV; the risk of moderate to high clinical severity in group III was 3.6 times higher than in group I and 4.6 times higher than group II.

[Russian observational programme SPEKTR: analysis of age-specific structure of patients with chronic venous diseases]

The authors studied the age-related structure of 864 patients with chronic venous diseases (CVD) by means of analysing the database of the Russian Programme SPEKTR (2011-2012). Most often special medical care was sought by persons of able-bodied age (31-60 years): men - 60.6%, women - 63.8%. Class C1 in women was registered at the age under 20 years in 49.5% of cases, in elder groups - from 66.4% to 76.1%. In men, it was registered 1.3-2-8 times less often in all age groups. Class C2 amounted to 75% of cases in women under 20 years; then 50% (21-30 years), increasing to 79.6% (61-70 years). Class C2 in men under 20 years was observed in 100%, then the proportion fluctuated within the bounds of 80% irrespective of the age. The maximum of registering C3 fell to the age of 41-50 years (women - 48%, men - 53.2%). The number of severe forms (C4-C6) in men was considerably more: 31-40 years - 20.2% versus 4.7% in women; 41-50 years - 59.6% versus 17.3%; 51-60 years - 46.7% versus 29.4%. Trophic ulcers were revealed in men most often at the age of 31 - 60 years - 22% in women in the analogous group - 4.9%. The anamnesis of CVD increased with age. Adequate treatment for CVD in all age groups prior to the visit to the phleblogist had been carried out very rarely.

Epidemiology of chronic venous disorders in geographically diverse populations: results from the Vein Consult Program

AIM

The Vein Consult Program is an international, observational, prospective survey aiming to collect global epidemiological data on chronic venous disorders (CVD) based on the CEAP classification, and to identify CVD management worldwide. The survey was organized within the framework of ordinary consultations, with general practitioners (GPs) properly trained on the use of the CEAP classification.

METHODS

Screening for CVD was to be performed by enrolling in the survey all consecutive outpatients >18 years whatever the reason for consultation, to record patient's data and classify them according to the CEAP, from the stage C0s to C6. The program enrolled 6232 GPs 91545 subjects were analysed. Their mean age was 50.6±16.9 years, younger patients being in the Middle East and older ones in Europe, and the proportion of women was higher than that of men.

RESULTS

The worldwide prevalence of CVD was 83.6%: 63.9% of the subjects ranging C1 to C6, and 19.7% being C0s subjects. C0s patients were more frequently men whatever the age and the geographical zone. C1-C3 appeared to be more frequent among women whatever the country but the rate of severe stages (C4-C6) did not differ between men and women. GPs consider CVD subjects as patients eligible to specialist referral beginning from C2 but some geographical disparities were observed.

CONCLUSION

The VCP survey provides reliable results on CVD global epidemiology and shows that CVD affects a significant part of the populations worldwide, underlining the importance of adequate screening for CVD and training of both GPs and specialist physicians.

[Clinico-histopathological correlations of venous wall modifications in chronic venous insufficiency]

The interest manifested for the conjunctive tissue pathology leaded to the study of the structural disorder that appears in the varicose veins walls. The study is a prospective one initiated in March 2007 made on 11 patients with varicose disease hospitalized at Cluj-Napoca within Surgery Clinic no. II. The purpose of this study is to point out the histopathological modifications in the varicose venous wall (great saphenous vein cross, communicating veins, perforating veins), as well as the correlation of histopathological results with the evolutive stage of chronic vein insufficiency (CEAP classification) and with the clinical score at these patients. The histopathological (HP) results for 2 of the patients revealed hypertrophy of the media, intimal hyperplasia (stage II) corresponding to a CEAP 3. Six patients were integrated in HP stage III due to the partial intimal fibrosis corresponding to a CEAP 6 for one case, CEAP 4 one case, CEAP 3 four cases. One patient had HP stage I with CEAP 3 and two patients had HP stage IV corresponding to CEAP 5, respectively CEAP 6.

Comparison of new continuous measurements of ambulatory venous pressure (AVP) with conventional tiptoe exercise ambulatory AVP in relation to the CEAP clinical classification of chronic venous disease

INTRODUCTION

Quantitative measurements of chronic venous insufficiency (CVI) are sensitive in detecting the presence of CVI but have low specificity in differentiating clinical severities of CVI as defined by the CEAP classification. One possible reason for this is measurement techniques do not assess variables that reflect hemodynamic changes that occur during normal exercise. Our aim was to compare the association of variables determined from a new technique, continuous ambulatory venous pressure monitoring (CAVPM), and those of conventional AVP measurement with the clinical severity of chronic venous insufficiency in patients with primary venous reflux.

METHODS

Fifty-four limbs of 49 patients with CVI and 15 healthy controls were studied. CVI clinical severity was classified according to CEAP as C2&C3 (mild disease), C4 (moderate disease), and C5&C6 (severe disease). All participants underwent duplex ultrasound scanning to rule out the presence of reflux in the control group and to confirm it in the patient groups. Conventional AVP measurements, including 90% refilling time (RT90), were compared with the new CAVP variables of mean walking pressure (MWP) and percentage fall in walking pressure (%FWP). Data were analyzed by analysis of variance using the Kruskal-Wallis test, and comparisons between groups were performed using Mann-Whitney tests. Discriminant analysis was used to determine the ability of a test to classify limbs into clinical classes.

RESULTS

Conventional AVP measurements could not differentiate between the control group and the presence of mild disease (P = .56) but did differentiate between controls and severe disease as well as mild and severe disease (P < .001). RT90 detected differences between controls and reflux groups (P < .001) but not between moderate (C4) and severe (C5&C6) clinical groups (P > .5). MWP and %FWP showed significant differences between all clinical severities and controls (P < .001).

CONCLUSION

In the assessment of CVI, mean walking pressure and percent fall in walking pressure are more reliably associated with anatomic distribution of reflux and clinical severity of CVI than the gold standard investigations of conventional AVP and RT90.

Ankle mobility in relation to chronic venous insufficiency in HIV-positive persons with and without a history of injection drug use

The purpose of this study was to examine ankle mobility in relation to chronic venous insufficiency (CVI) in HIV-positive persons with and without a history of injection drug use (IDU) and to examine the extent to which peripheral neuropathy further reduced ankle mobility. A cross-sectional, stratified design with quota sampling was used to recruit 27 persons with no history of IDU and 46 with a history of IDU from an infectious diseases clinic. Goniometric measurements of forefoot inversion-eversion and dorsiflexion-plantar flexion were obtained. CVI was assessed on a clinical scale. Peripheral neuropathy was identified from chart review and self-report. Injection drug users had less ankle flexion-extension right, inversion-eversion left and right, and total ankle motion than those who did not inject drugs (p < .05). Neuropathy was not associated with less mobility of the ankle joint (p < .01). A causal model supported the hypothesis of ankle mobility as a mediator of the effect of IDU on CVI.

Invasive therapeutic options in truncal varicosity of the great saphenous vein

It is known from current pathophysiology that disease stages I and II of truncal varicosity of the great saphenous vein do not cause changes in venous pressure on dynamic phlebodynamometry. This is possibly also the case for mild cases of the disease in stage III. In pronounced cases of stage III and all cases of stage IV, however, venous hypertension occurs which triggers the symptoms of secondary deep venous insufficiency and all the complications of chronic venous insufficiency. From these facts the therapeutic consequence is inferred that in stages I and II and perhaps also in very mild cases of stage III disease, it is enough "merely" to remove varicose veins without expecting there to be any other serious complications in the patient’s further life caused by the varicosity. Recurrence rates are not included in this analysis. In marked cases of disease stages III and IV of the great saphenous vein, however, secondary deep venous insufficiency is to be expected sooner or later. The classical operation with saphenofemoral high ligation ("crossectomy") and stripping strictly adheres to the recognized pathophysiologic principles. It also takes into account in the greatest detail aspects of minimally invasive surgery and esthetics. In the past few years, developments have been advanced to further minimize surgical trauma and to replace the stripping maneuver using occlusion of the trunk vein which is left in place. Obliteration of the vessel is subsequently performed via transmission of energy through an inserted catheter. This includes the techniques of radiofrequency ablation and endovenous laser treatment. High ligation is not performed as a matter of principle. In a similar way, sclerotherapy using microfoam is minimally invasive in character. All these procedures may be indicated for disease stages I and II, and with reservations also in mild forms of stage III disease. Perhaps high ligation previously constituted overtreatment in some cases. Targeted studies are still needed to prove whether secondary deep venous insufficiency can be avoided in advanced stages of varicose vein disease without high ligation and thus without exclusion of the whole recirculation circuit.

Use of microcirculatory parameters to evaluate chronic venous insufficiency

BACKGROUND

Microcirculatory impairment caused by chronic venous hypertension is usually not taken into account in chronic venous insufficiency, probably due to lack of practical means to observe it. The objective of this work was to use a new noninvasive technique to access quantitatively the cutaneous microangiopathy in female patients classified according to CEAP from C1 to C5 and matched with healthy controls.

METHODS

Forty-four patients and 13 healthy subjects (112 lower limbs), with a mean age +/- SD of 48 +/- 8 years, were evaluated by using orthogonal polarization spectral (OPS) imaging. Films of the internal perimaleolar region were analyzed by the CapImage software. The microcirculatory parameters evaluated were functional capillary density (number of capillaries with flowing red blood cells/mm), capillary morphology (percentage of abnormal capillaries), diameter (microm) of dermal papilla to quantify edema, diameter of capillary bulk (microm) to assess the degree of change, and diameter capillary limb to detect enlargement. A microcirculatory index combining these five parameters was proposed with I, II, and III stages, indicating normal microcirculation, and moderate and severe microangiopathy, respectively.

RESULTS

These microcirculatory parameters were significantly different (P < .05) from control values (C): capillary diameter and capillary morphology from C2 to C5, 8.1 +/- 0.8, 3.6 +/- 5.5 (C), and 9.7 +/- 1.3, 27.5 +/- 17.7 (C2); diameter of dermal papilla and diameter of capillary bulk from C3 to C5, 111.4 +/- 13.5, 52.8 +/- 8.8 (C), and 150.5 +/- 31.7, 87.8 +/- 26.9 (C3); and functional capillary density only from C4 to C5, 20.9 +/- 6.1 (C) and 14.5 +/- 4.5 (C4). The microcirculatory index showed good correlation to CEAP classification.

CONCLUSION

It was possible to quantify the microangiopathy using OPS imaging and to compare the microcirculatory changes of chronic venous insufficiency patients with healthy controls. Two parameters seemed more important to identify the differences between patients and controls: capillary morphology and capillary diameter. The suggested microcirculatory index can possibly demonstrate, in future studies, a prognostic capability when combined with the CEAP classification.

[Anatomy and physiopathology of venous system]

The field of chronic venous disease has suffered from a lack of precision in diagnosis. This deficiency has led to conflicting reports in studies of management of specific venous problem. The establishment of an uniform language for classifying the findings of CVD was needed. In 1995, the CEAP classification was proposed for classification and grading of CVD on the basis of clinical manifestations (C), etiologic factors (E), anatomic distribution of involvement (A) and underlying pathophysiologic findings (P). The purpose was to provide a comprehensive objective classification that could be used world-wide and serve as a basis for more scientific analysis of management alternatives.

[Functional assessment of the lymphatic bed of patients in the late clinical classes of chronic venous insufficiency according to the international GEAP classification]

The author revises the contents and limits of the anatomic CEAP classification. For this purpose 84 patients with different types of trophic disorders of the lower limbs were examined with the aid of the author's technique of functional lymphography and lymphoscintigraphy. Impairment of drainage and transport function of the lymphatic capillaries was established from the ulcer edge at the level of the outgoing (from skin to collector) and collecting (from foot to regional nodes) capillaries. A close relationship was discovered between secondary changes in the lymphatic bed and the severity of trophic disorders. In groups with dilated and stenosed vessels, there were subgroups of patients with preserved function of lympangions. The data obtained evidence that lymphovenous insufficiency beyond the area of trophic disorders is more pronounced than in the focus itself. This may play a decisive role in the choice of the treatment modality as dependent on the condition of the drainage pathways. To refine the diagnosis in patients showing disease progression, with failed treatment of trophic ulcers including ulcerous defects, the author suggests that A category may be divided into two subgroups: Av for characterization of different veins and Al for lymphatic vessels of varying levels: S (skin), (Tissue) and Lnd (lymph nodes). The use of additional criteria for the diagnosis substantially improves the characteristics of the international CAAP classification.

Revision of the CEAP classification for chronic venous disorders: consensus statement

The CEAP classification for chronic venous disorders (CVD) was developed in 1994 by an international ad hoc committee of the American Venous Forum, endorsed by the Society for Vascular Surgery, and incorporated into "Reporting Standards in Venous Disease" in 1995. Today most published clinical papers on CVD use all or portions of CEAP. Rather than have it stand as a static classification system, an ad hoc committee of the American Venous Forum, working with an international liaison committee, has recommended a number of practical changes, detailed in this consensus report. These include refinement of several definitions used in describing CVD; refinement of the C classes of CEAP; addition of the descriptor n (no venous abnormality identified); elaboration of the date of classification and level of investigation; and as a simpler alternative to the full (advanced) CEAP classification, introduction of a basic CEAP version. It is important to stress that CEAP is a descriptive classification, whereas venous severity scoring and quality of life scores are instruments for longitudinal research to assess outcomes.

Radionuclide assessment of the treatment by compression of patients with chronic venous insufficiency

A study was made of the efficacy of the compression medical tricot in the treatment of chronic venous insufficiency (CVI). To evaluate the treatment by compression, the authors, in addition to the clinical examination, used radionuclide techniques such as examination of the regional blood volumes and phleboscintigraphy. The results of the given work have shown that the compression products under test are effective agents for the treatment of CVI by compression which improves venous return and the patients' quality of life. The data obtained point out that in addition to the lowering of blood filling, the medical tricot influences the interstitial element of the edematous syndrome, leading to the elimination of the latter one. The use of elastic bandages creates the known difficulties (the necessity of the patient training in bandaging, complexity of creating an adequate bandage, quick depreciation). In view of this fact the use of the compression tricot which possesses the fixed grade of compression for a concrete form and stage of CVI is preferable in the therapy of chronic venous diseases.

Pathomechanism of chronic venous insufficiency and leg ulcer

Uniform view of chronic venous diseases has been formed in the last 3 decades. Chronic venous insufficiency (CVI) is a functional disorder of the venous system of the lower limb. The basis of the pathology is always the venous hypertension caused by valvular insufficiency and reflux with or without venous outflow obstruction. Epifascial, subfascial and transfascial forms of CVI can be distinguished. In the practice these forms are almost always combined. The consistent venous hypertension is the initiating factor in alterations in the microcirculation which leads to skin changes and venous ulceration. The precise mechanism of the development of venous leg ulcer is still uncertain. A recent hypothesis suggests that leukocytes are trapped in the capillaries and attaching to the endothel they become activated and release proteolytic enzymes, free radicals which have destructive effects on lipid membranes, proteins as well as on many connective tissue compounds. The endothelium plays active role in the complex mechanism. Increased expression of tissue metalloproteinases has been observed in the periulcer skin. The presence of perivascular leukocyte infiltration and fibrin cuff is a reflexion of an inflammatory process. The clinical stages of CVI are likely to be the results of a systemic inflammatory response to a period of venous hypertension.

Quantifying fibrosis in venous disease: mechanical properties of lipodermatosclerotic and healthy tissue

OBJECTIVES

To quantify the mechanical properties of medioposterior bulk calf tissue in patients with lipodermatosclerotic venous-insufficient tissue and individuals with apparently healthy tissue using a novel ultrasound indentometry method, and to identify parameters with the potential for quantifying fibrosis in subsequent studies.

DESIGN

2-group, quasi-experimental design

SETTING

Soft Tissue Mechanics Laboratory, University of Pittsburgh, Pittsburgh, PA PARTICIPANTS: 9 healthy and 9 venous-insufficient individuals aged 35 to 85 years

INTERVENTIONS

Ultrasound indentometry and computed tomography (CT) of calf tissue

MAIN OUTCOME MEASURES

Between group differences and associations among quasi-linear viscoelastic (QLV) tissue parameters and CT descriptors

MAIN RESULTS

Established the accuracy, validity, and reliability of the QLV model and ultrasound indentometry method. Demonstrated a range of significant differences between the groups (P <.020 to P <.004) for selected QLV parameters. Also found significant correlations between CT measures of fibrosis and dermal thickness and QLV elastic measures (P <.034 to P <.005).

CONCLUSION

Attempts to quantify fibrosis in lipodermatosclerosis have included histologic exams, palpation/pitting, durometer readings, and imaging techniques, but these efforts have failed to produce a clinically practical, noninvasive method. A novel ultrasound indentometry method was used to acquire in vivo data from which tissue parameters were derived. These data support the further development of ultrasound indentometry as a method to quantify fibrosis in venous disease.

Results of a questionnaire regarding improvement of 'C' in the CEAP classification

BACKGROUND

One of the shortcomings of the CEAP classification is that some of the clinical conditions in the original version were not defined and, therefore, were used in different ways by those who work with CEAP.

AIM

To clarify the definitions of the seven clinical classes in the CEAP classification and to improve universal understanding of these in phlebology.

METHODS

The authors prepared a short questionnaire regarding the 'C' part of CEAP with five main questions, dealing with definitions of clinical items: telangiectases, corona phlebectatica, reticular veins, varicose veins and the use of CEAP. The questionnaire was translated into 11 different languages and sent around the world by means of International Venous Digest by fax. Two hundred and six answers were received from 67 countries out of 3681 faxes sent (5.6%).

RESULTS

There were a wide variety of opinions returned thus demonstrating that the same term is used with various meanings by different physicians. All physicians classify telangiectases of thigh and foot as class C1, but discrepant answers were obtained concerning the differences between reticular veins and reticular varicose veins as well as the diameter of small and large varicose veins. Sixty per cent of physicians answering this survey use the CEAP classification.

CONCLUSION

Further clarification and refinement of the CEAP classification are necessary. The authors hope that this will result in broader acceptance of CEAP.

Relationship between clinical classification of chronic venous disease and patient-reported quality of life: results from an international cohort study

OBJECTIVES

The CEAP (clinical, etiologic, anatomic, pathophysiologic) clinical classification for chronic venous disease (CVD) is based on physician-evaluated clinical signs of CVD. The relationship between CEAP clinical classification and patient-perceived quality of life (QOL) has not been evaluated, but is important for the selection and interpretation of outcomes in clinical studies of patients with CVD. The purpose of this study was to evaluate whether CVD, as classified with CEAP, is related to patient-reported QOL, and to identify patient characteristics associated with CEAP class and QOL that need to be considered when interpreting outcomes in CVD.

METHODS

The Venous Insufficiency Epidemiologic and Economic Study (VEINES) population is an international cohort of 1531 patients with CVD recruited in Belgium, France, Italy, and Canada. At the baseline visit patients were categorized into one of seven CEAP clinical categories on the basis of a clinical examination, and completed standardized generic (Short-Form Health Survey, 36 items [SF-36]) and venous disease-specific (QOL [VEINES-QOL] and symptom severity [VEINES-Sym]) QOL questionnaires. Multivariate analyses were used to examine the relationship between CEAP class and QOL.

RESULTS

The proportion of patients in the seven CEAP classes (class 0-6) was 3.8%, 13.3%, 24.1%, 12.8%, 36.4%, 7.3%, and 2.3%, respectively. In univariate analyses, SF-36 Physical Component Summary scores and VEINES-QOL and VEINES-Sym scores decreased significantly (ie, poorer QOL) with increasing CEAP class. Multivariate analyses controlling for age, sex, country, education, body mass index, years since CVD onset and comorbid conditions confirmed findings for VEINES-QOL and VEINES-Sym (P<.0001 and P<.0001, respectively).

CONCLUSIONS

Physician-evaluated clinical category, based on the CEAP classification, predicts patient-reported QOL and symptom severity in CVD.

Varices. Insuffisance veineuse chronique. Ulcères des membres inférieurs. Point de vue

PURPOSE

Lower limbs chronic venous disorders are still considered as a minor disease from a university hospital point of view, yet it is a very common problem, affecting the quality of life, generating disability, and expensive for healthcare resources. Its teaching is neither satisfactory nor easy to do.

KEY POINTS

Apart from the fact that it rarely causes death, the complexity of venous anatomy and physiopathology, the lack of animal model, common practices lumping together visible varicose veins and chronic venous insufficiency, and moreover a certain carelessness in the vocabulary probably largely explain these difficulties. Our purpose is to discuss chronic venous disorders (varicose veins, chronic venous insufficiency, venous ulcers) on the basis of semantic, of anatomical, haemodynamic and clinical forms and finally of nosology.

Epidemiologie der chronischen Venenerkrankungen

Chronic venous diseases such as varicosis, post-thrombotic syndrome, and chronic venous insufficiency are among the most frequent clinical pictures in the Western world. The resultant consequences are persistent complaints such as a feeling of heaviness, tendency for swelling, and leg pain as well as vast skin changes culminating in an open leg ulcer. Although a series of past epidemiological studies are available, they are quite inconsistent with regard to implementation and definition of the clinical picture so that they cannot always be compared. Some are based solely on registration of disease history by questionnaires, which are inadequate to reliably assess actual prevalence. In only a very few studies are the results based on the actual examination of the subjects. Moreover, entirely difference age intervals and random samples are evaluated. The present study summarizes the most important epidemiological results with particular regard to the current Bonn Vein Study.

Kompressionstherapie bei chronischer ven�ser Insuffizienz

Chronic venous insufficiency (CVI) has a significant socioeconomic impact. The existent venous hypertension and the subsequent capillary hypertension result in trophic skin damage culminating in an ulcer. Venous ulcers affect 1-3% of the adult population. Compression therapy provides the basis for noninvasive treatment of CVI. It can be applied alone or in combination with invasive strategies. A variety of materials are available for phlebological compression therapy in the form of compression bandages and compression hosiery. Knowledge of the different qualities of the compression materials and their mode of action is important in choosing the correct means of compression with regard to clinical findings and the patient's needs. As far as possible, the compression method applied should be monitored for any loss of effectivity during regular follow-up examinations of the patients. The following article deals with this topic. A new option for compression therapy of crural ulcers is presented and the possibility for checking the effectiveness of the compression stockings during outpatient

[Lower limb chronic venous insufficiency: contemporary problems in diagnosis, classification and treatment]

The paper presents a brief analysis of contemporary problems in management of patients with lower limb chronic venous insufficiency (CVI). During the last decade occurrence of complicated CVI tended to diminish resulting from well-directed efforts in improvement of diagnostic and therapeutic methods, active participation of different specialists in management programs. The paper addresses the questions of assessment planning dependent on CVI manifestation and role of various diagnostic modalities (morphological and functional). The scope of therapeutic methods is enumerated, with special attention to their practical value and unresolved issues. Ultrasonography enabled to broaden indications for minimally invasive procedures in varices surgery. Accumulation of rich experience in sclerotherapy made possible to develop distinct indications for the procedure. The authors delineate promising directions for further research in CVI management.

Global venous function correlates better than duplex derived reflux to clinical class in the evaluation of chronic venous disease

AIM

To compare the symptoms and signs of patients with chronic venous disease with the objective results of duplex ultrasound and plethysmography (foot volumetry).

METHODS

One hundred and one patients with symptomatic chronic venous disease were investigated with duplex ultrasound and foot volumetry. Patients were classified according to the CEAP classification and the symptoms of pain, heaviness, tiredness, ankle swelling and night cramps were graded. The severity of the disease was judged objectively by the reflux time (sum of reflux time at 6 levels) and the venous function was measured globally with expelled volume (ml) and refilling rate (Q) (ml/100 mlxmin) after exercise, and expelled volume related to foot volume (EVrel), (ml/100 ml). The ratio Q/EVrel)was calculated. Correlation was calculated between clinical class, symptoms and objective parameters.

RESULTS

The correlation analyses showed a clear constant relationship between the CEAP clinical classification and the foot volumetry measures (Q/EVrel), r=0.48; p<0.01) There was no such relationship between clinical class and the sum of duplex calculated reflux time (r=-0.05), or between foot volumetry and reflux time. There was no correlation between the clinical class and the total score of symptoms (r=0.044).

CONCLUSION

The clinical class of CEAP classification correlates significantly with foot volumetry parameters. There is no correlation between clinical class and reflux time. The severity of the venous disorder and subsequently the need for treatment is more accurately judged by foot volumetry as a global measure. Clinical classification has a realistic meaning concerning the functional evaluation of venous disease.

Appraisal of the information content of the C classes of CEAP clinical classification of chronic venous disorders: a multicenter evaluation of 872 patients

OBJECTIVE

Clinical classifications attempt to summarize a large amount of information in a few indices. CEAP is the most comprehensive and widely used classification of chronic venous disorders. The objective was to evaluate, in a routine clinical setting, the information associated with each CEAP clinical class and their ascending severity and additivity.

METHODS

This work was a multicenter evaluation of newly designed software dedicated to the management of venous diseases. Forty-nine angiologists from nine European countries entered a total of 872 full records of unselected patients. The data were analyzed to evaluate the informational value of each of the clinical classes and to test their ascending severity and additivity, with monovariate and multivariate statistical techniques with SPSS/PC software on the database of the 872 right lower limbs.

RESULTS

The series consisted of 700 women (80.3%) and 172 men, aged 18 to 100 years (median, 53 years). The ascending severity of the classes was shown with the statistical association of higher severity C classes with the age of the patient, a history of previous deep vein thrombosis, the diameter class of the most dilated varicose vein, venous symptoms, and the presence of a corona phlebectatica. The additivity, as measured with the Cronbach alpha coefficient analysis, was satisfactory in highest classes but poorer within the first three classes, and factor analysis of correspondences showed the heterogeneity of the variables that make the classification.

CONCLUSION

The information summarized with the CEAP clinical classes shows a good ascending severity but a poorer additivity. These limitations seem to be related to the heterogeneity of the information content, which suggests some refinements of this basic tool for clinical research in the field of chronic venous disorders.

[Surgical treatment of chronic venous insufficiency--current views on prevention, diagnosis and therapy]

The authors describe their experiences with the therapy of CVI and inform about the present state of the surgical knowledge about this topic. The classification is based on the last recommendations from Roma (2000, modified CEAP). The surgical therapy of CVI they've divided into surgery of superficial venous system, surgical therapy of perforators and possibilities of surgical approach in the therapy of deep veins pathology (reflux and obstruction). They emphasize complex therapy in case of each patient and recommend the use of compressive and medical therapy as permanent and all life lasting method as the best strategy in this group of patients.

Duplex imaging analysis of the long saphenous vein reflux: basis for strategy of endovenous obliteration treatment

BACKGROUND

The purpose of this study was to characterize greater saphenous vein (GSV) reflux in order to better define indications for appropriate endovascular obliteration treatment.

METHODS

Color-flow duplex imaging was used prospectively to categorize 133 lower limbs of 102 consecutive outpatients, presenting with chronic superficial vein disease associated with GSV incompetence. Sapheno-femoral junction (SFJ) and tributaries morphology and hemodynamics, and GSV main trunk reflux extent were assessed.

RESULTS

GSV reflux was related to terminal valve incompetence in 70 (52.3%) limbs, to sub-terminal valve incompetence in 37 (27.8%), and to segmental incompetence of the GSV trunk in 26 (19.6%). Reflux originated from common femoral vein (CFV) and/or SFJ tributaries and/or GSV collaterals, including multiple origins combinations. CFV was the reflux origin in 77 (57.9%). GSV reflux arose from SFJ or trunk tributaries in 69 (51.9%) and 32 (24%), limbs respectively. Circumflex and superficial epigastric veins were involved in 65.2% and 50.7% respectively of the SFJ tributaries. GSV reflux extended down to the mid-third of the calf or below in only 45 cases (33.7%). The age of the patients was not correlated with reflux origin.

CONCLUSIONS

Preliminary analysis suggests that in 2/3 of the cases, endovenous obliteration treatment should extent from the thigh to just below the knee. Furthermore, in order to preserve GSV competent valves and collateral veins drainage, treatment should start just below the main SFJ tributary when the terminal valve is still competent, and just below the main branches connection when only the GSV trunk is incompetent.

The incidence of venous disease in Brazil based on the CEAP classification

BACKGROUND

Venous disease presents an extremely complex problem with various clinical manifestations. This is an epidemiological study of venous disease as it occurs in an area of Brazil. For the first time in Brazil the CEAP classification is used.

METHODS

A total of 2104 people, were randomly recruited at the registration desks of the General Policlinic Department of the University Hospital and public health centers. The "C" of the CEAP classification was used to classify the clinical features of the venous diseases. The subjects were categorized according to sex and age. In addition, women were also subdivided according to number of their pregnancies.

RESULTS

In the age group of females aged 14 to 22, we found 46.42% without symptoms and obvious veins (CEAP 0A/0A). Only 12.29% were symptomatic, and 41.25% of all patients in this group presented with visible veins or telangiectasias, though without symptoms. In the age group of women ranging from 23 to 48, 66.47% had had up to 3 pregnancies. In this group 10.43% were (CEAP 0A/0A). Those who had symptoms with prominent veins totaled 37.53% and those who presented with prominent veins without symptoms, 51.83%. In the female group over 48 years of age, only 4.67% were (CEAP 0A/0A). The majority (62.79%) had symptoms and prominent veins. In the male group, the greater part (65.54%) was (CEAP 0A/0A). Only 13.97% were considered symptomatic with some kind of prominent veins.

CONCLUSIONS

This large epidemiological study is the first in Brazil to validate the CEAP classification as an important tool in the epidemiology of venous pathology: a method allowing an objective approach to venous disease. The data in this study were similar to those of western countries. Venous disease was found to be much more frequent in females than males. Age and number of pregnancies are important factors in the development of the disease. Over 50% of young women presented with visible veins in their legs but were without symptoms and this was considered a purely esthetic problem.

Out of a recent CVI consensus: some features of a basic statement

In March 1997 at the Abbaye des Vaux de Cernay, France, a multidisciplinary meeting of venous specialists, to do guidelines on venous management was held. Subsequently the faculty members revised the document and a consensus statement was published in Circulation, in November 2000, based on wide-ranging and authoritative research into the investigation of chronic venous insufficiency (CVI). The statement gives information on the epidemiology and pathophysiology of CVI including the changes in the major veins as well as in the microcirculation and the associated hematological changes. It sets out the methods used for morphologic and hemodynamic investigations into venous disease and for the study of the microcirculation stating their usefulness and limitations, and indicating their place in clinical practice and research. A section deals also with the rare venous malformations. It concludes with an application of the methods in the investigation on CVI based on the CEAP classification that gives a uniform way of reporting venous disorders. The document is intended both for the clinician and the researcher. A shortened version appears below.

Diagnosis and treatment in the management of chronic venous insufficiency

Chronic venous insufficiency (CVI) is caused mainly by an alteration in the elasticity of venous walls and the dysfunction of venous valves. The diagnosis and treatment for CVI management are discussed in this paper.

Classification of chronic venous insufficiency: a review

Chronic venous insufficiency (CVI) is a very variable and complex entity that has stimulated different attempts at classification. Several proposals have been made in recent years, based on objective and anatomical criteria, most of them incomplete and unsatisfactory. Finally the CEAP classification was presented in 1994. This certainly is the most nearly complete classification, since it takes into consideration not only the main aspects of CVI: Clinical, Etiological, Anatomical, and Pathophysiological, but also the degrees of severity, reported in the form of scores. It is now accepted internationally although it still has some flaws (such as the absence of the corona phlebectactica sign) and inaccuracies (above all in the clinical part and the scoring). Recently, some members of the Promoting Committee proposed a substantial modification of the part on scores, coming closest to the clinical reality, instrumental diagnosis, and current therapies. The characteristics of CEAP enable us to affirm that this represents the most original and useful classification, not only for clinical studies, but also in the assessment of therapeutic results and in patient follow-up. Like all classifications, CEAP also needs to be validated by means of clinical studies in order to demonstrate its applicability. For this purpose, a European Working Group was set up in 1997. The first interesting results of 872 dossiers collected by means of a computerized program (European Phlebological File) were presented at several international congresses and concentrated on the consistency and reproducibility of the clinical part of the CEAP classification in different clinical settings.

[Endoscopic perforating vein surgery. Review of the literature and personal experience]

The endoscopic treatment of perforating veins incompetence of the legs has been recently introduced as an effective surgical therapy in serious cases of chronic venous insufficiency. According to CEAP classification, the primary indication is set on the class 5 or 6 patients, affected by active ulcers or relapsing ulcerative lesions. During the last two years, 53 operations of SEPS have been performed at the Vascular Surgery Unit of G. Salvini Hospital in Garbagnate Milanese. Here we present A perspective study of 24 cases with a 6 to 18 months follow-up is presented. In 8 patients (33%) an active ulcer was present, while in 16 cases history of relapsing ulcers was described. After the first month, all the lesions were healed and a subjective clinical improvement of the hypodermosclerosis was observed. At 12 months follow-up new ulcerations appeared only in four patients. On the basis the experiences of many authors and the results obtained in this study, following conclusions are made: the best results are achieved in case of sole perforating veins incompetence; the insufficiency of superficial venous circulation must be treated simultaneously or better previously, considering later the operation on the perforators veins; the sclerotherapy is introduced to cure the ectasic superficial veins in order to avoid a sponge effect with a precocious reappearance of the ulcers.

[Technique of endoscopic subfascial CO2 insufflation-dissection of perforator veins]

Endoscopic subfascial dissection of perforating veins (ESDP) represents a new additional technique for treatment of greater saphenous system varicosities. We present a modification of ESDP, entitled endoscopic subfascial insufflation-dissection of perforating veins (ESIDP). In ESIDP CO2-insufflation induced enlargement of subfascial space (subfascial pneumocave) facilitates identification and dissection of perforating veins. From 1.1.1998 to 1.7.2000, 150 procedures of ESIDP have been conducted in 127 patients (90 females, 37 males). Identification of incompetent perforating and superficial veins and assessment of deep veins were performed preoperatively using duplex sonography. In addition to a description of the surgical technique, we present an overview about indications for ESIDP and possible ESIDP-related postoperative complications.

Clinical classification of free-flap perfusion complications

Free-tissue transfer is a standard procedure in hand and other plastic and reconstructive surgery. The aim of the present article was to present a new clinical classification of disturbances of the circulation, and to assess the results of treating the specific complication at each of the stages described. Within a period of 29 months, 194 free microvascular flaps were prepared and evaluated in a prospective study. Postoperative monitoring was carried out from a purely clinical point of view. A distinction was made between arterial and venous circulatory disturbances and, in both cases, four stages were characterized, according to the time required for recapillarization, the color of the transfer, and bleeding on puncture. Complications occurred in 69 cases (36 percent), including intraoperative revisions during a first operation. The ratio of arterial to venous insufficiency was 33:35. In the presence of arterial disturbances of the circulation, the proportion of losses increased in progressive stages to 41 percent. With venous disturbances, losses which occurred in stages 1 and 2 were predominantly partial. In 164 cases (85 percent), the flaps remained undamaged. In 15 cases (8 percent), there was partial loss of the transfer and, in a further 13 cases (6 percent), there was complete loss. The authors' results confirmed that the presented clinical classification is, indeed, a measurement of the severity of circulatory impairment. Despite the relatively high complication rate, the use of various methods of treatment finally led, in the overwhelming majority of cases, to a positive result.

[Medical compression therapy]

In order to evaluate the correlation between the pressure exerted by compression stockings and a resulting improvement in venous hemodynamics, we carried out an open, randomized, prospective study on 22 patients (11 women and 11 men with an average age of 55.1 [10.3]) with chronic venous insufficiency (CVI) in the clinical stages C1-4, Ep, AS, Ap, PR. Dynamic strain gauge plethysmography was used to measure the acute effect on venous hemodynamics of 9 different compression stockings in compression class 2 (A-D). At the same time when venous function parameters were monitored, we also measured the pressure exerted by the compression stockings during rest and exercise. With all compression stockings the average resting pressure fulfilled in reclined patients the specifications for compression class 2 (25-35 mmHg at the ankle, CEN). The compression stockings lengthened venous refill time t0 in a statistically significant degree. The improvement in venous function was correlated with the ratios of maximal working pressure to resting pressure while standing (r = 0.97, p < 0.001). Compression stockings belonging to the same compression class vary in their acute effect on venous hemodynamics. The efficiency of the different therapeutic compression stockings was largely dependent on the amount of fabric stretch, which can be characterized in vivo with the ratio of maximum exerted pressure during movement to that while standing still. A knowledge of the hemodynamic effectivity of the various compression stockings allows the optimal stocking selection for each patient and his individual clinical situation.