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UPDATE ON DIAGNOSIS AND TREATMENT FOR VARICOSE VEINS (PART 1)



Introduction

Venous disease has very diverse clinical presentations, ranging from simple spider veins, unsightly varicose veins to debilitating venous ulcers. All of these are now grouped under the term Chronic Venous Disorder (CVD). In the US, it is estimated that 10-35% of the adult population has some form of CVD. The problem is more common in women as a result of pregnancy and child bearing. Although it is rarely a life- or limb-threatening problem, the disease greatly impacts quality of life. Many people affected are in their most productive years of life. They usually seek medical advice for cosmetic and health concerns.

This article will describe the current classification and diagnosis of CVD. Treatment with emphasis on minimally invasive therapy will be discussed in the next issue.



Classification of for Chronic Venous Disorder (CEAP)

The CEAP classification was introduced by the American Venous Forum in 1994 and was revised in 2004. It is now widely adopted around the world and is considered as the reporting standard for venous disease nowadays. The goal was to stratify clinical levels of venous insufficiency. The four categories selected for classification were: clinical state (C), etiology (E), anatomy (A), and pathophysiology (P). The CEAP classification helps to provide guidance in choosing the appropriate treatment for such patients.



The Clinical Classification (C1,2,3,4,5,6,A,S)

The clinical classification is the foundation of the concept. The six CVD categories range from small, thread-like veins to edema, discolouration, induration, and ulceration. Each is clearly defined in Table 1. C-0 is appropriate for those individuals with objective evidence of venous disease (i.e. E, A, and/or P), but with no clinical manifestations. The extent of varicose disease, along with the other clinical findings are categorized in the severity score. For clinical class 4 is now subdivided into (a) pigmentation and/or eczema, and (b) lipodermatosclerosis and/or atrophie blanchˆm, based upon observational survey data suggesting that lipodermatosclerosis or atrophie blanch (4b) was more likely to progress to more severe disease.

Subscripts are applied to designate S (symptomatic) from A (asymptomatic) limbs. Complaints qualifying for the S subscript include aches, pain, tightness, skin irritation, heaviness, muscle cramps, and other complaints that may be attributable to venous dysfunction.



Etiology (EC,P,S,N)

Four categories in this classification are: Congenital, Primary, Secondary, and None. Arteriovenous malformations represent an obvious congenital (C) etiology, it may be the uncommon conditions such as avalvulia (hereditary absence of venous valves). Secondary (S) designates any known cause of venous abnormality. Most commonly, it indicates veins that have been affected by thrombosis. Primary (P) refers to all others such as primary valvular reflux. None (N) indicates for no evident etiology of CVD.



Anatomy (AS,P,D,N)

Simple designation of one (or more) of the three major lower extremity anatomic venous systems (superficial, perforating, and deep veins) is sufficient to localize the site of the abnormality and will probably affect the treatment recommendations.



Pathophysiology (PR,O,R-O,N)

The veins may occur either reflux (R), obstruction (O), or in combination (R-O). Reflux is defined as reverse flow with a duration of >0.5 second by duplex analysis. Meanwhile, obstruction is defined objectively by imaging or noninvasive testing. (N) indicates no abnormality detected.



Duplex Ultrasound

Duplex ultrasound is B-mode ultrasound with colour Doppler, usually done by using a high frequency (7.5-10MHz) transducer. It is non-invasive, and has evolved to become the most important imaging study for patients with varicose veins. Colour flow scanners allow direct visual representation of flow with a change of colour from red to blue depending on the flow is towards or away from the probe.Reflux is best demonstrated with the patient in the standing position. The duplex examination is essential in planning for treatment, and also important to identify the specific points of reflux so that treatment is appropriate and reduces the chance of recurrence.



Summary

This classification is targeted at all forms of venous insufficiency. Physicians in general practice should be aware that CVD consists of a spectrum of clinical manifestations, ranging from simple telangiectasias, to the commonly seen varicose veins and the debilitating venous ulcers. The transition from one clinical stage to the other is progressive, but the deterioration rate and symptoms depends on the underlying etiology, anatomy and pathophysiology. In the presence of minimally invasive options in addition to conventional surgery in treating CVD, treatment can now be tailored to individual patients based on their clinical status and symptoms. In the next issue, minimally invasive options will be discussed further.



Table 1. CEAP Classification - Clinical, Etiologic, Anatomic, Pathophysiologic.

C-Clinical Class

Characteristics*

0

No clinical findings or symptoms

E-Etiology**

1

Telangiectasia or reticular veins

C

Congenital

2

Varicose veins

S

Secondary

3

Edema, only due to a venous etiology

P

Primary

4

(a) Pigmentation and/or eczema

A-Anatomy**

(b) Lipodermatosclerosis, atrophie blanché

S

Superficial (Great and short saphenous systems as well as any branch varices)

5

Prior ulceration, dermatitis

P

Perforator (Veins that communicate between the superficial and deep systems)

6

Active ulceration

D

Deep (Calf veins and sinuses, popliteal, femoral, iliac veins and vena cava)

A, S

Subscript: Asymptomatic, Symptomatic

P-Pathophysiology**

Date

Date of investigation

R

Reflux

Level

Level of investigation (I, II, III)

O

R-O

N**

Obstruction

Both

No evident disease**

*Complaints are expected to be related to venous insufficiency and are not classified if another etiology is present (i.e. edema secondary to heart failure).

**The N subscript indicates no evidence of disease. It is applicable to E, A, and/or P of CEAP.

Class 1: Telangiectasia

Class 2: Varicose vein

Class 3: Edema

Class 4: Pigmentation

Class 5: Dermatitis

Class 6: Venous Ulcer


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