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3 Presentation of Chronic Venous Disease
https://t.me/med1917
Table 3.1 Revised Venous Clinical Severity Score [ 20 ]
Pain None: 0 Mild: 1 Moderate: 2 Severe: 3
Or other discomfort (i.e.,
aching, heaviness, fatigue,
soreness, burning)
Presumes venous origin
Varicose veins None: 0 Mild: 1 Moderate: 2 Severe: 3
“Varicose” veins must be
≥3 mm in diameter to qualify
Venous edema None: 0 Mild: 1 Moderate: 2 Severe: 3
Presumes venous origin Limited to foot
Skin pigmentation None: 0 Mild: 1 Moderate: 2 Severe: 3
Presumes venous origin None or
Does not include focal
pigmentation over varicose
veins or pigmentation due
to other chronic diseases
(i.e., vasculitis purpura)
Infl ammation None: 0 Mild: 1 Moderate: 2 Severe: 3
More than just recent
pigmentation (i.e., erythema,
cellulitis, venous eczema,
dermatitis)
Induration None: 0 Mild: 1 Moderate: 2 Severe: 3
Presumes venous origin
of secondary skin and
subcutaneous changes
(i.e., chronic edema with
fi brosis, hypodermitis)
Includes white atrophy
and lipodermatosclerosis
Active ulcer number 0 1 2 ≥3
Active ulcer duration
(longest active)
Active ulcer size (largest
active)
Use of compression therapy 0 1 2 3
focal
N/A <3 months >3 months but
N/A Diameter <2 cm Diameter 2–6 cm Diameter >6 cm
Not used Intermittent use of
Occasional pain or
other discomfort
(i.e., not restricting
regular daily activity)
Few: scattered (i.e.,
isolated branch
varicosities or
clusters)
Also includes corona
phlebectatica (ankle
fl are)
and ankle area
Limited to
perimalleolar area
Limited to
perimalleolar area
Limited to
perimalleolar
area
stockings
Daily pain or other
discomfort (i.e.,
interfering with
but not preventing
regular daily
activities)
Confi ned to calf
or thigh
Extends above ankle
but below knee
Diffuse over lower
third of calf
Diffuse over lower
third of calf
Diffuse over lower
third of calf
<1 year
Wears stockings most
days
Daily pain or
discomfort (i.e.,
limits most regular
daily activities)
Involves calf
and thigh
Extends to knee
and above
Wider distribution
above lower third
of calf
Wider distribution
above lower third
of calf
Wider distribution
above lower third
of calf
Not healed for
>1 year
Full compliance:
stockings
39
questionnaires, ultrasonography, and physical
examination, it was possible to evaluate the rate
of occurrence of CVD and its effect on several
quality- of-life variables. Risk factors were determined for varicose veins (advanced age, female
sex, and number of times pregnant) and for CVI
(advanced age, obesity, and living in an urban
setting).
The San Diego Population Study, also based
on the CEAP classifi cation, involved a large
cohort evaluated specifi cally for telangiectases,
varicose veins, skin changes, and edema [ 29 ].
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Table 3.2 Instructions for using the Revised Venous Clinical Severity Score [ 20 ]
On a separate form, the clinician will be asked to: “For each leg, please check 1 box for each item (symptom and
sign) that is listed below”
Pain or other discomfort (i.e., aching, heaviness, fatigue, soreness, burning)
The clinician describes the four categories of leg pain or discomfort that are outlined below to the patient and asks
the patient to choose, separately for each leg, the category that best describes the pain or discomfort the patient
experiences
None = 0 None
Mild = 1 Occasional pain or discomfort that does not restrict regular daily
Moderate = 2 Daily pain or discomfort that interferes with, but does not prevent, regular daily activities
Severe = 3 Daily pain or discomfort that limits most regular daily activities
Varicose veins
The clinician examines the patient’s legs and, separately for each leg, chooses the category that best describes
the patient’s superfi cial veins
Veins must be ≥3 mm in diameter to qualify as “varicose veins”
None = 0 None
Mild = 1 Few, scattered, varicosities that are confi ned to branch veins or clusters. Includes “corona
phlebectatica” (ankle fl are), defi ned as >5 blue telangiectases at the inner or sometimes
the outer edge of the foot
Moderate = 2 Multiple varicosities that are confi ned to the calf or the thigh
Severe = 3 Multiple varicosities that involve both the calf and the thigh
Venous edema
The clinician examines the patient’s legs and, separately for each leg, chooses the category that best describes
the patient’s pattern of leg edema. The clinician’s examination may be supplemented by asking the patient about
the extent of leg edema that is experienced
None = 0 None
Mild = 1 Edema that is limited to the foot and ankle
Moderate = 2 Edema that extends above the ankle but below the knee
Severe = 3 Edema that extends to the knee or above
Skin pigmentation
The clinician examines the patient’s legs and, separately for each leg, chooses the category that best describes
the patient’s skin pigmentation. Pigmentation refers to color changes of venous origin and not secondary to other
chronic diseases (i.e., vasculitis purpura)
None = 0 None, or focal pigmentation that is confi ned to the skin over varicose veins
Mild = 1 Pigmentation that is limited to the perimalleolar area
Moderate = 2 Diffuse pigmentation that involves the lower third of the calf
Severe = 3 Diffuse pigmentation that involves more than the lower third of the calf
Infl ammation
The clinician examines the patient’s legs and, separately for each leg, chooses the category that best describes the
patient’s skin infl ammation. Infl ammation refers to erythema, cellulitis, venous eczema, or dermatitis, rather than
just recent pigmentation
None = 0 None
Mild = 1 Infl ammation that is limited to the perimalleolar area
Moderate = 2 Infl ammation that involves the lower third of the calf
Severe = 3 Infl ammation that involves more than the lower third of the calf
Induration
The clinician examines the patient’s legs and, separately for each leg, chooses the category that best describes the
patient’s skin induration. Induration refers to skin and subcutaneous changes such as chronic edema with fi brosis,
hypodermitis, white atrophy, and lipodermatosclerosis
None = 0 None
Mild = 1 Induration that is limited to the perimalleolar area
Moderate = 2 Induration that involves the lower third of the calf
Severe = 3 Induration that involves more than the lower third of the calf
M.A. Vasquez and C. Munschauer
3 Presentation of Chronic Venous Disease
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Table 3.2 (continued)
Active ulcer number
The clinician examines the patient’s legs and, separately for each leg, chooses the category that best describes
the number of active ulcers
None = 0 None
Mild = 1 1 ulcer
Moderate = 2 2 ulcers
Severe = 3 ≥3 ulcers
Active ulcer duration
If there is at least one active ulcer, the clinician describes the four categories of ulcer duration that are outlined
below to the patient and asks the patient to choose, separately for each leg, the category that best describes the
duration of the longest unhealed ulcer
None = 0 No active ulcers
Mild = 1 Ulceration present for <3 months
Moderate = 2 Ulceration present for 3–12 months
Severe = 3 Ulceration present for >12 months
Active ulcer size
If there is at least one active ulcer, the clinician examines the patient’s legs, and separately for each leg, chooses
the category that best describes the size of the largest active ulcer
None = 0 No active ulcer
Mild = 1 Ulcer <2 cm in diameter
Moderate = 2 Ulcer 2–6 cm in diameter
Severe = 3 Ulcer >6 cm in diameter
Use of compression therapy
Choose the level of compliance with medical compression therapy
None = 0 Not used
Mild = 1 Intermittent use
Moderate = 2 Wears stockings most days
Severe = 3 Full compliance: stockings
41
The study evaluated 2,211 individuals using a
combination of surveys, ultrasonography, and
physical examination. The results were presented as overall characteristics of venous disease, risk factors, symptoms, and quality of
life. Similar to the Bonn Vein Study, risk factors found in the San Diego Population Study
were advanced age and obesity, as well as
family history, hormonal factors, and activity
level [ 27 , 28 ].
The San Diego Population Study expanded
the reported results with a consideration of visual
and functional ramifi cations of venous disease
[ 29 ]. Visible hallmarks of venous disease, includ-
ing telangiectases, varicose veins, and skin
changes, were compared with anatomic (functional) ultrasonographic fi ndings of superfi cial
or deep venous refl ux or obstruction. Visible
disease was defi ned as varicose veins or skin
changes, not simply telangiectases or spider
veins, and functional disease was defi ned as the
ultrasonographic presence of superfi cial or deep
refl ux or obstruction. The agreement between
visible and functional disease was 92.0 %, with
17.4 % agreement for the presence of disease and
74.6 % agreement for the absence of disease.
The determination was made that “visible disease did not invariably mark underlying functional disease, and functional disease was
sometimes present in the absence of any visible
venous disease” [ 29 ].
Venous disease, and varicosities in particular,
is diagnosed with increasing frequency worldwide, with varicosities being the most frequently
diagnosed vascular anomaly [ 16 ]. Chronic
venous disease is a complex condition with
numerous possible presentations and manifestations. Diagnosis is not always straightforward,
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Fig. 3.4 ( a ) The “visual
language” of VCSS.
Consistency in physician
scoring and reporting allows
a common language of
venous disease to emerge.
Basic Clinical CEAP
3 – VCSS 7. ( b ) After
treatment scoring changes to
Clinical CEAP 2 – VCSS 3
M.A. Vasquez and C. Munschauer
ab
Fig. 3.5 Corona
phlebectatica
generally requiring a combination of clinical
experience and diagnostic testing.
Treatment for venous disease has evolved over
the years, and outcome assessment has had a role
in the acceptance of new procedures. Great
saphenous vein stripping was generally considered the standard of care for venous disease.
Removing the saphenous vein from circulation
virtually ensured resolution of symptoms attributed to it. However, recurrent symptoms were
seen when all levels of underlying disease were
not addressed, sometimes necessitating additional invasive procedures. O’Donnell wrote in
1999: “The adoption of a surgical strategy that
corrects the abnormal superfi cial venous system
alone (saphenous veins and perforators) in the
face of deep venous refl ux requires that the therapeutic outcomes of such a strategy be judged
with objective criteria” [ 30 ]. Implementation of
results-focused analysis means that the outcome
3 Presentation of Chronic Venous Disease
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abc
43
Fig. 3.6 Skin pigmentation. ( a ) Perimalleolar. ( b ) Lower third calf. ( c ) Above lower third calf
abc
Fig. 3.7 Infl ammation. ( a ) Cellulitis. ( b ) Dermatitis. ( c ) Venous eczema
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M.A. Vasquez and C. Munschauer
ab
Fig. 3.8 Induration. ( a ) White atrophy. ( b ) Lipodermatosclerosis
Fig. 3.9 Number of active
ulcers (remains one in
healing phase)
of any surgical procedure should be evaluated
alongside other options, including the natural
course of the disease itself, nonsurgical therapies,
additional surgical interventions, or other ways
of performing the intervention being evaluated
[ 25 ]. Eventually, the results of this type of analy-
sis enter into the planning and staging of interventions, with the ultimate goal of obtaining the
best results with fewer invasive procedures.
The movement toward less-invasive therapeutic techniques has affected venous surgery.
Modern surgical methods for CVD include
superfi cial venous ablation, deep venous reconstruction, injection of sclerosing foam, and ligation of perforating veins. Endovascular venous
ablation is proving effective as part of the strategy to address superfi cial veins, tributaries, and
perforators. Recurrence of clinical symptoms
3 Presentation of Chronic Venous Disease
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45
and the emergence of new veins generally occur
infrequently in patients treated with ablation, and
outcome assessment of the procedure over 5 years
or longer indicates that it provides a standard of
care comparable to saphenous vein stripping [ 31 ].
Because of variability in the presentation of
CVD, thorough outcome reporting instruments
have been diffi cult to devise. Meissner and colleagues wrote in 2002: “The ideal clinical outcome measure for CVD would include the full
spectrum of disease and be suffi ciently sensitive
to allow stabilization, improvement or deterioration to be precisely quantifi ed” [ 5 ]. The goal of
treating venous disease can vary widely in the
opinion of the physician versus the patient.
Morbidity and mortality statistics, while useful,
report only the direct clinical outcome of an
intervention, failing to consider other factors of
potential importance to others. For an outcome to
be fully evaluated, its effect on the physician,
patient, and community must be considered [ 32 ].
3.6 Symptoms
Chronic venous disease encompasses many
symptoms in many manifestations. Patients may
experience one or all, and symptoms may improve
and worsen many times throughout the course of
evaluation, treatment, and follow-up care.
Initially, telangiectases and reticular and varicose veins may be asymptomatic, with patients
noticing only discolored or prominent veins. As
venous disease progresses, leg symptoms may
develop, including achiness, heaviness, burning, throbbing, or itching, and may be accompanied by physical manifestations that include
edema, eczema (Fig. 3.7 ), pigmentation changes
(Fig. 3.6 ), induration (Fig. 3.8 ), or possibly ulcer-
ation (Fig. 3.9 ) [ 33 ].
Patient motivation to seek treatment for venous
disease can occur at any stage of severity and is
likely not triggered by any one symptom [ 4 ]. Many
individuals live with severe sequelae of CVD
without ever seeking treatment, some are seen
only when edema or ulcers are beyond self- care,
and others seek evaluation early with cosmetic
concerns representing very mild venous disease.
Some patients are concerned that their
symptoms may be related to peripheral artery
disease. Hallmarks of peripheral artery disease
include claudication, sensory or motor changes
in the legs, coolness, pallor, slow hair and nail
growth and shiny skin on the affected limb, weakening or loss of palpable pulse in the affected
limb, or open sores that are diffi cult to heal [ 34 ].
It is important to rule out peripheral artery disease
before initiating treatment for venous disease.
3.7 Physical Findings
When evaluating patients for CVD, several elements should be used to derive an appropriate
clinical assessment and treatment plan. Eklöf
et al. stratify this process into levels. Level 1 consists of the initial visit and examination, level 2 is
noninvasive vascular laboratory testing, and level
3 comprises additional imaging or invasive studies [ 11 ]. A detailed clinical examination is the
fi rst step in diagnosis and should be repeated at
each reevaluation. The initial visit should also
include assessment of venous disease manifestations (including edema, varicose veins, telangiectases, phlebitis, pigmentation and skin-quality
changes, lipodermatosclerosis, venous stasis dermatitis, and ulcers). This objective assessment
should be combined with a review of the patient’s
history that includes weight, smoking, pregnancies, venous thromboembolic event, physical
activity, and family history of venous disease,
along with relevant patient-reported symptoms
(including pain, aching, tingling or burning,
heaviness, and fatigue) [ 12 – 14 , 21 , 35 ].
The somewhat subjective elements of clinical examination make diagnostic testing a
useful objective measure [ 12 ]. Laboratory evalu-
ations are important not only in assisting with
the diagnosis of CVI but also in identifying or
excluding other conditions, such as arterial disease, deep vein thrombosis, deep venous refl ux,
perforator disease, and venous obstruction.
While primary venous disease involves refl ux,
a sequela of venous hypertension, secondary
CVD may involve refl ux and an obstructive event
[ 36 ]. The obstruction may be related to venous
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M.A. Vasquez and C. Munschauer
compression or the results of a deep vein thrombosis (post-thrombotic syndrome) [ 36 – 38 ].
Duplex Doppler is the usual fi rst level of
laboratory evaluation, providing data on refl ux
(superfi cial or deep) and valvular incompetence,
deep vein thrombosis, and obstruction, but may
be insuffi cient to demonstrate the hemodynamic signifi cance of obstruction or refl ux [ 39 ].
Ultrasonography is benefi cial in locating a duplicated femoral vein, which can be an unidentifi ed
source of deep vein thrombosis. Evidence has
shown that the incidence of duplicated femoral
vein is about 40 %, a signifi cant fi gure because it
represents possible undetected deep vein thrombosis; expanded ultrasonographic examination
was recommended to rule out duplicated femoral
vein in the case of leg swelling without an identifi able source [ 40 ]. Invasive diagnostic methods,
including venography and intravascular ultrasonography, provide greater detail about the hemodynamic signifi cance of venous abnormalities
[ 39 ]. Although not generally used in uncompli-
cated venous disease, venography is indicated in
complex disease, multilevel disease, and obstructive disease, including deep vein thrombosis,
post-thrombotic syndrome, and non-thrombotic
compressive phenomena, such as May-Thurner
syndrome and non-thrombotic iliac vein lesions
[ 38 – 43 ]. Symptoms of these lesions may mimic
CVI but may also consist of severe left leg swelling and pain that may interfere with normal
activity [ 38 ].
The treatment of CVI is multifactorial and
depends on many variables. From conservative
therapy (weight loss, leg elevation, and the use of
compression stockings) to direct intervention
(open surgery, endovascular therapy, or a combination of the two), the goals of therapy should be
established and agreed on by the patient and the
provider [ 44 ]. Regardless of the initial choice of
therapy, patients need to be aware that interventions for CVI are intended to treat manifestations
and slow progression of disease, not to provide a
cure. Furthermore, all interventions will affect
patient lifestyle, from wearing compression
stockings to practicing general leg hygiene following surgery [ 35 ]. While the patient may seek
treatment simply to remove unsightly and painful
varicose veins, the surgeon understands that
obliteration of refl uxing veins may be the optimal
choice for long-term relief and ultimate satisfaction [ 44 ]. In our practice, a combination of clini-
cal examination, duplex Doppler study, and
Revised VCSS is used to diagnose CVD, plan
intervention, and track outcomes. Any of these
elements on its own would most likely provide
insuffi cient information to plan a treatment strategy, but by integrating all three components,
a more complete picture of the clinical severity of
venous disease and factors that are most important to the patient can be developed. This threespoke strategy has proven most successful.
3.8 Basics of Recurrent Varices
The REVAS (recurrent varices after surgery)
study by Perrin et al. followed up 170 patients
(199 limbs) from 14 institutions seen with varicosities after venous surgery [ 22 ]. Three clas-
sifi cations of recurrence were identifi ed: actual
recurrent varices, residual veins with refl ux,
and new varicose veins due to disease progression. A classifi cation system was developed that
works in conjunction with CEAP to identify the
area, cause, source, and factors leading to recurrent varices. In the combined system, the site of
recurrence, source of refl ux, contributing factors,
and cause are classifi ed according to REVAS,
while the clinical, etiologic, anatomic, and pathophysiologic patterns are presented according to
CEAP. The advanced CEAP classifi cation was
used to analyze subgroups of patients scored
under REVAS. The long follow-up period (mean,
136 months) and variety of initial procedures
provided insight into the nature of varicose vein
presentation following initial intervention. The
authors concluded that recurrence is common
after venous surgery, that incompetent perforating veins not addressed at the initial procedure
contribute signifi cantly to symptoms and incidence of recurrent varices, and that a signifi cant
amount of time had elapsed for most patients
between their initial procedure and the onset of
recurrent varicosities. The information gained
from this study provided insight for following
3 Presentation of Chronic Venous Disease
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47
up patients after interventions. Surveillance and
future therapy can be planned within a common
framework, which facilitates discussion about
concomitant or staged adjunct procedures.
As endovenous ablation becomes more prevalent, questions about the timing and necessity of
adjunct procedures have arisen. With endovenous ablation, there are two schools of thought:
fi rst, that adjunct procedures should be performed
in the same setting to address all issues and avoid
reintervention and, second, that adjunct procedures should be delayed to derive the maximum
benefi t from the initial ablation and obviate reintervention [ 45 ].
Min and colleagues followed up a group of
423 patients (499 limbs) after endovenous ablation to assess outcomes and complications [ 46 ].
During the 2-year follow-up period, 93.4 % of all
treated veins remained occluded. Their examination of these veins by ultrasonography revealed
that “…what is found on the duplex imaging
early is predictive of what will be seen later, with
none of the treated patients developing recanalization of successfully occluded GSVs [greater
saphenous veins] at 2 or 3 years that was not seen
before 9 months” [ 46 ]. According to the authors:
“Although symptomatic resolution and signifi cant improvement in the appearance of the leg is
usually noted after endovenous laser treatment
alone, most patients will need additional complementary procedures to fully realize the restorative benefi ts of treatment” [ 46 ].
Based on the results of clinical assessment,
patient reporting, REVAS, CEAP, and VCSS, we
now recommend that adjunct procedures be
delayed at least 4 months following ablation to
allow the full effect to be demonstrated. In our
experience, most varices present at radiofrequency ablation diminished in size or resolved
over the 4 months following the initial procedure
but then leveled off in terms of change [ 4 ].
On assessment, our patients fell into several
groups. First were those who had an anterolateral
saphenous tributary that was recognized and
treated but only over a short segment (10–15 cm).
These tributary varices ran over a longer course
in the leg and were more frequently treated than
tributary calf varices. This has been observed by
others [ 47 ]. Second, most of our greater
saphenous vein ablations at the time were performed to the knee. Failure to recognize a high
calf (Boyd) perforator or a non-saphenous connecting tributary resulted in below-knee greater
saphenous vein refl ux and reintervention. We
have since adapted our preoperative mappings to
look for these to preemptively treat. This also has
been substantiated by others [ 22 , 48 ]. Third,
refl ux often occurs via perforators posteriorly or
laterally in the thigh or calf, with resultant varices
and no connection to saphenous systems. These
require direct treatment. Perforator refl ux was
most often noted in patients with C4–C6 disease.
We occasionally saw this in patients with C3 disease, with more localized swelling, symptoms,
and varices at and below the site of the perforator
in the medial low calf. Endothermal ablation of
perforators has mixed success; however, we now
often use a combination of radiofrequency (RF)
ablation and ultrasonography-guided foam ablation to treat the entire tributary bed under the diseased skin. In general, ultrasonography-guided
foam ablation, instead of microphlebectomy, for
tributary veins has increased in our practice, with
excellent results.
We have noted certain patterns of reintervention [ 4 ]. No neovascularization was identifi ed
following radiofrequency ablation. Most patients
who required intervention had residual fi rst-order
or second-order varices in the distribution of the
treated saphenous segment. Residual refl ux via
an anterolateral saphenous, small saphenous,
below-knee saphenous, or perforator vein constituted the second most common source of reintervention. Progression of disease (usually among
patients with more severe disease) was the least
common pattern of reintervention.
Limbs with higher initial CEAP and VCSS
were signifi cantly less likely to require further
intervention than those with lower baseline
CEAP and VCSS [ 4 ]. The reason for this is not
entirely clear. Patients with higher initial CEAP
had a greater drop in their overall VCSS. The
relief obtained through ablation alone may have
met these patients’ expectations. It may be that
patients with milder disease tend to focus on their
residual varices.
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M.A. Vasquez and C. Munschauer
The choice and timing of adjunct procedures
are important to providing the best patient care
and are a matter of increasing debate. Delaying
adjunct procedures allows many patients to avoid
potentially unnecessary procedures. Whether
considering disability, pain, complications, or
cost, this strategy has clear benefi ts. Delaying
adjunct procedures allows the clinician to formulate a more directed treatment plan that can best
address the individual needs of the patient as they
arise. Increasing use of ultrasonography-guided
foam ablation may change this paradigm.
3.9 Summary
In the realm of following outcomes in the treatment of CVD, what is the best means to report
procedural outcomes as a function of clinical resolution and patient quality of life? Many
advanced minimally invasive treatments for
venous disease have been developed. Despite
these innovations, the same question remains:
How should new therapies be assessed to provide
a common framework for treating patients at all
levels of venous disease? We have learned over
time that patients with even minor symptoms
improve after superfi cial vein ablation, albeit
not as dramatically as those with severe disease.
How do we accurately assess improvement in all
patients, regardless of initial disease severity?
How do we appropriately stage therapy while
simultaneously evaluating success from interventions and improvement in symptoms related
to disease progression?
We need to establish what is medically relevant for patients with venous disease. To properly
do so, we need to hear their concerns described in
their own words and then infuse medical understanding into it. After treatment, we listen again
and reevaluate. As providers, we need to look
forward, establish goals for outcome measures,
and move toward an era of commonality in
reporting standards. Outcome assessment is not a
new concept. Physicians, surgeons, and scientists
have been engaging in discussions using the
common language of outcomes for years. What
has changed in recent times to bring this topic to
the forefront, in America and beyond, is the need
to quantify the benefi t of a service in light of
increasingly competitive and dwindling healthcare dollars. Outcome studies promote understanding of the diseases we treat and the results
of treatment we provide. They allow us to stratify
disease and therapy, as well as to compare results
using a common language. The choice of a valid
and reliable assessment tool is crucial. It is
incumbent on us to look critically at ourselves
and to objectively improve on what we do.
Quality-of-life instruments and surveys are valuable indicators of patient perspective and are
proven to be practical and reliable. Combining
the patient-generated language of quality-of-life
instruments with physician-generated surveys,
such as CEAP and Revised VCSS, seems to be a
good starting point for outcome assessment. The
most important factor in improving treatment
outcomes is the decision to examine results and
to share them in a meaningful way.
References
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RB, Meissner MH, Murad MH, Padberg FT, Pappas
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