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applying these to the 18 possible anatomic segments is avoided in favor of
applying the simple s, p, and d descriptors to denote the superficial, perforator
and deep systems. Thus, using basic CEAP, the same patient cited in a previous
example (painful varicosities plus LDS and duplex scan-determined reflux
involving the superficial and perforator systems) would be classified as C4b, S,
Ep, As, p, Pr (rather than C2,4b,S, Ep, As,p, Pr2,3,18).
REVISION OF CEAP: AN ONGOING PROCESS
With improvement in diagnostics and treatment there will be continued demands to adapt
the CEAP classification to better serve future developments. There is a need to incorporate
appropriate new features without too frequent disturbances of the stability of the
classification. As one of the committee members (F. Padberg) stated in our deliberations:
“It is critically important that recommendations for change in the CEAP standard be
supported by solid research. While there is precious little that we are recommending which
meets this standard, we can certainly emphasize it for the future. If we are to progress we
should focus on levels of evidence for changes rather than levels of investigation. While a
substantial portion of our effort will be developed from consensus opinion, we should still
strive to achieve an evidence-based format.”
REVISION OF CEAP: SUMMARY
CLINICAL CLASSIFICATION
C0 no visible or palpable signs of venous disease
C1 telangiectasies or reticular veins
C2 varicose veins
C3 edema
C4a pigmentation and/or eczema
C4b LDS and/or atrophie blanche
C5 healed venous ulcer
C6 active venous ulcer
S symptoms including ache, pain, tightness, skin irritation, heaviness, muscle
cramps, as well as other complaints attributable to venous dysfunction
A asymptomatic
ETIOLOGIC CLASSIFICATION
Ec congenital
Ep primary
Es secondary (post-thrombotic)
En no venous etiology identified
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PATHOPHYSIOLOGIC CLASSIFICATION
Basic CEAP:
Pr reflux
Po obstruction
Pr,o reflux and obstruction
Pn no venous pathophysiology identifiable
Advanced CEAP—Same as Basic with the addition that any of 18 named venous
segments can be utilized as locators for venous pathology:
Superficial veins
1. telangiectasies/reticular veins
2. great saphenous vein (GSV) above knee
3. GSV below knee
4. small saphenous vein
5. nonsaphenous veins
Deep veins
6. inferior vena cava
7. common iliac vein
8. internal iliac vein
9. external iliac vein
10. pelvic: gonadal, broad ligament veins, other
11. common femoral vein
12. deep femoral vein
13. femoral vein
14. popliteal vein
15. crural: anterior tibial, posterior tibial, peroneal veins (all paired)
16. muscular: gastrocnemial, soleal veins, other
17. perforating veins, thigh
18. perforating veins, calf
ANATOMIC CLASSIFICATION
As superficial veins
Ap perforator veins
Ad deep veins
An no venous location identified.
Example: A patient presents with painful swelling of the leg and varicose veins, LDS
and active ulceration. Duplex scanning on May 17, 2004 showed axial reflux of GSV
above and below the knee, incompetent calf perforators and axial reflux in the
femoral and popliteal veins. No signs of post-thrombotic obstruction.
† Classification according to basic CEAP: C6, S, Ep, As, p, d, Pr.
† Classification according to advanced CEAP: C2,3,4b,6,S, Ep, As, p, d, Pr2, 3, 18,
13, 14 (2004-05-17, LII).
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OUTCOME ASSESSMENT
For the practicing physician, CEAP is an instrument for correct diagnosis to guide
treatment and assess prognosis. For the researcher and reporting standards, CEAP aids to
group the patients so that we are looking at the same type of patients. It is important again
to state that CEAP is a descriptive classification and a base for diagnosis and prognosis,
while venous severity scoring and quality of life (QoL) estimation are instruments for
longitudinal research to assess outcomes. From the introduction of CEAP classification in
1994, 138 scientific articles have been published according to medline search for CEAP
and venous disease. Most of them have, though, only used the basic part of CEAP or only
the clinical classification. A recently published study on 98 legs (83 patients) with open
venous ulcer, using the advanced CEAP classification, showed that 86% of the legs had
superficial venous incompetence that might be offered surgery and axial reflux in
superficial or deep veins were present in 79% of the legs (10). A randomized controlled
study comparing surgery of the superficial venous system and compression with
compression alone by Barwell et al. (11) came to similar conclusion, showing that 85%
of all patients with venous ulcer could be managed by simple venous surgery.
The venous severity scoring system was intended to complement the descriptive
CEAP classification and consists of three parts, venous clinical severity score (VCSS),
venous segmental disease score (VSDS) and venous disability score (VDS). The validity
and reliability of the scoring system have not yet been confirmed although it has been
validated regarding the effect of superficial venous surgery (12). VCSS was found to
better reflect changes in response to superficial venous surgery than the CEAP clinical
class did. It was concluded that the scoring is a valuable tool in clinical studies to quantify
venous outcome rather than using only the clinical class of CEAP. Meissner et al. (13)
found the score reliable with good correlation with the CEAP clinical classification. Ricci
et al. (14) found the VCSS useful as a screening tool for venous disease as it has a good
association with abnormalities on ultrasound scanning and it might therefore be valuable
in clinical practice.
Venous Clinical Severity Score
Outcome assessment with emphasis on skin changes and ulcer is the main part of the
Venous Clinical Severity Score (VCSS). Nine clinical characteristics of CVD are
described and the symptoms are graded from 0–3 (absent, mild, moderate, severe). The
only subjective symptom graded is the degree of pain. As the need for compression
therapy is an indirect indicator for the severity of the disease it has been added as a
separate factor in the VCSS. The nine clinical characteristics and the need for compression
therapy make totally a 30 point-maximum flat scale. Qualifying comments, describing in
detail how symptoms and grades are defined, are provided to ascertain homogeneity in the
clinical judgments (Table 5).
What is the main difference in the new VCSS compared to the previous severity
scoring system? In the VCSS the grading has been changed from a 3-count scale (0–2) to a
4-count scale (0–3), where 0 is none, 1 is mild, 2 is moderate and 3 is severe. In the VCSS
venous claudication and ulcer recurrence have been omitted and varicose veins and
induration been added instead. Compression therapy has also been added as an indirect
indicator for disease severity.
Although the VCSS seems valuable for patients with venous ulcer, the value of
judging the severity is limited for the majority of patients with CVD. Patients with
symptomatic varicose veins without skin changes and without pain belong to this group.
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Table 5 Venous Segmental Disease Score (VSDS)
Attribute AbsentZ0 MildZ1 ModerateZ2 SevereZ3
1. Pain None Occasional, not daily, restricting
activity or requiring analgesics
Moderate activity, limitation,
occasional analgesics
Daily, severly limits activities,
regular use of analgesics
2. Varicose veins None Few, scattered: branch VV w.
competent GS/LS
Multiple: single segment GS/LS
reflux
Extensive: multisegment GS/LS
reflux
3. Venous edema None Evening ankle edema only Afternoon edema above ankle Morning edema above ankle
requiring activity change,
elevation
4. Skin
pigmentation
None or focal, low
intensity (tan)
Diffuse, but limited in area and
old (brown)
Diffuse over gaiter distribution
(lower 1/3) or recent pigmen-
tation (purple)
Wider distribution (above lower
1/3) and recent pigmentation
5. Inflammation None Mild cellulitis, limited or
marginal area around ulcer
Moderate cellulitis, involves
most of gaiter area
Severe cellulitis (lower 1/3 or
above) or venous eczema
6. Induration None Focal,
circum-areolar (!5 cm)
Medial or lateral, less than lower
third
Entire lower third or more
7. Total no. ulcers 0 1 2–4 O4
8. Active ulceration, None !3mo O3 mo, !1 yr Not healed O1yr
9. Active ulcer, size None !2 cm diameter 2–4 cm diameter O4 cm diameter
10. Compressive therapy Not used or not
compliant
Intermittent use of stockings Wears elastic stockings most
days
Full compliance stockings
C elevation
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Although skin changes with or without ulcer are the most severe forms of venous disorder,
we cannot forget that most patients with CVD do not develop ulcer. It is also interesting to
compare the treatments for these patients. The importance of pain, as the subjective
parameter in the clinical score, may also be argued. Most patients with varicose veins do
not experience pain, and even patients with venous ulcer do not always report pain as the
main symptom. The VCSS does not take into account other symptoms as heaviness or
tiredness that can be the main reason for the patient to seek medical attention. Possible
alternative is to measure the most severe symptom (pain, heaviness, tiredness, night cramp,
etc.) reported by the patient and follow up changes regarding this one symptom over time.
An arguement against this is that most lower leg symptoms in patients with varicose veins
are probably non-venous in origin (according to the Edinburgh vein study (15)) and
therefore they should not be a part of a venous severity scoring system. Another issue that
has not been addressed is the length of the follow-up time. Almost all venous ulcers
eventually heal. The time factor is important when comparing different treatments. If the
follow-up VCSS is done when the ulcer has healed, almost any treatment can be shown to
be effective as regard to the VCSS. Ulcer history before treatment and ulcer recurrence
after treatment are not measured in VCSS, although the main goal of the treatment is to
keep the ulcer healed over time. Further modifications are probably needed before we have
the optimal tool for measuring the severity of CVD in all clinical classes of the CEAP.
Venous Segmental Disease Score
The Venous Segmental Disease Score (VSDS) combines the anatomical and the
pathophysiological components of CEAP. The major venous segments are graded
separately both regarding the occurrence of reflux and obstruction (Table 6). This is done
to highlight the importance of occlusion in the disease pattern and patients with a more
severe form of CVD, as post-thrombotic changes, will therefore get a higher score than
those with reflux only. Also, segments that are thought to be more important in the disease
manifestation, as popliteal and crural veins get a higher score (16,17). Other anatomical
segments with little or no role in CVD are excluded. Reflux in one segment is defined as
all valves in that segment are incompetent. Obstruction means that there is total occlusion
at some point in the segment or O50% narrowing of at least half of the segment. Points
can be assigned for both obstruction and reflux in the same segment, as can be in legs
Table 6 Venous Segmental Disease Score
Reflux Obstruction/occlusion Reflux Obstruction/occlusion
1. LSV 0–0.5 1. GSV 0–1
2. GSV 0–1 2. Calf veins, multiple 0–1
3. Perforating thigh 0–0.5 3. Popliteal 0–2
4. Perforating calf 0–1 4. FV 0–1
5. Calf veins, multiple 0–2 5. DFV 0–1
6. Popliteal 0–2 6. CFV 0–2
7. FV 0–1 7. Iliac vein 0–1
8. DFV 0–1 8. IVC 0–1
9. CFV 0–1
Abbreviations: LSV, lesser saphenous vein; GSV, greater saphenous vein; FV, femoral vein; DFV, deep femoral
vein; CFV, common femoral vein; IVC, inferior venal cava.
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with post-thrombotic changes. The maximal scoring is 20, 10 for reflux and 10 for
obstruction/occlusion.
According to the original system the anatomical score consisted of 18 venous
segments with one count for each diseased segment irrespective of whether it was reflux,
obstruction or both. This approach in the original system was criticized for overestimating
some insignificant features of the disease. For example, occlusion of the common iliac
vein adds the same weight to the severity score as reticular veins do. Scoring is also often
low using the system as eight of the segments are only occasionally involved in CVD.
The new VSDS grades the relative importance of each segment. The importance of
occlusion in the disease pattern is highlighted with separate scoring for occlusive
segments. The pathophysiological importance (weighting) of different venous segments
remains though to be confirmed.
Venous Disability Score
Venous Disability Score (VDS) measures the impact of CVD on the ability to carry out
usual daily activities, using a 4-point scale from 0 to 3. Patients that are symptomatic, but
can carry out usual activities without support, get 1 point, patients that need compression
therapy to be able to carry out usual activities get 2 points and patients that cannot carry
out usual activities even with compression or limb elevation get 3 points.
Quality of Life and CVD
How to adequately evaluate QoL in patients with CVD is unclear. A number of QoL
questionnaires have been used to measure the impact of CVD on the general health of
patients. Some of them have been generic and others have included more disease-specific
questions. The medical outcomes study, short form “health survey” (SF-36), often
regarded as the “golden standard” for QoL measures, has been extensively validated.
It consists of 36 item-generic measures of QoL, which measures eight health dimensions.
The perceived health of patients with varicose veins, as measured by the SF-36, was
significantly lower than that of samples of the general population according to a study by
Garratt et al. (18). The success of varicose vein surgery has been analyzed using SF-36,
including seven extra questions with more CVD-related topics (19). After six months, all
dimensions except social function and health perception were improved. A specific
questionnaire for venous ulcer patients was validated by Smith et al. (20) showing good
reliability, as assessed by means of the internal consistency. The validity was
demonstrated by means of a high correlation with all eight domains of the SF-36 and it
was concluded that clinically derived measures for patients with venous ulcers have
validity to measure the QoL. Another generic QoL questionnaire, the Nottingham Health
Profile (NHP), was used to assess patients with chronic leg ulcer, indicating that the
disease has a marked impact on the patients’ subjectively perceived health, especially in
men (21). NHP has been criticized for its problematic weighting scoring system and lack
of sensitivity to low levels of distress. CVI Questionnaire (CIVIQ) was developed by
a French group in 1996 (22). This is a 20-item self-administered questionnaire, which
explores four dimensions: psychological, physical and social functioning and pain. It is
simple and easy to administer. The conclusion was that the questionnaire might be used
with confidence to assess QoL in clinical trials on CVI. The Aberdeen Varicose Vein
Score (AVSS) was used to judge the effect of saphenous stripping on disease-specific QoL
showing improvement in 87% of the patients (23). There were significant improvements in
AVSS scores for as much as two years. After adjustment for recurrent disease, stripping
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conferred additional benefit in terms of AVSS at six months. SF-36 scores were, on
the other hand, not affected by stripping. An international population-based study by
Kurz et al. (24) indicated that impairment in physical QoL in patients with varicose veins
is associated with concomitant venous disease, rather than with the presence of varicose
veins, and therefore it could only be reliably interpreted when concomitant venous disease
is taken into account. The limitation of most QoL questionnaires in CVD is that they have
not been fully evaluated in terms of validity and reliability and they often focus on only
one part of the disease spectrum of CVD, as just varicose veins or ulcer.
CONCLUSION
The CEAP classification of CVD was adopted world-wide to facilitate meaningful
communication about CVD and serves as a basis for a more scientific analysis of
management alternatives. Today most published clinical papers on CVD use all or portions
of CEAP. Venous disease is complex, but can be described by the use of well-defined
categorical descriptions. The revision of CEAP can be a valuable instrument for the
practicing physician for correct diagnosis to guide treatment and assess prognosis. For the
researcher and reporting standards, CEAP allows grouping of patients so that the same type
of patients can be analyzed together and such a subgroup analysis allows their treatments to
be more accurately assessed. Furthermore, reports using CEAP can be compared with one
another with much greater certainty. CEAP is a descriptive classification, while venous
severity scoring and QoL estimation are instruments for longitudinal research to assess
outcomes. With these weapons in our hands we should be able to improve the scientific
approach to CVD and introduce evidence-based medicine for the benefit of our patients.
KEY POINTS
† The CEAP classification system has been adopted worldwide.
† Accurate classification allows better analysis and patient management.
† The CEAP is continuously revised to accommodate new developments.
† Venous scoring systems are used to grade severity and disability of venous
disease.
† Venous severity scoring and quality of life questionnaires are instruments for
longitudinal research to assess outcomes.
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SECTION B: ASSESSMENT AND INVESTIGATION
7
Clinical Assessment of Venous Disease
Sriram Subramonia and Tim A. Lees
Northern Vascular Centre, Freeman Hospital, Newcastle upon Tyne, U.K.
INTRODUCTION
Varicose veins are the commonest of all the vascular disorders affecting man. Of all the
earth’s mobile creatures man alone is afflicted by this abnormal condition due to his
penchant for maintaining an upright posture. Venous disease has interested mankind for
many centuries. “Serpentine windings” on the legs have been recorded as early as 1550 B.C.
in the papyrus of Ebers and the author advises against operation because it causes
hemorrhage and death! Since then, the assessment and treatment of venous disease
has advanced manyfold and surgery, when indicated, can be offered with acceptable risk to
those affected. However, an inadequate clinical assessment can result in an unsatisfactory
outcome following treatment with consequent significant patient dissatisfaction.
Diseases of the venous system cause significant morbidity and also have a major
socio-economic impact on society (1–5). They are more common in the lower limb than in
the upper limb. Acute presentations, the most common of which is deep vein thrombosis,
usually demand urgent attention. Chronic presentations, on the other hand, rarely threaten
limb or life. The past two decades have seen a greater application of physiologic principles
to the assessment and treatment of venous disease and a better understanding of the
pathophysiology underlying chronic venous insufficiency due to the advent of new
technology for non invasive testing, such as the continuous-wave hand held Doppler and
color duplex ultrasonography. Much of this chapter will focus on the clinical assessment of
patients who present to an outpatient clinic with features of uncomplicated (e.g., primary
varicose veins) or complicated (e.g., chronic venous insufficiency) venous disease. The
authors’ practice is to assess these patients in a “one-stop” venous clinic where duplex
ultrasonography can be performed, when indicated, to complement the findings of clinical
assessment. A sound understanding of the anatomical and physiological basis for the
development of venous disease is paramount to clinical assessment.
VENOUS ANATOMY
Lower Limb
The veins of the lower limb (6–8) can be divided into the superficial venous system that
lies subcutaneously, the deep veins accompanying major arteries beneath the deep fascia
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