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Table 5.1
CEAP Classification of Chronic Venous
Disease
Clinical classification
C0 No visible or palpable signs of venous
disease
C1
Telangictasias or reticular veins
C2 Varicose veins
C3
Edema
C4a Pigmentation and/or eczema
C4b
lipodermatosclerosis and/or atrophie
blanche
C5
Healed venous ulceration
C6 Active venous ulceration
Etiologic classification
E
c
Congenital
E
P
Primary
E
S
Secondary
E
n
No venous etiology identified
Anatomic classification
A
s
Superficial veins
1 Telangiectasias/reticular veins
2 Great saphenous vein (above knee)
3 Great saphenous vein (below knee0)
4 Small saphenous vein
5 Nonsaphenous veins
A
d
Deep veins
6 Inferior vena cava
7 Common iliac vein
8 Internal iliac vein
9 External iliac vein
10 Pelvis veins (gonadal, broad ligament,
other)
11 Common femoral vein
12 Deep femoral vein
13 Femoral vein
14 Popliteal vein
15 Crural vein (anterior tibial, posterior
tibial, peroneal)
16 Muscular vein (gastrocnemial, soleal,
other)
A
p
Perforating veins
17 Thigh perforator veins
18 Calf perforator veins
Pathophysiological classification
P
r
Reflux
P
o
Obstruction
P
r,o
Reflux and obstruction
P
n
No venous pathophysiology identified
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5.3.1 Special Considerations in the Elderly
During the workup of CVI, the physician gathers a patient’s full history and physi-
cal and weighs the risk and benefits of any therapeutic interventions. An important
consideration in the process of weighing operative therapy is the optimal type of
anesthesia for the procedure. Common modes of anesthesia for venous procedures
include local tumescent anesthesia (LA), regional anesthesia (RA), and general
anesthesia. While no dedicated studies exist on the type of optimal anesthesia for
CVI procedures in the elderly—indeed, optimal anesthesia is largely patient-
specific—one may extrapolate from studies in the elderly population as a whole. In
general, anesthesia-associated risks depend on American Society of Anesthesiologists
classification (ASA score), comorbidities, the type of surgery, and the emergent
nature of the surgery. A recent Cochrane review of LA, RA, and GA in noncardiac
surgery for patients >65 years reviewed morbidity and mortality in mostly orthope-
dic and various surgical disciplines (not vascular-specific) [17]. The review found
Table 5.2 Venous Clinical Severity Score (VCSS)
Attribute Clinical severity
Absent = 0 Mild = 1 Moderate = 2 Severe = 3
Pain None Occasional, not
restricting
activity, no
analgesics
Daily, moderate
activity limits,
occasional
analgesics
Daily, severe activity
limits, regular use of
analgesics
Varicose veins None Few, isolated
branch varices
Multiple, GSV, or
SSV varices, calf
only
Extensive, GSV or
SSV varices, calf
and thigh
Venous edema None Evening, ankle Afternoon, above
the ankle
Morning, above the
ankle, requires
activity change,
elevation
Skin
pigmentation
None or
focal, low
intensity (tan)
Diffuse, limited
in area and old
(brown)
Diffuse over gaiter
distribution (lower
1/3) or recent
pigmentation
(purple)
Wider distribution
(above lower 1/3)
and recent
pigmentation
Inflammation None Mild cellulitis,
limited to
marginal area
around ulcer
Moderate
cellulitis, involves
most of gaiter area
Severe cellulitis
(lower 1/3 and
above) or venous
eczema
Induration None Focal,
circum-
malleolar,
<5 cm
Medial or lateral,
less than lower
third of leg
Enter lower greater
third of leg or more
No. of active
ulcers
0 1 2–4 >4
Ulcer duration None <3 month >3 mo, <1
year Not healed >1 year
Ulcer size None <2
cm diameter 2–4 cm diameter >4 cm diameter
Compressive
therapy
Not used or
noncompliant
Intermittent use
of stockings
Use most days Full compliance and
elevation
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that in elderly orthopedic patients, RA showed a lower early-term mortality rate,
reduced fatal pulmonary embolisms rates, and lessened postoperative confusion
compared to GA. However, GA is associated with a lower incidence of hypotension.
Nausea and vomiting was observed in a lesser extent with LA compared to RA and
GA in elderly patients undergoing hernia surgery. Overall, the authors note that the
occurrence of true anesthesia-related complications is rare and that the postopera-
tive complications are often related to the procedure itself, not the anesthetic of
choice. While difficult to generalize these findings to vascular patients undergoing
procedures for CVI, physicians must work closely with the anesthesia team to opti-
mize the patient’s individual anesthetic choice.
5.4 Telangiectasias and Reticular Veins
As previously discussed (Table 5.1), the CEAP classification presents a standard-
ized system by which to catalog the clinical findings of chronic venous insuffi-
ciency. As the severity of CVI increases, the patient’s concerns typically shift from
cosmetic to impaired functional status and discomfort. In the early stage with telan-
giectasias and reticular veins (C1), however, cosmetic concerns typically drive the
request for physician evaluation and potential invasive intervention. In addition to
discussing surgical risks and benefits as with all patients, providers must make
aware to patients whose clinical severity is C1 that the insurance coverage may not
extend to procedures performed for cosmetic indications.
Patients with C1 disease with cosmetic concerns or minimal symptoms may ben-
efit from local ablative therapies [18]. These include chemical-based therapies such
as sclerotherapy and heat-based therapies such as thermocoagulation and laser treat-
ments. Sclerotherapy is often used for smaller affected veins, and common scleros-
ing agents are classified as detergents, hypertonic solutions, or chemical irritants.
While the agents act through different mechanisms, the ultimate result is sclerosis
through endothelial cell injury. Heat-based therapies also produce endothelial
injury, resulting in thrombosis and eventual fibrosis of the treated vein. Regardless
of the modality used to treat telangiectasias or reticular veins, posttreatment com-
pression of the lower extremity is recommended for more effective sclerosis and
improved cosmetic results. Postoperative bruising and hyper-pigmentation of the
treated areas are potential outcomes, which must be discussed specially with patients
who are undergoing the procedure for cosmetic purposes. Both bruising and the
hyper-pigmentation, caused by deposition of dermal hemosiderin, fade over time.
5.5 Varicose Veins
As CVI continues to progress from reticular veins and telangiectasias, varicose
veins develop, marking C2 disease in the CEAP classification. This chronic condi-
tion is estimated in more than 20% of adults in the United States [3], and risk factors
include older age, female gender, multiparity, family history, obesity, history of
thrombophlebitis, or history of thrombosis. As previously discussed in the “Venous
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Insufficiency” section, the underlying etiology of the development and progression
of CVI is from valvular insufficiency leading to reflux, obstruction, calf muscle
pump malfunction, or a combination of these factors. While some patients with
varicosities may not present with symptoms, those with more advanced disease may
complain of heaviness of the legs, tingling, achiness, prutitis, pain, and fatigue.
These symptoms are often exacerbated by prolonged dependency or heat and
relieved by leg elevation or compression elastic bandages or stockings. The pres-
ence of varicosities is often more than a nuisance or a cosmetic concern—they are
a frequent cause of discomfort, disability, and decreased quality of life.
Following a dedicated history and physical and imaging (duplex scanning as the
most common noninvasive modality) confirming varicose veins from underlying
CVI, treatment options are considered on a patient-specific basis. The clinical prac-
tice guidelines of the Society for Vascular Surgery and the American Venous Forum
[19] provide recommendations to enhance consistent evidence-based approaches to
care for patients with varicose veins and associated chronic venous diseases, and
they encompass medical therapy, compression, and surgical interventions.
Medical treatment incorporates venoactive drugs for the treatment of symptoms
of varicose veins, though they do not address the underlying etiology. While the
exact mechanism of action for most of these agents is unknown and they are unavail-
able in the United States, their use is intended to improve venous tone and capillary
permeability. A recent Cochrane review by Martinez and colleagues analyzed 44
studies and found diosmin, hesperidin, and MPFF were the most effective venoac-
tive drugs [20]. Diosmin and hesperidin also helped with the healing of trophic skin
changes and treated cramps and swelling. Cramps and restless legs were also
reduced by calcium dobesilate. Rutosides reduced venous edema. Overall, the
meta-analysis concluded that evidence was insufficient to support the global use of
these agents in the treatment of chronic venous disease.
Compression therapy is the most often used treatment of varicose veins and comes
in various forms including elastic compression stockings, multilayer elastic wraps,
bandages, and Unna boots. The use of compression is recommended in order to
decrease venous hypertension in the lower extremities. While randomized control tri-
als have not suggested definitive compressive pressures for addressing C2 disease,
currently, the SVS/AVF Guideline Committee suggests graded prescriptions stock-
ings with an ankle pressure of 20–30 mm Hg (Grade 2C). The use of compression
therapy prior to consideration for surgical therapy may be a requirement for some
practitioners due to insurance company policies for coverage. The REACTIV trial
(Randomized Clinical Trial, Observational Study and assessment of Cost-Effectiveness
of the Treatment of Varicose Veins), which randomized 246 patients with C2 disease
to conservative management or surgery, demonstrated a significant quality of life ben-
efit for surgery in the first 2 years after treatment, with substantial improvements in
symptomatic and anatomic measures [21]. As noted in the SVS/AVF guidelines, there
is virtually no scientific evidence to support requiring a trial of compression prior to
more aggressive intervention, even though third- party payers often require it. Indeed,
the REACTIV trial as described above has demonstrated that surgical treatment to
treat superficial reflux is more efficacious and more cost-effective.
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5.5.1 Special Considerations in the Elderly
In addition to considering the quality of life improvement from surgical interven-
tion compared to compression alone, one must consider the limited functional abil-
ity the elderly population may have in applying elastic stockings. Patients with
limited strength, pain from arthritis, chair- or bed-bound status, and obesity will
predictably have difficulty with tight elastic stockings or wraps. In these patients,
assistive devices, reliable family members, or nursing aides may improve compli-
ance and effectiveness of this conservative approach.
Frequent surgical options include ablation of axial reflux by radiofrequency
ablation (RFA) or endovenous laser treatment (EVLT) and phlebectomy by transil-
luminated powered phlebectomy (TIPP), stab approach, and, when relatively small,
with sclerotherapy. Classically, the surgical approach for varicose veins was liga-
tion and stripping, which was associated with large skin incisions and nerve injury.
Over the past decade, endovenous thermal ablation has replaced much of the previ-
ous approach except in circumstances such as an exceptionally large and tortuous
saphenous vein located immediately under the skin or difficult cannulation of the
affected vein due to previous thrombophlebitis. Notably though, limited incisions
are still made to perform ligations and miniphlebectomies of bulging varicosities of
the great and small saphenous vein.
Endovenous thermal ablation is performed on the saphenous veins in place of the
previous maximally invasive open surgical technique. This method encompasses
both radiofrequency ablation (RFA) and endovenous laser treatment (EVLT): with
both, the endothelium of the vein is destroyed by direct thermal energy to the vein
wall, ultimately leading to fibrosis and thrombosis of the vein. The percutaneous
placement of the radiofrequency or laser ablation catheter is minimally invasive,
and the procedure is performed under direct ultrasound visualization to ensure both
complete treatment of the saphenous vein and no thrombotic extension into the deep
system. This outpatient procedure is then followed by the application of either elas-
tic or nonelastic wraps or graduated compression stockings for at least 1 week, with
encouragement to ambulate the same postoperative day to minimize risk of DVT
and PE. Thrombosis prophylaxis is routine as well and driven by individual patient
thrombosis risk assessment. Postoperative progress may be tracked with VCSS
changes. Other new non-heat-inducing techniques to close off incompetent saphe-
nous veins are being developed today, including mechanicochemical and glue.
For the branch varicosities, traditionally stab incision technique and the use of spe-
cial vein hooks can be employed. Transilluminated powered phlebectomy (TIPP) is
another technique used to remove large clusters of varicosities. It is often performed in
combination with endothermal ablation to address both the source of reflux in addition
to the cluster of varicose veins. In this approach, typically only small incisions are nec-
essary in order to pass the instruments: an illuminator with a fiber optic cable for transil-
lumination under the skin and delivery of tumescence irrigation, a central power until
with an irrigation pump and a control of resection oscillation speeds, and a resector hand
piece. Additionally, small punch incisions are made to drain the blood following phle-
bectomy, which is further cleared out with the tumescence fluid.
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At our institution, the University of Michigan, 979 limbs from 3/31/2008–6/4/2014
were evaluated who had undergone RFA + TIPP compared to RFA alone. VCSS
improved more with RFA + TIPP (3.8 ± 3.4 vs. 3.2 ± 3.1, p = 0.018) compared to RFA
alone. Postoperative complications assessed were deep venous thrombosis/pulmonary
embolism, EHIT (endovenous heat-induced thrombosis), infection, hematoma, and
superficial venous thrombosis (SVT). More hematomas (p < 0.001) and SVTs
(p = 0.01) occurred in patients who had undergone RFA + TIPP compared to RFA
alone; other differences in complications between the two procedures were not sig-
nificant. These results suggest RFA + TIPP provides improved VCSS with only incre-
mental increases in morbidity for patients with symptomatic varicose veins and
superficial venous insufficiency and should be considered first-line therapy. From the
same University of Michigan database, a subset of these patients aged 65 and older
who underwent RFA versus RFA + TIPP was analyzed for VCSS changes and the
same complications as above, and WAS compared to those under age 65. Notably,
with the age 65 and older subset, there was a trend toward a higher percentage of
patients who had RFA alone compared to RFA + TIPP. In comparison to the entire
group and to those under age 65, VCSS improved more with RFA alone compared to
RFA + TIPP, although both groups improved VCSS improvement 4.1 and 3.8 for RFA
and RFA + TIPP, respectively. Compared to the all-ages complications, the age 65 and
older subset did not have significant differences in complications between the two
procedures. In the older patients, thus they appeared to improve more with the lesser
procedure. We speculate that this is because the underlying concern with the elderly is
addressing their pain rather than the concern of the extent of the varicosities.
5.6 Venous Stasis Ulceration and Therapeutic Interventions
Venous leg ulcers (VLUs) are defined as open skin lesions of the leg or foot which
occur in areas affected by venous hypertension and venous stasis. They account for
70% of all leg ulcers and are the most common ulceration of the lower extremity [22].
The Edinburgh study, a cross-sectional study examining 1566 subjects from age 18 to
64, found an estimate of venous leg ulcer prevalence of 1% with increasing prevalence
with age [23]. An estimated 20% of the 2.5 million people in the United States who
suffer from chronic venous insufficiency develop venous ulcers at some stage of their
lives [24], and the estimated direct cost of treating these ulcers has been estimated to
be $2500 per month per patient [25]. With such an economic impact and health care
burden, it is of utmost importance that the treatment protocols given to patients are
effective in maximizing the healing of VLUs and minimizing their recurrence.
The clinical practice guidelines of the Society of Vascular Surgery and the
American Venous Forum impart a consistent approach to diagnosing and treating
venous leg ulcers [26]. They provide both best practice guidelines for approaches
with the strongest level of evidence and, for guidelines with less definitive evi-
dence, recommendations and suggestions for additional approaches to care. Select
guidelines and recommendations are presented below for clinical evaluation, wound
care, compression, ancillary measures, and primary prevention.
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A. Clinical Evaluation
Best practice guidelines recommend clinical evaluation performed for evidence
of chronic venous disease for all patients with suspected leg ulcers. Additionally,
medical conditions that affect ulcer healing and nonvenous causes of ulcer
should be identified. All patients with VLUs are recommended to be classified
with CEAP, revised Venous Clinical Severity Score, and venous disease- specific
quality of life assessment.
Additional suggestions and recommendations include a recommendation for
comprehensive venous duplex ultrasound exam of the lower extremity in all
patients with suspected VLUs (Grade 1; level of evidence B) and a recommen-
dation for wound biopsy for leg ulcers that do not improve with standard wound
and compression therapy after 4–6 weeks (Grade 1; level of evidence C). They
also recommend arterial pulse exam and measurement of ankle-brachial index
on all patients with VLUs (Grade 1; level of evidence B). The guidelines suggest
against routine culture of VLUs, but to obtain when clinical evidence of infec-
tion is present (Grade 2; level of evidence C).
B. Wound Care
There are no best practice guideline recommendations for wound care.
Additional suggestions and recommendations include a recommendation for
VLUs to receive thorough debridement at their initial evaluation to remove
obvious necrotic tissue (Grade 1; level of evidence B) and a recommendation
that surgical debridement be performed for VLUs with slough, nonviable tissue,
or eschar, with serial wound assessment for determining the need for repeated
debridement (Grade 1; level of evidence B). The guidelines recommend that
cellulitis surrounding the VLU be treated with systemic gram-positive antibiot-
ics (Grade 1; level of evidence B) and suggest against systemic antimicrobial
treatment of VLU colonization or biofilm without clinical evidence of infection
(Grade 2; level of evidence C). Additionally, they recommend VLUs with clini-
cal evidence of infection to be treated with systemic antibiotics guided by wound
culture sensitivities (Grade 1; level of evidence C). Initial preferences are oral
antibiotics, with a duration limited to 2
weeks unless there is persistent evidence
of infection (Grade 1; level of evidence C).
The guidelines suggest hydrosurgical debridement as an alternative to standard
surgical debridement (Grade 1; level of evidence B) and suggest against ultrasonic
debridement over surgical debridement (Grade 2; level of evidence C). They sug-
gest application of skin lubricants under compression to reduce dermatitis to sur-
rounding skin (Grade 2; level of evidence C) and suggest cultured allogeneic
bilayer skin replacements to increase the chances for healing in patients with dif-
ficult to heal VLUs who have not shown signs of healing after standard therapy for
4–6 weeks, in addition to compression therapy (Grade 2; level of evidence A)
C. Compression
There are no best practice guideline recommendations for compression.
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Additional suggestions and recommendations include a recommendation for
compression therapy over none to increase VLU healing rate (Grade 1; level of
evidence A) and a suggestion of compression therapy in patients with healed
VLUs to decrease risk of ulcer recurrence (Grade 2; level of evidence B). The
guidelines recommend ablation of incompetent veins in addition to standard
compressive therapy for patients with VLU (C6) and incompetent superficial
veins with reflux directed to the bed of ulcer to prevent recurrence (Grade 1;
level of evidence B). The guidelines also recommend ablation of the incompe-
tent veins in addition to standard compressive therapy for patients with a healed
VLU (C5) and incompetent superficial veins with reflux directed to the bed of
the ulcer to prevent recurrence (Grade 1; level of evidence C). Percutaneous
techniques over open venous perforator surgery for patients who would benefit
from pathologic perforator vein ablation are also recommended (Grade 1; level
of evidence C). The guidelines suggest ablation of incompetent veins in addition
to standard compressive therapy for patients with VLU (C6) and incompetent
superficial veins with reflux directed to the bed of ulcer for improved ulcer heal-
ing (Grade 2; level of evidence C). They also suggest ablation of both the incom-
petent superficial veins with reflux to the ulcer bed and pathologic perforator
veins located beneath or associated with the ulcer bed to aid in ulcer healing and
to prevent recurrence (Grade 2; level of evidence C).
D. Ancillary Measures
Best practice guidelines recommend nutrition assessment to be performed and
nutritional supplementation to be provided if malnutrition identified.
Additional suggestions and recommendations include a recommendation for
treatment with either pentoxifylline or micronized purified flavonoid fraction in
combination with compression therapy for long-standing or large VLU (Grade
2; level of evidence B). They suggest supervised active exercise to improve mus-
cle pump function and to reduce pain and edema in patients with VLUs (Grade
2; level of evidence B) and suggest against use of ultraviolet light for the treat-
ment of VLUs (Grade 2; level of evidence C).
E. Primary Prevention
Best practice guidelines suggest patient and family education, regular exercise,
leg elevation when at rest, careful skin care, weight control, and appropriately
fitting foot wear for patients with C1-4 disease.
Additional suggestions and recommendations incorporate a recommendation
for compression 20–30 mm Hg, knee or thigh high, for patients with clinical
CEAP C3-4 disease due to primary valvular reflux (Grade 2; level of evidence C).
Additionally, they recommend compression 30–40
mm Hg, knee or thigh high, for
patients with clinical CEAP C1-4 disease related to prior deep venous thrombosis
(DVT) (Grade 1; level of evidence B). Finally, current evidence- based therapies
are recommended for acute DVT treatment, as postthrombotic syndrome is a com-
mon preceding event for VLUs (Grade 1; level of evidence B). Low-molecular-
weight heparin over vitamin K antagonist therapy is suggested for 3 months to
decrease postthrombotic syndrome (Grade 2; level of evidence B).
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A recent systematic review and meta-analysis of surgical approaches compared
to conservative treatment for VLUs evaluated open surgery versus compression,
endovascular surgery versus compression, and open versus endovascular surgery.
Mauck and colleagues did not uncover superiority of either surgical approach to
conservative therapy for ulcer healing or recurrence outcomes in patients with
VLUs [27]. However, the SVS/AVF guidelines propose a more aggressive approach
to promoting ulcer healing, prevent recurrence of an active ulcer, and address a
healed ulcer as indicated above. Due to the ulcer’s chronicity and high likelihood of
recurrence, this more aggressive method may be the more appropriate approach to
improve a patient’s ultimate quality of life.
5.6.1 Special Considerations for the Elderly
VLUs are wounds marked by chronicity and a difficulty in achieving healing without
recurrence. Elderly patients have a higher prevalence of comorbid conditions that lead
to poor wound healing such as malnutrition, diabetes mellitus, and arterial vascular
disease. The intrinsic changes in the components of the skin that occur with aging—
thinned epithelium, reduction in adnexa such as oil glands and sebaceous glands
resulting in drier skin more prone to cracking, deceased angiogenesis, decline in the
ability to re-epithelialize—all factor into impaired recovery [28]. These intrinsic fac-
tors cannot be altered, but external factors that can be addressed should be optimized
to improve the chances of healing. These include maximizing nutritional-balanced
intake—including the use of protein supplementation with commercially available
shakes for those with dental or digestive difficulties, improving glucose control and
compliance with diabetic restrictions, ceasing tobacco use, and improving arterial
inflow as appropriate. Decreasing ultraviolet light damage by reducing sun exposure
to beneficial levels should also be encouraged.
Key Points
• Chronic venous disease affects millions of patients in the United States, and its
prevalence rises with age.
• With an increasing elderly population, practitioners must weigh special consid-
erations specific to caring for all CEAP levels of CVI in this group.
• Special considerations for the care of CVI in the elderly involve unique attention
to the effects of multiple comorbidities, limited mobility and ability to tolerate
physiologic testing, the choice of various anesthetics when undergoing surgery,
and prolonged healing time for skin changes despite medical and surgical
interventions.
• Surgical treatment of varicose veins has demonstrated significant quality of life
benefit with substantial improvements in symptomatic and anatomic measures
compared to conservative treatment alone
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• Our institution’s experience demonstrated a trend toward a higher percentage
of patients who had RFA alone compared to RFA + TIPP in an age 65 and
older subset. The VCSS of this subset tended to improve more with RFA alone
compared to RFA + TIPP, though compared to the all-ages complications, this
subset did not have significant differences in complications between the two
procedures.
• The SVS/AVF guidelines are an invaluable approach to evidence-based care in
the maintenance, treatment, and prevention of CVI.
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