Elna M. Masuda

Diagnosis of Chronic Venous Disease of the Lower Extremities: The “CEAP” Classification

OBJECTIVE To test a new classification of chronic venous disease (CVD)--based on clinical, etiologic, anatomic, and pathophysiologic data (the CEAP system)--in a series of patients by using objective tests to establish all diagnoses. MATERIAL AND METHODS The CEAP classification was applied to 102 extremities in 70 consecutive patients with CVD. Diagnoses were based on objective testing with continuous-wave Doppler studies, duplex scanning, plethysmography, venous pressure, and phlebography, which were applied selectively (the more invasive methods were reserved for cases of greater severity). RESULTS Use of this classification provided an organized categorization of the key elements of the venous abnormalities in each case and clarified the interrelationships among the clinical manifestations, cause of the process, and anatomic distribution of involvement. For example, in this series of 102 extremities, 79% had primary venous disease, 18% had secondary disease, and 3% had congenital abnormalities. Ulcers were found in 7% of extremities with primary CVD and 44% with secondary CVD. Of the cases with ulceration, 43% were due to primary incompetence and 57% to postthrombotic disease. Reflux was the pathophysiologic problem in 86% of the total series and in 80% of ulcer cases. Similar relationships can be delineated for cases with varicose veins, edema, or skin changes. Study of the specific facets of the CEAP classification provided precise information about the cause and the effect of venous abnormalities that could be compared with cases in other series. CONCLUSION Use of the CEAP classification with diagnoses determined by objective testing accurately identifies categories of CVD. The objective date provide a clear description of the abnormalities in each case and may be used for analyses of meaningful relationships between categories of CVD. Adoption of this objective method of classifying CVD will facilitate interinstitutional studies.

The natural history of calf vein thrombosis: Lysis of thrombi and development of reflux

PURPOSE Although the fact is well accepted that deep venous thrombosis (DVT) of the iliac, femoral, and popliteal veins can lead to the post-thrombotic (postphlebitic) syndrome, the significance of isolated calf DVT on the development of late venous sequelae and physiologic calf dysfunction is unknown. The purpose of this study was to review the outcome of 58 limbs with isolated calf DVT and report the clinical, physiologic, and imaging results up to 6 years after the onset of DVT. METHODS The study consisted of 58 limbs of 54 patients in whom isolated calf vein DVT was diagnosed between 1990 and 1995. Proximal propagation of clot, lysis of thrombi, and development of symptomatic pulmonary emboli were examined. Of the patients, 28 received anticoagulation therapy, and 26 did not, but they had follow-up with serial duplex scans. At late follow-up 1 to 6 years later (median, 3 years), 23 patients were examined for the post-thrombotic syndrome, and all 23 underwent clinical examination, color-flow duplex scanning, and air plethysmography. RESULTS Proximal propagation of DVT from the calf veins into the popliteal or thigh veins occurred in 2 of 49 cases (4%) within 2 weeks of diagnosis. No patient had clinically overt pulmonary emboli develop regardless of whether anticoagulation therapy was received or not. The most common site for calf DVT was the peroneal vein (71%). Complete lysis of calf thrombi was found in 88% of the cases by 3 months. At 3 years, 95% of the patients were either asymptomatic or mildly symptomatic, and 5% had discoloration of the limb. No ulcers occurred. By air plethysmography, physiologic abnormalities were found in 27% of the cases, which was not significantly different from normal controls. Valvular reflux by duplex scanning of the calf vein segment with DVT was found in 2 of 23 cases (9%). However, reflux in at least one venous segment not involved with DVT was found in 7 of 23 cases (30%), which was higher than, but not statistically different from, normal controls, with reflux occurring in 5 of 26 cases (19%). CONCLUSIONS Isolated calf vein DVT leads to few early complications (ie, clot propagation, pulmonary emboli) and few adverse sequelae at 3 years. The peroneal vein is most commonly involved and should be a part of the routine screening for DVT. Lysis of clot usually occurs by 3 months. Although valvular reflux rarely is found in the affected calf vein at 3 years, reflux may be found in adjacent uninvolved veins in approximately 30% of the cases. The question of whether this will lead to future sequelae, such as ulceration, will require longer follow-up.

The controversy of managing calf vein thrombosis

BACKGROUND Controversy persists as to whether all calf vein thrombi should be treated with anticoagulation or observed with duplex surveillance. We performed a systematic review of the literature to assess whether data could support either approach, followed by examination of its natural history by stratifying results according to early clot propagation, pulmonary emboli (PE), recurrence, and postthrombotic syndrome (PTS). METHODS A total of 1513 articles were reviewed that were published from January 1975 to August 2010 using computerized database searches of PubMed, Cochrane Controlled Trials Register, and extensive cross-references. English-language studies specifically examining calf deep vein thrombosis (C-DVT) defined as axial and/or muscular veins of the calf, not involving the popliteal vein, were included. Papers were independently reviewed by two investigators (E.M., F.L.) and quality graded based on nine methodologic standards reporting on four outcome parameters. RESULTS Of the 1513 citations reviewed, 31 relevant papers meeting predefined criteria were found: six randomized controlled trials (RCT) and 25 observational cohort studies or case series. There was a single RCT directly comparing anticoagulation with no anticoagulation with compression and duplex surveillance, and they found no difference in propagation, PE, or bleeding in a low-risk population. Based on two studies of moderately strong methodology, C-DVT propagation was reduced with anticoagulation. When treatment was unassigned, moderately strong evidence suggested that about 15% propagate to the popliteal vein or higher. However, based on nonrandomized data but with moderate to high quality (level A and B studies), propagation to popliteal or higher was 8% in those with no anticoagulation treated with surveillance only. Propagation involving adjacent calf veins but remaining in the calf occured in up to one-half of all those who propagate. Major bleeding was an intended endpoint in three RCTs and was reported as 0% to 6%, with a trend toward lower bleeding risk in more recent studies. PE during surveillance in studies with unassigned treatment was strikingly lower than the historical reports of PE recorded at presentation, emphasizing the distinction that must be made between the two entities. Recurrence in C-DVT is lower than thigh DVT, and data suggest that in low-risk groups with transient risk factors, 6 weeks of anticoagulation may be sufficient, as opposed to 12 weeks. Studies of PTS reported that patients with C-DVT had fewer symptoms than their thigh DVT counterparts. Approximately one out of 10 showed symptoms of CEAP Class 4 to 6; however, C5 or C6 with healed or active ulceration were not commonly encountered. CONCLUSIONS No study of strong methodology could be found to resolve the controversy of optimal treatment of C-DVT. Given the risks of propagation, PE, and recurrence, the option of doing nothing should be considered unacceptable. In the absence of strong evidence to support anticoagulation over imaging surveillance with selective anticoagulation, either method of managing calf DVT must remain as current acceptable standards.

Prospective comparison of duplex scanning anddescending venography in the assessment of venous insufficiency

A prospective study comparing duplex scanning and descending venography was applied to 143 venous segments in 25 extremities with moderate to severe manifestations of chronic venous insufficiency (class 2 or 3). Duplex scanning was performed with the patient in the 15 degree reverse Trendelenburg position, and descending venography with the patient in the 60 degrees semi-erect position; the Valsalva maneuver was used to elicit reflux in both tests. The duplex parameter of reflux duration greater than 0.5 second correlated with venographic reflux in 94 of 105 segments (sensitivity of 90%). Conversely, reflux time less than or equal to 0.5 second correlated with venographic competence in 32 of 38 segments (specificity of 84%). A total of 17 discrepancies were identified among the 143 total segments studied, for an accuracy of 88%. The largest proportion of discrepancies was identified in the group with venographic competence and reflux duration greater than 0.5 second and less than or equal to 2.0 seconds; this was designated a gray zone. Mean peak velocities were significantly higher in the reflux group when compared with the competence group in the profunda femoris vein (p = 0.047), greater saphenous vein (p less than 0.001), popliteal vein (p less than 0.001), and tibial vein (p = 0.005). We conclude that venographic reflux correlates best with duplex scan findings of reflux duration greater than 0.5 second. Duration of reflux greater than 0.5 second and less than or equal to 2.0 seconds, however, represents a gray zone and should be interpreted with caution since this could lead to over-reading of reflux disease, in which case verification of incompetence by descending venography may be indicated.

Risk factors for venous thromboembolism following prolonged air travel. Coach class thrombosis.

Venous thromboembolism (VTE) in legs and lungs is a potentially life-threatening condition. The incidence of VTE associated with air travel is still unknown, but it may have increased. Most travelers who develop symptoms do so within 24 hours after their flight takes off. Predisposing risk factors may be divided into patient-related and cabin-related factors, both of which are described. It is emphasized that better information and better inflight precautions can minimize these risk factors.

Deep venous valve reconstruction

The place of deep venous valve reconstruction in the surgical management of the patient with chronic venous insufficiency has become clearer with collected experience over the past 25 years. The reasons to perform surgery in chronic venous disease and the specific rationale for deep venous repair are contrasted with the management of the same patient by medical means. A new classification of chronic venous disease has been developed and provides the basis for a more objective understanding of specific entities in the entire field of chronic venous symptoms. The requirements for diagnosis before reconstructive surgery are stringent and a diagnostic algorithm is discussed in the selection of candidates for deep venous reconstruction. The multiple surgical techniques for deep venous reconstruction include internal intravenous direct valve repair and extravenous tightening of the vein wall around the valve cusp. The results of valve repair for primary valve incompetence are discussed in terms of long-term clinical results, long-term imaging results and long-term physiologic results as reflected by venous pressure examinations. It is becoming increasingly clear with the passage of time and the sharpening of our diagnostic skills that reflux is the dominant cause of chronic venous insufficiency. The ability of surgical procedures to decrease reflux in a diseased extremity can be used to restore patients to their normal way of life free of pain, swelling and ulceration and, in the ideal case, free of the need for elastic support.

Reflux from Thigh to Calf, the Major Pathology in Chronic Venous Ulcer Disease: Surgery Indicated in the Majority of Patients

The aim of this study was to define the underlying anatomical and pathophysiological conditions in limbs with venous ulcers in order to get information for the most appropriate treatment selection. Ninety-eight limbs (83 patients, 59 men), with active chronic venous ulcers, were analyzed retrospectively and classified according to the CEAP (clinical, etiological, anatomical, and pathophysiological) classification. Duplex-ultrasound was performed in all patients, while air-plethysmography and venography were performed selectively on potential candidates for deep venous reconstruction. Sixty-six ulcers were primary in origin and 32 were secondary. Reflux was present in all limbs except 1. Isolated reflux in 1 system (superficial = 3, deep = 4, perforator = 3) was seen in 10 legs (10%), while incompetence in all 3 systems was seen in 51 legs (52%). Superficial reflux with or without involvement of other systems was seen in 84 legs (86%), 72 legs (73%) had deep reflux with or without involvement of other systems, and incompetent perforator veins were identified in 79 limbs (81%). Axial reflux (continuous reverse flow from the groin region to below knee) was found in 77 limbs (79%). The femoral vein was the single most common deep venous segment in which either reflux or obstruction was found. Axial distribution of disease was found in the majority of cases and no patient had isolated deep venous incompetence below knee. Primary disease was the predominant etiologic cause and reflux was the main pathophysiological finding. Practically all patients were found to have 1 or more sites of reflux or obstruction that could benefit from operative treatment.

Long-term effects of superficial femoral vein ligation: Thirteen-year follow-up

This study examines the late clinical, hemodynamic, and anatomic results of superficial femoral vein ligation performed in 35 extremities that were followed an average of 13 1/2 years (range, 5 to 22 years). Indications for interruption were to prevent recurrent embolization from distal deep venous thrombosis (14 cases), to prevent emboli in patients with contraindication to anticoagulants (eight cases), to prevent distal reflux in selected patients undergoing iliofemoral thrombectomy (11 cases), and to control reflux in failed venous reconstruction (two cases). Ligation was effective in the prevention of pulmonary emboli as indicated by no significant clinical events and 15 negative postligation ventilation-perfusion scans. Long-term clinical follow-up showed normal (class 0) or near-normal (class 1) extremities in 83%. Fourteen percent developed mild to moderate symptoms of pain or swelling but without ulceration (class 2), and only one case (3%) had ulcerative sequelae (class 3). The only two findings that correlated with worse clinical outcome were the presence of an incompetent profunda femoris or an obstructed greater saphenous vein. Profunda femoris reflux was found in 60% (3/5) of patients with class 2 or 3 sequelae, which was significantly higher than the 14% (3/22) found in those patients with class 0 or 1 results (p < 0.05). Obstruction of the greater saphenous vein was found in 50% of those patients with class 2 or 3 results as opposed to 9% with class 0 or 1 results (p = 0.05). A large collateral vessel between the profunda femoris and the distal superficial femoral or popliteal vein was associated with poor long-term results.(ABSTRACT TRUNCATED AT 250 WORDS)

The Case for Managing Calf Vein Thrombi With Duplex Surveillance and Selective Anticoagulation

ntroduction ince Kakkar and colleagues reported their findings on the natural istory of calf vein thrombosis in 1969, the decision as to whether to nticoagulate all calf vein thrombi has remained controversial. In this rticle, a case is made for duplex scan surveillance and selective nticoagulation for those who propagate to the popliteal vein or higher. his argument is based on reports that the risk of clinical pulmonary mboli (PE) during surveillance is low; that serious PE is highly mprobable if patients are closely monitored; and that most calf deep vein hrombi (DVT) remain confined to the calf during surveillance and either propagate nor embolize. Close surveillance is mandatory and hould not be misinterpreted as “no treatment.” Duplex surveillance ffers a safe and practical alternative to anticoagulation in especially ow-risk patients and in cases where anticoagulation may be contraindiated.

Risk Factors for Venous Thromboembolism Following Prolonged Air Travel: A “Prospective” Study

The aim of this study was to analyze patients with air-travel-related venous leg thromboembolism (VTE) concerning the occurrence of patient-related and cabin-related risk factors. Twenty-five patients, still in hospital, with deep-vein thrombosis (DVT) and/or pulmonary embolism (PE) with onset of symptoms during or after air travel were questioned according to a study protocol. There were 14 women and 11 men with an age range of 36-79 years. Flight times were 5-18 hours. All patients had DVT, and nine (36%) had PE as well. The proximal extensions of the thrombus were in tibial vein, five patients; popliteal vein, two patients; superficial femoral vein, three patients; common femoral vein, four patients; greater saphenous vein, four patients; and iliac vein, seven patients. All but two patients (92%) had one or more patient-related risk factors; the mean was three. Overweight was present in 76% of the patients; chronic heart disease in 44%; hormone medication in 40%; chronic disease, except chronic heart disease and malignancy in 32%; history of previous VTE in 28%; malignancy in 28%; smoking in 20%; recent lower limb injury in 16%; and recent surgery in 12%. Only two patients had no known patient-related risk factor. The flight travel itself does not seem to be an important risk factor in healthy individuals. However, when patient-related risk factors are superimposed, there is increasing evidence that cabin-related risk factors, such as immobilization, cramped “coach” position, insufficient fluid intake, low humidity, and hypoxia contribute to development of VTE. Improved information is required so that passengers can prepare their travel in good time. Active precautions are recommended.