Classification of Venous Disease
Since always the field of CVD has suffered from a lack of diagnostic precision which led to conflicting findings in studies of specific venous pathologies. These differences would probably not arise if the disorders of each limb were diagnosed and classified precisely before treatment started. Clearly, a single, universally acknowledged classification. system would make for clearer communication on CVI and permit more scientific, exact analysis of the therapeutic alternatives.
In February 1994, at a meeting organized by the Straub Foundation in Maui , Hawaii , USA , the American Venous Forum set up an international committee with the precise task of looking into this possibility. Chaired by Andrew Nicolaides, the committee drafted a Consensus Document for the classification and staging of CVI. Known as the CEAP classification, it was based on clinical manifestations (C), etiological factors (E), anato- mical distribution (A), and pathophysiological conditions (P). Its aim was to provide a full, objective classification, for use throughout the world. The CEAP classification was published in 25 journals, in eight languages, and today it is used in most publications in phlebology (Table I).
Heading 2 - Section Headings
The original drafters subsequently decided the classification needed extending and modifying in the light of recent findings. In 2000 2 revisions of the CEAP classification appeared. One came from an American Venous Forum committee, presenting a new method for assessing venous disease according to severity and the other was from an international Consensus Conference in Paris that proposed a new classification for varices recurring after surgery. The French group set up a European Phlebological Data Bank, starting with complete information on 872 patients supplied by 49 angiologists from 9 European countries. Statistical analysis showed that the external consistency of the clinical classification, "C", was good but its internal consistency less SO.36 The European group also studied the reproducibility of the C classes and found good intra-observer reproducibility - 85% - but the inter-observer figure was lower - 47%. This led to a consensus conference on the redefinition of the C in CEAP, during the 14th World Congress of the Union International de Phlebologie, held in Rome on 8-14 September 2001. This working group assessed the original CEAP definitions, and after much consideration decided that a better, extended definition was needed.
New CEAP classification
The table II explains how some clinical terms are used in the CEAP definitions.These must be employed correctly to ensure uniformity in "phlebological" language.(Table II). According to the new revision of CEAP classification proposed by Ad Hoc Committee of American Venous Forum,41 the clinical class 4, defined as "changes in the skin and subcutaneous tissue secondary to CVI", is now divided into 2 subclasses to better define the differing severity of venous disease: - C4a comprises pigmentation and/or eczema, - C4b lipodermatosclerosis and white atrophy. TABLE 1. - CEAP Classiflcation. Clinical classification CO - C6 CO no visible or palpable signs of venous disease Cl teleangectasia or reticular veins C2 varicose veins C3 edema C4a skin changes due to venous disorders: pigmentation, eczema, C4b skin changes due to venous disorders: dermatosclerosis, white atrophy C5 as C4 but with healed ulcers C6 skin changes with active ulcers a - asymptomatic; s - symptomatic Etiologic classification (Ec, Ep, Es, En) Ec, congenital (from birth) Ep, primary (cause not identifiable) Es, secondary (post-thrombotic, post-traumatic, etc.) En, no venous cause identified Pathophysiologic classification (PI; PO , Pr+o, Pn) Pr, reflux Po , obstruction Pr+o, both Pn, no venous pathophysiology identifiable Anatomic classification As, involving the superficial venous system Ad, involving the deep system Ap, involving perforator veins An, no venous location identified Superficial venous system: As 1. teleangectasias, reticular veins, great saphenous vein 2. above the knee 3. below the knee 4. small saphenous vein 5. non saphenous districts Deep venous system, Ad 6. inferior vena cava iliac vein: 7. common 8. internal 9. external 10. pelvic veins: genital, large ligament, others femoral vein 11. common 12. deep 13. superficial 14. popliteal vein 15. veins of the leg: posterior tibial, anterior tibial, peroneal 16. muscular veins: gastrocnemius, soleal, others Perforating veins: Ap 17. in the thigh 18. in the leg Definition of clinical items. Telangiectasia A confluence of permanently dilated intradermal venules of less than 1 mm in caliber. Explanations: these would normally be visible from a distance of 2 meters under good lighting conditions. Synonyms: spider veins, hyphen webs, thread veins.
Reticular veins
Permanently dilated bluish intradermal veins usually from 1 mm in diameter and less than 3 mm in diameter. Explanations: they are usually tortuous. This excludes "normal" visible veins in people with transparent skin. Synonyms: blue veins, intra-dermal varices, venulectasies.
Varicose veins
Subcutaneous permanently dilated veins equal to or more than 3 mm in diameter, in the upright position. Explanations: varicose veins are usually tortuous but refluxing tubular veins may be classified as varicose veins. These may be truncal varicose veins, tributaries, or non saphenous. Synonyms: varix, varices, varicositises.
Corona phlebectasica
Fan shaped intradermal telangiectasias on the medial and or lateral aspects of the foot. The place of corona in "c" is controversial and requires more consideration. Sometimes it could be the starting sign of advanced venous disease. Explanations: this may occur in limbs with simple telangiectasias elsewhere in the limb. Synonyms: malleolar flare, ankle flare.
Oedema
Perceptible increase in volume of fluid in subcutaneous tissue characterized by indentation under pressure. Explanations: this definition includes only oedema attributable to venous disease. Venous oedema usually starts on the forfoot and in the ankle region, then will extend to the entire leg.
Pigmentation
Brownish pigmentary darkening of the skin usually occurs in the ankle region, but may extend to leg and foot. Explanations: this is an early skin change. Eczema Erythematous, blistering, weeping or scaling eruption of the skin of the leg. Explanations: it is often located near varicose veins, but may be located anywhere in the leg. Sometime may spread to the entire body. Eczema is usually due to chronic venous disease, and/or to sensitization to local therapy. Synonyms: stasis dermatitis. Lipodennatosclerosis Localized chronic induration of the skin sometimes associated with scarring and/or contracture. Explanation: this is a sign of severe venous disease, characterized by fibrosis and chronic inflammation of the skin, subcutaneous tissues, and sometimes the fascia.
Hypodennitis
An acute form of lipodermatosclerosis is referred to as hypodermitis. This is characterized by diffuse reddening of the skin due to acute inflammation and by tenderness. Explanation: the absence of lymphadenitis and fever differentiates this condition from erysipelas or cellulitis.
Atrophie blanche or white atrophy
Circumscribed, often circular whitish and atrophic skin areas surrounded by dilated capillary spots and sometimes hyperpigmentation. Explanation: this is a sign of severe venous disease. Scars of healed ulceration are excluded in this definition.
Venous ulcer
Chronic defect of skin which fails to heal spontaneously, caused by chronic venous disease. The aim is to define more precisely the severity of the trophic changes, bearing in mind that the signs of class C4b are predictive of progression too ulcer.Each clinical class is further characterized by a subscript for the presence of symptoms (S, symptomatic) or absence of symptoms (A, asymptomatic), e.g. C2A, or CSS. To improve the assignment of designations under the E, A, and P a new descriptor n is now recommended for use where no venous abnormality is identified. This n could be added to E (En: no venous etiology identified), A (An: no venous location identified) and P (Pn: no venous pathophysiology identified). It is therefore recommend that any CEAP classification be followed by the date, e.g. C4b, S, Ep, As, p, Pr (2004-08-19).