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Chronic Venous Insufficiency: Clinical

Assessment and Patient Selection


Shyam Krishnan, M.D., F.A.C.S.,1 and Stephen C. Nicholls, M.D.1

ABSTRACT

Chronic venous insufficiency is a complex condition, with widely varied clinical


manifestations, etiologies, and underlying pathophysiology. An orderly workup is man-
datory to assess the nature of a patients underlying venous disease. This begins in the office
setting with a careful medical history, physical examination, and bedside diagnostic tests.
These are augmented by confirmatory diagnostic testing, including duplex ultrasonogra-
phy, venography, plethysmography, and ambulatory venous pressure measurement. Based
upon the results of these examinations, the patients venous disease can be classified
according to standardized classification schemes, which in turn leads to the selection of an
appropriate treatment strategy. This article outlines the steps in the clinical assessment and
classification of patients with chronic venous insufficiency.

KEYWORDS: Chronic venous insufficiency, diagnosis, patient classification, duplex


scanning, venous severity scoring

Objectives: Upon completion of this article, the reader should be able to (1) understand the proper steps in the clinical assessment of
patients with chronic venous insufficiency, including history, physical examination, bedside diagnostic tests, additional outpatient
diagnostic tests, and appropriate patient classification; and (2) utilize the patient classification system to select appropriate patients for
intervention.
Accreditation: Tufts University School of Medicine (TUSM) is accredited by the Accreditation Council for Continuing Medical Education
to provide continuing medical education for physicians.
Credit: TUSM designates this educational activity for a maximum of 1 Category 1 credit toward the AMA Physicians Recognition Award.
Each physician should claim only those credits that he/she actually spent in the activity.

H istorically, the condition known as chronic tions. An orderly and objective diagnostic workup is
venous insufficiency has suffered from a lack of detailed, mandatory. The following steps in diagnosis and clinical
objective investigation into its pathophysiology and assessment of the patient with chronic venous disease
treatment. With current technology, however, specific have been proposed1:
investigations can clearly delineate the cause of chronic
venous insufficiency in a particular patient and help 1. Determine the nature of the problem.
guide the clinician to appropriate therapeutic interven- 2. Determine the severity of the problem.

Venous Insufficiency; Editors in Chief, Brian Funaki, M.D., Peter R. Mueller, M.D.; Guest Editor, R. Torrance Andrews, M.D. Seminars in
Interventional Radiology, volume 22, number 3, 2005. Address for correspondence and reprint requests: Shyam Krishnan, M.D., F.A.C.S., Division
of Vascular Surgery, Department of Surgery, University of Washington Medical School, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195-
6410. 1Division of Vascular Surgery, Department of Surgery, University of Washington Medical School, Seattle, Washington. Copyright # 2005
by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. 0739-9529,p;2005,22,03,169,177,
ftx,en;sir00321x.
169
170 SEMINARS IN INTERVENTIONAL RADIOLOGY/VOLUME 22, NUMBER 3 2005

3. Perform diagnostic testing. trunk and spider veins should be noted. The limb is also
4. Determine CEAP classification. inspected for the presence or absence of edema and
5. Weigh treatment alternatives. angiomatous malformations. Large varicosities over
known sites of perforating veins should be identified.
Palpation of the limbs may detect additional varicosities
INITIAL CLINIC EVALUATION that are not readily apparent by inspection. This is
especially true of the terminal segments of the greater
History saphenous vein (GSV) and lesser saphenous vein (LSV)
Initial evaluation begins in the office setting with a where they join the femoral and popliteal veins, respec-
thorough history and physical examination. Typical tively. Careful palpation of the inner thigh and leg as
symptoms of venous insufficiency include aching, pain, well as the posterior calf may detect saphenous trunk
tightness, skin irritation, pruritus, heaviness, tingling, varicosities that may be missed by visual inspection
muscle cramps, and cosmetically unsatisfying varicose alone. Palpation of the legs should also be performed
veins.2 Symptoms often worsen during the course of to detect temperature differences between the legs, areas
the day and with prolonged standing. Patients with of induration, and the presence of firm subcutaneous
more severe insufficiency can present with complaints cords, which may be the sequelae of prior episodes of
of edema, skin changes, or ulceration.3 Several clinical superficial thrombophlebitis.
entities can mimic the symptoms of chronic venous Several tests can be performed in the outpatient
insufficiency, including osteoarthritis, sciatica, osteo- setting during the initial evaluation that often give clues
myelitis, tendonitis, ligamentous injuries, arthritis, pe- to the source of venous hypertension. The cough impulse
ripheral neuropathy, and arterial insufficiency. Specific test is performed by palpating the thigh at the fossa
features of the pain that should be noted include the ovalis over the saphenofemoral junction (SFJ) while the
degree to which the pain interferes with the patients patient is standing. The patient is asked to cough, and a
occupation or lifestyle as well as the amount of time that palpable thrill at the SFJ, which is a result of turbulent
the patient can stand before the onset of pain or swelling. retrograde flow, indicates reflux at the SFJ. The cough
The age of onset of varicose veins should be recorded, as impulse test is difficult to perform in obese patients or in
an early onset may suggest a congenital abnormality such patients who jerk or cough vigorously. The tap test, or
as Klippel-Trenaunay syndrome.4 A family history of percussion test, is also performed while palpating the SFJ
varicose veins is present in over one third of patients.4 It of a standing patient. The GSV is tapped at the level of
is crucial to note whether there has been a personal the knee. A palpable transmitted impulse at the SFJ
history of deep vein thrombosis or pulmonary embolism. suggests that the GSV is distended with blood. The SFJ
Some patients may not be able to provide this informa- is then tapped while the GSV is palpated at the knee.
tion directly, and it may be elicited only by asking A palpable transmitted pulse at the knee with this
specific questions regarding a history of leg swelling, maneuver indicates incompetence of GSV valves be-
previous operations, lower extremity injuries, prolonged tween the SFJ and the knee.5 These clinical tests are
bed rest, chest pain, hemoptysis, or anticoagulant use. largely of historical interest in the modern era and have
Finally, a careful history of past treatments for varicose been supplanted by more sophisticated diagnostic imag-
veins, including operative and percutaneous procedures, ing tests. When compared with Doppler ultrasonogra-
should be recorded. phy, clinical tests (cough impulse test and percussion
test, combined with palpation) were falsely negative in
28% of incompetent SFJs and 36% of incompetent
Physical Examination saphenopopliteal junctions (SPJs).6
Physical examination of the patient should include a The Brodie-Trendelenburg test is used to detect
general examination in addition to a detailed examina- venous incompetence and to differentiate between per-
tion of the lower extremities. The patient should be forator and GSV incompetence. The test is performed by
examined in the standing position and suitably un- initially draining the superficial lower extremity veins
dressed to permit complete examination of the entire by elevating the lower limbs to 45 degrees and gently
extremity from the groins to the toes. The examination stroking the limb from the foot along the course of the
should be performed in a warm and well-lit room that major veins. A tourniquet is then placed as close to the
respects the privacy of the patient.4 groin as possible and applied tightly enough to prevent
The examination begins with careful inspection superficial vein reflux. The patient is asked to stand and
and palpation of the legs. The location and distribution the limb is examined. If the distal veins remain collapsed
of all major subcutaneous varicosities should be noted for 15 to 30 seconds after standing, the tourniquet is
and recorded in the chart; this is facilitated by outline released. SFJ incompetence is diagnosed if the distal
drawings of each limb that show both anterior and veins fill rapidly upon release of the tourniquet. If the
posterior surfaces. Varicosities of the main saphenous caudal veins fill rapidly when the patient stands with the
CHRONIC VENOUS INSUFFICIENCY/KRISHNAN, NICHOLLS 171

tourniquet in place, perforator incompetence is sug- postphlebographic syndrome, characterized by pain,


gested. The location of the incompetent perforator can tenderness, and erythema around the ankle joint not
then be determined by varying the position of the associated with thrombosis. There are other limitations
tourniquet. Rapid filling of the varices with a tourniquet of venography besides potential technical complications.
in the suprapatellar position can identify an incompetent Competent valves in the upper leg can obscure valvular
midthigh perforator, and rapid filling with the tourni- reflux in the lower leg, and pressurized contrast injection
quet below the knee suggests incompetent lower leg can create false-positive results. Finally, the venograph-
perforators. In the case of combined SFJ incompetence ically observed severity of reflux does not necessarily
and perforator incompetence, direct palpation of the correlate with the clinical severity of the disease. Contra-
varix during tourniquet release may detect an increase indications to venography are few and include known
in venous distention.4 The Brodie-Trendelenburg test contrast allergy and local infection.
is highly sensitive for the identification of superficial Ascending venography is typically performed to
and perforator reflux (91%), although poorly specific determine the degree of patency of the deep venous
(15%).5 system and to identify the presence of incompetent
The Perthes test is performed with the patient in perforators.9 It is performed with the patient in reverse
the standing position with a tourniquet positioned below Trendelenburg position with the limb to be examined in
the knee. The patient is asked to activate the calf muscle a relaxed nonweight-bearing position. A superficial
pump by performing 10 heel raises. Emptying of the vein on the lateral aspect of the dorsum of the foot is
varicose veins signifies a site of reflux cranial to the selected and cannulated with a 21-gauge butterfly needle
tourniquet, namely the SFJ, SPJ, or thigh perforators. directed caudally. A tourniquet is inflated above the
Persistence of distended varicose veins signifies a site of ankle or the knee to improve deep venous filling (as
reflux caudal to the tourniquet, that is, calf perforators. opposed to filling of the saphenous veins) and assess
Pain associated with heel raising suggests the possibility for perforator incompetence. Then 50 to 100 cm3 of
of deep venous obstruction. As with the Trendelenburg nonionic contrast material is slowly injected by hand and
test, the Perthes test is highly sensitive but poorly the calf veins are examined under fluoroscopy. The
specific. injection site should be visualized intermittently to
Perhaps the most commonly performed maneuver ensure that there is no extravasation of contrast or
in the office setting is hand-held continuous -wave immediately if there is any local swelling or pain. If
Doppler ultrasound examination of the saphenous vein. contrast extravasation occurs, the injection should be
With the patient in the standing position, the SFJ is immediately terminated and the extravasated contrast
insonated while an assistant performs compression of the dispersed by means of saline dilution, massage, and/or
caudal calf. GSV incompetence can be demonstrated by warm compresses. After examination of the calf veins,
eliciting reflux with the release of calf compression. the popliteal, femoral, and iliac veins are sequentially
Similar interrogation of the SPJ can be performed to imaged. Opacification of the more cranial veins can be
detect LSV incompetence. Doppler examination of enhanced by raising the calf, having the patient lie
the SFJ to diagnose incompetence has a sensitivity supine, and releasing the tourniquet. Distorted veins
and specificity of 97% and 73%, respectively, when and valve cusps, excessive collaterals (especially around
compared with duplex ultrasonography as the gold the thigh, knee, and iliofemoral region), and intralumi-
standard.5 nal filling defects are pathognomonic for post-throm-
botic disease, and their absence suggests primary valvular
incompetence.8
ADDITIONAL DIAGNOSTIC STUDIES Descending venography is used to document the
presence and extent of reflux, to define valvular anatomy,
Venography and to identify specific incompetent valves. It is also
The historical gold standard for the diagnosis of venous performed with the patient in reverse Trendelenburg
insufficiency, in terms of both anatomic localization and position and with the limb to be examined in a relaxed
hemodynamic quantification, has been venography. nonweight-bearing position. A catheter is positioned
Although there are still situations in which venography in the common femoral vein, either by direct puncture or
is necessary for planning treatment, it has several draw- by advancement from an arm or the contralateral femoral
backs that have reduced its once widespread use. Venog- vein. A slow hand injection of contrast material is
raphy is an invasive procedure and carries with it performed under fluoroscopy and the patient is in-
attendant risks. Extravasation of contrast material into structed to breathe normally. If reflux is identified,
the foot can cause a chemical cellulitis and, rarely, this individual incompetent valves in the common femoral
can progress to tissue necrosis, ulceration, or gangrene.7 vein, profunda femoris vein, superficial femoral vein, and
Other complications include postphlebographic throm- GSV are noted. Contrast injection is then repeated while
bosis (reported in up to 13% of patients8) and the the patient is instructed to perform a sustained Valsalva
172 SEMINARS IN INTERVENTIONAL RADIOLOGY/VOLUME 22, NUMBER 3 2005

maneuver. This increases resistance to prograde flow and Plethysmography


causes valve closure. Incompetent valves are noted to Air plethysmography is a noninvasive test that can
allow leakage and retrograde flow of contrast material. quantify venous insufficiency and is reported to correlate
Individual valve function can be classified as normal (no with AVP measurements.13 It is performed with a
leakage despite Valsalva), minimal abnormality (wisp of 35-cm-long polyvinyl chloride air chamber that sur-
contrast reflux with Valsalva), moderate abnormality rounds the lower leg and is connected to a pressure
(contrast reflux with Valsalva), and severe abnormality transducer and chart recorder. The pressure transducer
(contrast material pours through valve).10 In addition to is calibrated with 100 mL of air. A baseline reading is
valve function, the caudal extent of reflux through obtained with the patient supine and with the leg
incompetent valves should be noted. elevated to 45 degrees to empty the veins. The patient
is then asked to stand upright with weight supported on
the opposite leg until the veins are full. This change in
Ambulatory Venous Pressure Measurement volume represents the functional venous volume, and the
Along with venography, ambulatory venous pressure venous filling index (VFI) is calculated by dividing 90%
(AVP) measurement was a historical gold standard of the venous volume by the time required for filling to
for the diagnosis of chronic venous insufficiency. It 90% of the venous volume. The patient is then asked to
is performed by introducing into a dorsal foot vein a perform a heel-raise maneuver and the volume displaced
21-gauge needle, which is then connected to a pressure by this maneuver is recorded as the ejection volume.
transducer. Baseline measurement is obtained with the The ejection fraction (EF) is calculated by dividing the
patient relaxed and bearing weight on the contralateral ejection volume by the venous volume. Finally, 10 heel-
limb. In this position, venous pressure approximates the raise maneuvers are performed to reach a residual volume
hydrostatic pressure exerted by the column of blood plateau. The residual volume fraction (RVF) is calcu-
extending from the right atrium to the foot.8 The patient lated by dividing the residual volume by the venous
is then asked to perform 10 tiptoe movements at the volume. The VFI is an index of global venous reflux,
rate of one per second. The AVP is then measured as the EF is a reflection of calf muscle pump function, and
the lowest pressure achieved at the end of exercise. The the RVF is a reflection of AVP.
recovery time is defined as the time required for The limitations of air plethysmography are that it
the pressure to rise to 90% of the baseline value after is imprecise in the localization of segmental reflux and
the cessation of exercise. A modification of this techni- the RVF correlates only loosely with disease severity. A
que involves manual calf compression instead of tiptoe VFI of 2.67 mL/s has been proposed as a cutoff point
movements. This modification has been shown to between normal limbs and limbs with chronic venous
produce identical results while avoiding the potential insufficiency, with a positive predictive value of 96%.14
difficulties of the patients cooperation and reactive
hyperemia.11
In healthy limbs, calf muscle contraction forces Duplex Scanning
blood up the leg and competent valves prevent retro- Duplex ultrasonography is arguably the most useful
grade flow.8 During AVP measurement, the venous initial diagnostic evaluation in the workup of chronic
blood pressure falls rapidly (typically to less than venous disease. Its advantages include that it is non-
30 mm Hg) and recovery, which is through capillary invasive, can be repeated as often as necessary, gives
inflow, is slow (typically more than 20 seconds). In limbs reproducible results, and allows anatomic, physiologic,
with incompetent valves, reflux occurs between contrac- and hemodynamic evaluation of the venous system. The
tions and the measured pressure remains proportionately study is performed with both B-mode imaging and
high while recovery, which occurs by rapid filling spectral Doppler analysis. It can identify the underlying
through incompetent valves, is fast. In limbs with deep pathophysiology (reflux, obstruction, or both) and local-
venous obstruction, the AVP may rise during exercise ize the disease to specific venous segments (deep system,
and produce a bursting pain related to calf vein con- superficial system, perforators). A 5- to 7.5-MHz linear
gestion (akin to a positive Perthes test). AVP has been transducer is used to evaluate the limb below the inguinal
correlated with the clinical severity of disease. The ligament, and a 2- to 3.5-MHz phased array transducer
incidence of ulceration increases in a linear fashion is used to evaluate the iliac system and the inferior vena
with an increase in the AVP, and ulceration never occurs cava.
at AVP less than 30 mm Hg and always occurs at AVP Duplex examination of the veins must be system-
greater than 90 mm Hg.12 atic and orderly. The deep venous system is evaluated
Like venography, AVP measurement is an inva- first, with the patient in the supine position with the hip
sive procedure that is not ideally suitable for screening or externally rotated and the knee flexed. The linear trans-
for repeated examinations to monitor the results of ducer is initially placed longitudinally just below the
therapy. inguinal ligament to visualize the common femoral vein
CHRONIC VENOUS INSUFFICIENCY/KRISHNAN, NICHOLLS 173

Figure 1 Venous reflux induced in greater saphenous vein with the Valsalva maneuver. Patient is in the standing position.

and the confluence of the superficial and deep femoral augmentation with foot compression may be required to
veins. Proper imaging of the popliteal vein is best document patency in the crural veins. After assessing
performed in the prone position with the calf supported patency, venous valvular competence is evaluated with a
on pillows, although a lateral approach can suffice if the Valsalva maneuver for upper thigh segments (Fig. 1) and
patient is unable to lie prone. Patency of the deep veins is limb compression for lower limb segments (Fig. 2).
evaluated both by assessing compressibility by the trans- Normal valve closure time is less than 2 seconds when
ducer during B-mode imaging and by evaluating flow the patient is in the supine position. For patients in mild
patterns. Venous flow patterns in patent deep veins are reverse Trendelenburg position, valve closure time of
spontaneous and phasic with respiration, although flow greater than 0.5 seconds has a sensitivity of 90% and

Figure 2 Augmented cephalad flow produced in the greater saphenous vein with calf compression followed by spontaneous reflux.
Patient is in the standing position.
174 SEMINARS IN INTERVENTIONAL RADIOLOGY/VOLUME 22, NUMBER 3 2005

specificity of 84% for diagnosing valve incompetence Table 1 CEAP Classification


when compared with descending venography.15 An C Class: Clinical Manifestation
alternative to the Valsalva maneuver for assessing valve C0: No visible or palpable signs of venous disease
competence is the rapid cuff deflation technique, which C1: Telangiectasias or reticular veins
has the benefit of providing a single method for studying C2: Varicose veins, distinguished from reticular veins by
all of the veins of the limb without relying on the a diameter  3 mm
presence of a more cephalad incompetent valve.16 C3: Edema
After evaluation of the deep venous system is C4: Changes in skin and subcutaneous tissue
performed, the superficial system is examined. This C4a: Pigmentation or eczema
portion of the examination is ideally performed with C4b: Lipodermatosclerosis or atrophie blanche
the patient in the standing position while bearing weight C5: Healed venous ulcer
on the contralateral limb. This position produces max- C6: Active venous ulcer
imal venous distention while relaxing the calf pump, Note: Further subdivided with subscript S (symptomatic)
which allows provocative maneuvers to identify incom- or A (asymptomatic)
petent segments. The transducer is angled medially in E Class: Etiologic Factors
the groin to visualize the SFJ. The GSV is examined for Ec: Congenital
patency and competence throughout its length. Vein Ep: Primary
diameter is recorded and major tributaries are followed Es: Secondary (post-thrombotic)
and similarly evaluated for patency and competence. En: No venous cause identified
Reflux is identified and documented with pulse wave A Class: Anatomic Distribution
Doppler imaging during and after an abrupt compres- As: Superficial veins
sion and release of the distal limb. The patient is then Ap: Perforator veins
turned around, and similar investigation of the LSV is Ad: Deep veins
performed. The LSV has a more variable termination in An: No venous location identified
the deep system and significant reflux may exist in the P Class: Pathophysiology
vein of Giacomini.17 Finally, the locations of known Pr: Reflux
perforators should be evaluated for incompetence. Po: Obstruction
Pr,o: Reflux and obstruction
Pn: No venous pathophysiology identifiable
CLASSIFICATION
After obtaining a thorough history, performing a careful
physical examination, and obtaining additional diagnos-
tic imaging studies, a final classification of the patients descriptor is used. Each clinical class is further
chronic venous disease can be made. Traditional classi- subdivided by a subscript for the presence of
fication systems were fairly simplistic and categorized symptoms (S, symptomatic) or absence of symptoms
disease on the basis of etiology. Examples include (A, asymptomatic). The E class consists of four levels
classification of disease as primary (idiopathic) or secon- of etiologic factors, and the A class consists of four levels
dary (post-thrombotic) or as reflux due to greater saphe- of anatomic distribution. The P class consists of four
nous reflux, lesser saphenous reflux, or perforator levels of underlying pathophysiology. In the basic form
incompetence. Other more descriptive systems included of the CEAP, no further subdivision is performed. In the
Widmers classification and Porters classification.18 complete (advanced) form of the CEAP, the underlying
In the early 1990s, advances in the diagnosis pathophysiology is further categorized according to 18
and understanding of the complex pathophysiology of named venous segments (Table 2).
venous disorders led to development of the CEAP In addition to the actual classification, it is rec-
classification system. The first CEAP consensus docu- ommended that the level of investigation that led to the
ment was developed at the sixth annual meeting of the classification be added, according to the following levels:
American Venous Forum in 1994 and was recently
revised,2 including the introduction of a basic CEAP Level I: Office visit with history and physical examina-
version. The CEAP classification (Table 1) consists of tion, with or without hand-held Doppler scanning
four parameters: the clinical manifestation (C), the Level II: Noninvasive vascular laboratory testing, includ-
etiologic factors (E), the anatomic distribution of disease ing duplex color scanning and plethysmography, as
(A), and the underlying pathophysiology (P). indicated
The C class consists of six levels of clinical Level III: Invasive or complex imaging studies, including
manifestations. In the basic form of the CEAP, the ascending and descending venography, venous pres-
single highest applicable descriptor is used, whereas in sure measurements, computed tomography, or mag-
the advanced form of the CEAP, every applicable netic resonance imaging.
CHRONIC VENOUS INSUFFICIENCY/KRISHNAN, NICHOLLS 175

Table 2 Venous Segments in the Complete CEAP gies, and anatomic segments and, as such, has become
P Class the standard system used in most published clinical
Superficial Veins papers on chronic venous disease. Despite this, there
1. Telangiectasias or reticular veins are certainly limitations to the CEAP classification. It is
2. Greater saphenous vein above the knee rather complex and somewhat daunting for the new user
3. Greater saphenous vein below the knee and is difficult to use in everyday routine. This may be
4. Lesser saphenous vein mitigated by the development of software packages to
5. Nonsaphenous vein facilitate classification. Other limitations include the
Deep Veins absence of strict hierarchy between the clinical classes,
6. Inferior vena cava omission from the clinical classification of corona phle-
7. Common iliac vein bectasia (fan-shaped intradermal telangiectasias on the
8. Internal iliac vein medial or lateral aspect of the foot, felt by many to be an
9. External iliac vein early sign of chronic venous insufficiency18), and lack of
10. Pelvic (gonadal veins, broad ligament veins, other) an accounting of the degree of reflux in the physiologic
11. Common femoral vein classification.19
12. Deep femoral vein
13. Femoral vein
14. Popliteal vein VENOUS SEVERITY SCORING
15. Crural (paired peroneal, anterior tibial, posterior tibial veins) Although the CEAP system is an excellent scheme for
16. Muscular (gastrocnemial veins, soleal veins, other) standardized classification of chronic venous disease, it is
Perforating Veins a relatively static system. The C (clinical) class of disease
17. Thigh does represent a spectrum of disease severity, but it does
18. Calf not allow a practical assessment of change in response
to treatment or adverse events. In response to this,
the American Venous Forums Ad Hoc Committee on
The CEAP system has been widely published in Venous Outcomes proposed three different severity
several languages in journals around the world, making it scoring systems to assess objectively an individual pa-
a truly universal document. It is a complete classification tients response to treatment as well as to allow improved
system that accounts for all etiologies, pathophysiolo- outcome assessment.20

Table 3 The Venous Clinical Severity Score

Attribute Absent 0 Mild 1 Moderate 2 Severe 3


Pain None Occasional, not restricting Daily, moderate activity Daily, severe, limiting
activity or requiring limitation, occasional activities or requiring
analgesics analgesics regular analgesic use
Varicose veins None Few, scattered: branch VVs Multiple: GS varicose veins Extensive: thigh and calf, or
confined to calf or thigh GS and LS distribution
Venous edema None Evening ankle edema only Afternoon edema, above Morning edema above
ankle ankle and requiring
activity change, elevation
Skin pigmentation None or focal Diffuse but limited in area Diffuse over most of gaiter Wider distribution (above
low intensity and old (brown) distribution (lower third) or lower third) and recent
(tan) recent pigmentation (purple) pigmentation
Inflammation None Mild cellulitis, limited to Moderate cellulitis, involves Severe cellulitis
marginal area around most of gaiter area (lower third and above) or
ulcer (lower third) significant venous eczema
Induration None Focal, circummalleolar Medial or lateral, less than Entire lower third of
(< 5 cm) lower third of leg leg or more
No. of active ulcers 0 1 2 >2
Active ulceration, None < 3 months > 3 months, < 1 year Not healed > 1 year
duration
Active ulcer, size None < 2 cm diameter 26 cm diameter > 6 cm diameter
Compressive therapy Not used or Intermittent use of Wears elastic stockings Full compliance:
not compliant stockings most days stockings and elevation
GS, greater saphenous; LS, lesser saphenous.
176 SEMINARS IN INTERVENTIONAL RADIOLOGY/VOLUME 22, NUMBER 3 2005

Table 4 The Venous Segmental Disease Score pare outcomes among various treatment groups. Thus, it
can be very useful for studies of outcome assessment in
Reflux Obstruction
patients with chronic venous insufficiency.20
1/2 Lesser saphenous 1 Greater saphenous (only if
thrombosed from groin to below knee)
1 Greater saphenous 1 Calf veins, multiple CONCLUSION
1/2 Perforators, thigh 2 Popliteal vein Current evaluation of patients with chronic venous
1 Perforators, calf 1 Superficial femoral vein insufficiency benefits from improved understanding of
2 Calf veins, multiple (posterior 1 Profunda femoris vein the etiology and pathophysiology of the disease as well as
tibial vein alone 1) precise diagnostic tests. Evaluation of these patients
2 Popliteal vein 2 Common femoral vein begins in the office with a careful history and physical
1 Superficial femoral vein 1 Iliac vein examination. Bedside diagnostic tests can be performed,
1 Profunda femoris vein 1 Inferior vena cava although these have essentially been replaced by more
1 Common femoral vein accurate imaging modalities. All patients who are likely
and above to require intervention should first undergo duplex
10 Maximum reflux score 10 Maximum obstruction score scanning, with additional tests such as venography, ple-
thysmography, and venous pressure measurement reserv-
The Venous Clinical Severity Score (VCSS) con- ed for equivocal findings. On the basis of these studies,
sists of nine clinical descriptors, each graded on a scale of the patients disease can be classified according to the
0 to 3 representing the spectrum of absent, mild, CEAP system and venous severity scoring systems,
moderate, and severe features. The nine descriptors are which then serves as the basis for appropriate selection
pain, varicose veins, edema, pigmentation, induration, of patients for treatment or interventions, or both.
inflammation, number of active ulcers, duration of active
ulceration, and size of the largest current ulcer (Table 3).
This scoring system is designed to be complementary to, REFERENCES
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