Standards In Venous Disease Research Articles

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Venous ulcer: Current concepts

16. Kumins NH, Weinzweig N, Schuler JJ. Free tissue transfer provides durable treatment for large non healing venous ulcers. J Vasc Surg 2000;32:848-54. 17. Steffe TJ, Caffee HH. Long-term results following free tissue transfer for venous stasis ulcers. Ann Plast Surg 1998;41:131-7. 18. Reddy MM, Reddy MD. Role of free tissue transfer in the management of chronic venous ulcer. Indian J Plast Surg 2004;37:28-33. 19. Vacuum-assisted closure versus standard therapy of chronic non-healing wounds. Wounds 2000;12:60-7. 20. Nelson EA, Harper DR, Prescott RJ, Gibson B, Brown D, Rutkey CV. Prevention of occurrence of venous ulcer randomised controlled trial of class 2, class 3 elastic compression. J Vasc Surg 2006;44:803-8. 21. Davies JA, Bull RH, Farrelly IJ, Wakelin MJ. A home based exercise programme improves ankle range of motion in long term venous ulcer patients. Phlebology 2007;22:86-9. 22. Porter JP, Rutherford RB, Clagett GP. Reporting standards in venous disease. J Vasc Surg 1988;8:172-81. 23. Sytchev GG. Classification of chronic venous disorders of lower extremities and pelvis. Int Angiol 1985;4:203-6 24. Barber C, Watt A, Pham C, Humphreys K, Penington A, Mutimer K, et al. Influence of bioengineered skin substitutes on diabetic foot ulcer and venous leg ulcer outcomes. J Wound Care 2008;17:517-27. 25. Falanga VJ. Tissue engineering in wound repair. Adv Skin Wound Care 2000;13:15-9. 26. Hissink RJ, Bruins RM, Erluns R, Castellenos Nuijits ML, van den Berg M. Innovative treatment in chronic venous insufficiency: Endovenous laser ablation of perforating veins: A prospective short-term analysis of 58 cases. Eur J Vasc Endo Vasc Surg 2010;40:403-6. 27. Amsler F, Willenberg T, Blattler W. Insearch of optimal compression therapy for venous leg ulcer: A meta analysis of studies comparing diver’s bandage with specifically designed stockings. J Vasc Surg 2009;50:66. 28. Netzen O, Bergquist D, Lindhagen A. Venous and nonvenous leg ulcers: Clinical history and appearance in a population study. Br J Surg 1994;81:182-3 29. Legendre C, Debure C, Meaume S, Lok C, Cronard JL, Senet P. Prevalence of protein deficiency on venous ulcer healing. J Vasc Surg 2000;48:688-93 30. Schnirring-Judge M, Belpedio D. Malignant Transformation of a chronic venous stasis ulcer to basal cell carcinoma in a diabetic patient: A case study and review of pathophysiology. J Foot Ankle Surg 2010;49:75-9 31. Coleridge Smith PD, Thomas P, Scurr JH, Dormandy JA. Causes of venous ulcerations: A new hypothesis. BMJ 1988;296:1726-7.

Guidelines for the treatment of venous ulcers

1. Co-chaired this panel2. University of South Florida, Tampa, FL3. Healthpoint Ltd., Fort Worth, TX4. University of California, San Francisco, CA5. University of Texas Medical Branch, Galveston, TX6. University of Cardiff, Cardiff, Wales, UK7. University of Pennsylvania, Philadelphia, PA8. Private practice, Warren, PA9. Private practice, Tamarac, FL10. University of Pittsburgh, Pittsburgh, PA11. St. Louis University, St. Louis, MO, and12. Washington University, St. Louis, MO

Management of the Primary Varicose Veins With Venous Ulceration With Assistance of Endoscopic Surgery

Two hundred sixty-two cases of primary varicose veins in which the lesions extended to the areas of the lower third of the leg and/or the ankle were treated with the assistance of endoscopic surgery. The conditions of varicose veins were classified by the reporting standards in venous disease. The number of cases in lesions of C2, C4, C5, and C6 were 60, 156, 31, and 15, respectively. They were also classified into 4 clinicoanatomic types according to varicositic changes in normal veins. The number of cases in types I, II, III, and IV were 57, 88, 42, and 75, respectively. The incidence of skin changes resulting from varicosity were 100%, 90.5%, 53%, and 50% in types I, II, III, and IV, respectively. The incidence of skin changes in this series was 77.6%. About one fourth of the cases having skin changes progressed to C5 and/or C6 lesions. Early and radical treatment of varicose veins could prevent the occurrence of skin changes and subsequently avoid the incidence of C5 and/or C6 lesions. The mean number of incisions in each limb was 2.9. With good illumination and magnified monitor view, the varicose veins and incompetent perforating veins were radically excised, but the normal veins were preserved. Forty-six cases of C5 and C6 lesions were followed up at least 1 year postoperatively. Four cases were lost from follow-up. In all cases except 1, there has been no recurrence. The conditions of skin changes improved subsequently. The recurrent rate of ulceration was 2.4%. In treatment of primary varicose veins with or without ulceration, surgery with assistance of endoscopic surgery achieved a low recurrence of ulcerations and minimal operative scarring.

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Revision of the CEAP classification for chronic venous disorders: a consensus statement

The CEAP classification for chronic venous disorders (CVD) was developed in 1994 by an international ad hoc committee of the American Venous Forum (AVF), endorsed by the Society for Vascular Surgery and incorporated into "Reporting standards in venous disease" in 1995. Today most published clinical papers on CVD use all or portions of CEAP. Rather than have it stand as a static classification system, an ad hoc committee of the AVF, working with an international liaison committee, has recommended a number of practical changes which are detailed in this consensus report. These include: refinements of several definitions used in describing CVD; refinement of the C-classes of CEAP; addition of the descriptor n (no venous abnormality identified); elaboration of the date of classification and level of investigation, and as a simpler alternative to the full (advanced) CEAP classification, introduction of a "basic" CEAP version. It is important to stress that CEAP is a descriptive classification, while venous severity scoring and quality of life scores are instruments for longitudinal research to assess outcomes.

Revision der CEAP-Klassifizierung für chronische Venenleiden

ZusammenfassungDie CEAP-Klassifizierung für chronische Venenleiden wurde 1994 durch ein internationales Ad-hoc-Komitee des American Venous Forum entwickelt, durch die Society for Vascular Surgery unterstützt und 1995 in die „Reporting Standards in Venous Disease“ inkorporiert. Inzwischen benutzen die meisten publizierten klinischen Arbeiten das CEAPSystem, ganz oder in Teilen.Um die Klassifizierung nicht als statisches System zu belassen, hat ein Ad-hoc-Komitee des American Venous Forum in Zusammenarbeit mit einem internationalen Verbindungskomitee eine Reihe von praktischen Änderungen empfohlen, die in diesem Konsensusbericht aufgelistet sind. Diese beinhalten eine Verfeinerung verschiedener Definitionen, welche der Beschreibung von chronischen Venenerkrankungen dienen, eine Verfeinerung der C-Klassen von CEAP, der Zusatz der Beschreibung n (no venous abnormality), das Datum der Klassifizierung, die Untersuchungsstufe sowie, als einfachere Alternative zur vollen (fortgeschrittenen) CEAP-Klassifizierung, die Einführung einer Basis-CEAP-Version. Es ist wichtig, darauf hinzuweisen, dass CEAP eine deskriptive Klassifizierung darstellt, wogegen das „Venous severity scoring“ sowie Lebensqualitäts- Scores Instrumente für longitudinale Outcome-Studien darstellen.

Revision of the CEAP classification for chronic venous disorders: Consensus statement

The CEAP classification for chronic venous disorders (CVD) was developed in 1994 by an international ad hoc committee of the American Venous Forum, endorsed by the Society for Vascular Surgery, and incorporated into "Reporting Standards in Venous Disease" in 1995. Today most published clinical papers on CVD use all or portions of CEAP. Rather than have it stand as a static classification system, an ad hoc committee of the American Venous Forum, working with an international liaison committee, has recommended a number of practical changes, detailed in this consensus report. These include refinement of several definitions used in describing CVD; refinement of the C classes of CEAP; addition of the descriptor n (no venous abnormality identified); elaboration of the date of classification and level of investigation; and as a simpler alternative to the full (advanced) CEAP classification, introduction of a basic CEAP version. It is important to stress that CEAP is a descriptive classification, whereas venous severity scoring and quality of life scores are instruments for longitudinal research to assess outcomes.

Is the nihilistic approach to surgical reduction of superficial and perforator vein incompetence for venous ulcer justified?

Twenty-five years ago, the senior author showed a 55% postoperative ulcer recurrence rate after open perforator ligation. Those data contributed to a nihilistic attitude toward incompetent perforating veins. Conversely, since the introduction of subfascial endoscopic perforator surgery (SEPS), we have undertaken ablation of superficial and perforator reflux as initial treatment in patients with ulcers (C6) or healed ulcers (C5). This report outlines our long-term results. Between December 1994 and November 1999, SEPS was performed on 51 limbs in 45 patients with C5/C6 disease. Sixteen limbs underwent SEPS alone, and 35 had additional surgery on the greater saphenous vein (GSV), the lesser saphenous vein, or the tributary varicies. Data were collected according to the reporting standards in venous disease. Preoperative duplex scan of deep, superficial, and perforating veins was performed. Data were analyzed with Kaplan-Meier method, Mantel-Cox log-rank test, or t test. Of the 51 limbs that underwent SEPS, the GSV was stripped in 28. Twenty-nine were C6, and 22 were C5. Etiology was primary (Ep) in 25 limbs and secondary (Es) in 26 limbs. All limbs had duplex scan evidence of perforator incompetence (Ap), and deep insufficiency (A(D)) was seen in 39 cases (76%). Reflux predominated (P(R)). The clinical follow-up period was 0 to 82 months (median, 38 months). Venous disability scores improved from 9.8 before surgery to 4.2 at last follow-up (P <.05). Kaplan-Meier analysis showed 74% healing at 6 months. The presence of an ulcer more than 2 cm in diameter, secondary etiology, and SEPS without concomitant GSV stripping were associated (P <.05) with delayed healing. Among patients in whom ulcers healed or who were seen with healed ulcers, the 5-year ulcer recurrence rate was 13%. Lesser saphenous vein reflux was the only factor that correlated with increased ulcer recurrence. Deep system reflux as measured with duplex scan valve closure times did not correlate with the rate of ulcer healing or recurrence. Nihilism has no place in the management of venous disease in the 21st century. An aggressive approach to superficial and perforating vein reflux in this cohort of patients with C5 and C6 disease resulted in rapid ulcer healing and low 5-year recurrence rates. Prior saphenous vein stripping, large ulcers, and secondary etiology were associated with delayed healing. A less aggressive posture toward lesser saphenous vein reflux contributed to a higher recurrence rate in this subgroup of patients. These risk factors are useful in counseling patients as to their expected postoperative course; however, no combination of factors should a priori preclude surgical intervention in this group of patients.

Determinants of chronic venous disease after acute deep venous thrombosis

Purpose: The purpose of this investigation was to evaluate the relationship between the presenting features of an acute deep venous thrombosis (DVT), the subsequent natural history of the thrombus, and the ultimate outcome as defined according to the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery reporting standards in venous disease. Methods: Patients with an acute DVT were followed with serial clinical and ultrasound examinations. Thrombus extent within 7 venous segments was scored retrospectively according to the reporting standards (scores ranged from 0 to 3), and segmental reflux was scored as present (1) or not present (0). The initial and final thrombus scores, the rates of recanalization and rethrombosis, and the total reflux scores were then calculated from these grading scales and related to ultimate chronic venous disease (CVD) classification. Results: Sixty-eight patients with an acute DVT in 73 limbs were followed for 18 to 110 months (mean, 55 ± 26 months). At the completion of the follow-up period, 20 extremities (27%) were asymptomatic (class 0), 13 (18%) had pain or prominent superficial veins (class 1), 25 (34%) had manifested edema (class 3), 13 (18%) had developed hyperpigmentation (class 4), and 2 (3%) had developed ulceration (class 5). In a univariate analysis, CVD classification was correlated with the reflux score ( P = .003) but not with the initial or final thrombus score or with the rate of recanalization or rethrombosis. In a multivariate model of features documented at presentation, only the tibial thrombosis score was a significant predictor of CVD classification ( R 2 = .06). Outcome was better predicted ( R 2 = .29) with a model that included variables defined during follow-up—the final reflux score, the final popliteal score, and the rate of recanalization. Conclusion: The ability to predict the severity of CVD after an acute DVT is currently limited, although the natural history appears more important than the presenting features of the event. The extent of reflux, the presence of persistent popliteal obstruction, and the rate of recanalization are related to ultimate CVD classification, but other determinants remain to be identified. (J Vasc Surg 1998;28:826-33.)

Duplex assessment of venous reflux and chronic venous insufficiency: the significance of deep venous reflux.

This study was undertaken to examine the role of superficial and deep venous reflux, as defined by duplex-derived valve closure times (VCTs), in the pathogenesis of chronic venous insufficiency. Between January 1992 and November 1995, 320 patients and 500 legs were evaluated with clinical examinations and duplex scans for potential venous reflux. VCTs were obtained with the cuff deflation technique with the patient in the upright position. Imaging was performed at the saphenofemoral junction, the middle segment of the greater saphenous vein, the lesser saphenous vein, the superficial femoral vein, the profunda femoris vein, and the popliteal vein. Not all patients had all segments examined because tests early in the series did not examine the profunda femoris or lesser saphenous vein and because some patients had previous ligation and stripping or venous thrombosis. VCTs were examined for individual segment reflux, grouped into superficial and deep systems, and then correlated with the clinical stage as defined by the SVS/ISCVS original reporting standards in venous disease. Segment reflux was considered present if the VCT was greater than 0.5 seconds, and system reflux was considered present if the sum of the segments was greater than 1.5 seconds. Between-group differences were analyzed with analysis of variance and post hoc tests where appropriate. Sixty-nine limbs studied were in class 0, 149 limbs were in class 1, 168 limbs were in class 2, and 114 limbs were in class 3. VCTs in the superficial veins were significantly lower in class 0 than in the other clinical classes. There was no difference in superficial reflux in the symptomatic limbs (classes 1 to 3). Reflux VCTs in the superficial femoral and popliteal veins increased as the clinical symptoms progressed, with a significant increase in class 3 ulcerated limbs when compared with nonuclerated limbs. The incidence of deep venous reflux was 60% in class 3 limbs, compared with 29% in class 2 limbs, whereas the incidence of superficial venous reflux did not differ among the symptomatic limbs. Isolated superficial femoral and popliteal vein reflux was uncommon, even in class 3 limbs, but combined superficial femoral and popliteal vein reflux was found in 53% of class 3 limbs, compared with 18.5% of class 2 limbs. Reflux in the deep venous system plays a significant role in the progression of chronic venous insufficiency. Deep system reflux increases as clinical changes become more severe, with significant axial reflux contributing to ulcer formation.

Reporting standards in venous disease: An update

At the request of the Ad Hoc Committee on Reporting Standards of the Joint Council of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery, this report updates and modifies "Reporting standards in venous disease" (J Vasc Surg 1988;8:172-81). As in the initial document, reporting standards for publications dealing with (1) acute lower extremity venous thrombosis, (2) chronic lower extremity venous insufficiency, (3) upper extremity venous thrombosis, and (4) pulmonary embolism are presented. Numeric grading schemes for disease severity, risk factors, and outcome criteria present in the original document have been updated to reflect increased knowledge of venous disease and advances in diagnostic techniques. Certain recommendations of necessity remain arbitrary. These standards are offered as guidelines whose observance will in our opinion improve the clarity and precision of communications in the field of venous disorders.

Reporting standards in venous disease

This report comprises suggested reporting standards for publications dealing with (1) acute lower extremity venous thrombosis, (2) chronic lower extremity venous insufficiency, (3) upper extremity venous thrombosis, and (4) pulmonary embolism. Attempts have been made to set forth numeric grading schemes for disease severity, risk factors, and outcome criteria. Some of the recommendations had to be arbitrary of necessity, but they were judged the most generally acceptable by members of the committee. They are offered not as binding rules but as guidelines whose observance will serve the clarity and precision of communication.

Reporting standards in venous disease

Reporting standards in venous disease