Clinical classification (C): from 0 to 6
C0 No visible sign of venous disease
C1 Telangiectasies or reticular veins
C2 Varicose veins
C3 Edema
C4 Changes in skin and subcutaneous tissue
4a Pigmentation or eczema
4b Lipodermatosclerosis or atrophie blanche
C5 Healed ulcer
C6 Active ulcer
S: symptomatic
A: asymptomatic
Etiological classification (E)
Ec Congenital
Ep Primary
Es Secondary (post-thrombotic syndrome, trauma)
En No venous cause identified
Anatomical classification (A)
As Superficial veins
Ad Deep veins
Ap Perforator
An No venous location identified
Pathophysiological classification (P)
Pr Reflux
Po Obstruction, thrombosis
Pr,o Reflux and obstruction
Pn No venous pathophysiology identified
For a better understanding of the various CEAP clinical classes (C) , precise definitions of each were described as shown below in Table 14.2 [22].
Corona phlebectatica | Fan-shaped pattern of numerous small intradermal veins on medial or lateral aspects of ankle foot |
Telangiectasia | Confluence of dilated intradermal venules less than 1 mm in caliber. Synonyms include spider veins, hyphen webs, and thread veins |
Reticular vein | Dilated bluish subdermal vein, usually 1 mm to less than 3 mm. Usually tortuous. Excludes normal visible veins in persons with thin, transparent skin. Synonyms include blue veins, subdermal varices, and venulectasies |
Varicose vein | Subcutaneous dilated vein 3 mm in diameter or larger, measured in upright position. May involve saphenous veins, saphenous tributaries, or no saphenous superficial leg veins. Varicose veins are usually tortuous, but tubular saphenous veins with demonstrated reflux may be classified as varicose veins. Synonyms include varix, varices, and varicosities |
Edema | Perceptible increase in volume of fluid in skin and subcutaneous tissue, characteristically indented with pressure. Venous edema usually occurs in ankle region, but may extend to leg and foot |
Eczema | Erythematous dermatitis, which may progress to blistering, weeping, or scaling eruption of skin of leg. Usually seen in uncontrolled chronic venous disorder, but may reflect sensitization to local therapy |
Pigmentation | Brownish darkening of skin, resulting from extravasated blood. Usually occurs in ankle region, but may extend to leg and foot |
Atrophie Blanche (White atrophy) | Localized, often circular whitish and atrophic skin areas surrounded by dilated capillaries and sometimes hyperpigmentation. Should not to be confused with healed ulcer scars |
Venous ulcer | Full-thickness defect of skin, most frequently in ankle region, that fails to heal spontaneously and is sustained by chronic venous disorder |
The Figs. 14.1, 14.2, 14.3, 14.4, 14.5, and 14.6 represent CEAP clinical classification from C1 to C6 respectively.
Fig. 14.1
CEAP C1: Telangiectases and diffuse reticular veins
Fig. 14.2
CEAP C2: Varicose veins
Fig. 14.3
CEAP C3: Right lower limb edema associated with varicose veins
Fig. 14.4
CEAP C4: Hyperpigmentation and eczema
Fig. 14.5
CEAP C5: Healed ulcer in right medial malleolus
Fig. 14.6
CEAP C6: Granulated circumferential venous ulcer
Diagnosis
Chronic venous disease diagnosis is made by medical history and physical examination.
Common symptom is pain, reported by the patient as heaviness or cramps, being exacerbated by prolonged orthostatic position and relieved by lower limb elevation and bed rest [21].
The physician should also inquire about the period of evolution of the disease, the manner and intensity of progression, the influence of the weather, particularly in hot seasons, the use of estrogens and worsening in menstrual period, the number of pregnancies and the variations observed during this period and in puerperium, the occupation, as well as the posture at work, daily activities in general, with the estimated period of orthostatic, the frequency and type of physical exercises, the existence of varicose veins in the family.
At physical examination, the presence of tortuous and dilated veins must be noted, as well as telangiectasies, angiomatous formation, edema, and trophic skin alterations [21]. Lower limb pulses examination in patients with varicose veins is essential to exclude concomitant peripheral artery disease, which could change the treatment approach. Noninvasive tests like the lower limb venous duplex scan may be requested after the decision to make an intervention. They confirm the diagnosis and evaluate the etiology, whether primary or secondary, and the anatomy of the affected vessels. These tests will be better discussed in another chapter of this book.
Differential Diagnosis
Chronic venous disease manifestations can be confounded with other diseases.
Pain in the morning or just when the person takes the orthostatic position are probably not of venous origin; as well as pain at the lateral part of the thigh, which suggests nerve irritation. Pain at the knee joint, worsening after effort is typical of osteoarthritis and when located in inguinal region could be hip osteoarthritis, tendinitis, or nerve injury.
There are several systemic diseases that manifest with lower limb edema such as cardiac failure, nephrotic syndrome, liver disease, endocrine dysfunction, kidney failure, metastatic cancer, and autoimmune and inflammatory diseases. In addition, it could be considered as side effect of some medications such as calcium channel blockers, oral hypoglycemic agents, anti-inflammatory drugs, among others [21].
Deep vein thrombosis should be kept in mind if there is previous history of trauma, prolonged immobilization or major surgery. However, it should also be differentiate with: rupture of Baker’s cyst, hematoma due to gastrocnemius muscle rupture, lymphedema, and erysipelas. In manifestations such as pigmentation and dermatosclerosis, the differential diagnosis should be made with dermatitis, myxedema, skin necrosis, and purpura [21].
Treatment
Clinical Treatment
Chronic venous disease initial treatment involves no interventionist action to control symptoms and improve the quality of life, as well as to prevent the development of secondary complications and disease progression. Lifestyle modifications, such as the practice of regular physical activity, intermittent elevation of the limb and weight loss should be encouraged. Compression therapy and occasionally pharmacotherapy could also be added as part of the clinical treatment.
If clinical treatment is insufficient, invasive treatment should be considered according to the anatomy and pathophysiology of the patient. Specific treatment is based on the disease’s severity. Patients classified as CEAP C4 to C6 often require invasive treatment and early treatment of patients CEAP C3 could prevent disease progression to more advanced classes [23].
Compression Therapy
Compression therapy is an essential component in the treatment of patients with chronic venous disease . It promotes a graduated external compression of the leg to oppose the hydrostatic force of venous pressure that is main pathogenic factor of the disease. It also improves calf pump function, increasing the velocity of venous flow, with good effects on the microcirculation, improving the oxygenation of the skin and lymphatic circulation [23]. However, it is not efficient to prevent the disease progression [24].
External compression above 60 mmHg in patients in standing position causes the occlusion of limb vessels, which could harm the skin circulation. Therefore, this value is considered to be the safe upper limit for compression therapy [23].
Several compression methods are available: graduated compression stockings, Unna boot, elastic and nonelastic bandages, and intermittent pneumatic compression.
Graduated Compressive Stockings
Compressive stockings are designed to have the highest compressive pressure at the ankle. The compression progressively reduces from the ankle to one-third at the upper leg and a half at the thigh.
The socks are available in four scales: 15–20 mmHg, 20–30 mmHg (gentle compression), 30–40 mmHg (medium compression), 40–50 mmHg (high compression), and three lengths: 3/4 (below the knee), 7/8 (thigh), and pantyhose. Usually, the 3/4 stocking is sufficient to control the symptoms.
The appropriate stocking size is provided according to the patient’s measures (thigh, calf, and ankle). Some obese patients or those with advanced chronic venous disease may require special size, and therefore it should be customized. The durability of the elastic stocking is 6–9 months, once the elasticity expires after that period [24].
Unna Boot
Unna boot is an artisanal preparation of a multilayer inelastic bandage for the lower limbs. The strips are impregnated with a paste consisting of zinc oxide, glycerin, and gelatin. This bandaging allows movement of the ankle joint and the normal gait, helping the functioning of the calf muscle pump, preventing the occurrence of edema, improving the skin and subcutaneous microcirculation, which accelerates the healing of stasis ulcer [25]. Not every patient is well adapted to the Unna boot, and it has to be changed weekly by a health professional, which makes its use difficult for many patients. Furthermore, the Unna boot cannot be used in the presence of infection.
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