Fig. 6.1
Telangiectasias /spider veins affecting the posterior calf
Telangiectasias are a confluence of dilated intradermal venules less than 1 mm in caliber. Synonyms include spider veins, hyphen webs, and thread veins. Reticular veins are dilated bluish subdermal veins, usually 1 mm to less than 3 mm in diameter. They are usually tortuous. Normal visible veins in persons with thin, transparent skin are not considered reticular veins. Synonyms include blue veins, subdermal varices, and venulectasies [15].
Varicose veins are distinguished from reticular veins by a diameter of 3 mm or more, measured in the upright position. They are subcutaneous, dilated, and usually tortuous and may involve saphenous veins, saphenous tributaries, or nonsaphenous superficial leg veins. Synonyms include varix, varices, and varicosities [15].
Edema is a perceptible increase in volume of fluid in the skin and subcutaneous tissue, characteristically indented with pressure. Venous edema usually affects the ankle region but may also extend into the leg and foot [15].
However, there are many causes of lower extremity edema. Edema caused by venous insufficiency is typically limited to the lower extremities and often affects only one leg, and other signs of venous disease (i.e., varicose veins, hyperpigmentation) are typically present. In contrast, generalized edema is usually bilateral and not limited to the lower extremities. Venous edema typically improves with recumbency, in comparison to edema due to lymphatic disease, which does not subside with recumbency. Central venous pressure is normal with venous edema, unless there is concomitant heart failure. Venous edema also responds poorly to the use of diuretics.
C4: changes in skin and subcutaneous tissue secondary to chronic venous disease
C4a: pigmentation or eczema
Pigmentation is defined and brownish darkening of the skin, resulting from extravasation of blood. It usually occurs in the ankle region but may extend to the leg and foot. It is due to hemosiderin deposition due to the extravasation of red blood cells through damaged capillaries into the dermis [15].
Eczema is described as an erythematous dermatitis, which may progress to blistering, weeping, or scaling eruption of the skin of the leg. It is most often located near varicose veins but may be located anywhere along the leg. It is usually seen in uncontrolled chronic venous disease but may also reflect sensitization to local therapy. The pruritus associated with venous eczema is often difficult to relieve. Patients can present with excoriations, making them vulnerable to skin infections [15].
C4b: lipodermatosclerosis or atrophie blanche (Fig. 6.4)
Fig. 6.4
Lipodermatosclerosis affecting the left leg
Lipodermatosclerosis (LDS) is localized, chronic inflammation and fibrosis of the skin and subcutaneous tissues of the lower leg, sometimes associated with scarring or contracture of the Achilles tendon. It is characterized by areas of firm induration that can begin at the medial ankle but can progress to involve the entire leg circumferentially. There is usually heavy pigmentation and fibrosis that constricts the leg, impeding venous and lymphatic flow. LDS is sometimes preceded by diffuse inflammatory edema of the skin, which may be painful and which is often referred to as hypodermitis. LDS should be differentiated from lymphangitis, erysipelas, or cellulitis. However, patients with LDS are prone to cellulitis caused by staphylococcal and streptococcal organisms . LDS is a sign of severe chronic venous disease, and in its most advanced form, the limb can begin to resemble an inverted champagne bottle. The fibrosed ankle area represents the neck of the bottle and, the edematous leg, the rest of the bottle [15].
Atrophie blanche (white atrophy) is localized, often circular whitish and atrophic skin areas surrounded by dilated capillaries and sometimes hyperpigmentation. Healed ulcer scars may have a very similar appearance but are distinguishable from atrophie blanche by a history of ulceration [15].
C5: healed venous ulcer (Fig. 6.5)
Fig. 6.5
Healed large area of venous ulceration over medial malleolus
Venous ulcers are full-thickness defects of the skin, most frequently found in the ankle region. They fail to heal spontaneously and are caused by chronic venous hypertension, the most common cause of lower extremity ulcers [15]. It is estimated that venous insufficiency accounts for about 45–80% of chronic leg ulcers. Venous ulcers are often located over a perforator vein or along the course of the great or small saphenous vein. They do not affect the forefoot nor do they present above the knee. They can be single or multiple, tender, shallow, and exudative. They have irregular, but not undermined borders and a granulated base. If advanced, they can affect the leg circumferentially [7].
It is important to distinguish venous ulcers from other lower extremity ulcers or other lower extremity skin abnormalities. Arterial insufficiency is the cause of approximately 5–20% of chronic leg ulcers. Arterial ulcers are usually found over pressure points and over the toes. They are painful, full-thickness wounds and have a punched-out appearance. Often, other signs of arterial insufficiency are present, including shiny, atrophic, hairless skin; poor or absent peripheral pulses; diminished capillary refill; and hypertrophic deformed toenails. Symptoms of arterial insufficiency, including claudication and rest pain, are also usually present.
Diabetic or other neuropathic foot ulcers account for about 15–25% of all chronic leg ulcers. They occur over bony prominences or areas of increased pressure. They are often hyperkeratotic with undermined borders. There is usually accompanying diminished sensation of the ulcer as well as the extremity.
There are other causes of lower extremity ulcers, including rheumatoid arthritis, systemic sclerosis, vasculitis, sickle cell disease, pyoderma gangrenosum, and skin cancer, including squamous and basal cell carcinoma. Biopsy may be necessary to determine the etiology of a lower extremity ulcer.
S: symptomatic
Symptoms may include aching, pain, tightness, skin irritation, heaviness, muscle cramps, and other complaints attributable to venous dysfunction.
A: asymptomatic
No symptoms or complaints attributable to venous dysfunction are present.
E: Etiologic Classification
Ec: congenital
Congenital etiologies may include arteriovenous malformations and avalvulia, the hereditary absence of venous valves [15].
Ep: primary
Primary valvular reflux is present. There is no other known cause of the chronic venous disease.
Es: secondary (postthrombotic)
Secondary etiologies are any known cause of the chronic venous disease. Typically the cause is thrombosis, but trauma and surgical alteration are also considered secondary etiologies.
En: no venous cause identified
If there is not an evident etiology of chronic venous disease, the n subscript is used.
A: Anatomic Classification
Basic CEAP assigns a limb to one or more of three commonly recognized anatomic venous systems—superficial, perforator, and/or deep.
As: superficial veins
The superficial system includes the great and small saphenous systems and any branch varicosities.
Ap: perforator veins
The perforator system includes veins that communicate between the superficial and deep systems.
Ad: deep veins
The deep system includes the calf veins and sinuses; popliteal, femoral, and iliac veins; and the vena cava .
P: Pathophysiologic Classification
Basic CEAP describes the presence of reflux and/or obstruction. They may occur alone or in combination.
Pr: reflux
Reflux is defined as the reversal of venous blood flow with a duration >0.5 s by duplex analysis [10].
Po: obstruction
Obstruction is confirmed by visualization of an occluded vein segment by imaging or by demonstrating prolonged outflow via a noninvasive study such as plethysmography [10].
Pn: no venous pathophysiology identifiable
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