ABC of Vascular Disease

The Classification of Venous Disease

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Venous disease of the legs can be classified according to the severity, cause, site and specific abnormality using the CEAP classification.  Use of such a classification improves the accuracy of the diagnosis and improves communication between specialists. The elements of the CEAP classification are:

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Clinical severity

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Etiology or cause

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Anatomy

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Pathophysiology

For the initial assessment of a patient, the clinical severity is the most important and can be made by simple observation and does not need special tests.  There are seven grades of increasing clinical severity:

Grade Description
C 0 No evidence of venous disease.
C 1 Superficial spider veins (reticular veins) only 
C 2 Simple varicose veins only
C 3 Ankle oedema of venous origin (not foot oedema)
C 4 Skin pigmentation in the gaiter area (lipodermatosclerosis)
C 5 A healed venous ulcer
C 6 An open venous ulcer

The majority of patients referred to the vascular surgical clinic have grade 2 disease (simple varicose veins).  Recent work done by my team at Good Hope Hospital shows that this large group can be sub-divided on the basis of a simple non-invasive test called photoplethysmography (PPG).

  1. The first sub-group have varicose veins with normal PPG measurements which indicates that the varicose veins are not causing a functional disturbance.  It is assumed (though not yet proven) that these patients have a less severe form of venous disease.

  2. The second sub-group have varicose veins and abnormal PPG measurements which indicates that the varicose veins are associated with a functional disturbance.  It is assumed (though again not yet proven) that these patients have a more severe for of venous disease and are more likely to progress to the higher severity grades of venous disease (C3-6).

Patients with C3-6 disease are demonstrating and increasing severity of chronic venous insufficiency, and all have a functional abnormality of the venous system.  These patients are most at risk of chronic ulceration and require specialised tests such as venous duplex and ambulatory venous pressure measurement to diagnose and characterise the underlying venous abnormality.

Recommendations for new patients with venous disease

Group Action
CEAP 1 No need to refer to NHS clinic, cosmetic problem only
CEAP 2 Refer routinely to "Fast Track Varicose Vein Clinic" for photoplethysmography assessment
CEAP 3 - 5 Refer soon to "Fast Track Varicose Vein Clinic" for venous duplex ultrasound assessment
CEAP 6 Refer urgently to "One Stop Leg Ulcer Clinic" for full leg ulcer assessment

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S.R.Dodds 2001

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