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Disclaimer Due to the evolving field of medicine, new research may, in due course, modify the recommendations presented in this document. At the time of publication, every attempt has been made to ensure that the information provided is up to date and accurate. It is the responsibility of the treating physician to determine the best treatment for the patient. The authors, committee members, editors, and publishers cannot be held responsible for any legal issues that may arise from the citation of this statement. Rules of evidence Management of patients with chronic venous disorders has been traditionally undertaken subjectively among physicians, often resulting in less than optimal strategies. In this document, a systematic approach has been developed with recommendations based upon cumulative evidence from the literature. Levels of evidence and grades of recommendation range from Level I and Grade A to Level III and Grade C. Level I evidence and Grade A recommendations derive from scientifically sound randomized clinical trials in which the results are clear-cut. Level II evidence and Grade B recommendations derive from clinical studies in which the results among trials often point to inconsistencies. Level III evidence and Grade C recommendations result from poorly designed trials or from small case series.1, 2 Meta-analysis Meta-analyses are included in the present document but there should be caution as to their possible abuse. Certain studies may be included in a meta-analysis carelessly without sufficiently understanding of substantive issues, ignoring relevant variables, using heterogenous findings or interpreting results with a bias.3 It has been demonstrated that the outcomes of 12 large randomized controlled trials were not predicted accurately 35% of the time by the meta-analyses published previously on the same topics.4

The CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification is an internationally accepted standard for describing patients with chronic venous disorders and it has been used for reporting clinical research findings in scientific journals. Developed in 1993, updated in 1996, and revised in 2004, CEAP is a classification system based on clinical manifestations of chronic venous disorders, on current understanding of the etiology, the involved anatomy, and the underlying venous pathology. As the evidence related to these aspects of venous disorders, and specifically of chronic venous diseases (CVD, C2-C6) continue to develop, the CEAP classification needs periodic analysis and revisions. In May of 2017, the American Venous Forum created a CEAP Task Force and charged it to critically analyze the current classification system and recommend revisions, where needed. Guided by four basic principles (preservation of the reproducibility of CEAP, compatibility with prior versions, evidence-based, and practical for clinical use), the Task Force has adopted the revised Delphi process and made several changes. These changes include adding Corona phlebectatica as the C4c clinical subclass, introducing the modifier "r" for recurrent varicose veins and recurrent venous ulcers, and replacing numeric descriptions of the venous segments by their common abbreviations. This report describes all these revisions and the rationale for making these changes.

A 59-year-old female secretary was referred for evaluation and treatment of a non-healing painful ulcer on the medial aspect of her right lower leg. The ulcer had been recurrent almost every year for the past 9 years, often healing during the winter season. She had since early childhood been overweight (currently 87 kg, 170 cm, body mass index 30) and had difficulty in using compression stocking. She was otherwise healthy. She had two children, the first child born when she was 32 year of age and her second child 2 years later. After the birth of her second child she began to notice varicose veins on the lower leg on both sides and she often felt tiredness and heaviness in the leg in the afternoon. There was no history of deep venous thrombosis. She had been on birth control pills for 10 years and was currently on hormone replacement therapy because of severe postmenopausal symptoms. She had been treated at a local dermatological clinic for the past 2 years and was now being evaluated by a vascular surgeon. Clinical evaluation showed that she had 5 × 5 cm well-granulated ulceration above the right median malleolus which was surrounded by brownish leathery skin. She had slight swelling of the right leg with large varicosities below the knee. The left leg had large varicosities below the knee but no swelling or skin changes. Doppler examination revealed clear reflux in the groin that could be followed over both great saphenous veins (GSV) down the thigh. A possible minimal reflux was also noted in the popliteal fossa on the right side, although it was difficult to confirm this when the Doppler examination was repeated. Foot arteries were palpable on the dorsum of the foot on both sides.

Aim The aim of this review is to try to explain the controversy by critical analysis of previously published randomized controlled trials on the value of elastic compression stockings in the treatment of acute proximal deep vein thrombosis in prevention of post-thrombotic syndrome, which forms the scientific basis for our present management. Methods A research was made through Medline and Embase databases to identify relevant original articles, not abstracts, with the following keywords: post-thrombotic syndrome, deep venous thrombosis, venous thromboembolism, compression stockings, prevention and compliance. Results We identified five randomized controlled trials (RCTs) before the SOX trial including 798 patients with acute proximal deep vein thrombosis. Brandjes (1997): at two years’ follow-up, elastic compression stockings reduced post-thrombotic syndrome by 50%; Ginsberg (2001): no difference in post-thrombotic syndrome with or without elastic compression stockings after more than two years’ follow-up; Partsch (2004): elastic compression stockings with routine above knee and early ambulation reduced the incidence and severity of post-thrombotic syndrome after two years’ follow-up; Prandoni (2004) showed significantly less post-thrombotic syndrome after elastic compression stockings for two years with a five-year follow-up; Aschwanden (2008) showed no difference with elastic compression stockings after three years’ follow-up. Conclusion Prescription of elastic compression stockings for the prevention of post-thrombotic syndrome is now in doubt. Immediate compression after diagnosis of acute deep vein thrombosis to prevent swelling and reduce pain, permitting early ambulation in combination with adequate anticoagulation has proven benefit, although a secondary analysis of the SOX trial refutes this belief. Continued long-term compression treatment is questioned. Two major questions remain: Is the lack of positive outcome on the development of post-thrombotic syndrome after proximal deep vein thrombosis due to the fact that there were a few patients with iliofemoral extension in the quoted randomized controlled trials who may benefit from prolonged medical compression treatment? Compliance is the major issue, and the two randomized controlled trials with excellent control of compliance showed significant reduction in the rate of post-thrombotic syndrome, but we know that in daily practice the adherence is closer to Kahn’s data.

This chapter presents the approved revised format of Clinical Etiological Anatomical Path physiological (CEAP). It examines the fundamental importance of defining the etiologic basis of the clinical problem. The CEAP classification deals with all forms of chronic venous disorders. The term “chronic venous disorder” includes the full spectrum of morphological and functional abnormalities of the venous system, from telangiectasias to venous ulcers. Chronic symptoms which may include pelvic pain, perineal heaviness, urgency of micturition, and post-coital pain, caused by ovarian and/or pelvic vein reflux and/or obstruction, and which may be associated with vulvar, perineal, and/or lower leg varices. Venous disease is often considered to be a simple problem undeserving of a multi-categorized classification format. In contrast to primary disease, post-thrombotic secondary disease is an acquired inflammatory venous problem that begins as a purely obstructive phenomenon and evolves into a mixture of reflux and obstruction in the deep veins.

BACKGROUND This study compares the outcome 5 years after treatment of varicose veins with endovenous radiofrequency ablation (RFA), endovenous laser ablation (EVLA), ultrasound guided foam sclerotherapy (UGFS) or high ligation and stripping (HL/S) by assessing technical efficacy, clinical recurrence and the rate of reoperations. METHODS Five hundred patients (580 legs) with Great Saphenous Vein (GSV) reflux and varicose veins were randomized to one of the 4 treatments. Follow-up included clinical and duplex ultrasound examinations. RESULTS During 5 years there was a difference in the rate of GSV recanalization, recurrence and reoperations across the groups, KM P

In the past decade, the development of minimally invasive correction of primary venous reflux of the great saphenous vein (GSV) by endovenous techniques has provided a patient-friendly means to treat this disorder as an office- based procedure with ablation of the GSV using radiofrequency (RFA), laser (EVLA), or sclerotherapy. What do the randomized controlled trials (RCT) teach us about these new endovenous procedures? There are 7 RCT's (493 patients) in 9 papers comparing RFA with open surgery (OS); 12 RCT's (2327 patients) in 16 papers comparing EVLA with OS; 5 RCT's (570 patients) comparing RFA with EVLA; 6 RCT's (699 patients) with modifications of EVLA; 2 RCT's (153 patients) in 3 papers comparing EVLA with cryostripping; 6 RCT's (1406 patients) in 7 papers comparing foam sclerotherapy with OS; 2 RCT's (166 patients) comparing EVLA with foam sclerotherapy; 1 RCT (580 patients) in 2 papers comparing RFA versus EVLA versus foam sclerotherapy versus OS. Conclusion Based on the presented RCT's with caveats mentioned in the paper, the differences between modern open surgery and the new endovenous procedures are insignificant and no treatment modality can be recommended as superior to another. Nevertheless it is established that chemical ablation is the cheapest, but redo-treatment is more frequent related to recurrence.

Many physicians in Kuwait have contributed to the development of the management of acute iliofemoral deep venous thrombosis utilizing open surgical thrombectomy for early thrombus removal. This concept is now accepted around the world, with new endovascular procedures replacing open surgery. Its development is described and the latest guidelines for early thrombus removal are presented.

Objective This is the first randomized controlled trial with a 5-year follow-up comparing endovenous laser ablation (EVLA) with high ligation and pin-stripping in patients with great saphenous vein (GSV) incompetence. Methods One hundred twenty-one consecutive patients (137 legs) with GSV incompetence were randomized to EVLA (980 nm bare fiber) or high ligation and stripping using tumescent local anesthesia with light sedation. Mini-phlebectomies were performed in all patients. The patients were examined with duplex scanning before treatment and after 12 days, and then after 1, 3, and 6 months, and yearly thereafter for up to 5 years. The primary end point was open refluxing GSV. Secondary end points were recurrent varicose veins, frequency of reoperations, Venous Clinical Severity Score, and quality of life scores (Aberdeen Varicose Vein Symptoms Severity Score and Short Form-36). Results In the EVLA and stripping group, nine (Kaplan-Meier [KM] estimate, 17.9%) and four (KM estimate, 10.1%) of GSVs had open refluxing segments of 5 cm or more (ns). Clinical recurrence was recorded in 24 (KM estimate, 46.6%) and 25 (KM estimate, 54.6%), whereas reoperations were performed in 17 (KM estimate, 38.6%) and 15 (KM estimate, 37.7%) legs (ns). Venous Clinical Severity Score and Aberdeen Varicose Vein Symptoms Severity Score improved whereas Medical Outcomes Study Short Form-36 quality of life score improved in several domains in both groups with no difference between the groups. Conclusions Five-year follow-up of our randomized controlled trial comparing EVLA with open surgery in patients with GSV incompetence did not show any significant difference between the two groups in primary or secondary end points, perhaps because of the small sample size. EVLA seems to be a valid alternative to open surgery.

Purpose To study intermediate clinical outcomes, rates of recurrent varicosities and neovascularisation, ultrasound changes of the GSV, and the quality of life changes in patients from EVOLVeS trial. Methods Forty five patients were re-examined 1 year and 65 two years after treatment. Follow-up visits included clinical examination with CEAP classification and calculation of venous clinical severity score (VCSS), ultrasound examination, and a quality of life questionnaire. Results The clinical course of the disease (CEAP, VCSS) was similar in the two treatment groups. 51% of the GSV trunks occluded by RFO underwent progressive shrinkage with the external diameter decreased from 6.3 SD 1.4 mm at 72 h after treatment to 2.9 SD 1.5 mm at 2 years. An additional 41% of the GSV became undetectable by ultrasound at 2-year follow up. In two patients we observed re-opening of an initially closed GSV lumen. Neovascularisation was found in one RFO case and in four S and L cases. Cumulative rates of recurrent varicose veins at combined 1 and 2 years follow-up were 14% for RFO and 21% for S and L (NS). The difference in global QOL score in favour of RFO re-appeared at 1 year and remained significant at 2 years after treatment. Conclusion The 2-year clinical results of radiofrequency obliteration are at least equal to those after high ligation and stripping of the GSV. In the vast majority of RFO patients the GSV remained permanently closed, and underwent progressive shrinkage to eventual sonographic disappearance. Recurrence and neovascularisation rates were similar in the two groups although limited patient numbers prevent reliable statistical analysis. Improved quality of life scores persisted through the 2-year observations in the RFO group compared to the S and L group.

The Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) have developed clinical practice guidelines for the care of patients with varicose veins of the lower limbs and pelvis. The document also includes recommendations on the management of superficial and perforating vein incompetence in patients with associated, more advanced chronic venous diseases (CVDs), including edema, skin changes, or venous ulcers. Recommendations of the Venous Guideline Committee are based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system as strong (GRADE 1) if the benefits clearly outweigh the risks, burden, and costs. The suggestions are weak (GRADE 2) if the benefits are closely balanced with risks and burden. The level of available evidence to support the evaluation or treatment can be of high (A), medium (B), or low or very low (C) quality. The key recommendations of these guidelines are: We recommend that in patients with varicose veins or more severe CVD, a complete history and detailed physical examination are complemented by duplex ultrasound scanning of the deep and superficial veins (GRADE 1A). We recommend that the CEAP classification is used for patients with CVD (GRADE 1A) and that the revised Venous Clinical Severity Score is used to assess treatment outcome (GRADE 1B). We suggest compression therapy for patients with symptomatic varicose veins (GRADE 2C) but recommend against compression therapy as the primary treatment if the patient is a candidate for saphenous vein ablation (GRADE 1B). We recommend compression therapy as the primary treatment to aid healing of venous ulceration (GRADE 1B). To decrease the recurrence of venous ulcers, we recommend ablation of the incompetent superficial veins in addition to compression therapy (GRADE 1A). For treatment of the incompetent great saphenous vein (GSV), we recommend endovenous thermal ablation (radiofrequency or laser) rather than high ligation and inversion stripping of the saphenous vein to the level of the knee (GRADE 1B). We recommend phlebectomy or sclerotherapy to treat varicose tributaries (GRADE 1B) and suggest foam sclerotherapy as an option for the treatment of the incompetent saphenous vein (GRADE 2C). We recommend against selective treatment of perforating vein incompetence in patients with simple varicose veins (CEAP class C2; GRADE 1B), but we suggest treatment of pathologic perforating veins (outward flow duration >500 ms, vein diameter >3.5 mm) located underneath healed or active ulcers (CEAP class C5-C6; GRADE 2B). We suggest treatment of pelvic congestion syndrome and pelvic varices with coil embolization, plugs, or transcatheter sclerotherapy, used alone or together (GRADE 2B). (J Vasc Surg 2011;53:2S-48S.)

Non-uniform terminology in the world's venous literature has continued to pose a significant hindrance to the dissemination of knowledge regarding the management of chronic venous disorders. This VEIN-TERM consensus document was developed by a transatlantic interdisciplinary faculty of experts under the auspices of the American Venous Forum (AVF), the European Venous Forum (EVF), the International Union of Phlebology (IUP), the American College of Phlebology (ACP), and the International Union of Angiology (IUA). It provides recommendations for fundamental venous terminology, focusing on terms that were identified as creating interpretive problems, with the intent of promoting the use of a common scientific language in the investigation and management of chronic venous disorders. The VEIN-TERM consensus document is intended to augment previous transatlantic/international interdisciplinary efforts in standardizing venous nomenclature which are referenced in this article.

Objective To evaluate the results of the expanded National Venous Screening Program (NVSP) as administered by the American Venous Forum. Methods Eighty-three physicians across 40 states participated in screening Americans for venous disease. The NVSP instrument included demographics, venous thromboembolism (VTE) risk assessment, quality-of-life (QOL) assessment, duplex ultrasound scan for reflux and obstruction, and clinical inspection. Participants received educational materials and a report card to give their physician. Results A total of 2234 individuals underwent screening (mean, 26 people/site; range, 4-42). Demographic data observed included mean age of 60 years (range, 17-93 years); 77% female; 80% Caucasian; mean BMI of 29 (range, 11-68); 40% current or previous smoker; and 24% taking antiplatelet therapy and 4% taking warfarin. If placed in a situation conducive for VTE, 40% of participants were low risk, 22% were moderate risk, 21% were high risk, and 17% were very high risk. On a venous QOL assessment, 17% had a combined total score for all 11 questions of "very limited" or "impossible to do." Reflux or obstruction was noted in 37% and 5% of participants, respectively. CEAP class 0 to 6 was 29%, 29%, 23%, 10%, 9%, 1.5%, 0.5%, respectively. Discussion Despite a dramatic expansion in the second annual NSVP (from 17 to 83 centers), the presence of venous disease observed in a larger screened population continues to be high. The NVSP represents one pathway to increasing public awareness about venous disease.

Acute venous disorders include deep venous thrombosis, superficial venous thrombophlebitis, and venous trauma. Deep venous thrombosis (DVT) most often arises from the convergence of multiple genetic and acquired risk factors, with a variable estimated incidence of 56 to 160 cases per 100,000 population per year. Acute thrombosis is followed by an inflammatory response in the thrombus and vein wall leading to thrombus amplification, organization, and recanalization. Clinically, there is an exponential decrease in thrombus load over the first 6 months, with most recanalization occurring over the first 6 weeks after thrombosis. Pulmonary embolism (PE) and the post-thrombotic syndrome (PTS) are the most important acute and chronic complications of DVT. Despite the effectiveness of thromboembolism prophylaxis, appropriate measures are utilized in as few as one-third of at-risk patients. Once established, the treatment of venous thromboembolism (VTE) has been defined by randomized clinical trials, with appropriate anticoagulation constituting the mainstay of management. Despite its effectiveness in preventing recurrent VTE, anticoagulation alone imperfectly protects against PTS. Although randomized trials are currently lacking, at least some data suggests that catheter-directed thrombolysis or combined pharmaco-mechanical thrombectomy can reduce post-thrombotic symptoms and improve quality of life after acute ileofemoral DVT. Inferior vena caval filters continue to have a role among patients with contra-indications to, complications of, or failure of anticoagulation. However, an expanded role for retrievable filters for relative indications has yet to be clearly established. The incidence of superficial venous thrombophlebitis is likely under-reported, but it occurs in approximately 125,000 patients per year in the United States. Although the appropriate treatment remains controversial, recent investigations suggest that anticoagulation may be more effective than ligation in preventing DVT and PE. Venous injuries are similarly under-reported and the true incidence is unknown. Current recommendations include repair of injuries to the major proximal veins. If repair not safe or possible, ligation should be performed.

This account of chronic venous disease summarizes the clinical aspects of the disorder and reviews the recent advances in studies of the hydrodynamic and biochemical changes that underlie the disorder.

Background Anecdotal evidence suggests a possible link between travel and venous thromboembolism (VTE). We systematically evaluated the evidence from observational studies. Methods We searched studies evaluating the risk of venous thrombosis in relation to traveling from MEDLINE and EMBASE up to March 2004, together with a hand search of reference lists from retrieved literature, and we contacted some of the experts. Observational studies estimating the risks of VTE and isolated calf vein thrombosis were eligible. Methodologic quality was assessed based on prior criteria, and meta-analysis was considered where applicable. Results A total of 194 English-language publications were initially identified. Sixteen studies were included: 9 casecontrol, 2 prospective controlled, and 5 other observational studies. They differed drastically in study designs, selection of controls where applicable, mode and duration of travel, and subtypes of VTE under consideration. Ten studies concluded that travel, mostly through air and of prolonged duration, is a risk factor for venous thrombosis and/or pulmonary embolism, and the risk increases for passengers with preexisting venous thrombosis risk factors. Outcomes examined ranged from asymptomatic isolated calf muscle vein thrombosis to severe fatal pulmonary embolism. Conclusions Current literature is controversial over any association between travel and VTE, and although the quality and power of these studies have been variable, studies of higher quality have shown a strong and significant association between prolonged air travel and VTE. No conclusions could be drawn about other modes of transportation. Since VTE is a disease of multifactorial causation, those with preexisting VTE risk factors are most vulnerable.

Purpose. To define the association between venous volume as measured with air-plethysmography and the duplex ultrasound measured diameter of incompetent perforator of the lower limb. Patients and methods. Thirty-six patients with chronic venous disease were investigated with air-plethysmography and duplex ultrasound. Venous volume and venous filling time was measured. Venous filling index was calculated. The findings were correlated with the diameter of the largest incompetent perforator vein of the lower limb. Results. Twenty-six patients with venous volume in the normal range (80-170 ml) had a median perforator diameter of 3. 5 non (IQR 3.2-4.3). Ten patients with venous volume above 170 ml had median perforator diameter of 5.5 mm (lQR 4.6-7.7). (p=0.001, Mann-Whitney). There was a correlation between the venous volume and diameter of the largest incompetent perforator vein. (Pearson correlation factor 0.69, p=0.01). Conclusion. Limb volume correlates to the diameter of the largest incompetent perforator of the calf. Increase in venous limb volume could be partly responsible for an increase in the size of calf perforators thereby promoting incompetence. (Less)

Clinically, it has been observed that severely and morbidly obese individuals more often have venous leg symptoms related to venous stasis than normal-weight persons have. Obesity is associated with an increased intraabdominal pressure (IAP). The increased IAP in severely and morbidly obese patients would reasonably cause an elevated iliofemoral venous pressure (IFVP), which transmits via incompetent femoral veins, causing venous stasis in the lower limbs. The aim of this study was to determine whether the elevated IAP assessed by the urinary bladder pressure (UBP) corresponded with an increased directly measured IFVP. Fifteen women with morbid obesity were investigated with simultaneous UBP and direct iliofemoral vein pressures. Four normal-weight controls were investigated in the same manner. The obese patients had significantly higher UBP than the controls had, 19.1 and 8.5 cm H2O, respectively. They also had elevated IFVP compared with the controls, 19.7 and 7.5 cm H2O, respectively, and these IFVPs correlated well with the UBPs. The assumption that increased IAP in morbidly obese patients causes increased IFVP was consequently determined. To our knowledge, this has not previously been demonstrated in human individuals. How these elevated pressures contribute to the development of lower limb venous insufficiency is subject to further studies.

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.

Purpose To study intermediate clinical outcomes, rates of recurrent varicosities and neovascularisation, ultrasound changes of the GSV, and the quality of life changes in patients from EVOLVeS trial. Methods Forty five patients were re-examined 1 year and 65 two years after treatment. Follow-up visits included clinical examination with CEAP classification and calculation of venous clinical severity score (VCSS), ultrasound examination, and a quality of life questionnaire. Results The clinical course of the disease (CEAP, VCSS) was similar in the two treatment groups. 51% of the GSV trunks occluded by RFO underwent progressive shrinkage with the external diameter decreased from 6.3 SD 1.4 mm at 72 h after treatment to 2.9 SD 1.5 mm at 2 years. An additional 41% of the GSV became undetectable by ultrasound at 2-year follow up. In two patients we observed re-opening of an initially closed GSV lumen. Neovascularisation was found in one RFO case and in four S and L cases. Cumulative rates of recurrent varicose veins at combined 1 and 2 years follow-up were 14% for RFO and 21% for S and L (NS). The difference in global QOL score in favour of RFO re-appeared at 1 year and remained significant at 2 years after treatment. Conclusion The 2-year clinical results of radiofrequency obliteration are at least equal to those after high ligation and stripping of the GSV. In the vast majority of RFO patients the GSV remained permanently closed, and underwent progressive shrinkage to eventual sonographic disappearance. Recurrence and neovascularisation rates were similar in the two groups although limited patient numbers prevent reliable statistical analysis. Improved quality of life scores persisted through the 2-year observations in the RFO group compared to the S and L group.

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.

Introduction There are no published reports on the association between ethnicity and outcome after aortoiliac stent grafting to treat aneurismal disease. Because Hawaii is a state with an ethnically diverse population, we conducted a retrospective study to examine this potential association. We hypothesized that individuals of Asian ancestry may have higher complication rates after endovascular repair compared with non-Asians. Methods All endovascular devices placed to treat aneurysm disease from 1996 to 2003 were evaluated in two institutions. The association between ethnicity and access-related and device-related complications, both periprocedural and delayed, was examined with logistic regression analysis. Results Ninety-two aortoiliac endografts were placed during the study period, including 87 in patients with abdominal aortic aneurysms with or without iliac aneurysm disease, and five patients with isolated iliac artery aneurysms. Forty-four percent of patients were categorized as Asian, 39% as white, 16% as Pacific Islander, and 1% as African American. Access-related and device-related complications (ADRCs) occurred in 11 of 92 (12%) of these patients. The following parameters were significantly associated with ADRCs: Asian ethnicity ( P =.015), age greater than 80 years ( P = .02), and external iliac diameter smaller than 7.5 mm ( P =.01). Asian patients were more likely to have experienced ADRCs than were non-Asian patients (odds ratio, 7.3; 95% confidence interval, 1.5-35.8; P = .015). Asians also had smaller external iliac artery diameters ( P = .0003) and more tortuous iliac arteries ( P = .03) compared with non-Asians. After adjusting for iliac artery diameter and tortuosity, the association between Asian ethnicity and ARDCs became nonsignificant ( P = .074), which suggests that the association between race and complications may be at least in part due to small and tortuous iliac arteries. There was no association between age, gender, or ethnicity and postoperative detection of endoleak. Conclusion Our data indicate that individuals of Asian ancestry are far more likely to experience adverse access-related and device-related complications after aortoiliac stent grafting than are non-Asians. We found that this association is at least partly attributable to the smaller and more tortuous iliac arteries in persons of Asian ancestry.

The aim of this study was to define the underlying anatomical and pathophysiological conditions in limbs with venous ulcers in order to get information for the most appropriate treatment selection. Ninety-eight limbs (83 patients, 59 men), with active chronic venous ulcers, were analyzed retrospectively and classified according to the CEAP (clinical, etiological, anatomical, and pathophysiological) classification. Duplex-ultrasound was performed in all patients, while air-plethysmography and venography were performed selectively on potential candidates for deep venous reconstruction. Sixty-six ulcers were primary in origin and 32 were secondary. Reflux was present in all limbs except 1. Isolated reflux in 1 system (superficial = 3, deep = 4, perforator = 3) was seen in 10 legs (10%), while incompetence in all 3 systems was seen in 51 legs (52%). Superficial reflux with or without involvement of other systems was seen in 84 legs (86%), 72 legs (73%) had deep reflux with or without involvement of other systems, and incompetent perforator veins were identified in 79 limbs (81%). Axial reflux (continuous reverse flow from the groin region to below knee) was found in 77 limbs (79%). The femoral vein was the single most common deep venous segment in which either reflux or obstruction was found. Axial distribution of disease was found in the majority of cases and no patient had isolated deep venous incompetence below knee. Primary disease was the predominant etiologic cause and reflux was the main pathophysiological finding. Practically all patients were found to have 1 or more sites of reflux or obstruction that could benefit from operative treatment.

Objective We undertook this cross-sectional study to investigate the distribution of venous reflux and effect of axial reflux in superficial and deep veins and to determine the clinical value of quantifying peak reverse flow velocity and reflux time in limbs with chronic venous disease. Patients and methods Four hundred one legs (127 with skin changes, 274 without skin changes) in 272 patients were examined with duplex ultrasound scanning, and peak reverse flow velocity and reflux time were measured. Both parameters were graded on a scale of 0 to 4. The sum of reverse flow scores was calculated from seven venous segments, three in superficial veins (great saphenous vein at saphenofemoral junction, great saphenous vein below knee, small saphenous vein) and four in deep veins (common femoral vein, femoral vein, deep femoral vein, popliteal vein). Axial reflux was defined as reflux in the great saphenous vein above and below the knee or in the femoral vein to the popliteal vein below the knee. Reflux parameters and presence or absence of axial reflux in superficial or deep veins were correlated with prevalence of skin changes or ulcer (CEAP class 4-6). Results The most common anatomic presentation was incompetence in all three systems (superficial, deep, perforator; 46%) or in superficial or perforator veins (28%). Isolated reflux in one system only was rare (15%; superficial, 28 legs; deep, 14 legs; perforator, 18 legs). Deep venous incompetence was present in 244 legs (61%). If common femoral vein reflux was excluded, prevalence of deep venous incompetence was 52%. The cause, according to findings at duplex ultrasound scanning, was primary in 302 legs (75%) and secondary in 99 legs (25%). Presence of axial deep venous reflux increased significantly with prevalence of skin changes or ulcer (C4-C6; odds ratio [OR], 2.7; 95% confidence interval [CI], 1.56-4.67). Of 110 extremities with incompetent popliteal vein, 81 legs had even femoral vein reflux, with significantly more skin changes or ulcer, compared with 29 legs with popliteal reflux alone ( P = .025). Legs with skin changes or ulcer had significantly higher total peak reverse flow velocity ( P = .006), but the difference for total reflux time did not reach significance ( P = .084) compared with legs without skin changes. In contrast, presence of axial reflux in superficial veins did not increase prevalence of skin changes (OR, 0.73; 95% CI, 0.44-1.2). Incompetent perforator veins were observed as often in patients with no skin changes (C0-C3, 215 of 274, 78%) as in patients with skin changes (C4-C6, 106 of 127, 83%; P = .25). Conclusion Continuous axial deep venous reflux is a major contributor to increased prevalence of skin changes or ulcer in patients with chronic venous disease compared with segmental deep venous reflux above or below the knee only. The total peak reverse flow velocity score is significantly higher in patients with skin changes or ulcer. It is questionable whether peak reverse flow velocity and reflux time can be used to quantify venous reflux; however, if they are used, peak reverse flow velocity seems to reflect venous malfunction more appropriately.

Background and purpose Deep venous reflux resolution after great saphenous vein surgery has been reported, but the studies evaluated mainly patients with deep segmental reflux. We prospectively analyzed the effects of greater saphenous vein ablation on coexisting primary deep axial venous reflux compared with segmental venous reflux. Patients and methods Between February 1997 and June 2001, patients with primary deep venous reflux scheduled for greater saphenous vein surgery were included in the study. Limbs of patients with a history of deep venous thrombosis, thrombophlebitis, trauma, and orthopedic or venous surgery were excluded. After surgery, duplex scanning was repeated and patients were examined for persistent deep venous reflux. Results Thirty-three patients (38 limbs) were followed up with duplex scanning. Follow-up ranged from 2 weeks to 38 months. Preoperative axial deep reflux was present in 17 extremities, and segmental reflux was present in 21. The total number of incompetent segments was 59. Overall reflux abolishment rate was similar in extremities with axial and segmental reflux (30% vs 36%; P > .05). When segments were analyzed individually, abolishment of superficial femoral vein reflux was observed more often in extremities with segmental reflux than those with axial reflux (odds ratio, 4). In the extremities where deep reflux was not abolished with greater saphenous vein ablation, degree of reflux did not change significantly ( P > .1). Duplex scanning was performed more than once during follow-up in 9 patients. In 3 of these patients reflux resolved by the second follow-up evaluation, and in 2 reflux was decreased at the second and third follow-up evaluations. Conclusion In patients with concomitant deep and superficial venous reflux, saphenous vein ablation results in resolution of deep reflux in about a third of patients. Superficial femoral vein reflux is seldom corrected in limbs with axial reflux compared with those limbs with segmental reflux. To appreciate the effects of greater saphenous vein ablation, longer follow-up may be needed.

Purpose: The purpose of this study was to investigate the three likely mechanisms of intermittent pneumatic compression (IPC) in deep vein thrombosis prophylaxis (increased volume flow, increased flow velocity, and acceleration of flow) and to do this in a variety of positions, in different venous segments, and with the stimulus of three different compression garments. Methods: In 12 healthy volunteers, three types of compression cuffs were used: foot, calf, and calf + thigh. The foot was compressed with 80 mm Hg, and the calf and thigh with 40 mm Hg. Duplex ultrasound scan was performed before and during the compression in the horizontal, 15-degree head-down, and 15-degree head-up positions. The common femoral, greater saphenous, profunda femoral, superficial femoral, and popliteal veins were examined. Results: In comparison with the horizontal position, the 15-degree head-down position was associated with an increase of volume flow and velocities and the head-up position was associated with decreased flow and velocities in the deep veins. The application of IPC caused significant increases in velocities and volume flow in all venous segments. The lowest increase in velocities and volume flow in the deep veins was observed with the subjects in the head-down position, and in the two other positions, the increases were greater and similar to each other. IPC caused a much more prominent increase in flow velocities and volume flow in deep veins compared with simple elevation of the legs. Conclusion: IPC produces significant increases of venous flow volume and flow velocity and acceleration of flow. This is true whether the limbs are elevated, horizontal, or dependent. Segmental flow changes vary with the position of the patient and the compression garment used. Foot compression increases volume flow and velocity primarily in the popliteal vein. Calf compression provides maximal increases of volume flow and flow velocity through the deep veins. (J Vasc Surg 2003;37:137-42.)

Long-distance air travel is increasing and cases of venous thromboembolism (VTE) following air travel have attracted both considerable public attention and legal claims against airlines. VTE is a common disorder worldwide with a notably high incidence in older individuals. Many biochemical factors that lead to, or accentuate, thrombus formation are associated with increased risk of VTE. These factors include thrombophilia, activated protein C resistance and factor V Leiden, prothrombin gene mutation, antiphospholipid antibodies, protein S and protein C deficiencies, and methylene tetrahydrofolate reductase polymorphism and homocysteinemia. Individual physical characteristics including age, weight and height are significant for personal risk of VTE as are other factors such as use of oral contraceptives in women. In the case of air travel-related venous thrombosis, superimposed upon these individual factors are the environmental factors directly related to air travel. Travel-related factors include stasis associated with prolonged periods of immobility, physiological stresses resulting from exposure to the cabin environment (low humidity and hypoxia) in long-haul flight and other in-flight factors. It is suggested that passenger behavior (movement, avoidance of dehydration and of alcohol) and appropriate pharmacological prophylaxis for high-risk travelers can reduce the likelihood of VTE. Physical prophylaxis (use of compression stockings or in-flight exercise devices) may also be of general benefit to passengers. It is recommended that airlines become more proactive in educating passengers concerning the dangers of VTE and in promoting passenger actions that can reduce risk. Airlines should also work to avoid cramped seating conditions (seat size and pitch) that contribute to prolonged immobility. Governments and regulatory authorities should mandate the provision of adequate seating conditions and a good cabin environment and should support studies that will define risks and determine the efficacy of protocols to minimize dangers of VTE. Increased long-haul air traffic and an aging population suggest that travel-related VTE may present a growing healthcare threat and has highlighted a need for additional biomedical research into the causes and potential solutions to this problem.

Persistent sciatic artery (PSA) is a continuation of the internal iliac artery into the poplitealtibial vessels and provides the major supply to the lower limb bud in early embryologic development, and its remnants participate in the formation of the inferior gluteal, deep femoral, popliteal, peroneal, and pedal vessels. When the femoral artery develops, the PSA involutes. In rare circumstances it persists and has a bilateral location in 22% of cases of PSA. This rare vascular anomaly is associated with aneurysmal formation in 15% to 46% of cases. Persistent sciatic artery aneurysm (PSAA) was first described in 1864. At present 87 cases, including this case, have been reported in the international literature. The authors describe a patient affected with PSAA and treated with a combination of thrombolysis, arterial reconstruction, and aneurysm embolization in a staged fashion. Embryology, anatomy, pathology, clinical presentation, diagnosis, and treatment of this rare disease are briefly discussed.

The authors investigate the impact of overweight in patients with chronic venous disease and determine if the eventual effect can be explained by increased venous reflux alone. Patients with chronic venous disease who underwent duplex-ultrasound scanning at the Vascular Center, Straub Clinic and Hospital during 1999 were classified according to the clinical, etiologic, anatomic, and pathophysiologic (CEAP) system and body mass index (kg/M2) was calculated. Reflux duration was measured in seconds and peak reverse flow velocity in cm/second. Multisegment reflux score (total score) was calculated for both reflux duration and peak reverse flow velocity. The reflux pattern and body mass index were correlated to the clinical presentation. Four hundred and one lower extremities (204 right, 197 left) in 272 patients (173 female) with a mean age of 60 years (range 14-90) were investigated. The mean body mass index was 28.9 (±7.76). One hundred sixty-seven patients (61%) were overweight (body mass index 25 kg/M2 or more). There was a significant association between body mass index and the clinical severity (p < 0.001). This association persisted after adjustments for total peak reverse flow velocity and total reflux score were made (p 2, despite similar values for total reflux time (p = 0.92) and total peak reverse flow velocity (p = 0.98). There was an ethnic difference, with Pacific Islanders being significantly heavier and younger compared to patients of white, Asian and Filipino ancestries. The variations in the frequency of skin changes were consistent with ethnic differences in body mass index. The correlation of body mass index with clinical severity independent of reflux measurements indicates that the effect of overweight may involve a mechanism separate from local effects on venous flow. Overweight appears to be a separate risk factor for increased severity of skin changes in patients with chronic venous disease.

Purpose: The purpose of this study was the analysis of the rapid changes in the size and shape of the peripheral vein and the associated changes in blood flow velocities and the estimation of their effect on the reliability of the ultrasound scan volume flow (VF) measurements. Methods: Ten patients with primary chronic venous insufficiency and 10 healthy volunteers were studied. Two duplex scanners were used simultaneously: one for the velocity measurements in longitudinal plane and another for the cross-sectional area (CSA) measurements in transverse plane during quiet respiration, Valsalva's maneuver (VM), pneumatic cuff compression-decompression, and active dorsiflexion. The patients underwent examination in standing and 15-degrees reverse Trendelenburg's (RT) positions. VF was calculated on the basis of real-time CSA and velocity values. Results: Rapid changes in the CSA as much as 130% for 0.2 seconds were observed. In most cases, the changes in CSA and the flow velocity were inversely related, which resulted in near constant VF. With the exception of VM in the RT position, the difference between real-time VF and mean VF was not significant ( P >.05). In the RT position, significant changes in CSA were observed during and immediately after VM. These changes resulted in 23% ± 15% changes in outflow (both groups) and in 24% ± 13% changes in reflux (chronic venous insufficiency group). Conclusion: The CSA of the peripheral vein and the flow velocities undergo rapid changes during time intervals of a fraction of a second. The vein can have a noncircular cross-section. To minimize the potential error, VF measurements should be performed during quiet respiration or with cuff compression-decompression. With these conditions, the rapid changes in velocities and CSA do not significantly affect the accuracy of VF measurements because of their inverse relation. CSA should be measured planimetrically, or the site of the measurements should be where the vein is close to a circular shape. (J Vasc Surg 2002;35:522-6.)

Axial deep venous reflux can be found in the majority of extremities with advanced skin changes and ulceration. It frequently is associated with recurrent disease and tends to progress with time. More than 30 years' experience with deep venous reconstructive surgery, as well as recent advances in diagnostic imaging, makes possible the rational use of such techniques in the management of chronic venous insufficiency. This report reviews the role of deep venous reflux in the natural history and progression of venous disease, the options for surgical correction of deep venous reflux, the current diagnostic abilities and limitations, and the results of surgical interventions.

Thomas F. O’Donnell Jr, MD, Marc A. Passman, MD, William A. Marston, MD, William J. Ennis, DO, Michael Dalsing, MD, Robert L. Kistner, MD, Fedor Lurie, MD, PhD, Peter K. Henke, MD, Monika L. Gloviczki, MD, PhD, Bo G. Eklof, MD, PhD, Julianne Stoughton, MD, Sesadri Raju, MD, Cynthia K. Shortell, MD, Joseph D. Raffetto, MD, Hugo Partsch, MD, Lori C. Pounds, MD, Mary E. Cummings, MD, David L. Gillespie, MD, Robert B. McLafferty, MD, Mohammad Hassan Murad, MD, Thomas W. Wakefield, MD, and Peter Gloviczki, MD