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• W1984366284 abstract "In response to the need for a disease severity measurement, the American Venous Forum committee on outcomes assessment developed the Venous Severity Scoring system in 2000. There are three components of this scoring system, the Venous Disability Score, the Venous Segmental Disease Score, and the Venous Clinical Severity Score (VCSS). The VCSS was developed from elements of the CEAP classification (clinical grade, etiology, anatomy, pathophysiology), which is the worldwide standard for describing the clinical features of chronic venous disease. However, as a descriptive instrument, the CEAP classification responds poorly to change. The VCSS was subsequently developed as an evaluative instrument that would be responsive to changes in disease severity over time and in response to treatment.Based on initial experiences with the VCSS, an international ad hoc working group of the American Venous Forum was charged with updating the instrument. This revision of the VCSS is focused on clarifying ambiguities, updating terminology, and simplifying application. The specific language of proven quality-of-life instruments was used to better address the issues of patients at the lower end of the venous disease spectrum. Periodic review and revision are necessary for generating more universal applicability and for comparing treatment outcomes in a meaningful way. In response to the need for a disease severity measurement, the American Venous Forum committee on outcomes assessment developed the Venous Severity Scoring system in 2000. There are three components of this scoring system, the Venous Disability Score, the Venous Segmental Disease Score, and the Venous Clinical Severity Score (VCSS). The VCSS was developed from elements of the CEAP classification (clinical grade, etiology, anatomy, pathophysiology), which is the worldwide standard for describing the clinical features of chronic venous disease. However, as a descriptive instrument, the CEAP classification responds poorly to change. The VCSS was subsequently developed as an evaluative instrument that would be responsive to changes in disease severity over time and in response to treatment. Based on initial experiences with the VCSS, an international ad hoc working group of the American Venous Forum was charged with updating the instrument. This revision of the VCSS is focused on clarifying ambiguities, updating terminology, and simplifying application. The specific language of proven quality-of-life instruments was used to better address the issues of patients at the lower end of the venous disease spectrum. Periodic review and revision are necessary for generating more universal applicability and for comparing treatment outcomes in a meaningful way. As awareness of the morbidity and socioeconomic consequences of chronic venous disease has increased, so has the technology available for treatment. A critical need now exists for outcomes assessment instruments that reflect the morbidity associated with chronic venous disease and the response to treatment. Several instruments have been developed that serve to describe the severity of disease or to measure clinical outcomes. Disease-specific patient-reported quality-of-life tools are popular in venous disease reporting and have high sensitivity.1Davies A.H. Rudarakanchana N. Quality of life and outcome assessment in patients with varicose veins.in: Davies A.H. Lees T.A. Lane I.F. Venous disease simplified. TFM Publishing Ltd, Shropshire, England2006Google Scholar Tools relying on physician observation classify venous disease and evaluate clinically relevant changes over time.2Vasquez M.A. Munschauer C.E. Venous Clinical Severity Score and quality-of-life assessment tools: application to vein practice.Phlebology. 2008; 23: 259-275Crossref PubMed Scopus (99) Google Scholar Many of these outcomes tools have been validated,3Meissner M.H. Natiello C. Nicholls S.C. Performance characteristics of the Venous Clinical Severity Score.J Vasc Surg. 2002; 36: 889-895Abstract Full Text PDF PubMed Scopus (108) Google Scholar, 4Kahn S.R. M'Lan C.E. Lamping D.L. Kurz X. Berard A. Abenhaim L.A. VEINES Study GroupRelationship between clinical classification of chronic venous disease and patient-reported quality of life: results from an international cohort study.J Vasc Surg. 2004; 39: 823-828Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar, 5Launois R. Reboul-Marty J. Henry B. Construction and validation of a quality of life questionnaire in chronic lower limb venous insufficiency (CIVIQ).Qual Life Res. 1996; 5: 539-554Crossref PubMed Scopus (342) Google Scholar and each has strengths and weaknesses. The Venous Clinical Severity Score (VCSS) was designed not to replace the CEAP classification but to supplement it and provide a method for serial assessment.6Rutherford R.B. Padberg Jr, F.T. Comerota A.J. Kistner R.L. Meissner M.H. Moneta G.L. American Venous Forum's Ad Hoc Committee on Venous Outcomes AssessmentVenous severity scoring: an adjunct to venous outcome assessment.J Vasc Surg. 2000; 31: 1307-1312Abstract Full Text Full Text PDF PubMed Scopus (574) Google Scholar, 7Kakkos S.K. Rivera M.A. Matsagas M.I. Lazarides M.K. Robless P. Belcaro G. et al.Validation of the new venous severity scoring system in varicose vein surgery.J Vasc Surg. 2003; 38: 224-228Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar It was also designed to give additional weight to more severe manifestations of chronic venous disease (CEAP clinical class 4 and class 6).6Rutherford R.B. Padberg Jr, F.T. Comerota A.J. Kistner R.L. Meissner M.H. Moneta G.L. American Venous Forum's Ad Hoc Committee on Venous Outcomes AssessmentVenous severity scoring: an adjunct to venous outcome assessment.J Vasc Surg. 2000; 31: 1307-1312Abstract Full Text Full Text PDF PubMed Scopus (574) Google Scholar It has been shown to withstand differences in intraobserver and interobserver reproducibility and to be responsive to change.3Meissner M.H. Natiello C. Nicholls S.C. Performance characteristics of the Venous Clinical Severity Score.J Vasc Surg. 2002; 36: 889-895Abstract Full Text PDF PubMed Scopus (108) Google Scholar The VCSS has been used and evaluated in multiple studies,7Kakkos S.K. Rivera M.A. Matsagas M.I. Lazarides M.K. Robless P. Belcaro G. et al.Validation of the new venous severity scoring system in varicose vein surgery.J Vasc Surg. 2003; 38: 224-228Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar, 8Mekako A.I. Hatfield J. Bryce J. Lee D. McCollum P.T. Chetter I. A nonrandomized controlled trial of endovenous laser therapy and surgery in the treatment of varicose veins.Ann Vasc Surg. 2006; 20: 451-457Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar, 9Gillett J.L. Perrin M.R. Allaert F.A. Clinical presentation and venous severity scoring of patients with extended deep axial vein reflux.J Vasc Surg. 2006; 44: 588-594Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 10Ricci M.A. Emmerich J. Callas P.W. Rosendaal F.R. Stanley A.C. Naud S. et al.Evaluating chronic venous disease with a new venous severity scoring system.J Vasc Surg. 2003; 38: 909-915Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 11Rasmussen L.H. Bjoern L. Lawaetz M. Blemings A. Lawaetz B. Eklof B. randomized trial comparing endovenous laser ablation of the great saphenous vein with high ligation and stripping in patients with varicose veins: short-term results.J Vasc Surg. 2007; 46: 308-315Abstract Full Text Full Text PDF PubMed Scopus (238) Google Scholar, 12Vasquez M.A. Wang J. Mahathanaruk M. Buczkowski G. Sprehe E. Dosluoglu H.H. The utility of the Venous Clinical Severity Score in 682 limbs treated by radiofrequency saphenous vein ablation.J Vasc Surg. 2007; 45: 1008-1015Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 13Perrin M. Dedieu F. Jessent V. Blanc M.P. Evaluation of the new severity scoring system in chronic venous disease of the lower limbs: an observational study conducted by French angiologists.Phlebolymphology. 2006; 13: 6-16Google Scholar with varied results. Despite widespread use of the CEAP clinical class and the large volume of venous procedures being performed, use of the VCSS has been limited. Although the usefulness of the VCSS has been clearly demonstrated, several areas of deficiency have also been noted.9Gillett J.L. Perrin M.R. Allaert F.A. Clinical presentation and venous severity scoring of patients with extended deep axial vein reflux.J Vasc Surg. 2006; 44: 588-594Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 10Ricci M.A. Emmerich J. Callas P.W. Rosendaal F.R. Stanley A.C. Naud S. et al.Evaluating chronic venous disease with a new venous severity scoring system.J Vasc Surg. 2003; 38: 909-915Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 12Vasquez M.A. Wang J. Mahathanaruk M. Buczkowski G. Sprehe E. Dosluoglu H.H. The utility of the Venous Clinical Severity Score in 682 limbs treated by radiofrequency saphenous vein ablation.J Vasc Surg. 2007; 45: 1008-1015Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar Ambiguity in the clinical descriptors has been identified as a primary shortcoming of the instrument.9Gillett J.L. Perrin M.R. Allaert F.A. Clinical presentation and venous severity scoring of patients with extended deep axial vein reflux.J Vasc Surg. 2006; 44: 588-594Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Other investigators have suggested that the VCSS is more appropriate for use in severe chronic venous disease.13Perrin M. Dedieu F. Jessent V. Blanc M.P. Evaluation of the new severity scoring system in chronic venous disease of the lower limbs: an observational study conducted by French angiologists.Phlebolymphology. 2006; 13: 6-16Google Scholar In response to these initial experiences with the VCSS and under the auspices of the American Venous Forum, an ad hoc outcomes working group of international, interdisciplinary experts was assembled to evaluate and revise the current VCSS. The intent of this revision (Table I) includes continuing to promote use of the instrument, while not undermining current databases and ongoing trials. An excellent model of an accepted refinement is found in “Revision of the CEAP Classification for Chronic Venous Disorders: Consensus Statement.”14Eklöf B. Rutherford R.B. Bergan J.J. Carpentier P.H. Gloviczki P. Kistner R.L. et al.American Venous Forum International Ad Hoc Committee for Revision of the CEAP ClassificationRevision of the CEAP classification for chronic venous disorders: consensus statement.J Vasc Surg. 2004; 40: 1248-1252Abstract Full Text Full Text PDF PubMed Scopus (1395) Google Scholar The specific language of proven quality-of-life instruments was used to better address the issues of patients at the less severe disease end of the venous disease spectrum. The objective of this revision is to improve the VCSS, while acknowledging its limitations and preserving its strengths (Table II) . Future studies are in progress to validate the reliability, reproducibility, and responsiveness of the revised VCSS.Table IRevised Venous Clinical Severity ScoreNone: 0Mild: 1Moderate: 2Severe: 3Pain or other discomfort (ie, aching, heaviness, fatigue, soreness, burning) Presumes venous originOccasional pain or other discomfort (ie, not restricting regular daily activities)Daily pain or other discomfort (ie, interfering with but not preventing regular daily activities)Daily pain or discomfort (ie, limits most regular daily activities)Varicose veins “Varicose” veins must be ≥3 mm in diameter to qualify in the standing position.Few: scattered (ie, isolated branch varicosities or clusters)Also includes corona phlebectatica (ankle flare)Confined to calf or thighInvolves calf and thighVenous edema Presumes venous originLimited to foot and ankle areaExtends above ankle but below kneeExtends to knee and aboveSkin pigmentation Presumes venous origin Does not include focal pigmentation over varicose veins or pigmentation due to other chronic diseasesNone or focalLimited to perimalleolar areaDiffuse over lower third of calfWider distribution above lower third of calfInflammation More than just recent pigmentation (ie, erythema, cellulitis, venous eczema, dermatitis)Limited to perimalleolar areaDiffuse over lower third of calfWider distribution above lower third of calfInduration Presumes venous origin of secondary skin and subcutaneous changes (ie, chronic edema with fibrosis, hypodermitis). Includes white atrophy and lipodermatosclerosisLimited to perimalleolar areaDiffuse over lower third of calfWider distribution above lower third of calfActive ulcer number012≥3Active ulcer duration (longest active)N/A<3 mo>3 mo but <1 yNot healed for >1 yActive ulcer size (largest active)N/ADiameter <2 cmDiameter 2-6 cmDiameter >6 cmUse of compression therapy0Not used1Intermittent use of stockings2Wears stockings most days3Full compliance: stockings Open table in a new tab Table IIInstructions for using the Revised Venous Clinical Severity ScoreOn a separate form, the clinician will be asked to:“For each leg, please check 1 box for each item (symptom and sign) that is listed below.”Pain or other discomfort (ie, aching, heaviness, fatigue, soreness, burning)The clinician describes the four categories of leg pain or discomfort that are outlined below to the patient and asks the patient to choose, separately for each leg, the category that best describes the pain or discomfort the patient experiences.None = 0:NoneMild = 1:Occasional pain or discomfort that does not restrict regular daily activitiesModerate = 2:Daily pain or discomfort that interferes with, but does not prevent, regular daily activitiesSevere = 3:Daily pain or discomfort that limits most regular daily activitiesVaricose VeinsThe clinician examines the patient's legs and, separately for each leg, chooses the category that best describes the patient's superficial veins. The standing position is used for varicose vein assessment. Veins must be ≥3 mm in diameter to qualify as “varicose veins.”None = 0:NoneMild = 1:Few, scattered, varicosities that are confined to branch veins or clusters. Includes “corona phlebectatica” (ankle flare), defined as >5 blue telangiectases at the inner or sometimes the outer edge of the footModerate = 2:Multiple varicosities that are confined to the calf or the thighSevere = 3:Multiple varicosities that involve both the calf and the thighVenous EdemaThe clinician examines the patient's legs and, separately for each leg, chooses the category that best describes the patient's pattern of leg edema. The clinician's examination may be supplemented by asking the patient about the extent of leg edema that is experienced.None = 0:NoneMild = 1:Edema that is limited to the foot and ankleModerate = 2:Edema that extends above the ankle but below the kneeSevere = 3:Edema that extends to the knee or aboveSkin PigmentationThe clinician examines the patient's legs and, separately for each leg, chooses the category that best describes the patient's skin pigmentation. Pigmentation refers to color changes of venous origin and not secondary to other chronic diseases.None = 0:None, or focal pigmentation that is confined to the skin over varicose veinsMild = 1:Pigmentation that is limited to the perimalleolar areaModerate = 2:Diffuse pigmentation that involves the lower third of the calfSevere = 3:Diffuse pigmentation that involves more than the lower third of the calfInflammationThe clinician examines the patient's legs and, separately for each leg, chooses the category that best describes the patient's skin inflammation. Inflammation refers to erythema, cellulitis, venous eczema, or dermatitis, rather than just recent pigmentation.None = 0:NoneMild = 1:Inflammation that is limited to the perimalleolar areaModerate = 2:Inflammation that involves the lower third of the calfSevere = 3:Inflammation that involves more than the lower third of the calfIndurationThe clinician examines the patient's legs and, separately for each leg, chooses the category that best describes the patient's skin induration. Induration refers to skin and subcutaneous changes such as chronic edema with fibrosis, hypodermitis, white atrophy, and lipodermatosclerosis.None = 0:NoneMild = 1:Induration that is limited to the perimalleolar areaModerate = 2:Induration that involves the lower third of the calfSevere = 3:Induration that involves more than the lower third of the calfActive Ulcer NumberThe clinician examines the patient's legs and, separately for each leg, chooses the category that best describes the number of active ulcers.None = 0:NoneMild = 1:1 ulcerModerate = 2:2 ulcersSevere = 3:≥3 ulcersActive Ulcer DurationIf there is at least 1 active ulcer, the clinician describes the 4 categories of ulcer duration that are outlined below to the patient and asks the patient to choose, separately for each leg, the category that best describes the duration of the longest unhealed ulcer.None = 0:No active ulcersMild = 1:Ulceration present for <3 moModerate = 2:Ulceration present for 3-12 moSevere = 3:Ulceration present for >12 moActive Ulcer SizeIf there is at least 1 active ulcer, the clinician examines the patient's legs, and separately for each leg, chooses the category that best describes the size of the largest active ulcer.None = 0:No active ulcerMild = 1:Ulcer <2 cm in diameterModerate = 2:Ulcer 2-6 cm in diameterSevere = 3:Ulcer >6 cm in diameterUse of Compression TherapyChoose the level of compliance with medical compression therapyNone = 0:Not usedMild = 1:Intermittent useModerate = 2:Wears stockings most daysSevere = 3:Full compliance: stockings Open table in a new tab At the 20th Annual Meeting of the American Venous Forum in 2008, an outcomes ad hoc working group was created to review and revise the original VCSS (Table III). This group evaluated available patient-reported and clinical outcomes instruments, examined studies regarding use of the VCSS, and considered recommendations from the assembled experts. In addition to several meetings, correspondence was conducted by e-mail. Published studies using the VCSS were reviewed and considered for this revision. Based on these interactions, the clinical descriptors were altered to clarify the language and use universally accepted terms, while retaining the basic construct of the instrument. Based on the clinician's examination and objective measurements, a venous origin is presumed for all clinical descriptors. Each limb is considered and scored separately.Table IIIOriginal Venous Clinical Severity ScoreAttributeAbsent = 0Mild = 1Moderate = 2Severe = 3PainNoneOccasional, not restricting activity or requiring analgesicsDaily, moderate activity limitation, occasional analgesicsDaily, severe limiting activities or requiring regular use of analgesicsVaricose veinsa“Varicose” veins must be >4-mm diameter to qualify so that differentiation is ensured between C1 and C2 venous pathology.NoneFew, scattered: branch VVsMultiple: GS varicose veins confined to calf or thighExtensive: Thigh and calf or GS and LS distributionVenous edemabPresumes venous origin by characteristics (eg, brawny [not pitting or spongy] edema), with significant effect of standing/limb elevation and/or other clinical evidence of venous etiology (ie, varicose veins, history of DVT). Edema must be regular finding (eg, daily occurrence). Occasional or mild edema does not qualify.NoneEvening ankle edema onlyAfternoon edema, above ankleMorning edema above ankle and requiring activity change, elevationSkin pigmentationcFocal pigmentation over varicose veins does not qualify.None or focal, low intensity (tan)Diffuse, but limited in area and old (brown)Diffuse over most of gaiter distribution (lower 1/3) or recent pigmentation (purple)Wider distribution (above lower 1/3) and recent pigmentationInflammationNoneMild cellulitis, limited to marginal area around ulcerModerate cellulitis, involves most of gaiter area (lower 1/3)Severe cellulitis (lower 1/3 and above) or significant venous eczemaIndurationNoneFocal, circummalleolar (<5 cm)Medial or lateral, less than lower third of legEntire lower third of leg or moreNo. of active ulcers012> 2Active ulceration, durationNone<3 mo>3 mo, <1 yNot healed >1 yActive ulcer, sizedLargest dimension/diameter of largest ulcer.None<2-cm diameter2- to 6-cm diameter>6-cm diameterCompressive therapyeSliding scale to adjust for background differences in use of compression therapy.Not used or not compliantIntermittent use of stockingsWears elastic stockings most daysFull compliance: stockings + elevationa “Varicose” veins must be >4-mm diameter to qualify so that differentiation is ensured between C1 and C2 venous pathology.b Presumes venous origin by characteristics (eg, brawny [not pitting or spongy] edema), with significant effect of standing/limb elevation and/or other clinical evidence of venous etiology (ie, varicose veins, history of DVT). Edema must be regular finding (eg, daily occurrence). Occasional or mild edema does not qualify.c Focal pigmentation over varicose veins does not qualify.d Largest dimension/diameter of largest ulcer.e Sliding scale to adjust for background differences in use of compression therapy. Open table in a new tab The first descriptor, pain, was amended to include frequently encountered patient symptoms including aching, heaviness, fatigue, soreness, and burning. These terms are pertinent in establishing pain as venous in origin,15Eklöf B. Perrin M. Delis K.T. Rutherford R.B. Gloviczki P. American Venous Forum; European Venous Forum; International Union of Phlebology; American College of Phlebology; International Union of AngiologyUpdated terminology of chronic venous disorders: the VEIN-TERM transatlantic interdisciplinary consensus document.J Vasc Surg. 2009; 49: 498-501Abstract Full Text Full Text PDF PubMed Scopus (247) Google Scholar and usually change in response to treatment, as has been demonstrated by disease-specific quality-of-life measures.1Davies A.H. Rudarakanchana N. Quality of life and outcome assessment in patients with varicose veins.in: Davies A.H. Lees T.A. Lane I.F. Venous disease simplified. TFM Publishing Ltd, Shropshire, England2006Google Scholar, 4Kahn S.R. M'Lan C.E. Lamping D.L. Kurz X. Berard A. Abenhaim L.A. VEINES Study GroupRelationship between clinical classification of chronic venous disease and patient-reported quality of life: results from an international cohort study.J Vasc Surg. 2004; 39: 823-828Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar, 5Launois R. Reboul-Marty J. Henry B. Construction and validation of a quality of life questionnaire in chronic lower limb venous insufficiency (CIVIQ).Qual Life Res. 1996; 5: 539-554Crossref PubMed Scopus (342) Google Scholar, 16Kahn S.R. Lamping D.L. Ducruet T. Arsenault L. Miron M.J. Roussin A. et al.VETO Study InvestigatorsVEINES-QOL/Sym questionnaire was a reliable and valid disease-specific quality of life measure for deep venous thrombosis [published correction appears in J Clin Epidemiol 2006;59:1334].J Clin Epidemiol. 2006; 59: 1049-1056Abstract Full Text Full Text PDF PubMed Scopus (108) Google Scholar, 17Padberg F. Regarding ‘Evaluating outcomes in chronic venous disorders of the leg: development of a scientifically rigorous, patient-reported measure of symptoms and quality of life’.J Vasc Surg. 2003; 37: 911-912Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 18Howard A. Davies A.H. Health-related quality of life in patients with venous ulceration.Phlebology. 2001; 16: 12-16Crossref Scopus (16) Google Scholar Pain with exercise, as more commonly experienced with iliofemoral obstruction (ie, venous claudication19Meissner M.H. Eklof B. Smith P.C. Dalsing M.C. Depalma R.G. Gloviczki P. et al.Secondary chronic venous disorders.J Vasc Surg. 2007; 46: 68S-83SAbstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar) may be scored with this component. The pain component was also modified to assess its limiting effect on regular daily activities. Pain of nonvenous origin (such as arthritic or at the site of a treatment) is not to be included in this category. Within the second descriptor, varicose veins, the vein size criterion was modified to “at least 3-mm diameter” to remain consistent with the revised CEAP classification.14Eklöf B. Rutherford R.B. Bergan J.J. Carpentier P.H. Gloviczki P. Kistner R.L. et al.American Venous Forum International Ad Hoc Committee for Revision of the CEAP ClassificationRevision of the CEAP classification for chronic venous disorders: consensus statement.J Vasc Surg. 2004; 40: 1248-1252Abstract Full Text Full Text PDF PubMed Scopus (1395) Google Scholar In this definition, “varicose veins” involve any subcutaneous saphenous veins, saphenous tributaries, or nonsaphenous superficial leg veins. The standing position for varicose vein assessment has been clarified in the instructions for use (Table II). Therefore, an overall change in the standing position size of previously engorged or enlarged veins may affect the score of this section if those veins shrink to less than 3 mm in diameter. Varicosities that are confined to either the calf or thigh are distinguished from varicosities that are present in both the calf and thigh. Great saphenous varicose vein distributions are not differentiated from small saphenous vein distributions in this revised version. Telangiectasias and reticular veins are still not included and remain without a score. Corona phlebectatica (ankle flare) is defined as more than five blue telangiectasias on the inner or outer edge of the foot. Corona phlebectatica is associated with chronic venous insufficiency (CVI) and perforator reflux 20Uhl J.F. Cornu-Thenard A. Carpentier P.H. Widmer M.T. Partsch H. et al.Clinical and hemodynamic significance of corona phlebectatica in chronic venous disorders.J Vasc Surg. 2005; 42: 1163-1168Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar but is not truly “skin pigmentation,” which is defined by the revised CEAP classification as “brownish darkening of skin, resulting from extravasated blood.”14Eklöf B. Rutherford R.B. Bergan J.J. Carpentier P.H. Gloviczki P. Kistner R.L. et al.American Venous Forum International Ad Hoc Committee for Revision of the CEAP ClassificationRevision of the CEAP classification for chronic venous disorders: consensus statement.J Vasc Surg. 2004; 40: 1248-1252Abstract Full Text Full Text PDF PubMed Scopus (1395) Google Scholar Therefore, corona phlebectatica was added to the mild category and assigned a score of 1 (Fig 1). The third descriptor, venous edema, was amended to reflect the anatomic distribution and extent. Edema of presumed venous origin is defined in the revised CEAP classification as a “perceptible increase in volume of fluid in skin and subcutaneous tissue, characteristically indented with pressure.”14Eklöf B. Rutherford R.B. Bergan J.J. Carpentier P.H. Gloviczki P. Kistner R.L. et al.American Venous Forum International Ad Hoc Committee for Revision of the CEAP ClassificationRevision of the CEAP classification for chronic venous disorders: consensus statement.J Vasc Surg. 2004; 40: 1248-1252Abstract Full Text Full Text PDF PubMed Scopus (1395) Google Scholar The revised VCSS edema attribute is scored by extent: (1) limited to the foot and ankle, (2) extends above the ankle but below the knee, or (3) extends to the knee or above. Considering that patients have differing daily routines, the clinician's examination should be supplemented by asking the patient about the nature and extent of leg edema experienced. Guideline criteria are now provided for the fourth attribute, skin pigmentation, with regard to both anatomic distribution and extent. This is also reflected in the inflammation and induration categories. The criteria include skin pigmentation that is (1) limited to the perimalleolar area, (2) involves the lower third of the calf, or (3) extends beyond the lower third of the calf. Skin pigmentation refers only to color changes of venous origin and not those related to other chronic diseases such as vasculitis purpura. Focal pigmentation that is confined to the skin over a varicose vein is not considered to signify the same severity of venous disease as more diffuse pigmentation and is given a score of 0. Skin color changes occurring at the site of a previous venous procedure such as endovenous ablation, phlebectomy, or sclerotherapy should not be included in the assessment of skin pigmentation. Different levels of pigmentation are illustrated in Fig 2. The inflammation fifth descriptor was expanded to focus on more than just recent skin pigmentation changes or underlying infection. Inflammation here refers to the acute aspects of venous disease, those likely to respond to treatment, which may occur at the same time as other more chronic changes of skin pigmentation, induration, or ulceration. The terms erythema, cellulitis, venous eczema, and dermatitis were incorporated here. Also, the descriptors now provide for anatomic distribution and extent, similar to the skin pigmentation and induration categories (Fig 3). Induration, the sixth descriptor, was modified to reflect more severe venous disease. Chronic edema with fibrosis, hypodermitis, white atrophy, and lipodermatosclerosis were terms added in part to promote more universal use. It is recognized that this category, similar to skin pigmentation, is usually much slower to respond to treatment, if at all. For simplicity, the distribution language is the same as that for skin pigmentation and inflammation (Fig 4). In the active ulcer categori" @default.
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• W1984366284 title "Revision of the venous clinical severity score: Venous outcomes consensus statement: Special communication of the American Venous Forum Ad Hoc Outcomes Working Group" @default.
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