CONTENTS  •  Volume 10  Number 2 1995

I have discussed the usefulness and validity of consensus statements in an earlier editorial [1] considering that they may be ignored, misused and sometimes helpful! This issue contains a further statement concerning the classification of venous disease, an area where problems remain. Numerous publications appear each year on venous disease, and yet the data from different centres maybe difficult to compare. A lack of international standardization in the classification of venous diseases results in different investigators using dissimilar methods of patient grouping for from the purposes of data analysis. For example, there are many ways in which the terms ‘chronic venous insufficiency’ or ‘trophic skin changes’ are interpreted. The standards currently used for venous classification include those of Widmer and those published by a joint committee of the (North American) Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery [2]. The latter is widely quoted but has the disadvantage that is describes only the clinical severity of disease, and this has only five stages. Such a classification reflects the difficulty in reaching agreement between participants of a consensus group in an area of clinical medicine where few objective tests are available to define the pathology. A single axis system of this type can only take into account one aspect of the disease, such as clinical presentation. We now regularly investigate patients using colour duplex ultrasonography which can provide detailed information of the cause and anatomical extent of venous disease. None of these data could be included in the earlier methods of classification. The requirement for a system of describing each aspect of a patient with venous disease, without undue complexity, has long been recognized.

This problem was put to an international group of phlebologists who secured themselves in an air-conditioned room in Maui, Hawaii and eventually arrived at the classification published in this issue. Determination to further the interests of international phlebology surpassed the urges of all to visit the magnificent beaches! The result is a multi-axial system of describing venous disease, referred to as ‘CEAP’ (Clinical, [a]Etiological, Anatomical and Pathophysiological components). The clinical classification differentiates telangiectases from truncal varicose veins, and healed ulcers from open ulcers, in a seven stage description. This gives better definition of the clinical appearances than any earlier system. The remaining three categories allow entry of data accrued from special investigations such as duplex ultrasonography or phlebography, recording the disease as congenital, primary or secondary, the presence of obstruction or incompetence, and the exact anatomical location of the disease. This process is more exhaustive than the earlier methods and certainly produces much more complex codes, for example:

C₆E_SA_DP_R,O-I

which would describe a post-thrombotic leg ulcer, with residual iliac vein obstruction. Although such codes can he read by humans, these days data recording is usually undertaken with the aid of a computer. Modern computer software is ideally suited to converting the simple sets of data recorded by the classification into the correct code. Data encoded in this way will be far more informative than any simple method, and most importantly, will allow comparison of studies performed in different centres and countries. The system of encoding includes the use of extensions of the classification to provide exact anatomical and pathological detail. Whilst not essential for publication, such data allows each clinician to use the same method of recording information about his patients and facilitates exchange of data between investigators. The resulting codes are complex, and best suited for handling by a computerized system, but at least an internationally agreed system is now in existence.

Investigators who have recorded the data concerning their patients using this system will have no difficulty in writing papers which include details from their computer databases. Counting the cases in each section of the classification will completely describe the types of pathological problem that are being considered. The full value of this system of classification will only be achieved if it is widely adopted. May I recommend that it is used by all authors submitting papers to journals, including Phlebology.

References

1. Coleridge Smith PD, Consensus or confusion? Phlebology 1992;7:47.

Setting: Human microvascular studies laboratory of a teaching hospital.

Subjects: Patients with arm oedema following successful breast cancer treatment.

Main outcome measures: (1) Arm volume calculations using multiple circumferential measurements by tape measure. (2) Interstitial fluid pressure measurements by wick-in-needle technique in subcutis.

Results: The mean swollen arm was 33% greater in volume than the contralateral arm (n = 50). There was no significant correlation between the size of the arm and the duration of the swelling. There was no significant change in arm volume over 2 weeks (n = 8) but there was a small (50 ml), significant increase overnight (p <0.05). The mean (SD) interstitial fluid pressure while wearing one brand of hosiery (Sigvaris) was 18.7 (5.8) cmH₂O compared with 1.2 (2.8) cmH₂O after its removal. There was a significant correlation between the pressure under the sleeve and the pressure without the sleeve (r = 0.68, p <0.05).

Conclusions: The Sigvaris sleeve exerts sufficient compression to underlying tissue to raise interstitial fluid pressure. This may control arm swelling by reducing fluid filtration rate and/or raising fluid drainage rate from the arm.

* Present address: Department of Human Physiology, The Medical School, University of California, Davis, California 95616, USA.

Design: A double-blind, randomized, parallel-group, placebo-controlled clinical trial.

Setting: Lymphoedema clinic, Royal Marsden Hospital, London, UK.

Patients: Forty-six females with unilateral lymphoedema of the arm secondary to therapy for carcinoma of the breast.

Main outcome measures: Arm volume, symptom assessment on a five-point scale.

Results: The difference in arm volumes was significantly better for HR than placebo at 6 months, but not at 1—5 months.

Conclusion: HR appears to stabilize the patients’ condition against increasing lymphoedema in the placebo group.

Objective: To identify the current practice of surgeons and variations between these surgeons in the investigation and treatment of varicose veins.

Design: Questionnaire submitted to all surgeons treating varicose veins.

Setting: All general surgeons in the Northern Region of England.

Results: The response was 83% with 60 surgeons (85% of responders) treating varicose veins. Thirty-five per cent have a vascular specialist interest and treat 58% of all the varicose veins; 37% of surgeons complement initial assessment by clinical examination with hand-held Doppler examination. For long saphenous vein incompetence all surgeons perform high saphenous ligation, with 67% stripping the vein to the knee and 23% to the ankle. For short saphenous incompetence, 28% localize the saphenopopliteal junction by investigation prior to treatment, 92% perform saphenopopliteal ligation and 13% strip the vein.

Conclusions: The extent of investigation and the nature of treatment of varicose veins vary considerably between consultants. Relatively few surgeons use hand-held Doppler and surgeons remain divided on the use and extent of stripping of the saphenous veins.

Design: In the first part of the study healthy volunteers and one investigator were used to evaluate the intraobserver reproducibility; in the second part one healthy volunteer and different investigators were used to evaluate the interobserver reproducibility.

Setting: Department of Dermatology, Academisch Ziekenhuis Maastrict, The Netherlands.

Patients: Twenty healthy volunteers for the first part of the study; eight doctors and one healthy volunteer for the second part.

Main outcome measures: Optoelectronic volume measurements on one leg over a standard distance of 40 cm and over 20 cm with the use of a laser pointer as calibration. A total of eight measurements were performed on each volunteer. The same procedure was performed by different investigators on one volunteer.

Results: The modified optoelectronic measurement system with laser pointer calibration showed an improvement of the reproducibility of 27% in the intraobserver study. An improvement of 11% was found in the interobserver study.

Conclusions: The modified optoelectronic volume measurement system (the volometer) provides a better reproducibility than the standard system. The instrument can be used for easy and rapid volume measurements in phlebological practice.

Design: Ambulatory leg ulcer patients were assessed as to the clinical diagnosis. Diagnoses other than venous ulceration were excluded.

Setting: Department of Dermatology, Sahlgrenska Hospital, Göteborg, Sweden.

Patients: One hundred and fourteen patients (133 legs) with venous leg ulcers were investigated.

Main outcome measures: All patients were also investigated by measuring systolic ankle and arm pressure measurements. The ankle/arm (AI) was below 0.9 in 22 of the 133 ulcerated legs.

Results: Of the 111 ulcerated legs with an AI>0.9, 10% had an isolated SVI.

Conclusions: Isolated SVI is an important cause of venous leg ulcer development. Strain-gauge plethysmography is an inexpensive screening method, and is easy to use. Further examination with the more exact, but also more expensive and time-consuming, colour duplex should be performed in selected cases.

Design: A prospective study of femoral veins obtained from controls and STZ-induced diabetes rats.

Setting: Department of Morphology, Universidad de Las Palmas de Gran Canaria, Spain.

Interventions: Experimental diabetes induced by intraperitoneal injection of streptozotocin.

Main outcome measures: The samples were studied at 6 and 12 weeks post-injection using light and transmission electron microscopy.

Results: The results show that the venous wall is affected by an increase in the deposition of extracellular tissue. In addition the endothelial, muscular and adventitial cells show morphological changes.

Conclusions: Our results demonstrate significant alterations in the venous wall due to hyperglycaemia in the STZ-animal model.