14S Gloviczki et al
Guideline 3. Plethysmography
JOURNAL OF VASCULAR SURGERY
May Supplement 2011
Guideline |
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GRADE of |
Level of |
No. |
3. Plethysmography |
recommendation |
evidence |
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1. Strong |
A. High |
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quality |
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2. Weak |
B. Moderate |
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quality |
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C. Low or very |
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low quality |
3.1 |
We suggest that venous plethysmography be used selectively for the |
2 |
C |
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noninvasive evaluation of the venous system in patients with simple |
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3.2 |
varicose veins (CEAP class C2). |
1 |
B |
We recommend that venous plethysmography be used for the noninvasive |
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evaluation of the venous system in patients with advanced chronic |
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venous disease if duplex scanning does not provide definitive |
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information on pathophysiology (CEAP class C3-C6). |
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Guideline 4. Imaging studies
Guideline |
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GRADE of |
Level of |
No. |
4. Imaging studies |
recommendation |
evidence |
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1. Strong |
A. High |
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quality |
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2. Weak |
B. Moderate |
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quality |
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C. Low or very |
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low quality |
4.1 |
We recommend that in patients with varicose veins and more advanced |
1 |
B |
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chronic venous disease, computed tomography venography, magnetic |
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resonance venography, ascending and descending contrast venography, |
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and intravascular ultrasonography are used selectively for indications, |
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including but not limited to post-thrombotic syndrome, thrombotic or |
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nonthrombotic iliac vein obstruction (May-Thurner syndrome), pelvic |
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congestion syndrome, nutcracker syndrome, vascular malformations, |
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venous trauma, tumors, and planned open or endovascular venous |
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interventions. |
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tests are not routinely performed. In those with recurrent DVT, thrombosis at a young age, or thrombosis in an unusual site, we recommend screening for thrombophilia. Laboratory examination is also needed in patients with long-standing recalcitrant venous ulcers. One study found 2.1% of venous and arterial ulcers had a secondary etiology, including neoplasia, chronic inflammation, sickle cell disease, vasculitis, rheumatoid arthritis, pyoderma gangrenosum, and hydroxyurea.103 Patients who undergo general anesthesia for treatment of CVD may need a blood cell count or an electrolyte panel.
CLASSIFICATION OF CVD
The cornerstone for management of CVD is the proper diagnosis and accurate classification of the underlying venous problem, which create the base for correctly directed treatment. The clinical and laboratory evaluation of the patient with varicose veins or more advanced CVD should be completed by establishing the clinical class of the disease. The CEAP classification was developed by the AVF in 1994 and later revised in 2004.76,77 The classification is based on
clinical signs of venous disease (C), etiology (E), anatomy (A), and the underlying pathophysiology (P).
Clinical class includes the full spectrum of venous disorders, from no signs of visible venous disease (C0) to telangiectasia or reticular veins (C1), varicose veins (C2), edema (C3), skin changes, such as pigmentation or eczema (C4a) or lipodermatosclerosis or atrophie blanche (C4b), and healed (C5) or active (C6) ulcer. The presence or absence of symptoms is also recorded as S (symptomatic) or A (asymptomatic).
Etiology can be congenital (Ec), primary (Ep), or secondary (Es).
The anatomic classification separates superficial venous disease (As) from involvement of the perforators (Ap) or deep veins (Ad). Failure to identify an anatomic location is also coded (An).
Pathophysiology of the disease can be reflux (Pr), obstruction (Po), or both. Failure to identify venous pathophysiology is also noted (Pn). Table II includes the full CEAP classification, and Table III lists the venous segments that can be involved in the disease.