How to use CEAP and VSS in

Clinical Practice

Marc A. Passman, M.D.

Associate Professor of Surgery

University of Alabama at Birmingham

Disclosure

Marc Passman, M.D.

I have no financial relationship(s) to disclose.

• “Since statistical associations do not dictate clinical significance, how do we translate outcome scores into meaningful clinical differences? How much change is clinically significant?”

• “Everyone will benefit from an integrated assessment of symptoms, clinical findings, noninvasive examinations, and functional outcomes to better define the role of surgical, physical, and medical therapies for CVD.”

J Vasc Surg 2003 37 (4): 911-912

Venous Assessment Tools Testimonials?

• "I feel better about wearing shorts in the summer!"

Carol K

• "Its easy to use and the spider veins disappeared in just weeks"

Suzan R

• "It's all natural and not greasy. I can't believe my spider veins went a way that quick."

Margaret J

• I've had Spider Veins for years. In two weeks, they were lighter and after a month they were gone.

Carol B.

Diminish the vein

appearance, strengthen

vein walls and boost

circulation.

Rutin, citrus bioflavanoids (Vit P), grape

seed extract, hesperidin complex, lemon

peel, horse chestnut seed oil

• What is the best way to follow outcomes after

venous intervention?

– Surrogate outcomes?

– Clinically important outcomes?

Venous Assessment Tools Compare Outcomes?

Venous Assessment Tools Pain Parameters

• Visual Analogue Pain Scales

0

Happy

No Pain

2

Hurts

Alittle

4

Hurts

Alittle

More

6

Hurts

Even

more

8

Hurts

Alot

10

Worst

Pain

Venous Assessment Tools Other Objective Parameters

• Leg circumference

• Leg volume

measurements

• VFI

• Venous occlusion

pressures

• Duplex derived

parameters

Venous Assessment ToolsCEAP

J Vasc Surg 2004;40:1248-52.

Clinical Classification (C):– 0: No visible signs of venous

disease

– 1: telangiectasies or reticular vein

– 2: varicose veins (>3mm)

– 3: edema

– 4: chronic venous skin changes• 4a: pigmentation, eczema,

• 4b: lipodermatosclerosis, atrophie blanche

– 5: healed venous ulcer

– 6: active venous ulcer

Healed ulcer (C5) Active ulcer (C5)Atrophe

Blanche(C4b)Pigmentation (C4a)

Telangiectasies (C1) Varicose veins (C2)

Venous Assessment ToolsCEAP

• Prevalence of venous disease by CEAP

Bonn Vein Study Polish Study French Study(Phlebologie 2003) (Phlebology 2003) (J Vasc Surg 2004)

Venous Assessment ToolsVenous Severity Score (VSS)

• 2000 AVF, Ad Hoc Committee on

Venous Outcomes Assessment

• Venous Severity Scoring

– Venous Disability Score (VDS)

– Venous Segmental Disease Score

(VSDS)

– Venous Clinical Severity Score

(VCSS)

• Complement CEAP

• Compare outcomes treatment of

chronic venous insufficiency

– Clinical utility

– Research

Venous Assessment ToolsVenous Clinical Severity Score - VCSS

Attibute Absent (0) Mild (1) Moderate (2) Severe (3)

Pain None Occasional Daily Daily with

meds

Varicose Veins None Few Multiple Extensive

Venous Edema None Evening only Afternoon Morning

Skin

Pigmentation

None Limited, old Diffuse, more

recent

Wider, recent

Inflammation None Mild cellulitis Moderate

cellulitis

Severe

Induration None Focal < 5cm < 1/3 gaiter > 1/3 gaiter

# Active Ulcers None 1 2 >2

Active Ulcer

Size

None < 2cm 2 – 6cm > 6cm

Ulcer Duration None < 3 months 3 – 12 months > 1 year

Compression None Intermittent Most days Fully

compliant

Venous Assessment ToolsVCSS - Validation

Venous Assessment ToolsVCSS - Validation

• Multi-institutional studies

(2-3 institutions)

• Small sample size • VCSS correlation good

Venous Assessment ToolsVCSS – Validation - Outcomes

Venous Assessment ToolsVCSS – Validation - Outcomes

From Vasquez MA. Phlebology. 2008

Venous Assessment ToolsVCSS – Validation - Outcomes

Before treatment

After treatment

From Vasquez MA. Phlebology. 2008

Venous Assessment ToolsVCSS – Validation - Outcomes

Before treatment

After treatment

From Vasquez MA. Phlebology. 2008

Venous Assessment ToolsVCSS – Validation - Outcomes

Venous Assessment ToolsVCSS - Modification

Venous Assessment ToolsQuality of Life Parameters

• SF-36

• Nottingham Health Profile

• Venous Disability Score (VDS)

• Charing Cross Venous Ulceration Questionnaire

• Aberdeen QOL

• Chronic Venous Insufficiency Questionnaire (CIVIQ)

• VEnous Insufficiency Epidemiological and Economic Study (VEINES – QOL/ Sym)

Venous Assessment ToolsDocumentation

Venous Assessment ToolsDocumentation

Venous Assessment ToolsConclusion

• No Universal Tool

• Use Venous Assessment Tools:

– Progression of CEAP?

– Progression of VCSS?

– Change in QOL?

• Not just a Research Tool

• Assess Impact of Therapy

• Reported Outcomes – Improved Quality of

Care