CEAP 2020: Understanding and Applying the Updated ...

CEAP classification is a discriminative instrument. Examination of a patient with chronic venous disease has to include a detailed description for each of the ... Centers Carotid Coding Dialysis Embolization EVAR HTN LimbSalvage Neurointervention Oncology Radial Regulatory Renal SFA TEVAR Venous News CurrentIssue Archive DeviceGuide Advertising About Calendar Contact Privacy Submissions Carotid Coding Dialysis Embolization EVAR HTN LimbSalvage Neurointervention Oncology Radial Regulatory Renal SFA TEVAR Venous Advertisement Advertisement July2020 CEAP2020:UnderstandingandApplyingtheUpdatedChronicVenousDiseaseClassifications Dr.TeresaCarmaninterviewsDr.FedorLurietoexploretheprocessesbywhichthe2020CEAPclassificationrevisionswerearriveduponandgaininsightsintotheirapplication. WithTeresaCarman,MD,andFedorLurie,MD ViewPDF Reprints Group5Copy CreatedwithSketch. facebook CreatedwithSketch. LinkedIn CreatedwithSketch. email-icon CreatedwithSketch. link-icon CreatedwithSketch. TeresaCarman,MD Director,VascularMedicine UHClevelandMedicalCenter Cleveland,Ohio [email protected] Disclosures:None. FedorLurie,MD,PhD,RPVI,RVT AssociateDirector,JobstVascularInstitute Toledo,Ohio AdjunctResearchProfessor,DivisionofVascularSurgery UniversityofMichigan AnnArbor,Michigan [email protected] Disclosures:None. Dr.Carman:Congratulationsonthecompletionofaveryextensive,nearly3-yearprocessrevisingtheCEAPclassificationsystem.WithCEAPlastupdatedin2004andwellingrainedintovenousdiseasepractice,whydidtheAmericanVenousForum(AVF)feelitneededanupdateafter15years? Dr.Lurie:Thankyouforprovidingmetheopportunitytotalkabouttherevisedclassification.TheCEAPclassificationisbasedonourcurrentunderstandingofvenouspathologyandmanifestationsofthechronicvenousdisorders,whichofcoursechangesovertime.Therefore,CEAPclassificationrequiresperiodicrevisions.Thefirstrevisionsweredonein2004afterCEAPhadexistedfor7years,andittooklongerforthesecondupdate.TheAVFfeltthatitwasnecessarytoanalyzewhethertheclassificationneededrevision.TherewereanumberofsuggestionsovertimethatpointedtodeficienciesandshortcomingsoftheexistingCEAPclassification.Ataskforcefirsthadtoexaminewhetherthoserevisionswereneeded,andifso,suggestwhichoneswerereasonableforupdating. Dr.Carman:Canyoubrieflyexplainhowtherevisionprocessbeganandthefourkeyconsiderationsusedfortherevision? Dr.Lurie:That’saveryimportantquestion.Everytimeyoureviseaclassification,althoughnecessary,newissuesarecreated.Withthisinmind,wedecidedthatthisrevisionshouldbedoneverycarefullytonotimpacttheprevioususesofCEAPclassification.Onemajorconsiderationwasthatarevisedorupdatedclassificationwouldbebackwardcompatible.AnypublicationsorreportsthatwereusingCEAPbeforecancontinuetobeanalyzedwithoutinterruption;whetherwehaveachievedthisisyettobeseen.Wealsodecidedthatthosechangesshouldbeevidence-based.Ifarevisionseemstobereasonablebutdoesnothavedatatosupportit,thoserevisionswouldprobablybenotaccepted.TheotherimportantpartwasthattherearepractitionerswhofeeltheCEAPclassificationisnotverypractical.Whatweconsideredveryseriouslyforeachsuggestedchangewashowpracticalthechangewas,whetheritwouldincreasetheuseofCEAPclassification,ormakeitmoredifficulttoimplement. Weunderstandthataclassificationsystemisbasicallyaconsensusdocument.It’snotasystematicanalysis,althoughitincludesthis.Asaconsensusdocument,wefollowthemostappropriatemethodology,whichisthemodifiedDelphiprocess.WeinitiallysplitthetaskintofourgroupsforeachofthecomponentsofCEAPclassification:clinical,etiology,anatomy,andpathology.Therewereseveralroundsofdiscussionforeverysuggestionmade.AbriefsummaryofchangescanbeseeninFigure1. Figure1.Abriefsummaryofthe2020revisionsmadetotheCEAPclassification.ModifiedfromLurieF,DeMaeseneerMGR.The2020updateoftheCEAPclassification:whatisnew?EurJVascEndovascSurg.2020;59:859-860.doi:10.1016/j.ejvs.2020.04.020 Dr.Carman:Canyouexplainanddiscussthedifferencesbetweendiscriminativeinstrumentsandevaluativeinstruments?HowdoesadiscriminativeinstrumentlikeCEAPimproveourclinicalpractice? Dr.Lurie:Discriminativeinstrumentsaredesignedtodescribeacondition,patient,ordiseasethatisdifferentfromothers.Usingthisinstrument,youcanplaceapatientintoacertaincategory,whichisdifferentfromanotherpatient.Thecategorythatisassignedtoapatientcananddoeschangeovertime.Ateachpoint,adiscriminativeinstrumenthelpstodetermineifthispatient’sconditionisdifferentorthesame.Theseinstrumentscannotbeusedtogaugethemagnitudeofadifference,toassesstheseverityofthecondition,ortomeasureoutcomes.Theysimplyshowiftheconditionisthesameorifitisdifferent.Evaluativeinstrumentsmeasuretheseverityofacondition,anditschangeovertimeorasaresultofatreatment.Theyincludequality-of-lifequestionnairesandseverityscores,suchastheVenousClinicalSeverityScore. CEAPclassificationisadiscriminativeinstrument.Examinationofapatientwithchronicvenousdiseasehastoincludeadetaileddescriptionforeachofthelowerextremities.TheCEAPclassificationprovidesastructure,helpingtoaddressallimportantaspectsofthemanifestationsofchronicvenousdisease.Thesignsandthesymptomaticstatusarecomponentsoftheclinicalclass,or“C.”Acompletedescriptionofalimbaffectedbychronicvenousdiseaseshouldalwaysincludetheetiology,aswellastheanatomicdistributionofthechanges,andwhetherit’srefluxobstructionoracombinationofthose.Thisisdoneroutinelyineachpractice,butwhenyoudoitsystematically,applyingaCEAPclassification,itwillgiveyouastructureandasimplewaytocommunicatetheresults. Dr.Carman:PossiblythemostoftenusedcomponentofCEAPistheCortheclinicalcomponent.However,inthelasttworevisions,theetiology,anatomy,andphysiologycomponentsaretheonesthathavereallybeenexpandedthemostandhavebecomemoreinclusiveanddescriptiveinnature.Fromyourperspective,doyoufindthismorehelpfulclinicallyorfromareportingpurpose?Whenwereportexpandedportions,particularlytheanatomicandphysiologicportions,wedon’treallyreportthoseinaresearchfashion.Whatisthepracticalityoftheseongoingextensions? Dr.Lurie:ThathasbeenacontentiousissuethroughthehistoryoftheCEAPclassification.Letmeaddressthisfromtwoperspectives—theresearchperspectiveandthentheclinicalperspective.Asaclinicalresearcher,Iincurthesameissuerepeatedly:Wehaveagoodquestionandweknowwehaveenoughexperiencewithpatientstoaddressthequestion,butwhenwelookatthemedicalrecords,wefindgapseverytime;wearenotperfect.Whenwewritetheclinicnote,wefrequentlymisssomethingthatbecomesveryimportantinthefuture.Thisisthemostseriouslimitationofallretrospectivestudies;wedonotsystematicallycollectinformation. Now,letmeaddressthisfromtheclinicalperspective.Forexample,whenweexamineapatientwithchronicvenousdiseasewithlipodermatosclerosis,westartlookingatpossiblecauses.Wewanttoknowwhetheritisaprimarydiseaselimitedtosuperficialreflux,anobstructivediseaseinthefemoropoplitealsegment,oranobstructionintheiliacvein,becausethetreatmentwillbedifferentforeachsetting.Identificationanddocumentationofthisinformationarecomponentsofappropriateclinicalcare.ThosearetheE,A,andPcomponentsofCEAPclassification.Insteadofwritinganentiredescriptionofthepatientanddescribingtheultrasoundorotherimagingfindingseverytime,wesimplycanwriteaCEAPformulathathasallthisinformationincluded.Inpractice,itcreatesaneasystructuretoaddressthemostimportantpartofthedisease. Dr.Carman:Whatdoyouthinkarethetopthreestrengthsofthe2020CEAPclassificationupdate? Dr.Lurie:First,Ithinkthemostimportantupdatewasdoneforetiology:aseparatedistinctionforextravenousandintravenouscausesofsecondarydisease.Theseconditionsmaylooksimilar,withpatientshavingthesamesignsandsymptoms,buttheyrequireverydifferenttreatments.Sometimesclinicalreportsinthejournalsdonotmakesensebecausewedonotknowhowmanyoftheenrolledpatientsinastudyhaveadiseasecausedbyobesityorexternalcompressionversushowmanywerecausedbyasasequelaofdeepveinthrombosis.Ibelieveincludingthetwosubcategoriesofsecondarychronicvenousdiseaseisoneofthebigstrengthsoftherevisedclassification. Secondisthedecisiontoreplacethenumbersintheanatomicdescriptionwithcommonlyusedabbreviations,whichmakesitamorenaturallanguageforthecliniciansandmakesCEAPeasiertouse.IdonotbelievethatmanypractitionersrememberthatA4inCEAPstandsforthesmallsaphenousvein.Replacingthenumberfourwiththeabbreviation“SSV”canbereallyhelpful,especiallyincombinationwiththe“P”ofCEAP.Whenitiswrittenas“As,PrSSV”itclearlydescribesthatonlysuperficialveinsareaffected,andspecificallythatthereisrefluxinthesmallsaphenousvein. Third,themodifierRforrecurrentvaricoseveinsandrecurrentulcersisanexcellentrevision.Recurrentulcersandrecurrentvaricoseveinshavedifferentnaturalhistoryandrequiredifferentmanagementcomparedwiththefirstepisodeofulcerationoruntreatedvaricoseveins. Dr.Carman:Fromyourperspective,youknowulcersdonotalwaysrecurinthesamelocation.Wedoseepatientswhohavehadmultipleepisodesbutnotnecessarilyinthesamelocation.Wasthereanyconsiderationastolocationofrecurrence? Dr.Lurie:Excellentquestion,andyesthatwasdiscussedseveraltimes.Myexperienceisthatarecurrentulcerinthesamelocationmaybemoreofachronicskinconditionandnotalwaysassociatedwithcorrectablevenousabnormalities.Onthecontrary,arecurrenceatadifferentlocationmostoftenindicatesongoingproblemswithvenoushemodynamics,oftencorrectablebyintervention.IncludingalocationoftheulcerintoCEAPmaybeasolution,butitwilladdtothecomplexityandmakeCEAPlessusable.You’reabsolutelyright,chronicvenousdiseaseisnotasimpledisease,andsometimesthecomplexityshouldbesacrificedforpracticalreasons. Dr.Carman:Whatdoyouseeasthebiggestlimitationofthe2020CEAPupdate? Dr.Lurie:Thereareacouplesignificantlimitations.Thefirstispracticality—thereisalwaysacompromise.Ifyoumakeitverypractical,yousacrificeinformation,butifyouareusingtoomuchinformation,itbecomesimpractical.Thatbalancemovesbackandforthallthetime.Itisalwaysgoingtobealimitationofanyclassification,includingCEAP. AnotherlimitationisthatCEAPisfocusedonlyonchronicvenousdisorders.Weknowthatchronicconditionsaresometimestheresultofacuteevents,andacuteconditionscancomplicatechronicdisorders.Forexample,phlebitiscanbeacomplicationofvaricoseveins.ItmaybereasonabletoincludesomeofthecomplicationsinfuturerevisionsofCEAP.Inordertodoso,weneedmoreinformationontheincidenceoftheseconditionsinpatientswithdifferenceclinicalclassesandhowthesecomplicationsaffectthediseasenaturalhistory.ThelimitationsofCEAPshouldbeseenasanopportunitytoexplorerelevantissuesandimprovetheclassificationsinthefuture. Dr.Carman:Forthefirstconsensuspublicationin1996,theAVFsoughtendorsementfromthejointcounciloftheSocietyforVascularSurgery(SVS)andtheNorthAmericanchapteroftheInternationalSocietyforCardiovascularSurgery.YoupreviouslyreferredtotheCEAPclassificationasaconsensusdocuments,butgiventheexpandingvarietyofcliniciansinvolvedinvenousdiseasepractice,whywasthisdocumentlimitedtoAVFsocietymemberswithoutinclusionofothersocietiesmembershipsinthepanelsorendorsementsfromothersocieties? Dr.Lurie:First,IhavetodisclosethatIamnottalkingonbehalfoftheAVFrightnow.You’reexactlycorrect.ThehistoryofCEAPclassificationisthatitwasinitiallydevelopedatthePacificVascularSymposium.ThiswenttothecommissionoftheAVF,anditwasfinalizedthereasaconsensusthatdidrequirethetime,participation,andendorsementofallsocietiestomakethattotallynewclassificationaccessibleandusable. Thatwasaverysuccessfuleffort.Overtime,however,theCEAPclassificationitselfisnolongeraconsensusdocument;it’saclassificationsystemthathasbeenusedformorethan20years.It’saninstrumentthatwasverywellestablishedandpracticallyused,andtheAVFownsthatinstrument.Whenitcametorevisionofthisclassification,therewasnodesiretohaveitbeacomplicatedpoliticalprocessthatmightlastaverylongtimewithoutimprovingtheclassification. TheAVFhasputtogetheraverydiversetaskforceforrevision.AlthoughthemembersofthetaskforcearemembersoftheAVF,theyarealsoprominentmembersofothersocietiesinternationallyandnationally.Thetaskforceisalsosubstantialinsize.Havingsaidthat,publicationofthisclassificationisaninvitationforothersocietiesandotherpractitionerstoexpresstheiropinionsandsuggestions.Moreimportantly,itisaninvitationtoactivelyparticipatewiththeAVF,investigate,andpublishnewevidencethatsupportssuggestedrevisions. Dr.Carman:ArethereanyplansfortheAVFtoworkwithlargerelectronicmedicalrecordscompaniestoincludetheCEAPreportingstandardandclassificationsystemasamoduletofacilitatereporting?Theclinicalresearchershaveawaytouseprospectivelycollecteddata,evenifitisinaretrospectivemannerandhavetheconsistencythatyouarelookingfororincludeitintheSVSdatabase.Doyouthinkthatwouldhelp,orwouldthathaveadetrimentaleffectonadvancingvenousdisease? Dr.Lurie:It’sdefinitelygoingtobeveryhelpful.WeactuallystartedworkingwiththeSVSVascularQualityInitiative(VQI)tointegratetheCEAP2020inusingthevenousmodulesoftheVQI.AsofJune2020,IlearnedthattherevisedCEAPclassificationwasusedastheweb-basedcalculatorthatisveryeasytouseinSpanish,Italian,Portuguese,andRussian;however,itisnotyetavailableinEnglish. Ifyouusethatcalculatoronyourphone,itwillbereallypractical.IlookatacoupleofthosethatIcanunderstand(eg,https://ceap.phlebology-sro.ru/),andit’sreallyaneasytooltouseinaclinicalpractice.IttakessecondstogenerateacompleteCEAPanditwillbeveryusefulifit’sincorporatedintheelectronicmedicalrecords. Advertisement Advertisement AnticoagulationintheCOVID-19Era:WhatWeKnowSoFar WithRaghuKolluri,MS,MD,RVT,FSVM;andGeoffreyD.Barnes,MD,MSc,FACC,FAHA,FSVM,RPVI left-arrow CreatedwithSketch. PreviousArticle DeterminingandApplying“AppropriateUse”ofVenousCare WithKathleenOzsvath,MD,andElnaMasuda,MD NextArticle right-arrow CreatedwithSketch. July2020 CurrentConversationsinVenousCare ViewIssue Advertisement Advertisement RelatedArticles AnInterviewWithEricA.Secemsky,MD,MSc Innovations RoundtableDiscussion:ManagingPost-PESyndrome:ImprovingandStandardizingPost-PECare WithGeoffreyD.Barnes,MD,MSc;SoniaJasuja,MD;andJohnM.Moriarty,MD,FSIR,FSVM MostReadArticles Women’sVascularHealthinFocus ByGloriaSalazar,MD,andKiremaGarcia-Reyes,MD PanelDiscussion:Women’sAorticHealth:AreWeMeetingtheNeed? Moderator:LindaM.Harris,MD,FACS,DFSVSPanelists:YoungErben,MD;JavairiahFatima,MD,FACS,DFSVS;JosephV.Lombardi,MD;andJessicaP.Simons,MD,MPH BeyondTrialsandResearch:APatient’sPerspectiveonUndiagnosedChronicPelvicPain WithBrookeSpencer,MD,FSIR,andNicholeVollmer Aortic|EndovascularAorticRepair:WhyLong-TermDurabilityShouldNotBeaCompromise WithJavairiahFatima,MD,FACS,RPVI,DFSVS;CarlosF.Bechara,MD,RPVI,FACS,DFSVS;ThomasS.Maldonado,MD,FACS;andTaraM.Mastracci,MD,FRCSC,FACS CaseReport:CombinationTreatmentofHepatocellularCarcinomaUsingMicrowaveAblationandDEB-TACE ByGovindarajanNarayanan,MD;ThompsonAntony;andRaihanNoman July2020 CurrentConversationsinVenousCare ViewIssue Carotid Coding Dialysis Embolization EVAR HTN LimbSalvage Neurointervention Oncology Radial Regulatory Renal SFA TEVAR Venous CardiacInterventionsToday Group7Copy3 CreatedwithSketch. bmc-secondary-mark-colorcopy CreatedwithSketch. ©2022BrynMawrCommunicationsII,LLC. AllRightsReserved • PrivacyPolicy one-trust-button