3.
EPIDEMIOLOGY OF CHRONIC PERIPHERAL
VENOUS DISEASE
Michael H. Criqui, Julie O. Denenberg , Robert D. Langer, Robert M. Kaplan, and Arnost Fronek
INTRODUCTION
The term “chronic venous disease,” or more specifically of
interest here, “chronic peripheral venous disease” (CPVD)
has been used more generally to refer to either visible and/
or functional abnormalities in the peripheral venous system.
The most widely used classification of such abnormalities
is the CEAP (clinical, etiological, anatomic, pathophysi-
ologic), which employs both anatomic (superficial, deep,
or perforating veins) and pathophysiologic (reflux, obstruc-
tion, or both) categories.1 The CEAP classification is fur-
ther described in Chapter 10.
The CEAP classification reflects the clinical situation in
which patients are typically referred to a vascular specialist
for clinically significant venous disease. In contrast to the
clinical situation, population studies of CPVD have typi-
cally focused on broader categories determined by visual
inspection only. The three major categories of interest have
been varicose veins (VV), chronic venous insufficiency
(CVI), and venous ulcers. However, there has not been a
standard definition of these categories. VV has been defined
at differing levels of visible disease severity. CVI has typi-
cally been defined by skin changes and/or edema in the dis-
tal leg. Venous ulcers, both active and healed, have been
defined by visible inspection and subjective inference as to
etiologic origin.
Two studies have now reported results on defined
free-living populations with simultaneous assessment of
both visible abnormalities and functional impairment by
Duplex ultrasound.2,3 The Duplex examination for the San
Diego Population Study (SDPS) determined both obstruc-
tion and reflux, while the Edinburgh study determined
only the latter. The results were revealing in that to some
degree the validity of both the assumptions of earlier pop-
ulation studies and of the CEAP classification, at least as
applied to population samples, were brought into question.
Specifically, the general concept that visible disease neces-
sarily implied underlying functional disease, and vice versa,
was true in the large majority of affected limbs, but not
universally so.
27
Although these discrepancies occurred in a minority of
cases, they were frequent enough to lead us to separately clas-
sify visible and functional CPVD in each limb evaluated in
the SDPS. Specifically, we classified each limb into four vis-
ible categories: normal, telangiectasias/spider veins (TSV),
VV, and trophic changes (TCS); the latter category being
one or more of hyperpigmentation, lipodermatosclerosis,
or active or healed ulcer. The presence or absence of edema
was not by itself a criterion for TCS. For functional disease,
we determined the presence of obstruction and reflux sepa-
rately for the superficial, perforating, and deep systems. The
presence of either reflux or obstruction in superficial or deep
veins was categorized as functional disease, and because of
small numbers, abnormalities of the perforating veins were
considered as deep disease. Three functional categories were
defined: normal, superficial functional disease (SFD), and
deep functional disease (DFD). Here, the term “functional”
is essentially interchangeable with “anatomic.” Also, in this
population study, obstruction was uncommon and virtually
all legs with obstruction also had reflux, such that SFD and
DFD essentially refer to reflux.
In addition to separately assessing edema, we asked
about a history of superficial venous thrombosis (SVT) and
deep venous thrombosis (DVT), with or without pulmo-
nary embolism.
Table  3.1 shows the prevalence of various manifesta-
tions of CPVD in the SDPS by age, gender, and ethnicity.
Specifically, prevalence rates are given for TSV, VV, TCS,
SFD, DFD, edema on physical examination, and SVT and
DVT by history.
AG E A N D   C VP D
Using mutually exclusive categories for both visible and
functional CVPD, we found a graded relationship with
increasing age for VV, with those aged 70–79 years having
nearly twice the prevalence of those aged 40–49 years. TSV
also increased with age, but this difference was obscured by
the mutually exclusive categories, with increasing numbers