Editor's Choice – European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs

anterior accessory saphenous vein ankle brachial index adjustable compression garments ambulatory phlebectomy Ambulatory Selective Varicose vein Ablation under Local anaesthesia Aberdeen Varicose Vein Questionnaire arteriovenous fistula body mass index cyanoacrylate adhesive closure Clinical Etiological Anatomical Pathophysiological (classification) catheter directed foam sclerotherapy common femoral vein ambulatory conservative haemodynamic treatment of venous incompetence in outpatients (= French acronym for ‘Cure Hémodynamique de l’Insuffisance Veineuse en Ambulatoire’) confidence interval common iliac vein chronic Venous Insufficiency Questionnaire cryolaser and cryosclerotherapy guided by augmented reality chronic pelvic pain computed tomography computed tomography venography chronic venous disease chronic venous insufficiency deep femoral vein direct oral anticoagulant duplex ultrasound deep vein incompetence deep vein thrombosis endovenous Ambulatory Selective Varicose vein Ablation under Local anaesthesia elastic compression stockings endothermal heat induced thrombosis external iliac vein eutectic mixture of local anaesthesia electromagnetic therapy European Society of Cardiology European Society for Vascular Surgery Effect of Surgery and Compression on Healing And Recurrence endovenous laser ablation endovenous microwave ablation Early Venous Reflux Ablation endovenous steam ablation endovenous thermal ablation flush endovenous laser ablation femoral vein great saphenous vein Guideline Writing Committee high ligation and stripping inelastic bandages international units internal iliac vein intermittent pneumatic compression inferior vena cava intravascular ultrasound potassium titanyl phosphate (laser) low molecular weight heparin mechanochemical ablation micronised purified flavonoid fraction magnetic resonance magnetic resonance venography non-thrombotic iliac vein lesion odds ratio posterior accessory saphenous vein pulsed dye laser pulmonary embolism pelvic venous disorders polidocanol popliteal vein PResence of Varices After Interventional Treatment patient reported outcome measures post-thrombotic syndrome perforating vein pelvic vein incompetence quality of life randomised controlled trial recurrent varicose veins after surgery radiofrequency ablation radiofrequency induced thermal therapy revised venous clinical severity score subfascial endoscopic perforator surgery saphenofemoral junction Short Form 36 saphenopopliteal junction static stiffness index small saphenous vein sodium tetradecyl sulphate superficial vein thrombosis transcutaneous laser transvaginal ultrasound ultrasound guided foam sclerotherapy unfractionated heparin venous aneurysm venoactive drug visual analogue scale venous clinical severity score VEnous INsufficiency Epidemiological and Economic Study Quality of Life/symptoms venous thromboembolism venous leg ulcer varicose vein Compared with the 2015 version of the guidelines on the management of chronic venous disease (CVD),1Wittens C. Davies A.H. Baekgaard N. Broholm R. Cavezzi A. Chastanet S. et al.Editor's Choice - Management of chronic venous disease: clinical practice guidelines of the European Society for Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2015; 49: 678-737Abstract Full Text Full Text PDF PubMed Scopus (470) Google Scholar the global structure of the document has been modified considerably in an attempt to make it more practical and user friendly. Special subsections on management strategy with accompanying flowcharts have been added to the different chapters.•An extensive chapter has been entirely dedicated to superficial venous incompetence. A new subsection on evidence supporting endovenous non-thermal ablation has been included. A new subsection on incompetence of perforating veins has been added, as well as a subsection on practical strategies for special anatomical presentations. The management of recurrent varicose veins is discussed at the end of this chapter.•Deep venous pathology is discussed in a separate chapter, with an emphasis on the increasing evidence in the field of managing iliofemoral and iliocaval obstruction. In addition, new topics in this chapter are the combination of superficial and deep venous problems, aneurysms of the deep veins and popliteal vein entrapment syndrome.•An entirely new chapter has been dedicated to the management of patients with venous leg ulcers.•A new chapter describes the management of patients with varicose veins, related to underlying pelvic venous disorders.•A new chapter considers special patient characteristics and their potential influence on management strategy.•Gaps in evidence and future perspectives are briefly discussed in a separate chapter.•A lay summary of the guidelines provides useful information for patients. In view of the new chapters and subsections, many new recommendations have been added, briefly summarised in Fig. 1. Compared with the 2015 CVD guidelines, five recommendations have also been upgraded, while another three have been downgraded (Fig. 2).Figure 2Changes in class of recommendations included in the European Society for Vascular Surgery 2022 clinical practice guidelines on the management of chronic venous disease of the lower limbs in comparison to the previous 2015 guidelines. Numbers correspond to the numbers of the recommendations in the guideline document. ASVAL = Ambulatory Selective Varices Ablation under Local Anaesthesia; EVTA = endovenous thermal ablation; PTS = post-thrombotic syndrome; SSV = small saphenous vein; UGFS = ultrasound-guided foam sclerotherapy.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The European Society for Vascular Surgery (ESVS) has prepared new guidelines for the treatment of patients with CVD, to update the existing ESVS guidelines on the management of CVD, which were published in 2015.1Wittens C. Davies A.H. Baekgaard N. Broholm R. Cavezzi A. Chastanet S. et al.Editor's Choice - Management of chronic venous disease: clinical practice guidelines of the European Society for Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2015; 49: 678-737Abstract Full Text Full Text PDF PubMed Scopus (470) Google Scholar The focus of the present guidelines is on CVD of the lower limbs, related to pathology of the superficial, perforating and deep veins of the lower limbs as well as to abdominal and pelvic venous pathology. The guidelines report several recommendations on diagnosis and treatment of these pathologies in different chapters, with details on health questions and population described in the related text. These guidelines do not include patients with venous pathologies unrelated to CVD of the lower limbs nor patients suffering from venous or arteriovenous malformations. These guidelines provide guidance for vascular and general surgeons, vascular physicians, interventional radiologists, phlebologists, dermatologists, and emergency medicine physicians. The guidelines promote high standards of care (based on evidence, whenever available), established by specialists in the field. We wish to clarify that these guidelines are intended to support clinical decision making and that the recommendations may not be appropriate in all circumstances. The authors have created a clinical guideline and, as such, this reports only on treatment efficacy and clinical outcomes, not on costs, which may be very different from one country to another. In most healthcare systems, the question of management, whether to opt for conservative management or to intervene, as well as when and with which technique to intervene in CVD patients, is heavily influenced by cost (and cost effectiveness). The decision to follow a recommendation from the guidelines must be made by the responsible practitioner on an individual patient basis, taking into account the specific condition of the patient as well as local resources, regulations, laws, and clinical practice recommendations. Deviation from the guidance for specific reasons is perfectly permissible and should not in itself be interpreted as negligence. To further underline the supportive character of the guidelines, both European and non-European reviewers were invited to review the document, so that the document also can serve practitioners treating patients outside Europe. This is also the rationale behind the decision that all ESVS guidelines are free to download from the publisher’s website and the ESVS website www.esvs.org. In addition, an ESVS clinical guidelines App is available, where the guidelines can be found in easily readable form for use in everyday practice. Members of the Guideline Writing Committee (GWC) were selected by the ESVS to represent clinicians involved in the treatment of CVD and included vascular surgeons, vascular physicians, an interventional radiologist, and a gynaecologist - obstetrician. All members of the GWC were involved in selecting and rating the evidence for each of the different chapters and subsections under their responsibility (see Appendix with Supplementary Table of topics, search terms, and responsible authors), as agreed in the introductory meeting. All GWC members were involved in formulating the final recommendations. GWC members have provided disclosure statements regarding all relationships that might be perceived as real or potential sources of conflicts of interest. These are filed and available at the ESVS headquarters. GWC members received no financial support from any pharmaceutical, device, or surgical industry to develop these guidelines. The GWC held an introductory meeting in November 2019 in Amsterdam, Netherlands, at which the list of topics and author tasks were determined. Contributions from GWC members were compiled into a draft of the guidelines by the chair and co-chair. After the first draft was completed and internally reviewed, the GWC met again in September 2020 in Frankfurt, Germany, to review and approve the wording of each recommendation. The guidelines then underwent three rounds of external reviews, and appropriate revisions were implemented. GWC members agreed on a common systematic literature search strategy for each of the chapters. A comprehensive literature search of articles published was performed using MEDLINE (through PubMed), Embase, Cardiosource Clinical Trials Database, and the Cochrane Library databases between 1 January 2013 and 30 June 2020, for relevant papers published in English. The search terms used for the different chapters and subsections are mentioned in the Appendix (Supplementary Table). Reference checking and manual search by the GWC members added other relevant literature. Only peer reviewed, published literature and studies presenting pre-defined outcomes were considered. The selection process followed the “pyramid of evidence”, with aggregated evidence at the top of the pyramid (meta-analyses of several randomised controlled trials [RCTs], other meta-analyses, and systematic reviews), followed by RCTs and finally observational studies. Single case reports, abstracts, and in vitro studies were excluded, leaving expert opinion at the bottom of the pyramid. Articles published after the search date or in another language were included only if they were of paramount importance to this guideline. After the first and second external review, the members of the GWC performed a second and third literature search within their area of responsibility to determine if any important publications had been published between July 2020 and February 2021, and further until the end of June 2021, respectively. The European Society of Cardiology (ESC) system was used for grading evidence and recommendations. A, B, or C reflects the level of current evidence (Table 1) and the strength of each recommendation was then determined to be class I, IIa, IIb, or III (Table 2).Table 1Levels of evidence according to ESC (European Society of Cardiology)Level of evidence AData derived from multiple randomised clinical trials or meta-analysesLevel of evidence BData derived from a single randomised clinical trial or large non-randomised studiesLevel of evidence CConsensus of experts opinion and/or small studies, retrospective studies, and registries Open table in a new tab Table 2Classes of recommendations according to ESC (European Society of Cardiology)Class of recommendationDefinitionClass IEvidence and/or general agreement that a given treatment or procedure is beneficial, useful and effectiveClass IIConflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure Class IIa Weight of evidence/opinion is in favour of usefulness/efficacy Class IIb Usefulness/efficacy is less well established by evidence/opinionClass IIIEvidence or general agreement that the given treatment or procedure is not useful/effective, and in some cases may be harmful Open table in a new tab To formulate recommendations, the strengths and limitations of the available evidence were considered, as well as benefit versus harm and applicability to clinical practice context. Details of study methodology limitations, appropriateness of primary and secondary outcomes, and consistency of results across studies were discussed in the main text. The members of the GWC provided summaries of the selected articles, used to support the evidence for the different recommendations, in Tables of Evidence (ToEs). These ToEs are available online, as Supplementary Material. The guidelines document underwent external review for critical evaluation of the content and recommendations by members of the ESVS Guidelines Steering Committee, and by other independent experts in the field. After each review round, the reviewers’ general and detailed comments were compiled into one document. The manuscript was then revised according to the reviewers’ comments and all amendments were discussed and approved by all members of the GWC. In addition, a point to point reply to the reviewers was provided. After three review and subsequent revision rounds, the final document was approved and submitted to the European Journal of Vascular and Endovascular Surgery on 10 November 2021. These guidelines will be updated in 2026, according to the ESVS policy to update all guidelines which are part of the core curriculum of the vascular surgeon every four years. The importance of patient and public involvement in clinical guideline development is widely recognised and accepted. Patient engagement improves validity, increases quality of decisions, and is encouraged by national and international groups. To improve accessibility and interpretability for patients and the public, a plain English summary has been produced for this guideline and subjected to a lay review process. Information for patients was drafted for each subchapter which was read and amended by a vascular nurse specialist and at least one lay person or patient. Lay summaries were evaluated by a patient focus group, consisting of eight patients in the United Kingdom National Health Service with a history of CVD (six patients with C2-C5 disease and two patients with C6 disease) and three lay members of the public without CVD. All members of the focus group had been sent the lay summaries prior to the meeting, which was held virtually because of COVID-19 restrictions. At the meeting, the background and rationale for the ESVS CVD guidelines were presented and focus group feedback was obtained for each section of the document, systematically. All members of the focus group welcomed the invitation to contribute to the process and many commented that their personal experiences of care had been very different to the treatments recommended in the guidelines. Specifically, referral for specialist venous assessment had often been very delayed, although this may be a specific reflection of the United Kingdom National Health Service. Several patients stated that they had tried compression garments but found them difficult to wear. The group felt it important to express that where compression is recommended to patients, aids to help donning and removal of the stockings should be provided. The section describing superficial venous ablation procedures was found to be complex by the patients and lay members of the focus group and was simplified accordingly. Six of the patients in the focus group had been treated with endovenous ablation procedures. The group emphasised the importance of shared decision making and stated that they would want to discuss potential treatment options even if not locally available. Feedback from the focus group was used to amend the lay summaries. The general rule for ESVS guidelines is to avoid covering groups of patients in multiple guidelines as that may result in redundancy. Therefore, patients with superficial vein thrombosis (SVT) are mentioned only briefly and patients with deep vein thrombosis (DVT) are not covered in these guidelines, even if both SVT and DVT may occur as acute complications in patients with CVD. As these acute conditions require different management, the reader is referred to the ESVS 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis.2Kakkos S.K. Gohel M. Baekgaard N. Bauersachs R. Bellmunt-Montoya S. Black S.A. et al.Editor's Choice - European Society for Vascular Surgery (ESVS) 2021 clinical practice guidelines on the management of venous thrombosis.Eur J Vasc Endovasc Surg. 2021; 61: 9-82Abstract Full Text Full Text PDF PubMed Google Scholar It was also decided to leave out congenital venous malformations, which will be part of future ESVS guidelines on vascular malformations, as well as venous tumours. In the VEIN-TERM transatlantic interdisciplinary consensus document, the term chronic venous disease (CVD) has been defined as “(any) morphological and functional abnormalities of the venous system of long duration manifest either by symptoms and/or signs indicating the need for investigation and/or care”.3Eklof B. Perrin M. Delis K.T. Rutherford R.B. Gloviczki P. American Venous Forum et al.Updated terminology of chronic venous disorders: the VEIN-TERM transatlantic interdisciplinary consensus document.J Vasc Surg. 2009; 49: 498-501Abstract Full Text Full Text PDF PubMed Scopus (254) Google Scholar As not all venous abnormalities can be considered a “disease”, the term “chronic venous disorders” has also been introduced, to encompass the full spectrum of morphological and functional abnormalities of the venous system. In the present guideline document the focus is on patients with symptoms and/or signs of CVD, requiring investigation and/or care. To describe CVD in the lower limbs of these patients, the Clinical, Etiological, Anatomical, Pathophysiological (CEAP) classification is used, which is the most widely used descriptive tool for chronic venous disorders and disease.4Beebe H.G. Bergan J.J. Bergqvist D. Eklof B. Eriksson I. Goldman M.P. et al.Classification and grading of chronic venous disease in the lower limbs. A consensus statement.Eur J Vasc Endovasc Surg. 1996; 12: 487-492Abstract Full Text PDF PubMed Scopus (126) Google Scholar,5Eklof B. Rutherford R.B. Bergan J.J. Carpentier P.H. Gloviczki P. Kistner R.L. et al.Revision of the CEAP classification for chronic venous disorders: consensus statement.J Vasc Surg. 2004; 40: 1248-1252Abstract Full Text Full Text PDF PubMed Scopus (1435) Google Scholar CEAP allows detailed documentation of disease status at a specific time point, within four domains: clinical, aetiological, anatomical, and pathophysiological (Table 3). A recent update of the CEAP classification was published in 2020, including new categories for corona phlebectatica (C4c), recurrent varicose veins (C2r), and recurrent leg ulceration (C6r), a subdivision of secondary aetiology into intravenous (Esi) and extravenous (Ese) causes, and new abbreviations for anatomical terms, to replace the previously used numerical description (Table 4).6Lurie F. Passman M. Meisner M. Dalsing M. Masuda E. Welch H. et al.The 2020 update of the CEAP classification system and reporting standards.J Vasc Surg Venous Lymphat Disord. 2020; 8: 342-352Abstract Full Text Full Text PDF PubMed Scopus (98) Google ScholarTable 3The 2020 update of the CEAP (Clinical Etiological Anatomical Pathophysiological) classification6Lurie F. Passman M. Meisner M. Dalsing M. Masuda E. Welch H. et al.The 2020 update of the CEAP classification system and reporting standards.J Vasc Surg Venous Lymphat Disord. 2020; 8: 342-352Abstract Full Text Full Text PDF PubMed Scopus (98) Google ScholarClassDescriptionClinical (C) class C0No visible or palpable signs of venous disease C1Telangiectasia or reticular veins C2Varicose veinsC2rRecurrent varicose veins C3Oedema C4Changes in skin and subcutaneous tissue secondary to CVDC4aPigmentation or eczemaC4bLipodermatosclerosis or atrophie blancheC4cCorona phlebectatica C5Healed ulcer C6Active venous ulcerC6rRecurrent venous ulceration Symptomatic or not: subscript ‘S’ or subscript ‘A’S: symptomatic, including ache, pain, tightness, skin irritation, heaviness, and muscle cramps, and other complaints attributable to venous dysfunctionA: asymptomaticEtiological (E) class EpPrimary EsSecondary EsiSecondary – intravenous EseSecondary – extravenous EcCongenital EnNone identifiedAnatomical (A) class AsSuperficial AdDeep ApPerforators AnNo identifiable venous locationPathophysiological (P) class*Reporting of pathophysiological class must be accompanied by the relevant anatomical location (see Table 4). CVD = chronic venous disease. PrReflux PoObstruction Pr,oReflux and obstruction PnNo pathophysiology identified∗ Reporting of pathophysiological class must be accompanied by the relevant anatomical location (see Table 4). CVD = chronic venous disease. Open table in a new tab Table 4The 2020 update of CEAP (Clinical Etiological Anatomical Pathophysiological): Summary of anatomical classification6Lurie F. Passman M. Meisner M. Dalsing M. Masuda E. Welch H. et al.The 2020 update of the CEAP classification system and reporting standards.J Vasc Surg Venous Lymphat Disord. 2020; 8: 342-352Abstract Full Text Full Text PDF PubMed Scopus (98) Google ScholarAnatomical classificationSegment number∗Numbers of anatomical segments used in the 2004 revision5 of the CEAP classification.New anatomical site†New specific anatomical location(s) to be reported under each Pathophysiological (P) class to identify anatomical location(s) corresponding to P class.DescriptionAs (Superficial)1TelTelangiectasia1RetReticular veins2GSVaGreat saphenous vein, above knee3GSVbGreat saphenous vein, below knee4SSVSmall saphenous vein–AASVAnterior accessory saphenous vein5NSVNon-saphenous veinAd (Deep)6IVCInferior vena cava7CIVCommon iliac vein8IIVInternal iliac vein9EIVExternal iliac vein10PELVPelvic vein11CFVCommon femoral vein12DFVDeep femoral vein13FVFemoral vein14POPVPopliteal vein15TIBVCrural (Tibial) vein15PRVPeroneal vein15ATVAnterior tibial vein15PTVPosterior tibial vein16MUSVMuscular veins16GAVGastrocnemius vein16SOVSoleal veinAp (Perforator)17TPVThigh perforator vein18CPVCalf perforator veinAn (No venous anatomic location identified)∗ Numbers of anatomical segments used in the 2004 revision5Eklof B. Rutherford R.B. Bergan J.J. Carpentier P.H. Gloviczki P. Kistner R.L. et al.Revision of the CEAP classification for chronic venous disorders: consensus statement.J Vasc Surg. 2004; 40: 1248-1252Abstract Full Text Full Text PDF PubMed Scopus (1435) Google Scholar of the CEAP classification.† New specific anatomical location(s) to be reported under each Pathophysiological (P) class to identify anatomical location(s) corresponding to P class. Open table in a new tab The term “chronic venous insufficiency” (CVI) is reserved for advanced CVD, which is applied to functional abnormalities of the venous system, producing oedema, skin changes, or venous ulcers, corresponding with C3 to C6 of the CEAP classification.3Eklof B. Perrin M. Delis K.T. Rutherford R.B. Gloviczki P. American Venous Forum et al.Updated terminology of chronic venous disorders: the VEIN-TERM transatlantic interdisciplinary consensus document.J Vasc Surg. 2009; 49: 498-501Abstract Full Text Full Text PDF PubMed Scopus (254) Google Scholar A recently published comprehensive systematic review on global epidemiology of CVD identified 32 studies from six continents including > 300 000 adults.7Salim S. Machin M. Patterson B.O. Onida S. Davies A.H. Global epidemiology of chronic venous disease: a systematic review with pooled prevalence analysis.Ann Surg. 2021; 274: 971-976Crossref PubMed Scopus (1) Google Scholar Nineteen studies were used for unadjusted, pooled prevalence for each C class of the CEAP classification, from C0S (symptomatic, no clinical signs) to C6 (venous leg ulcer). Pooled estimates were: C0S: 9%, C1: 26%, C2: 19%, C3: 8%, C4: 4%, C5: 1%, C6: 0.4%. The pooled prevalence of C2 disease was highest in Europe (21%) and lowest in Africa (5.5%). The annual incidence of C2 disease ranged from 0.2% to 2.3%. CVD progression was estimated to affect 31.9% of patients at a mean follow up of 13.4 years. C2 disease had a progression rate of 22% developing a venous leg ulcer (VLU) in six years. Commonly reported risk factors for CVD included female gender, age, obesity, prolonged standing, positive family history and parity. The authors of this review conclude that significant heterogeneity exists in epidemiological studies and future research needs to use diagnostic duplex ultrasound (DUS), to provide more complete data. The high prevalence of C0S in the systematic review mentioned above is mainly the result of an important contribution by studies from the Vein Consult Programme, an international survey performed by general practitioners worldwide during 100 000 routine consultations, without DUS, where a prevalence of C0S of 19.7% was found.8Rabe E. Guex J.J. Puskas A. Scuderi A. Fernandez Quesada F. VCP Coordinators Epidemiology of chronic venous disorders in geographically diverse populations: results from the Vein Consult Program.Int Angiol. 2012; 31: 105-115PubMed Google Scholar It should be acknowledged that the available evidence on C0S remains very limited. Although progression of CVD is important, few epidemiological studies have investigated its natural history. In the Edinburgh Vein Study, a random sample of 1 566 men and women aged 18 – 64 years had been examined at baseline.9Evans C.J. Fowkes F.G. Ruckley C.V. Lee A.J. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study.J Epidemiol Community Health. 1999; 53: 149-153Crossref PubMed Google Scholar Of these, 880 were followed up for 13 years and underwent clinical evaluation and DUS scanning of the deep and superficial venous systems, and 0.9% (CI 0.7 – 1.3%) of this adult population developed reflux each year. Progression occurred more often in overweight subjects and in those with a history of DVT, but there was no association with patient sex or age. In two thirds of all cases reflux was limited to the superficial venous system. The presence of venous reflux at baseline was significantly associated with the development of new varicose veins (VVs) at follow up, especially when combined deep and superficial reflux was present.10Robertson L.A. Evans C.J. Lee A.J. Allan P.L. Ruckley C.V. Fowkes F.G. Incidence and risk factors for venous reflux in the general population: Edinburgh Vein Study.Eur J Vasc Endovasc Surg. 2014; 48: 208-214Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar During the 13 years of observation, CVD progression was reported in 57.8%, for an annual rate of 4.3%, and one third of patients with uncomplicated VVs at baseline developed skin changes.11Lee A.J. Robertson L.A. Boghossian S.M. Allan P.L. Ruckley C.V. Fowkes F.G. et al.Progression of varicose veins and chronic venous insufficiency in the general population in the Edinburgh Vein Study.J Vasc Surg Venous Lymphat Disord. 2015; 3: 18-26Abstract Full Text Full Text PDF PubMed Google Scholar The natural history of CVD was also investigated in a large longitudinal study, the Bochum study I-IV, which included initially 740 pupils of 10 – 12 years (Bochum I), 136 of whom underwent follow up to the age of 30 years (Bochum IV). This study revealed that preclinical venous reflux, identified in a young population, represented a 30% risk (95% CI 13 – 53%) of developing truncal VVs within four years.12Schultz-Ehrenburg U. Reich-Schupke S. Robak-Pawelczyk B. Rudolph T. Moll C. Weindorf N. et al.Prospective epidemiological study on the beginning of varicose veins. Bochum Study I–IV.Phlebologie. 2009; 38: 17-25Crossref Scopus (21) Google Scholar The anatomy of the superficial, perforating, and deep veins of the lower limbs has been described extensively.13Caggiati A. Bergan J.J. Gloviczki P. Jantet G. Wendell-Smith C.P. Partsch H. et al.Nomenclature of the veins of the lower limbs: an international interdisciplinary consensus statement.J Vasc Surg. 2002; 36: 416-422Abstract Full Text PDF PubMed Scopus (273) Google Scholar,14Caggiati A. Bergan J.J. Gloviczki P. Eklof B. Allegra C. Partsch H. et al.Nomenclature of the veins of the lower limb: extensions, refinements, and clinical application.J Vasc Surg. 2005; 41: 719-724Abstract Full Text Full Text PDF PubMed Scopus (175) Google Scholar The anatomical terms and their abbreviations used in the present guidelines correspond with the 2020 update of the CEAP classification (Table 4).6Lurie