Integrated anatomic and hemodynamic classification for primary superficial venous disease: results from an expert survey

Background: There is general perception among vascular physicians that primary lower limb superficial chronic venous disease (CVD) can present in various clinical, anatomical and hemodynamical patterns. Nonetheless, and despite the diversity of classifications on this subject, none specifically addresses such patterns in an integrative form. In the authors opinion, an integrated anatomic and hemodynamic classification could prove a valuable tool for both patient stratification and treatment, as well as postoperative outcomes assessment and homogeneous comparison among groups. The purpose of this study was to collect expert opinion on the usefulness and applicability of a new integrated anatomic and hemodynamic classification for primary superficial venous disease, as well as the anatomic and hemodynamic variables to consider. Methods: A survey was administered via a web-based platform to a worldwide selected group of experts on vascular pathology. The survey included 27 questions and collected data on physician demographics and clinical experience (6 questions); usefulness and applicability of a new classification (6 questions); and anatomic and hemodynamic variables to consider (15 questions). A 5-point Likert Scale was used for categorization, and open-ended questions were included for commentary. Results: A total of 278 surveys were sent to experts worldwide, out of which 122 participated (response rate 43.9%). Most participants were European based (85.2%) vascular surgeons (85.2%), but experts from 39 countries across all continents were represented. 88.9% of the respondents agreed that primary varicose veins can be divided in different anatomic and hemodynamic patterns, although only 45.1% believe current classifications are appropriate to differentiate such patterns; 58.2% of respondents agree with an anatomical classification of varicose veins (VV) according to their area of distribution in the lower limb (anterior, posterior, medial, lateral), and 77.1% agree with a hemodynamic categorization of VV in 3 major patterns: VV related with saphenous insufficiency; VV related with pelvic insufficiency; isolated insufficient tributaries and perforator veins. There is general consensus that an integrated anatomic and hemodynamic classification for primary superficial venous disease would be of great use for patient stratification (80.3%), treatment selection (72.2%) and postoperative outcome assessment (70.5%); furthermore, 68.9% of the respondents would use the aforementioned classification, as long as it remained simple and easy to apply in a clinical practice daily basis. Conclusions: The results of the present survey demonstrate that vascular physicians involved in the treatment of primary superficial venous disease recognize the limitations on current varicose vein classifications and agree on the need for a more comprehensive classification for such pathology. Experts agree that an integrated anatomic and hemodynamic classification for primary superficial venous disease would be of great use for patient stratification, treatment selection and postoperative outcome assessment, as long as it remained simple and easy to apply in a clinical practice daily basis. Collected evidence provides significant insights on expert opinion on anatomic and hemodynamic variables to assess and may set the bases for a new classification. Further validations using methodologically solid strategies for expert consensus are required.