Revised Venous Clinical Severity Score
In response to the need for a disease severity measurement, the American Venous Forum committee on outcomes assessment developed the Venous Severity Scoring system in 2000. There are 3 components of this scoring system, the Venous Disability Score, the Venous Segmental Disease Score, and the Venous Clinical Severity Score (VCSS). The VCSS was developed from elements of the CEAP classification (clinical grade, etiology, anatomy, pathophysiology), which is the worldwide standard for describing the clinical features of chronic venous disease. However, as a descriptive instrument, the CEAP classification responds poorly to change. The VCSS was subsequently developed as an evaluative instrument that would be responsive to changes in disease severity over time and in response to treatment.
Based upon initial experiences with the VCSS, an international ad hoc working group of the American Venous Forum was charged with updating the instrument. This revision of the VCSS is focused on clarifying ambiguities, updating terminology, and simplifying application. The specific language of proven quality-of-life instruments was used to better address the issues of patients at the lower end of the venous disease spectrum. Periodic review and revision are necessary for generating more universal applicability and for comparing treatment outcomes in a meaningful way.
Table I: Revised Venous Clinical Severity Score
| Clinical descriptor | None: 0 | Mild: 1 | Moderate: 2 | Severe: 3 |
|---|---|---|---|---|
| Pain or other discomfortie, aching, heaviness, fatigue, soreness, burning. Presumes venous origin. | None | Occasional pain or other discomfort (ie, not restricting regular daily activities) | Daily pain or other discomfort (ie, interfering with but not preventing regular daily activities) | Daily pain or discomfort (ie, limits most regular daily activities) |
| Varicose veins“Varicose” veins must be ≥3 mm in diameter to qualify in the standing position. | None | Few: scattered (ie, isolated branch varicosities or clusters). Also includes corona phlebectatica (ankle flare) | Confined to calf or thigh | Involves calf and thigh |
| Venous edemaPresumes venous origin. | None | Limited to foot and ankle area | Extends above ankle but below knee | Extends to knee and above |
| Skin pigmentationPresumes venous origin. Does not include focal pigmentation over varicose veins or pigmentation due to other chronic diseases. | None or focal | Limited to perimalleolar area | Diffuse over lower third of calf | Wider distribution above lower third of calf |
| InflammationMore than just recent pigmentation (ie, erythema, cellulitis, venous eczema, dermatitis). | None | Limited to perimalleolar area | Diffuse over lower third of calf | Wider distribution above lower third of calf |
| IndurationPresumes venous origin of secondary skin and subcutaneous changes (ie, chronic edema with fibrosis, hypodermitis). Includes white atrophy and lipodermatosclerosis. | None | Limited to perimalleolar area | Diffuse over lower third of calf | Wider distribution above lower third of calf |
| Active ulcer number | 0 | 1 | 2 | ≥3 |
| Active ulcer durationLongest active. | N/A | <3 mo | >3 mo but <1 y | Not healed for >1 y |
| Active ulcer sizeLargest active. | N/A | Diameter <2 cm | Diameter 2-6 cm | Diameter >6 cm |
| Use of compression therapy | Not used | Intermittent use of stockings | Wears stockings most days | Full compliance: stockings |
Source: Vasquez MA, et al. Revision of the venous clinical severity score. J Vasc Surg. 2010. Table I.
Table II: Instructions for Using the Revised VCSS
On a separate form, the clinician will be asked to: “For each leg, please check 1 box for each item (symptom and sign) that is listed below.”
Pain or other discomfort (ie, aching, heaviness, fatigue, soreness, burning)
The clinician describes the four categories of leg pain or discomfort that are outlined below to the patient and asks the patient to choose, separately for each leg, the category that best describes the pain or discomfort the patient experiences.
| None = 0 | None |
| Mild = 1 | Occasional pain or discomfort that does not restrict regular daily activities |
| Moderate = 2 | Daily pain or discomfort that interferes with, but does not prevent, regular daily activities |
| Severe = 3 | Daily pain or discomfort that limits most regular daily activities |
Varicose Veins
The clinician examines the patient’s legs and, separately for each leg, chooses the category that best describes the patient’s superficial veins. The standing position is used for varicose vein assessment. Veins must be ≥3 mm in diameter to qualify as “varicose veins.”
| None = 0 | None |
| Mild = 1 | Few, scattered, varicosities that are confined to branch veins or clusters. Includes “corona phlebectatica” (ankle flare), defined as >5 blue telangiectases at the inner or sometimes the outer edge of the foot |
| Moderate = 2 | Multiple varicosities that are confined to the calf or the thigh |
| Severe = 3 | Multiple varicosities that involve both the calf and the thigh |
Venous Edema
The clinician examines the patient’s legs and, separately for each leg, chooses the category that best describes the patient’s pattern of leg edema. The clinician’s examination may be supplemented by asking the patient about the extent of leg edema that is experienced.
| None = 0 | None |
| Mild = 1 | Edema that is limited to the foot and ankle |
| Moderate = 2 | Edema that extends above the ankle but below the knee |
| Severe = 3 | Edema that extends to the knee or above |
Skin Pigmentation
The clinician examines the patient’s legs and, separately for each leg, chooses the category that best describes the patient’s skin pigmentation. Pigmentation refers to color changes of venous origin and not secondary to other chronic diseases.
| None = 0 | None, or focal pigmentation that is confined to the skin over varicose veins |
| Mild = 1 | Pigmentation that is limited to the perimalleolar area |
| Moderate = 2 | Diffuse pigmentation that involves the lower third of the calf |
| Severe = 3 | Diffuse pigmentation that involves more than the lower third of the calf |
Inflammation
The clinician examines the patient’s legs and, separately for each leg, chooses the category that best describes the patient’s skin inflammation. Inflammation refers to erythema, cellulitis, venous eczema, or dermatitis, rather than just recent pigmentation.
| None = 0 | None |
| Mild = 1 | Inflammation that is limited to the perimalleolar area |
| Moderate = 2 | Inflammation that involves the lower third of the calf |
| Severe = 3 | Inflammation that involves more than the lower third of the calf |
Induration
The clinician examines the patient’s legs and, separately for each leg, chooses the category that best describes the patient’s skin induration. Induration refers to skin and subcutaneous changes such as chronic edema with fibrosis, hypodermitis, white atrophy, and lipodermatosclerosis.
| None = 0 | None |
| Mild = 1 | Induration that is limited to the perimalleolar area |
| Moderate = 2 | Induration that involves the lower third of the calf |
| Severe = 3 | Induration that involves more than the lower third of the calf |
Active Ulcer Number
The clinician examines the patient’s legs and, separately for each leg, chooses the category that best describes the number of active ulcers.
| None = 0 | None |
| Mild = 1 | 1 ulcer |
| Moderate = 2 | 2 ulcers |
| Severe = 3 | ≥3 ulcers |
Active Ulcer Duration
If there is at least 1 active ulcer, the clinician describes the 4 categories of ulcer duration that are outlined below to the patient and asks the patient to choose, separately for each leg, the category that best describes the duration of the longest unhealed ulcer.
| None = 0 | No active ulcers |
| Mild = 1 | Ulceration present for <3 mo |
| Moderate = 2 | Ulceration present for 3-12 mo |
| Severe = 3 | Ulceration present for >12 mo |
Active Ulcer Size
If there is at least 1 active ulcer, the clinician examines the patient’s legs, and separately for each leg, chooses the category that best describes the size of the largest active ulcer.
| None = 0 | No active ulcer |
| Mild = 1 | Ulcer <2 cm in diameter |
| Moderate = 2 | Ulcer 2-6 cm in diameter |
| Severe = 3 | Ulcer >6 cm in diameter |
Use of Compression Therapy
Choose the level of compliance with medical compression therapy.
| None = 0 | Not used |
| Mild = 1 | Intermittent use |
| Moderate = 2 | Wears stockings most days |
| Severe = 3 | Full compliance: stockings |
Source: Vasquez MA, et al. Revision of the venous clinical severity score. J Vasc Surg. 2010. Table II.
