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Background Corona phlebectatica (corona) is a clinical sign associated with chronic venous disorders (CVD). It is a good predictor for skin changes indicating a decompensation of the disease. However, it is not yet included in the clinical part of the CEAP classification, mainly due to the lack of operational criteria for its positive diagnosis. Aim To focus on the diagnostic and predictive values of corona, and to answer some relevant questions: How to define relevant operational criteria for a simple and reliable diagnosis in daily practice? Is the diagnosis reproducible? What is the value of this sign for the prognosis of CVD and their treatment? Results In order to clinically define corona, the association of blue telangiectases and stasis spots has the best specificity, and the blue telangiectases is the most sensible item. Their associated presence can be considered as a good operational criterion for the positive diagnosis of corona. Corona has also shown to be significantly correlated with the presence of incompetent leg perforator veins. The presence of corona also has a high value to predict the occurrence of skin changes and venous ulceration in the next few years of evolution of the disease. Conclusion Corona should no longer be considered as simple telangiectases of the foot (C1). It is a simple and reliable clinical entity, extremely relevant for the severity of the disease. This is the reason why a careful examination of the ankle should be done in any patient with CVD.
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REVIEW
Focus on corona phlebectatica: Diagnostic, signicance and predictive
value in chronic venous disorders
Jean-François Uhl
a,
n
, André Cornu-Thenard
b
, Patrick H. Carpentier
c
, Pier Luigi Antignani
d
a
Unité de recherche URDIA, EA 4465, Université Paris Descartes, 45 rue des Saints Pères, 75006 Paris, France
b
Hôpital Saint Antoine, rue du Fg St Antoine, F-75012 Paris, France
c
Clinique Universitaire de Médecine Vasculaire, CHU de Grenoble, F-38043 Grenoble, France
d
Department of Angiology, San Giovanni Hospital, Roma, Italy
a r t i c l e i n f o
Article history:
Received 14 June 2013
Accepted 11 July 2013
a b s t r a c t
Background: Corona phlebectatica (corona) is a clinical sign associated with chronic venous disorders
(CVD). It is a good predictor for skin changes indicating a decompensation of the disease. However, it is
not yet included in the clinical part of the CEAP classication, mainly due to the lack of operational
criteria for its positive diagnosis.
Aim: To focus on the diagnostic and predictive values of corona, and to answer some relevant questions:
How to dene relevant operational criteria for a simple and reliable diagnosis in daily practice? Is the
diagnosis reproducible? What is the value of this sign for the prognosis of CVD and their treatment?
Results: In order to clinically dene corona, the association of blue telangiectases and stasis spots has the
best specicity, and the blue telangiectases is the most sensible item. Their associated presence can be
considered as a good operational criterion for the positive diagnosis of corona.
Corona has also shown to be signicantly correlated with the presence of incompetent leg
perforator veins.
The presence of corona also has a high value to predict the occurrence of skin changes and venous
ulceration in the next few years of evolution of the disease.
Conclusion: Corona should no longer be considered as simple telangiectases of the foot (C1). It is a simple
and reliable clinical entity, extremely relevant for the severity of the disease.
This is the reason why a careful examination of the ankle should be done in any patient with CVD.
&2013 Elsevier B.V. All rights reserved.
Contents
History and denition of corona . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Place of corona in CVD and CEAP classication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Diagnosis of corona and its reproducibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Clinical relevance of the 4 clinical components of corona, and their relationship with the CEAP Cclasses . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Investigation by capillaroscopy (P.H Carpentier) (Fig. 8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Reproducibility of the clinical items. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Correlation between corona and other parameters of the CVI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Clinical parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Hemodynamical parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Predictive and prognosis value of corona . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
In summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Contents lists available at ScienceDirect
journ al h omepa ge: www.e lsevi er .com/ locate/ rvm
Reviews in Vascular Medicine
2212-0211/$- see front matter &2013 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.rvm.2013.07.002
n
Corresponding author. Tel.: +33 618654994.
E-mail address: jeanfrancois.uhl@gmail.com (J.-F. Uhl).
Reviews in Vascular Medicine 1 (2013) 3842
History and denition of corona
Corona phlebectatica paraplantaris (corona) was rst described
in 1960 by Van der Molen [13] as a consequence of venous stasis,
and included three elements [4]:
Telangiectases which are dilated intradermal veinules, ramica-
tions of birch twigslocated at the medial or and lateral
aspects of the foot, next to the malleolar areas.
These lesions can be distinguished as blue (Fig. 1) and red ones
(Fig. 2).
Venous cups (Fig. 3) extend to the plantar arch as 68 blue cups.
These elements are due to the dilatation of the triangular
shaped venous convergence coming from the plantar arch
The stasis spots are made of sub-epidermal capillaries (Fig. 4),
nummular purple-colored areas.
All of these components are often found associated on the same
foot (Fig. 5)
However, it should be noted that already in 1953, Frank Cockett
[5] described the same condition as a malleolar areand
underlined its correlation with a severe venous stasis, frequently
associated with leg incompetent perforators.
Place of corona in CVD and CEAP classication
Corona was used in the Basle study as the denition of the rst
grade of the chronic venous insufciency CVI1[6], as well as in
subsequent literature that used the Widmer classication [7,8].
Fig. 2. Red telangiectases of the foot. (For interpretation of the references to color
in this gure legend, the reader is referred to the web version of this article.)
Fig. 1. Blue telangiectases of the foot. (For interpretation of the references to color
in this gure legend, the reader is referred to the web version of this article.)
Fig. 3. Venous cups of the plantar arch. (For interpretation of the references to color in
this gure, the reader is referred to the web version of this article.)
Fig. 4. Stasis spots (epidermal capillaries). (For interpretation of the references to
color in this gure, the reader is referred to the web version of this article.)
Fig. 5. The 4 components ofcorona phlebectatica together (clinical aspect). avenous
cups (veins) bblue telangiectases (intradermal veinules). cred telangiectases
(supercial veinules) dstasis spots (capillaries). (For interpretation of the references
to color in this gure legend, the reader is referred to the web version of this article.)
J.-F. Uhl et al. / Reviews in Vascular Medicine 1 (2013) 3842 39
It was not taken into account in the CEAP classication of
Hawaii in 1994 [9], but considered as telangiectases of the foot and
so considered as C1also described as malleolar are[10].
However, during the consensus conference of the UIP in Roma
(2001) a renement of the CEAP was proposed, with a better
denition of the clinical items of CVD, including corona [11], which
was dened as Fan-shaped pattern of numerous small intrader-
mal veins on medial or lateral aspects of ankle and foot. Commonly
thought to be an early sign of advanced venous disease. Synonyms
include malleolar are and ankle are.
This new denition of corona was then included in the
renement of the CEAP in 2004 [12], but it was not yet included
in the CEAP classication due to the lack of clear diagnostic
criteria: Corona was only recognized as an early sign of advanced
venous disease as stated in the UIP consensus of Roma of 2001.
In 2010, the revision of the VCSS [13] included corona into the
VCSS scoring system, but restricted its presence to a score of 1(i.
e. mild) in the varicose veins score.
We think that corona deserves a better place in the CEAP
classication, because of its high predictive value for the future
occurrence of skin changes and ulcer, during the evolution of the
disease.
Diagnosis of corona and its reproducibility
Clinical relevance of the 4 clinical components of corona, and their
relationship with the CEAP Cclasses
The relevance of each of the 4 components of corona for the
diagnosis was described in a recent study [4]:Stasis spots
(Po0.001; r0.44) and blue telangiectases (Po0.01; r0.32)
were linearly associated with the ascending order of Cclasses
(Fig. 6), whereas the relationship is less clear for the red telan-
giectases and the venous cups.The association pattern of the
four components showed that only the blue telangiectases and the
stasis spotswere consistent with each other. Blue telangiectases
were found more sensitive (0.91 vs. 0.75) but less specic (0.52 vs.
0.80) than stasis spotsfor advanced venous insufciency (CEAP
C4-6), as seen in Table 1.
Finally, the association of blue telangiectases and stasis spots
has the best specicity, and the blue telangiectases is the most
sensible item (Fig. 7).
Investigation by capillaroscopy (P.H Carpentier) (Fig. 8)
These 4 clinical components can also be checked by capillaro-
scopy, which could be a way of renement of our clinical criteria:
The cup-shaped dilatations are hypodermal veinules, which
extend to the plantar arch as 68 blue cups, and are secondary
to the dilatation of the triangular shaped venous convergences
coming from the plantar arch.
The blue and red telangiectases are made of dilated ramied
intradermal venules.
The stasis spots are made of sub-epidermal papillary capillaries
grouped into nummular red or purple-colored areas.
Reproducibility of the clinical items
Arst study done before the UIP consensus of Roma in 2001
demonstrated the poor reproducibility of the clinical items of the
CEAP [14] and this was also true for corona [15].
We recently performed a reproducibility study on 100 corona
photographs by 6 experts and found a good reproducibility only
Fig. 6. Prevalence of the blue telangiectases and Stasis spots according to the CEAP
clinical classes.
Table 1
Diagnostic value of corona phlebectatica components for advanced venous insuf-
ciency (CEAP C4-C6), and rank correlation with Cclasses.
Corona
components
Likelihood
ratio
Sensitivity Specicity Spearman rank
correlation
Stasis spots3.83 0.75 0.80 0.39
Blue
telangiectases
1.89 0.91 0.52 0.31
Venous cups1.79 0.68 0.65 0.21
Red
telangiectases
1.24 0.91 0.27 0.29
Fig. 7. Prevalence of the corona according to the presence of its 2 main clinical
components and their associations. (BTblue telangiectases SSstasis spots).
Fig. 8. Capillaroscopy of the 4 clinical components of corona. (For interpretation of
the references to color in this gure, the reader is referred to the web version of this
article.)
J.-F. Uhl et al. / Reviews in Vascular Medicine 1 (2013) 384240
for the blue telangiectases (unpublished data) as mentioned in the
consensus document on Corona of the UIP of Prague [16].
According to the new recommendations two grades of severity
are proposed by the experts [16] (Table 2).
1. Incipient corona (or corona grade 1): more than 5 clusters of
bluish intradermal veins in the submalleolar area.
2. Denite corona (or corona grade 2): tortuous bluish intrader-
mal veins with a diameter less than 3 mm in the submalleolar
area, extended over the half length of the foot or more.
Correlation between corona and other parameters of the CVI
Clinical parameters
We previously found a signicant correlation between corona
and the clinical items of the CEAP classication in a series of 874
patients [17]. Corona was correlated with the ascending severity
related to the CEAP Cclinical classes from C0 to C6 (Chi 2:
Po0.001, Spearman rank correlation coefcient r0.28).
In a second series of 287 unselected patients [18], the presence
of corona and its severity grade were found signicantly related to
2 of the main risk factors for chronic venous insufciency: age and
personal history of deep vein thrombosis. Corona was also corre-
lated with the presence of so-called venous symptoms, including
pain, pruritus, burning sensation, feeling of swelling, cramps,
heavy legs.
Furthermore, among the patients without skin changes (classes
C1C3), the presence and grade of corona appeared to be sig-
nicantly associated with the severity of the disease, with increas-
ing CEAP clinical class (Po0.05), disability score (Po0.03), and
anatomical score (Po0.01). The presence of corona and its
severity grade were also found signicantly related to the CEAP
clinical classes themselves (Po0.001), the CEAP disability
(Po0.001) and clinical severity scores (Po0.001). A comparison
between the CEAP classication without corona and a modied
classication including corona in C3 shows a better reliability
coefcient of Cronbach [17]. This suggests that corona should not
be considered to be similar to telangiectases and reticular veins in
other locations. The same signicant association with the severity
of CVD as shown in the ascending CEAP Cclasses was shown in
the Bonn vein study [Rabe, Pannier unpublished data]. Severe
stage of corona (grade 2) was associated with a higher prevalence
of corona.
Hemodynamical parameters
A hemodynamical correlation was also demonstrated [18]
between corona and the presence of supercial reux in the
saphenous and non saphenous territories (Po0.05) and in the
leg and calf perforator veins (Po0.001): The relative risk of
nding incompetent leg or calf perforators by duplex ultrasound
is 4.4 times greater in patients with corona (Po0.001). However,
the presence of a deep venous reux was not found to be
signicant in this series.
All these data suggest that corona well correlates with a distal
venous reux. This corroborates the hypothesis of Van der Molen
that corona should be a consequence of the venous stasis of the
foot [3], related to a prolonged or severe venous hypertension.
It was also the hypothesis described by Cockett [5] as the
ankle blow out syndrome, which was recently supported by
the data of the Edinburgh study [19]. This is also consistent with
the ndings of Hirai [20] showing a signicant relationship
between some coronas and venous photoplethysmography (shor-
tened half lling time in corona group). Finally, the study of
Kolbach et al. [21] proofed a good correlation between post-
thrombotic syndrome and Widmer classication (where the
corona plays a pregnant role).
Predictive and prognosis value of corona
Before the occurrence of skin changes, corona is the best
predictor of severity during the evolution of CVI. This is conrmed
by the large case control study of Robertson et al. [22] on the risk
factors for leg ulceration, corona phlebectatica was found to be the
second best independent predictor (OR 4.52, 95% CI 1.8111.3)
after the presence of skin changes (OR 8.90, 95% condence
interval 1.4454.8).
In summary
The deciding characteristics to differentiate corona from simple
spider veins of the ankle classied C1 are:
More than 5 non conuent intradermal veins.
The presence of stasis spots (clusters of dilated papillary
capillaries)
An extension equal or superior to half length of the foot
(criterion of a grade 2 corona)
Tiny areas of perivenous pigmentation.
The proposed diagnostic criteria and grading for corona:Pre-
sence of at least 5 non conuent clusters (bunches-clumps) of blue
telangiectases (intradermal veins) can be found on the medial or
lateral aspects of ankle and foot below the malleolas.
An extension of the lesions to equal or superior to half length of
the foot is a criteria for severity (grade 2 corona). It could be
reinforced by the presence of stasis spots, or tiny areas of
perivenous pigmentation.
Conclusion
The diagnostic of corona is determined by the presence of blue
telangiectases below the malleolar areas and or stasis spots.
Corona is signicantly associated with the presence of incom-
petent leg perforators and saphenous reux, characteristic of an
important venous stasis.
Corona strongly correlates with the clinical severity and hemo-
dynamic disturbances of the disease. Due to its high predictive
value for the occurrence of skin changes, a careful examination of
the ankle is mandatory in any patient with CVD.
A renement of the CEAP scoring system giving more weight to
the presence of corona might also be suggested.
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Table 2
Proposed criteria for the grading of extension.
Grade 0 o5 telangiectasesC1 (no corona)
Grade I ohalf length of the foot
Grade II 4half length of the foot
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J.-F. Uhl et al. / Reviews in Vascular Medicine 1 (2013) 384242
... • Stasis spots are made up of sub-epidermal capillaries, nummular, purple-colored areas. The diagnosis of corona phlebectatica is determined by the presence of blue telangiectasias below the malleolar areas and/or stasis spots (9). The association of blue telangiectasias and stasis spots has the best specificity, and the blue telangiectasias is the most sensible item (9). ...
... The diagnosis of corona phlebectatica is determined by the presence of blue telangiectasias below the malleolar areas and/or stasis spots (9). The association of blue telangiectasias and stasis spots has the best specificity, and the blue telangiectasias is the most sensible item (9). To complement the diagnostic reproducibility, UIP proposed diagnostic criteria and grades of severity (10) ( Table 1). ...
Article
Full-text available
Reproducibility of the “C” Classes of the CEAP Classification.
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Full-text available
it is possible to read lot of papers on CORONA PHLEBECTATICA just cleck on the words
Article
Objective To investigate the clinical significance of corona phlebectatica. Design Clinical and plethysmographic evaluation of corona phlebectatica associated with primary varicose veins. Setting Department of Surgery, Aichi Prefectural College of Nursing, Nagoya, Japan. Main outcome measures In 411 limbs with greater saphenous incompetence, including 101 with skin changes and 310 without skin changes, clinical analysis and plethysmographic evaluation using the photoplethysmographic technique were carried out. Results In 204 of 411 limbs, corona phlebectatica was observed, including 75 coloured red and 129 coloured blue. Blue coronas were observed significantly more often then red coronas in limbs with skin changes. The half refilling time in limbs with skin changes was significantly shorter than that in limbs without skin changes. In limbs without skin changes, limbs with blue coronas showed a significantly shortened half refilling time than those with red coronas. Conclusions Blue coronas are a strong indicator of the presence of prolonged venous hypertension in varicose veins.
Article
At the request of the Ad Hoc Committee on Reporting Standards of the Joint Council of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery, this report updates and modifies "Reporting standards in venous disease" (J VASC SURG 1988;8:172-81). As in the initial document, reporting standards for publications dealing with (1) acute lower extremity venous thrombosis, (2) chronic lower extremity venous insufficiency, (3) upper extremity venous thrombosis, and (4) pulmonary embolism are presented. Numeric grading schemes for disease severity, risk factors, and outcome criteria present in the original document have been updated to reflect increased knowledge of venous disease and advances in diagnostic techniques. Certain recommendations of necessity remain arbitrary. These standards are offered as guidelines whose observance will in our opinion improve the clarity and precision of communications in the field of venous disorders. (J VASC SURG 1995;21:635-45.)
Article
Objective: To investigate the clinical significance of corona phlebectatica. Design: Clinical and plethysmographic evaluation of corona phlebectatica associated with primary varicose veins. Setting: Department of Surgery, Aichi Prefectural College of Nursing, Nagoya, Japan. Main outcome measures: In 411 limbs with greater saphenous incompetence, including 101 with skin changes and 310 without skin changes, clinical analysis and plethysmographic evaluation using the photoplethysmographic technique were carried out. Results: In 204 of 411 limbs, corona phlebectatica was observed, including 75 coloured red and 129 coloured blue. Blue coronas were observed significantly more often then red coronas in limbs with skin changes. The half refilling time in limbs with skin changes was significantly shorter than that in limbs without skin changes. In limbs without skin changes, limbs with blue coronas showed a significantly shortened half refilling time than those with red coronas. Conclusions: Blue coronas are a strong indicator of the presence of prolonged venous hypertension in varicose veins.