Prevalence, risk factors, and clinical patterns of chronic venous disorders of lower limbs: a population-based study in France

Avaliação do segmento venoso femoropoplíteo pela ultrassonografia Doppler em pacientes com úlcera varicosa

CONTEXTO: Como a úlcera é uma grave complicação da insuficiência venosa crônica, é necessário o conhecimento amplo de sua fisiopatologia. A ultrassonografia Doppler venosa é o exame complementar mais adequado, que possibilita o estudo do sistema venoso superficial e profundo, sua anatomia e fisiologia. Trabalhos recentes valorizam o refluxo em Veia Poplítea como importante fator para o desenvolvimento deste quadro clínico. OBJETIVOS: Avaliar o refluxo em segmento venoso femoropoplíteo em pacientes com úlcera varicosa. TIPO DE ESTUDO: Estudo de prevalência. MÉTODOS: Cento e quatro pacientes apresentando 118 membros inferiores com úlcera varicosa. Procedimentos: exame de ultrassonografia Doppler venosa do membro acometido, observado o refluxo no segmento venoso femoropoplíteo e diâmetro da Veia Poplítea. Variáveis: Primária: refluxo no segmento venoso femoropoplíteo. Secundária: diâmetro da Veia Poplítea. RESULTADOS: A presença de refluxo no segmento venoso femoropoplíteo foi observada em 56 (47,45%) dos 118 membros com úlcera varicosa, examinados em 104 pacientes. O diâmetro médio da Veia Poplítea foi de 1,14 cm, sendo o diâmetro médio normal da população 0,6 cm. CONCLUSÃO: O refluxo venoso no segmento venoso femoropoplíteo é um importante fator na avaliação do prognóstico destes pacientes, o aumento de diâmetro da Veia Poplítea reflete a magnitude da insuficiência venosa.

Trophic ulcers-Practical management guidelines

The management of patients with trophic ulcers and their consequences is difficult not only because it is a recurrent and recalcitrant problem but also because the pathogenesis of the ulcer maybe different in each case. Methodically and systematically evaluating and ruling out concomitant pathologies helps to address each patient's specific needs and hence bring down devastating complications like amputation. With incidence of diabetes being high in our country, and leprosy being endemic too the consequences of neuropathy and angiopathy are faced by most wound care specialists. This article presents a review of current English literature available on this subject. The search words were entered in PubMed central and appropriate abstracts reviewed. Relevant full text articles were retrieved and perused. Cross references from these articles were also reviewed. Based on these articles and the authors’ experiences algorithms for management have been presented to facilitate easier understanding. It is hoped that the information presented in this article will help in management of this recalcitrant problem.

Analysis of a series of patients with varicose vein recurrence

OBJECTIVE

Varicose veins of the lower extremities is a common clinical condition. Although surgical treatment is often successful, the recurrence rate remains high. This retrospective study evaluated the reasons for postoperative recurrence of varicose veins by analysing ultrasonography and venography findings in patients with recurrent disease.

METHODS

A series of consecutive cases of recurrent varicose veins of the lower limbs was reviewed. Data collected included clinical characteristics, symptoms and vascular imaging.

RESULTS

The study included 109 legs with recurrent varicose veins (92 patients): 101/109 legs (92.7%) showed perforating vein insufficiency and 86/109 (78.9%) showed reflux of the superficial femoral vein, of varying degrees of severity. Residual saphenous vein was recorded for 82 legs (75.2%), while 19 (17.4%) had blocked iliac veins due to post-thrombotic syndrome.

CONCLUSIONS

Several factors that may contribute to varicose vein recurrence have been identified. These include failure to ligate perforating veins and initial failure to perform the appropriate surgical intervention. Prevention of varicose vein recurrence after surgical correction requires a more extensive use of preoperative imaging, to tailor surgical intervention to suit individual patients.

Age, body mass index and severity of primary chronic venous disease

AIM

The aim of this cross-sectional prospective study was investigate whether there is a correlation between age, BMI and severity of chronic venous disease (CVD), evaluated clinically (CEAP classification) and anatomically (extent of the epifascial venous reflux).

METHODS

213 patients, 65 males (30.5%, mean age 45.1 ± 13.9 years) and 148 females (69.5%, mean age 47.5 ± 13.5 years) were divided into three age categories: 18-40 years (40.8%), 41-74 years (56.3%) and ≥75years (2.8%). BMI was classified as normal weight (18.5 - <25 kg/m(2)), overweight (25 - <30 kg/m(2)) and obesity (≥30 kg/m(2)). Clinical examination of the lower limbs assessed presence and severity of venous signs as included in the CEAP classification. BMI was calculated. Anatomical extent of CVD was described as the number of segments of the superficial and perforating veins with documented reflux by duplex imaging.

RESULTS

Median age increased the number of insufficient venous segments (1 insufficient venous segment - median age 41.0 years, 5 insufficient venous segments - median age 51.0 years). The frequency of reflux in the superficial and perforating veins significantly increased with age (p<0.05). A statistically significant correlation was also found between age and the CEAP classification (p<0.01). This was more significant than the correlation between age and number of insufficient venous segments. In the whole group and in women the Spearman's correlation analysis revealed only a weak positive correlation between BMI and reflux in the superficial veins (r=0.145 respectively r=0.264) (p<0.05). No correlation was found in men (r=0.091). Weak positive correlation between BMI and stage of venous insufficiency (CEAP classification) was demonstrated for the whole group of patients (r=0.229, p<0.01), for women (r=0.293, p<0.05) and for men (r=0.245, p<0.01). Multiple linear regression showed age (p<0.0001) and BMI (p=0.049) as significant predictors of clinical grade according to the CEAP classification and the CEAP clinical class (p<0.0001) as a significant predictor of extent of the epifascial venous reflux.

CONCLUSIONS

The study confirmed the relationship between age, clinical (CEAP clinical class) and pathophysiological (extent of the venous reflux) severity of CVD Older age means an increased number of insufficient venous segments and increased risk of the clinical progression of CVD from varicose veins to chronic venous insufficiency (C(3)-C(6), trophic skin changes and venous ulcers). Our results support the BMI, in term of frequency of venous reflux, as a risk factor in the whole group of patients but only in women but not in men. Multiple linear regression showed BMI together with age as significant predictors of clinical grade of CVD (p<0.05) according to the CEAP classification. As regards the influence of BMI on clinical severity/grade of CVD (CEAP), the results of our study support BMI as an important risk factor.

Family history and risk of hospital treatment for varicose veins in Sweden

Background

Family history has been suggested as a risk factor for varicose veins, but recall bias may inflate the familial risks. The aim of this nationwide study was to determine familial risks for hospital treatment for varicose veins.

Methods

Data from the Swedish Multi-Generation Register of people aged 0-76 years were linked to Hospital Discharge Register data for 1964–2008. Standardized incidence ratios (SIRs) were calculated for individuals whose relatives were treated in hospital for varicose veins and compared with those whose relatives were not. Only main diagnoses of varicose veins were considered.

Results

A total of 39 396 people had hospital treatment for varicose veins. The familial SIR among offspring with one affected parent was 2·39 (95 per cent confidence interval 2·32 to 2·46). The SIR for those with one affected sibling was 2·86 (2·76 to 2·97). SIRs were increased in both men and women. The SIR for individuals with two or more affected siblings or with two affected parents was 5·88 (5·28 to 6·53) and 5·52 (4·77 to 6·36) respectively. The SIR for the wives of men treated for varicose veins was 1·69 (1·59 to 1·80); that for the husbands of women treated for varicose veins was 1·68 (1·58 to 1·79).

Conclusion

Using the Swedish Hospital Discharge Register, and thereby eliminating recall bias, family history of hospital treatment for varicose veins was associated with an increased risk of similar treatment among relatives. The increased spousal risk suggests a contribution from non-genetic factors.

Comparative study on the effectiveness of myofascial release manual therapy and physical therapy for venous insufficiency in postmenopausal women

OBJECTIVES

Venous insufficiency is present in a large number of postmenopausal women, increasing their risk of disability. The objective of this study was to determine the effects of myofascial release therapy and conventional kinesiotherapy on venous blood circulation, pain and quality of life in postmenopausal patients with venous insufficiency.

METHODS

A randomised controlled trial was undertaken. We enrolled 65 postmenopausal women with stage I or II venous insufficiency on the clinical, aetiological, anatomical and physiopathological (CEAP) scale of venous disorders, randomly assigning them to a control (n=32) or experimental (n=33) group. The control and experimental group patients underwent physical venous return therapy (kinesiotherapy) for a 10-week period, during which the experimental group patients also received 20 sessions of myofascial release therapy. Main outcome measures determined pre- and post-intervention were blood pressure, cell mass, intracellular water, basal metabolism, venous velocity, skin temperature, pain and quality of life.

RESULTS

Basal metabolism (P<0.047), intracellular water (P<0.041), diastolic blood pressure (P<0.046), venous blood flow velocity (P<0.048), pain (P<0.039) and emotional role (P<0.047) were significantly higher in the experimental group than in the control group after the 10-week treatment programme.

CONCLUSION

The combination of myofascial release therapy and kinesiotherapy improves the venous return blood flow, pain and quality of life in postmenopausal women with venous insufficiency.

Prevalence, risk and aggravating factors of chronic venous disease: an epidemiological survey of the general population of Greece

INTRODUCTION

Chronic venous disease (CVD) is a common disease all over the world, mainly in Western Europe and the USA.

AIM

To evaluate the prevalence of CVD in the Greek general population and the characteristics of CVD.

MATERIALS AND METHODS

The study sample included 1500 individuals, 15-64 years of age, who were citizens of Athens, Thessaloniki, or one of five Greek cities with more than 10,000 in the population. The sample was selected by a stratified, multistage, random sampling procedure based on the Greek Census 2001. Questionnaires were completed for each individual by personal interview.

RESULTS

From 1500 individuals, 224 (14.9%) had symptoms and/or signs of CVD, 9.6% were men and 20.1% were women. The highest percentage of presenting CVD symptoms was among 45-54-year-olds (23.4%) and 55-64-year-olds (27%). The symptoms that were mostly mentioned among sufferers were 58% achy legs, 37.4% swollen legs and 25.3% heavy legs, whereas the frequent signs were broken capillaries - telangiectasia (19.2%) and varicose veins (14.8%). About 62.9% with CVD had an obese body mass index (BMI > 25). The prevalence of CVD in patients with prolonged standing hours at work (4+ hours) was 20.8%. The symptoms of CVD were worse during the summer period only in 26.8% of the patients whereas in 50.8% during all the year. Regarding quality of life, more than 40% of the patients had either health or cosmetic problems. Sufferers mentioned that they took first advice from physicians (28%), or from friends and relatives (27%) or from pharmacists (26%).

CONCLUSION

This is a real whole-population study of Greece - a Mediterranean country that provides important and remarkable data on the epidemiology of CVD and highlights that we need improvement of relations within the triangle constituted by physicians, patients and disease.

Risk factors for chronic venous disease

OBJECTIVE

Chronic venous disease (CVD) is a common problem in developing and developed countries.

METHODS

A cross-sectional study, conducted in two major towns in Serbia, comprised 3225 subjects over 18 years old, enrolled in the survey consecutively by general practitioners (GPs) within their normal framework. Diagnosis of CVD was made by GPs on the basis of symptoms and visual examination. Data on potential risk factors were collected by the use of a questionnaire.

RESULTS

The prevalence of CVD was significantly higher in women (73.7%) than in men (70.1%), although severe forms of CVD were significantly more frequent in men. Risk factors for CVD were age, body mass index ≥ 25.00 kg/m(2), family history of CVD, history of blood clots in veins and ever-smoking in both sexes, and menopause, increased number of child births and physical inactivity in women.

CONCLUSION

The results obtained suggest the possibility of CVD prevention by modification of some behavioural risk factors.

Characteristics of venous insufficiency in western Turkey: VEYT-I study

OBJECTIVES

Syndromes of venous hypertension and reduced venous clearance are important causes of morbidity and disability in patients with varicose venous disease. Published estimates of the prevalence of varicosities range from 7% to 55% in the adult population, with most studies demonstrating clinical varicose reflux in about 40% of the population where the frequency of venous insufficiency is believed to be higher in Westernized and industrialized nations, most likely due to differences in lifestyle and activity. Unfortunately, the prevalence in a Turkish population is not known. The goal of the VEYT-I study was to determine the characteristics of venous insufficiency in a Turkish population.

METHOD

Randomized patients who applied to a health-care centre were included in this study. The Tübingen questionnaire was used to evaluate the signs and symptoms of venous insufficiency and their seriousness in a Turkish population. Patients were additionally questioned on demographic data, education, working, living habits, quality of life and actual health status.

RESULTS

A total of 2167 patients were involved in this study. Four patients with chronic renal failure and 40 patients with congestive heart failure were excluded. In patients with venous insufficiency, 90.1% did not receive any therapy. In all, 51.53% of patients with venous insufficiency were men, and mean age was 56.9 ± 9.4.

CONCLUSION

The prevalence of venous insufficiency seems to be somewhat higher when compared with Western populations. One of the most prominent facts is that about 90% of patients with venous insufficiency did not receive any therapy. Therefore, disease-related complications or discomfort might emerge soon, and so more importance should be given to venous insufficiency. The VEYT-I study is a continuing database study and the target is to enlarge the study population.

Results of Radiofrequency Ablation of the Small Saphenous Vein in the Supine Position

Objectives: To report the results of a novel approach using supine positioning for radiofrequency ablation (RFA) of the small saphenous vein (SSV) with combined ablation of the great saphenous vein (GSV). Methods: Over a 24-month period, we identified patients with symptomatic SSV incompetence. Access to the SSV was accomplished by ultrasound-guided venipuncture with the patient in the supine position. Results: Small saphenous vein ablation was performed on 27 limbs in 26 patients. Median follow-up was 94 days (interquartile range [IQR] 26, 171). Mean clinical–etiologic–anatomic–pathophysiologic (CEAP) score was 3.5 ± 1.3. Small saphenous vein ablation was performed in conjunction with GSV ablation in 17 patients and with phlebectomy in 14 patients. Postoperative ultrasound was performed after 26 of 27 procedures. The SSV was sealed in all 26 cases. Two patients (8%) had a deep venous thrombosis (DVT). Conclusions: The SSV can be effectively sealed by RFA from the supine position and combined SSV/GSV ablation can be carried out in a single setting.

Can bilateral varicose vein surgery be performed safely in an ambulatory setting?

OBJECTIVES

Surgery for varicose veins is still the method of choice worldwide. When varicose veins require bilateral surgery, a single procedure often is the preferred choice by the patient. Today, unilateral varicose vein surgery is frequently performed as an outpatient procedure, while in many institutions bilateral surgery is done as an in-hospital procedure.

DESIGN

Retrospective comparative study.

METHODS

Between 1 October 2004 and 31 October 2006, 433 patients underwent surgery for the great saphenous vein as in-patient procedure (303 unilateral and 130 bilateral), period 1. From 1 November 2006 until 31 December 2009, 825 patients had ambulatory great saphenous vein surgery (550 unilateral and 275 bilateral), period 2. We have compared unilateral and bilateral varicose vein surgery (high ligation and stripping of the great saphenous vein) and in-hospital procedures with ambulatory surgery, with regard to postoperative complications, postoperative pain and midterm follow-up.

RESULTS

Operation time and total length of stay in the institution following varicose vein surgery were significantly shorter for period 2 compared with period 1 for both unilateral and bilateral surgery, without other differences between the groups. There were few postoperative complications without differences between periods, and between unilateral and bilateral surgery (wound infection 0.5%, haematoma requiring drainage 0.2%, transient paraesthesia 1.1%, superficial localised thrombophlebitis 0.6% and deep vein thrombosis in one unilaterally operated case only).

CONCLUSIONS

Bilateral varicose vein surgery can be safely performed as an outpatient procedure, without increased risk of postoperative complications, increased postoperative discomfort or midterm adverse effects compared with unilateral surgery.

Early and long-term results of physical methods in the treatment of venous leg ulcers: randomized controlled trial

OBJECTIVE

To estimate early and long-term results of physical methods in the treatment of venous leg ulcers.

METHOD

In group A after surgical operation, 40 patients were treated with the high-voltage stimulation (HVS) (100 µs, 100 Hz, 100 V) and drug therapy. In group B after operation, 37 patients were treated with ultrasound (0.5 W/cm(2), 1 MHz) and drug therapy. In group C after operation, 33 patients were treated with low-level laser therapy (LLLT) (810 nm, 65 mW) and drug therapy. In group D after operation, 35 patients were treated with the compression stockings (25-31 mmHg) and drug therapy. In group E after operation, 37 patients were only treated with drug therapy. Group F consisted of 32 patients, conservatively treated with the HVS and drug therapy. Group G consisted of 20 patients, conservatively treated with ultrasound and drug therapy. Group H consisted of 21 patients, conservatively treated with LLLT and drug therapy. Group I consisted of 30 patients, conservatively treated with compression and drug therapy. Group J consisted of 27 patients only treated with drug therapy.

RESULTS

Both short and long term parameters showed that compression therapy is the most efficient in ulcer healing. The electrical and ultrasound methods are less effective. The laser therapy ared useless.

CONCLUSION

Superficial venous surgery in addition to compression therapy is the most efficient treatment of venous leg ulcers. The compression therapy should be continued both surgically and conservatively treated patients with healed ulcers. In special cases after superficial venous surgery (isolated superficial reflux) compression therapy could be applied only to the time of ulcer closure without continuing it longer. HVS and ultrasound therapy are useful methods in conservative treatment of venous leg ulcers. For surgically-treated patients these physical therapies are efficient only in superficial plus deep reflux cases. HVS and ultrasound can be alternative methods, but are less effective in recurrence risk. LLLT is not an efficient physical method in treatment of venous leg ulcers.

Efeitos da terapia física descongestiva na cicatrização de úlceras venosas

Objetivou-se neste estudo verificar os efeitos da terapia física descongestiva (TFD) na cicatrização de úlceras venosas. Trata-se de um estudo intervencionista, quase experimental, do qual participaram 20 clientes, divididos em 2 grupos: o grupo controle (n=10) e o grupo de intervenção (n=10). Os clientes do primeiro grupo foram tratados apenas com curativo convencional e os do segundo grupo, com curativo convencional e terapia física descongestiva (associação de técnicas: drenagem linfática manual, enfaixamento compressivo, elevação dos membros inferiores, exercícios miolinfocinéticos e cuidados com a pele). Ambos os grupos foram tratados durante seis meses. Os clientes submetidos à TFD apresentaram significante redução de edema e da dor, além de melhora no processo cicatricial. Os resultados permitiram verificar que a terapia descongestiva estimula o processo de cicatrização de úlceras venosas, melhorando a qualidade de vida dos indivíduos.

Polymorphisms in MMP-9 and TIMP-2 in Chinese patients with varicose veins

BACKGROUND

Varicose veins (VVs), a common vascular disease, are functionally characterized by dilation and tortuosity and are widely prevalent in the adult population. The pathophysiology and molecular mechanism of VVs are still unclear. A genetic risk for VVs has been demonstrated, although no genetic variant pertaining to VVs has been identified. Matrix metalloproteinases (MMPs) and their endogenous tissue inhibitors (TIMPs), which can prevent excessive extracellular matrix (ECM) degradation, greatly impact vascular remodeling and may play a vital role in patients with VVs. We evaluated a potential association between polymorphisms in the promoters of MMP-9 and TIMP-2 and the risk for VVs in the Chinese population.

MATERIALS AND METHODS

Genotyping of the promoter region polymorphisms -1562C/T in MMP-9 and -418G/C in TIMP-2 was performed with PCR and restriction fragment length polymorphism (PCR-RFLP) assays with a group of 60 patients with VVs and 60 healthy controls. Purified PCR products were sequenced.

RESULTS

A significant correlation was found between patients with VVs and controls at -1562C/T in MMP-9. The TIMP-2 gene polymorphism -418G/C was also associated with VVs.

CONCLUSIONS

Our results suggest that polymorphisms in the promoter region of MMP-9 and TIMP-2 are associated with VVs in the Chinese population.

Lifestyle factors and varicose veins: does cross-sectional design result in underestimate of the risk?

OBJECTIVES

To assess whether smoking, alcohol drinking and dietary factors are linked with varicose veins.

METHODS

A middle-aged general population of 4903 was studied, and prevalence rates at entry and five-year incidence of varicose veins were assessed. Lifestyle habits were recorded at entry and at the end of the follow-up.

RESULTS

New varicose veins were significantly more common in individuals with regular alcohol intake, incidence odds ratio (OR) 1.5 (95% confidence interval [CI]: 1.05-2.3) in a multivariate analysis (of 2202 individuals). The association was particularly strong in women. Smokers had a higher incidence of varicose veins compared with non-smokers, OR 1.3 (95% CI: 0.9-1.8), but without statistical significance. Having daily meals of meat implied less new varicose veins than having 0-2 weekly meals of meat.

CONCLUSION

Alcohol was likely to increase the risk of varicose veins in women and smoking in both genders. These findings were seen in the follow-up design, but not when the data of these risk factors were compared with varicose veins prevalent at entry.

Venous thrombosis in the elderly: incidence, risk factors and risk groups

The incidence of venous thrombosis (VT) increases sharply with age: it is very rare in young individuals (<1 per 10,000 per year) but increases to ∼ 1% per year in the elderly, which indicates that aging is one of the strongest and most prevalent risk factor for venous thrombosis. The cause of this steep age gradient is as yet, unexplained. The aim of this review was to provide an overview of studies on the effect of conventional risk factors as well as age-specific risk factors for thrombosis in the elderly. Limited data are available on risk factors for thrombosis in the elderly, i.e. all results are based on small study groups. Results indicate that, of the conventional risk factors, malignant disease, the presence of co-morbidities and the genetic risk factors factor (F)V Leiden and the prothrombin mutation seem to be associated with an increased risk of venous thrombosis. In the elderly, the population attributable risk (PAR) of malignancy is approximately 35%, for co-morbidities a PAR up to 25% is found, and the contribution of genetic risk factors to the thrombosis incidence is estimated to be 7-22%. Age-specific risk factors of thrombosis, i.e. endothelial dysfunction and frailty may be important in the explanation of the increased incidence of VT in the elderly. In conclusion, as aging is a major risk factor for thrombosis, further identification of the risk factors for thrombosis in the elderly is needed to elucidate the age gradient of the incidence of VT and to target preventive measures.

Superficial thrombophlebitis in varicose vein disease: the particular role of methylenetetrahydrofolate reductase

BACKGROUND

The purpose of this study was to compare the genetic background of superficial (SVT) and deep vein thrombosis (DVT).

METHODS

Factor V (FV)-Leiden (G16891A)-, factor II(G20210A)-mutations, protein C- and S, as well as methylenetetrahydrofolate reductase (MTHFR) polymorphisms at C677T and A1298C, and serum homocysteine levels (hcy) were determined in 29 patients with SVT and 26 with DVT. Findings FV- and -II-mutations were less frequent in patients with SVT (2/3) compared with DVT (9/5), respectively (P < 0.002 in case of FV). However, the frequency of the MTHFR C677T polymorphism was significantly higher in patients with SVT compared with DVT (CT 12 versus 10, and TT 7 versus 1, respectively, P << 0.001). The distribution of the MTHFR A1298C genotype and serum hcy levels was similar in both patient groups. Protein S-deficiency was recorded once (SVT). Interpretation These results suggest that the MTHFR C677T-mutant genetically predisposes its carriers to SVT which may contribute to hypercoagulation in pre-existing varicose vein disease.

Epidemiology and risk factors for varicose veins among older people: cross-sectional population study in the UK

Background

There are many hypotheses concerning risk factors for the development of varicose veins based mostly on pathophysiological plausibility. Population studies have been carried out mostly on the middle aged with relatively few on elderly populations.

Objectives

To investigate epidemiological risk factors for varicose veins in an elderly population in the UK.

Methods

The South Wales Skin Cancer study – an examination survey undertaken between 1988 and 1991 of a random sample ( n = 792) drawn from all patients aged 60 and over registered with a general practitioner in South Glamorgan. Exposure variables were obtained from a structured administered questionnaire combined with clinical examination. Unadjusted and adjusted odds ratios were estimated using logistic regression.

Results

The response rate was 71% with an average age of 71 years (range 60–97). The age-adjusted prevalence of trunk varices was 63.2% (95% confidence interval [CI] 57.9–68.4%) in men and 57.0% (95% CI 50.6–63.4%) in women. In a multiple logistic regression the significant risk factors for varicose veins were increasing age ( P value = 0.001), obesity (odds ratio [OR] 3.28, 95% CI 1.25–8.63, P = 0.042), self-reported history of deep vein thrombosis (DVT) (OR 3.19, 1.16–8.78, P = 0.024) and history of hypertension (OR 0.58, 0.38–0.89, P = 0.013). The results for gender suggested that women were at greater risk than men, but this was not statistically significant (OR 1.53, 0.99–2.38, P = 0.056).

Conclusion

Trunk varices occur very commonly in older age groups with increasing age, obesity and possibly female sex as risk factors. Associations found with DVT and hypertension were based on history alone and must be interpreted with caution.

Pharmacological treatment in patients with C4, C5 and C6 venous disease

Background

A range of surgical, endovenous, physical and medical treatments are available for patients with chronic venous disease. The aim of this review was to evaluate the evidence for pharmacological agents used for the treatment of chronic venous disease.

Methods

A literature search was performed using Pubmed, Embase, Cochrane and Google Scholar databases. The initial search terms ‘varicose vein’, ‘venous ulcer’, ‘venous disease’ and ‘lipodermatosclerosis’ were used to identify relevant clinical studies of pharmacotherapy in patients with chronic venous disease (C4–C6).

Results

A huge range of naturally occurring and synthetic drugs have been studied in patients with chronic venous disease. For patients with C4 venous disease, micronized purified flavonoid fraction (MPFF), oxerutin, rutosides and calcium dobesilate may reduce venous symptoms and oedema. MPFF and pentoxifylline have been shown to improve venous ulcer healing when used in addition to multilayer compression bandaging. The clinical benefits of other medications remain unproven. Reliability of meta-analyses was limited by study heterogeneity, small sample sizes and lack of long-term follow-up.

Conclusions

In prospective randomized studies, MPFF (Daflon®), other flavonoid derivatives and pentoxifylline have demonstrated clinical benefits in patients with C4–C6 venous disease. Pharmacotherapy should be part of a range of treatment options in the modern management of patients with chronic venous disorders.

Does the number of pregnancies affect patterns of great saphenous vein reflux in women with varicose veins?

Objectives

Impact of pregnancies on great saphenous vein (GSV) reflux patterns deserves clarification. Which GSV segment is most affected? Is the saphenofemoral junction (SFJ) involved?

Methods

Colour-flow duplex ultrasonography was performed in 583 women extremities with primary varicose veins (clinical, aetiological, anatomical and pathological elements [CEAP C2]), without oedema, skin changes or ulcer. Women with previous thrombosis or varicose surgery were excluded. GSV reflux sources and drainage points were located at SFJ, thigh, knee and calf. Prevalence of most proximal reflux source was noted as a function of 0, 1, 2, 3 and 4 or more pregnancies. χ2 statistics was employed.

Results

Prevalence of GSV reflux was not dependent on 0, 1, 2, 3 or ≥4 pregnancies: 75%, 69%, 79%, 70% and 76% for right leg ( P = 0.79) and 78%, 81%, 82%, 79% and 73% for left leg ( P = 0.87), respectively. Prevalence of SFJ reflux and GSV reflux, starting at the thigh, knee or calf, was similar and showed no tendencies to increase with number of pregnancies.

Conclusions

Number of pregnancies did not influence GSV reflux patterns in women with primary varicose veins.

Heritability of chronic venous disease

Varicose veins without skin changes have a prevalence of approximately 20% in Northern and Western Europe whereas advanced chronic venous insufficiency affects about 3% of the population. Genetic risk factors are thought to play an important role in the aetiology of both these chronic venous diseases (CVD). We evaluated the relative genetic and environmental impact upon CVD risk by estimating the heritability of the disease in 4,033 nuclear families, comprising 16,434 individuals from all over Germany. Upon clinical examination, patients were classified according to the CEAP guidelines as either C2 (simple varicose veins), C3 (oedema), C4 (skin changes without ulceration), C5 (healed ulceration), or C6 (active ulcers). The narrow-sense heritability (h²) of CVD equals 17.3% (standard error 2.5%, likelihood ratio test P = 1.4 × 10⁻¹³). The proportion of disease risk attributable to age (at ascertainment) and sex, the two main risk factors for CVD, was estimated as 10.7% (Kullback–Leibler deviance R²). The heritability of CVD is high, thereby suggesting a notable genetic component in the aetiology of the disease. Systematic population-based searches for CVD susceptibility genes are therefore warranted.

Chronic venous disease. A state of art

Az európai lakosság egyharmadát érintő krónikus vénás betegségnek jelentős társadalmi, gazdasági kihatása van. Egyre inkább bizonyítható, hogy a vénafal strukturális átépülését két tényező okozza: a nagy vénás nyomás következtében létrejött áramlási zavar és egy progresszív gyulladásos láncreakció. A mikrocirkulációban a „fehérvérsejtcsapda” és a leukocyta-endothel interakció vezet bőrelváltozásokhoz, lábszárfekélyhez. A CEAP-osztályozás teszi lehetővé az egész világon a betegség egységes értelmezését, az egyes osztályok leírását. A gyakorló orvos számára a duplex scan ad értékes segítséget a pontos diagnózis felállításához, a kezelés irányításához. Ez az ultrahangvizsgálat számos, hasznos információt ad az alsó végtag vénás rendszeréről, kimutatja a reflux jelenlétét és helyét, a proximalis vénák esetleges elzáródását. A kezelés lehetőségei: konzervatív bázisterápia – beleértve a kompressziót, venoaktív gyógyszereket, vénás tornát, tanácsadást és gondozást –, a műtéti kezelés és a szklerotizáció. Világszerte gyorsan terjednek az új, ígéretes terápiás módszerek: a rádiófrekvenciával vagy lézerrel végzett endovénás beavatkozások és a habszkleroterápia.

Pathogenesis of primary varicose veins

BACKGROUND

Valvular incompetence and reflux are common features of primary varicose veins, and have long been thought to be their cause. Recent evidence, however, suggests that changes in the vein wall may precede valvular dysfunction.

METHODS

A literature search was performed using PubMed and Ovid using the keywords 'varicose vein wall changes', 'pathogenesis', 'aetiology' and 'valvular dysfunction'. Articles discussing the pathophysiology of complications of varicose veins, such as ulceration, recurrence, thrombophlebitis and lipodermatosclerosis, were excluded.

RESULTS AND CONCLUSION

Positive family history, age, sex and pregnancy are important risk factors for varicose vein formation. Areas of intimal hyperplasia and smooth muscle cell proliferation are often noted in varicose veins, although regions of atrophy are also present. The total elastin content in varicose as opposed to non-varicose veins is reduced; changes in overall collagen content are uncertain. Matrix metalloproteinases (MMPs), including MMP-1, MMP-2, MMP-3, MMP-7 and MMP-9, and tissue inhibitor of metalloproteinase (TIMP) 1 and TIMP-3 are upregulated in varicose veins. Activation of the endothelium stimulates the recruitment of leucocytes and the release of growth factors, leading to smooth muscle cell proliferation and migration. Dysregulated apoptosis has also been demonstrated in varicose veins. An understanding of the pathophysiology of varicose veins is important in the identification of potential therapeutic targets and treatment strategies.

Prevalence, risk factors, and clinical correlates of ulnar artery occlusion in the general population

BACKGROUND

Occlusion of the ulnar artery is found in a substantial proportion of elderly patients. The aim of this study was to estimate the prevalence of ulnar artery occlusion in a sample of the general population of France, look for its risk factors, and evaluate its clinical correlates.

METHODS

This study was an offshoot of a cross-sectional epidemiologic study in the general population of four locations in France (Tarentaise, Grenoble, Nyons, and Toulon). In phase I, random samples of 2000 individuals per location aged >or=18 years old were interviewed by phone for screening of Raynaud phenomenon. In phase II, subsamples of individuals were invited to a medical interview and physical examination where the presence of Raynaud phenomenon and occupational risk factors were recorded and a bilateral clinical Allen test was performed for the detection of ulnar artery occlusion. Phase II comprised 688 women and 335 men.

RESULTS

In 36 men and seven women, at least one occluded ulnar artery was found. The estimated prevalence was 9.6% in men and 1.0% in women (P < .001). The occluded artery was more often in the dominant hand of both men (8.1% vs 2.4%; P < .001) and women (0.9% vs 0.4%; P = .34). Ulnar artery occlusion was found more often in men aged >50 years (16.4%) than in younger men (1.4%; P < .001). Besides age, male sex, and dominant side, the only independent risk factor was an occupational exposure in men to repeated palmar trauma, with a significant quantitative relationship in the frequency of the impacts (P < .001) and the duration of the exposure (P < .001). Exposures to hand-held vibrating tools and cigarette smoking did not show a significant relationship in the multivariate analysis. Most individuals with ulnar artery occlusion did not have associated complaints; however, the diagnostic criteria for Raynaud phenomenon was validated in 13 of the 36 affected men. The association remained significant after adjusting for occupational exposure to vibrating tools. One individual reported a previous episode consistent with an attack of permanent digital ischemia.

CONCLUSION

This study confirms a substantial prevalence of ulnar artery occlusions in the general population, mostly in middle-aged and elderly men, which appears to be principally related to an occupational exposure to repeated occupational palmar trauma. Although there is a significant association with Raynaud phenomenon, most often the consequences of this occlusion remain subclinical.

Effect of family history on the incidence of varicose veins: a population-based follow-up study in Finland

In the literature, the estimates of high risk of family history for varicose veins are based on prevalence rates from cross-sectional studies. The purpose of this study was to compare such prevalence rates with incidence rates from our longitudinal follow-up study to find out whether there is a difference due to the methodology. A validated questionnaire was used in 3 middle-aged cohorts (n = 6874) in Tampere, Finland. Positive family history was more common both in men (prevalence odds ratio 6.6; 95% confidence interval, 4.7-9.3) and women (4.9; 95% confidence interval, 4.0-6.0) with varicose veins compared to those without. However, positive family history was linked much less with the incidence of varicose veins than the prevalence of varicose veins in women (incidence odds ratio 1.8; 95% confidence interval, 1.1-2.8) and men 1.4 (95% confidence interval, 0.7-2.6). There is likely to be a hereditary component of varicose veins, but it is substantially less than usually proposed in literature.

Cirurgia de varizes dos membros inferiores em pacientes receptores de transplante hepático: relato de caso

O transplante hepático vem progressivamente apresentando melhores resultados e maior preocupação com a qualidade de vida dos pacientes. As varizes dos membros inferiores são comuns na população e causam sintomas em boa parte dos casos, comprometendo a qualidade de vida. Em pacientes com boa condição clínica e funcionamento normal do enxerto, o tratamento cirúrgico das varizes de membros inferiores pode ser a opção com resultado mais eficaz e duradouro. Os autores relatam dois casos de pacientes que haviam sido submetidos a transplante hepático e apresentavam varizes sintomáticas de membros inferiores, e foram submetidos a cirurgia de varizes após liberação pela equipe de transplante hepático. As operações ocorreram sem intercorrências, com bom resultado no seguimento. A cirurgia de varizes dos membros inferiores pode ser realizada com segurança em pacientes receptores de transplante hepático, sendo uma opção eficaz e duradoura no tratamento da insuficiência venosa crônica nesses pacientes.

MMP-2 induced vein relaxation via inhibition of [Ca2+]e-dependent mechanisms of venous smooth muscle contraction. Role of RGD peptides

BACKGROUND

Matrix metalloproteinases (MMPs) are implicated in the pathogenesis of varicose veins. We have shown that MMP-2 causes relaxation of venous segments and suggested a role of venous smooth muscle (VSM) hyperpolarization; however, the downstream mechanisms are unclear. We tested whether MMP-2 induced venous relaxation involves inhibition of the Ca(2+) mobilization mechanisms of VSM contraction due to generation of Arg-Gly-Asp (RGD)-containing peptides.

METHODS

Circular segments of inferior vena cava (IVC) were isolated from male Sprague-Dawley rats, suspended between two wires in a tissue bath, and isometric contraction was measured. Contraction data in mg/mg tissue were presented as means +/- SEM.

RESULTS

In IVC incubated in normal Krebs (2.5 mM Ca(2+)), the alpha-adrenergic agonist phenylephrine (Phe, 10(-5) M) caused initial peak (133.2 +/- 17.5) followed by a maintained contraction (73.4 +/- 11.6), that was inhibited by MMP-2 (1 microg/mL) to 32.4 +/- 12.8 in 30 min. The inhibitory effects of MMP-2 were reversible by washing the tissue with Krebs or in the presence of the MMP inhibitors TIMP-1 (1 microg/mL), Ro 28-2653, and BB-94 (10(-6) M), and were not associated with changes in IVC structure, demonstrating specificity. Angiotensin II (AngII, 10(-6) M) caused a monophasic contraction (114.2 +/- 12.2), that was also inhibited by MMP-2 (66.0 +/- 7.4), suggesting a post-receptor effect on the downstream mechanisms of VSM contraction. To test the role of Ca(2+) release from the sarcoplasmic reticulum, IVC was incubated in Ca(2+)-free 2 mM ethylene glycol-bis(2-aminoethyl ether-N,N,N',N'-tetra-acetic acid (EGTA) Krebs with or without MMP-2. In Ca(2+)-free Krebs, caffeine did not cause contraction, suggesting a limited role of the Ca(2+)-induced Ca(2+)-release mechanism, and Phe and AngII caused a small contraction (7.2 +/- 1.7 and 14.9 +/- 2.8) that was slightly increased by MMP-2 (10.4 +/- 3.0 and 33.8 +/- 10.0), suggesting little effect on IP(3)-induced Ca(2+) release. To test the role of Ca(2+) entry through membrane channels, after eliciting a transient Phe contraction in nominally 0 Ca(2+) Krebs, increasing concentrations of CaCl(2) (0.1, 0.3, 0.6, 1, 2.5 mM) were added and the extracellular Ca(2+) concentration [Ca(2+)](e)-contraction relationship was constructed. The [Ca(2+)](e)-contraction relation was reduced in MMP-2 treated IVC, suggesting inhibition of Ca(2+) entry. In IVC treated with MMP-2, the Ca(2+) channel blocker diltiazem (10(-5)M) did not cause any further inhibition of Phe contraction, suggesting that Ca(2+) entry is already inhibited by MMP-2. To test whether MMP-2 actions involve generation of RGD and modulation of integrin receptors, experiments where repeated in IVC segments saturated with RGD (10(-5) M), or pretreated with the alpha(v)beta(3) integrin blocker cyclo(Ala-Arg-Gly-Asp-3-aminomethylbenzoyl) (cyclo-RGD). RGD-peptide caused only small relaxation of Phe contracted IVC (6.4 +/- 3.4%), and addition of MMP-2 to RGD-treated IVC caused further relaxation (69.7 +/- 3.0%). Pretreatment of IVC with cyclo-RGD did not significantly affect MMP-2 induced relaxation (55.0 +/- 5.0%).

CONCLUSIONS

In rat IVC, MMP-2 attenuates [Ca(2+)](e)-dependent VSM contraction without affecting Ca(2+) release from intracellular Ca(2+) stores. MMP-2 induced VSM relaxation may not involve RGD generation or activation of alpha(v)beta(3) integrin receptor. MMP-2 induced inhibition of the Ca(2+) entry mechanism of VSM contraction may play a role in the venous dilation associated with varicose vein formation.

Persons with varicose veins have a high subsequent incidence of arterial disease: a population-based study in Tampere, Finland

The aim of this population research was to find out the risk of arterial disease (defined as angina pectoris, myocardial infarction, peripheral occlusive arterial disease, and cerebrovascular disease) and hypertension in persons with varicose veins. A 5-year follow-up study was conducted in Tampere, Finland. A validated questionnaire was used in 3 middle-aged cohorts (40, 50, and 60 year olds) in a general population of 6,874. In the follow-up study, 71% (n = 4,903) replied. The incidence of arterial disease and hypertension was studied in those with varicose veins and those without at the entry to the study. During the follow-up, new arterial disease occurred significantly more often in individuals with varicose veins. The incidence odds ratio was 2.0 (95% confidence interval, 1.5-2.7; n = 3,032), but the incidence odds ratio of new hypertension was 1.0 (95% confidence interval, 0.8-1.3; n = 2,915). Varicose veins are a risk indicator of arterial disease but not of hypertension. Varicose veins likely do not cause arterial disease, but they may have common causes that, however, are not related with hypertension.

Primary chronic venous disorders

Primary chronic venous disorders, which according to the CEAP classification are those not associated with an identifiable mechanism of venous dysfunction, are among the most common in Western populations. Varicose veins without skin changes are present in about 20% of the population while active ulcers may be present in as many as 0.5%. Primary venous disorders are thought to arise from intrinsic structural and biochemical abnormalities of the vein wall. Advanced cases may be associated with skin changes and ulceration arising from extravasation of macromolecules and red blood cells leading to endothelial cell activation, leukocyte diapedesis, and altered tissue remodeling with intense collagen deposition. Laboratory evaluation of patients with primary venous disorders includes venous duplex ultrasonography performed in the upright position, occasionally supplemented with plethysmography and, when deep venous reconstruction is contemplated, ascending and descending venography. Primary venous disease is most often associated with truncal saphenous insufficiency. Although historically treated with stripping of the saphenous vein and interruption and removal of major tributary and perforating veins, a variety of endovenous techniques are now available to ablate the saphenous veins and have generally been demonstrated to be safe and less morbid than traditional procedures. Sclerotherapy also has an important role in the management of telangiectasias; primary, residual, or recurrent varicosities without connection to incompetent venous trunks; and congenital venous malformations. The introduction of ultrasound guided foam sclerotherapy has broadened potential indications to include treatment of the main saphenous trunks, varicose tributaries, and perforating veins. Surgical repair of incompetent deep venous valves has been reported to be an effective procedure in nonrandomized series, but appropriate case selection is critical to successful outcomes.

Exploring the aetiology and management of venous eczema

Many older people living at home or in residential settings in the community suffer from inflammation of the skin of the lower legs, or venous eczema. Management of this condition may depend on the background of the professional who carries out the initial assessment. Those with a tissue viability background may plan their care based on an assessment of the patient for suitability for compression, to reverse the venous hypertension which may be a causative factor of the eczema. On the other hand, professionals with a background in dermatology may base initial care plans on the use of emollients and topical steroids to reduce inflammation. This article examines the evidence base for our understanding of what causes venous eczema, questions whether current management of the condition is truly evidence-based, and argues for a more pro-active approach to both assessment and management of venous eczema.