What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey

Most patients with varicose veins have fears or concerns about the future, in addition to their presenting symptoms

INTRODUCTION

This study aimed to document fears and concerns of patients about their varicose veins.

REPORT

Completed questionnaires about symptoms and concerns were brought to clinic by 62% (203/329) patients referred with uncomplicated primary varicose veins. 'Concerns, worries or fears' about their veins were reported by 79%. These were seldom mentioned in referral letters, and included fears about thrombosis (31%), trauma (16%), ulcers (15%) and general concerns about the future (57%).

DISCUSSION

Many patients have unrecognised fears and concerns about their varicose veins. Specific enquiry and reassurance about these is part of good management and may avoid unnecessary treatment.

Chronic Venous Insufficiency in Italy: The 24-cities Cohort Study

OBJECTIVE

To assess the relationship between sex, age, geographical region, lower limb symptoms and the presence of trunk varicose veins and venous incompetence.

DESIGN

Cross-sectional population study in 24 cities in the North, centre and South of Italy.

PARTICIPANTS

Five thousand two hundred and forty-seven people were selected during spring and summer 2003 by advertising on television, in newspapers, and by leaflets in 24 Italian cities. In all 5187 (4457 [85.9%] women and 730 men [14.1%]) volunteers were assessed. The median age was 54 (range: 18-90) years for the women and 61 (range: 18-89) years for the men.

METHODS

Self-administered questionnaire on subjective symptoms of chronic venous insufficiency (CVI) in the lower limbs, and clinical examination, including colour duplex ultrasonography to assess the presence and severity of varicose veins.

RESULTS

Overall only 22.7% of the subjects examined were free of visible signs of venous disease, with approximately 53% of the population over 50 years of age showing some venous reflux. People living in Southern Italy were more severely affected than those living in the North. Varicosities and telangiectases were the most frequent objective signs in both sexes. Trunk varicosities (27%) and saphenous reflux (41%) increased with age and were more common in men; in contrast, minor objective symptoms such as telangiectases (70%), as well as subjective symptoms such as heavy (79%) and tired legs (78%), were more common in women and were not age-related.

CONCLUSIONS

Venous disease is very common in Italy, in particular in people living in the South. A correlation between varicose veins and venous incompetence is more marked in men, while minor objective and subjective symptoms prevail in women. The findings from this non-random sample closely match results from previous studies, in which random sampling was used.

Impact of the informed consent process on patients’ understanding of varicose veins and their treatment

AIM

It is particularly important that patients have reasonable understanding of the risks, benefits and nature of elective surgery. This study sought to analyse this level of understanding in patients undergoing varicose vein surgery

METHODS

Eighty two patients completed a questionnaire in the vascular outpatient clinic and were asked to complete a telephone questionnaire following the clinic.

RESULTS

Pain (n = 46) was the primary reason patients considered varicose vein surgery followed by appearance (n = 32). Most patients felt that varicose veins placed them at high risk of leg ulcers (n = 46) and DVT (n = 41). A high level of expectation that surgery would significantly affect pain and flares was recorded. While the outpatient visit did not materially change these misconceptions, an educational leaflet significantly enhanced the recall of complications (p = 0.028) in patients who remembered receiving a leaflet.

CONCLUSION

Patients attending varicose vein clinics have an unrealistic expectation of the benefits of surgery and fail to understand the benign nature of their condition. The outpatient process has little effect on patient-held beliefs.

The profile of leg symptoms, clinical disability and reflux in legs with previously operated varicose disease

PURPOSE

It is difficult to assess the severity and location of venous insufficiency in legs with recurrent varicose disease. This present purpose was to evaluate the distribution of reflux and the diagnostic role of current classifications in a consecutive series of legs with previously operated varicose disease.

METHODS

A total of 90 legs in a cohort of 66 patients were included. The examination comprised CEAP clinical class, clinical disability score (CDS) and leg symptoms. Colour-flow duplex imaging (CFDI) was used to observe reflux in deep and superficial veins. Details of prior surgery were assessed.

RESULTS

The site of superficial reflux was at the groin in 58% (recurrent or residive vein trunk or unoperated great saphenous vein), and the rate in the popliteal fossa was 11% (unoperated short saphenous vein). In 58% of the legs presenting superficial reflux at groin level, previous surgery at the saphenofemoral junction was noted. A sensation of pain was observed in 74% of the legs, sensation of oedema in 64%, itching in 26 %, and night cramps in 8%, respectively. Only itching was significantly infrequent in uncomplicated (CEAP C 2-3) legs, and in legs with local reflux was restricted to vein tributaries. Higher CDS (classes 2-3) were significantly more frequent among complicated legs (CEAP clinical class C2-3: 22% versus CEAP clinical class C4-6: 77%; p < 0.005). A similar situation was noted when legs with only local reflux were compared to those with more severe reflux (local reflux: 7% versus severe reflux: 48%; p < 0.005).

CONCLUSIONS

Superficial reflux is frequently detected at groin level despite prior surgery. Unstructured evaluation of leg symptoms is not beneficial. Clinical disability scores associate well with the severity of the venous disease.

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

OBJECTIVES

The goals of this study were to document the prevalence of varicose veins, skin trophic changes, and venous symptoms in a sample of the general population of France, to document their main risk factors, and to assess relationships between them.

METHODS

This cross-sectional epidemiologic study was carried out in the general population of 4 locations in France: Tarentaise, Grenoble, Nyons, and Toulon. Random samples of 2000 subjects per location were interviewed by telephone, and a sub-sample of subjects completed medical interviews and underwent physical examination, and the presence of varicose veins, trophic changes, and venous symptoms was recorded.

RESULTS

Prevalence of varicose veins, skin trophic changes, and venous symptoms was not statistically different in the 4 locations. In contrast, sex-related differences were found: varicose veins were found in 50.5% of women versus 30.1% of men ( P < .001); trophic skin changes were found in 2.8% of women versus 5.4% of men ( P = NS), and venous symptoms were found in 51.3% of women 51.3% versus 20.4% of men ( P < .001). Main risk factors for varicose veins were age and family history in both sexes, and pregnancy in women. Female sex was a significant factor only for non-saphenous varicose veins. Varicose veins, age, and pitting edema were the most significant risk factors for trophic skin changes. The risk factors for venous symptoms were female sex, varicose veins, and prolonged sitting or standing. A negative relationship with age was found in women.

CONCLUSION

Our results show a high prevalence of chronic venous disorders of the lower limbs in the general population of France, with no significant geographic variations. They also provide interesting insights regarding the association of varicose veins, skin trophic changes, and venous symptoms.

Surgery versus sclerotherapy for the treatment of varicose veins

BACKGROUND

Varicose veins are a relatively common condition and account for around 54,000 in-patient hospital episodes per year. The two most common interventions for varicose veins are surgery and sclerotherapy. However, there is little comparative data regarding their effectiveness.

OBJECTIVES

To identify whether the use of surgery or sclerotherapy should be recommended for the management of primary varicose veins.

SEARCH STRATEGY

Thirteen electronic bibliographic databases were searched covering biomedical, science, social science, health economic and grey literature (including current research). In addition, the reference lists of relevant articles were checked and various health services research-related resources were consulted via the internet. These included health economics and HTA organisations, guideline producing agencies, generic research and trials registers, and specialist sites.

SELECTION CRITERIA

All studies that were described as randomised controlled trials comparing surgery with sclerotherapy for the treatment of primary varicose veins were identified.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted and summarised data from the eligible studies using a data extraction sheet for consistency. All studies were cross-checked independently by the reviewers.

MAIN RESULTS

A total of 2306 references were found from our searches, 61 of which were identified as potential trials comparing surgery and sclerotherapy. However, only nine randomised trials, described in a total of 14 separate papers, fulfilled the inclusion criteria. Fifty trials were excluded and one trial is ongoing and is due for completion in 2004. The trials used a variety of outcome measures and classification systems which made direct comparison between trials difficult. However, the trend was for sclerotherapy to be evaluated as significantly better than surgery at one year; after one year (sclerotherapy resulted in worse outcomes) the benefits with sclerotherapy were less, and by three to five years surgery had better outcomes. The data on cost-effectiveness was not adequately reported.

REVIEWERS' CONCLUSIONS

There was insufficient evidence to preferentially recommend the use of sclerotherapy or surgery. There needs to be more research that specifically examines both costs and outcomes for surgery and sclerotherapy.

The Effect of Superficial Venous Surgery on Generic Health-related Quality of Life

BACKGROUND

Superficial venous surgery (SVS) is associated with a significant improvement in disease-specific health related quality of life (HR-QoL) but the effect on generic HR-QoL remains uncertain. The aim of this study was to determine the effect of SVS on responses to the Short Form [SF]-36, the most widely used generic HR-QoL instrument.

METHOD

Two hundred and three patients undergoing SVS completed the SF-36 pre-operatively and 24 months post-operatively. Scores for the 8 SF-36 domains [physical (PF) and social functioning (SF), role limitation due to physical (RP) and emotional (RE) problems, mental health (MH), vitality (V), pain (P), and general health perception (HP)] were calculated and normalised using UK standard data.

RESULTS

Pre-operatively, patients scored significantly lower (worse) than the general UK population in PF, RP and P. Surgery was associated with a significant improvement in PF and P (45.3 vs. 42.5 and 48.9 vs. 43.8 postop vs. preop, p<0.001, WSR) at 2 years.

CONCLUSION

SVS leads to a statistically and clinically significant improvement in the physical components of the SF-36. These data will allow the clinical benefits of SVS to be compared with other interventions so helping informing decisions about how venous surgery should be prioritised appropriately within the NHS.

Waiting for elective general surgery: physical, psychological and social consequences

BACKGROUND

Long surgical waiting lists are common and receive serious consideration. To evaluate the positive and negative effects of waiting lists, insight into the consequences of waiting is needed. The present study aims to assess what insight the current literature provides into the effects of delayed surgery for varicose veins, inguinal hernia in adults, gallstones, and breast cancer in terms of physical, psychological and social aspects.

METHODS

Searches of Medline and Embase, for the period January 1985-September 2003, were performed to identify articles providing direct or indirect insight into the consequences of waiting for surgery for each disorder. Reference lists of retrieved reports were examined for relevant articles.

RESULTS

Seven studies were identified with direct data on consequences of delay in elective surgery. Relevant indirect data were found in 32 reports. Results indicated that delayed varicose vein surgery or inguinal hernia repair involves marginal physical, psychological or social suffering, and that severe deterioration is unlikely. The impact of delayed cholecystectomy seems more profound by suffering on all three health aspects. Complications while waiting do occur, with a higher risk for patients with previous complications. Longer delays for breast cancer surgery seem to adversely affect prognosis, although it is unclear which interval is associated with such an effect. Moreover, having breast cancer undoubtedly affects psychological health.

CONCLUSIONS

There is a remarkable paucity of studies addressing the consequential impact of waiting for elective surgery on patients' health for each of the four studied disorders. Current literature permits merely general estimation of this consequential impact. As specific assessment of these consequences is important for daily practice and for policy, further research is required.

Primary Varicose Veins: Altered Transcription of VEGF and its Receptors (KDR, flt-1, Soluble flt-1) with Sapheno-femoral Junction Incompetence

OBJECTIVE

Loss of regulation of vascular endothelial growth factor (VEGF) production and action disturbs vascular homeostasis leading to pathology. Primary varicose veins (VVs) demonstrate aberrant production/release of VEGF. Our aim was to examine transcription of genes for VEGF (VEGF(121)/VEGF(165)) and its receptors (KDR, flt-1, s.flt-1) in VVs, in relation to underlying venous incompetence.

MATERIALS AND METHODS

Samples of varicose (n=83, 18 patients) or normal (n=14, five subjects) great saphenous vein were divided into segments, determined by anatomical position from the sapheno-femoral junction (SFJ). SFJ and segmental incompetence were determined from duplex scans. Gene transcripts were amplified by RT-PCR, analysed by scanning densitometry, and the levels of transcription determined by ratio to control gene GADPH-3 (GAP-3).

RESULTS

VEGF(121)/(165), KDR and flt-1 transcription was elevated in VVs overall (p<0.001), and in VVs with an incompetent SFJ (p<0.001), but not when the SFJ was functional; s.flt-1 was unaltered. Notably, gene transcription was unaffected by segmental position, or incompetence. Position below the SFJ correlated with increased transcription of s.flt-1 when the SFJ was incompetent (p<0.04), and s.flt-1 and VEGF(121) when the segment was incompetent (p<0.03).

CONCLUSIONS

SFJ incompetence is associated with altered transcription of VEGF and its receptors reflecting an aetiological mechanism or later stage of disease development. Altered VEGF(121) and s.flt-1 transcription may be an early event in varicogenesis.

Varicose veins: a qualitative study to explore expectations and reasons for seeking treatment

BACKGROUND

Patients experience a wide range of symptoms from varicose veins and are seeking treatment from health care providers. However, there is little data on the relative effectiveness of the treatments available. Patients are therefore often confronted with a choice regarding treatment that they are ill-equipped to make. This lack of certainty and the resultant potential for variability in treatment decisions can mean that patients have expectations that are unrealistic or unfulfilled.

AIMS AND OBJECTIVES

The aim of our study was to explore patients' expectations and reasons for seeking treatment for varicose veins. Additional aims included the exploration of symptoms associated with varicose veins and their impact on quality of life.

DESIGN

Qualitative study conducted in a large NHS Trust.

METHODS

A total of 16 patients, who had been referred to a specialist vascular service for the treatment of varicose veins, were recruited. Semi-structured interviews were used to explore the patients' reasons for seeking treatment. Framework analysis was used to analyse the data from the anonymized transcripts.

RESULTS

Participants attributed a wide range of symptoms to their varicose veins, and were actively seeking treatment with the expectation that they would gain symptom relief. The symptoms attributed to their varicose veins had a significant negative impact on their quality of life and lifestyle. Improving the cosmetic appearance of their legs was seen as a secondary benefit.

CONCLUSIONS

The perceived symptoms of varicose veins can impact on lifestyle and quality of life. Patients seek treatment with the expectation of treatment outcomes that are not supported by robust clinical evidence. Appropriate education and management of such expectations are an essential step in caring for this group of patients.

RELEVANCE TO CLINICAL PRACTICE

Nurses are caring for patients with varicose veins in a range of clinical settings. When caring and providing information for this group of patients, nurses need to be aware of the impact of varicose vein symptoms and to understanding that patients may have unrealistic expectations or invalid reasons for seeking treatment.

The utilisation of superficial venous surgery for chronic venous insufficiency by the U.K. Asian population

BACKGROUND

The epidemiology of superficial venous disease is relatively well defined in the U.K. Caucasian population. By contrast, there are currently no data available for Asians, who comprise 3.6% of the U.K., and 14.1% of this institution's catchment population. The aim of this study was to compare surgery for superficial venous disease in Caucasians and Asians in this institution, in the context of our local population.

METHODS

A prospectively gathered database of all 2011 superficial venous operations performed between January 1997 and April 2002 was retrospectively analysed with regard to ethnicity. The ethnic, gender and age composition of our catchment area was determined from U.K. census data. The full institutional records of 100 Asian and 100 randomly selected age and sex-matched Caucasian patients were compared in a case control study.

RESULTS

After adjusting for age and gender according to census data, Asians were 40% less likely to undergo superficial venous surgery (SVS). Considering the 2011 operated patients as a whole, Asians were significantly younger and more likely to be male. In the case control study, Asians were significantly less likely to be operated for recurrent disease and significantly more likely to be operated for advanced disease.

CONCLUSIONS

Although Asians are significantly less likely to undergo SVS; those that do are more likely to be young, male and operated for skin changes and ulcers. This strongly suggests that the under-representation of Asians is due to cultural, genetic or environmental factors and unmet health care need, rather than a lower prevalence of clinically significant venous disease in the Asian population.

A comparison of patients who developed venous leg ulceration before and after their 50th birthday

BACKGROUND

although chronic venous ulceration (CVU) is often viewed primarily as a disease of the elderly, recent epidemiological data suggest that a significant proportion of patients first develop CVU before middle age. Such patients may represent a distinct group in terms of aetiology, natural history, prognosis and therapeutic options.

AIM

to compare patients who developed CVU before (Group 1) and after (Group 2) their 50th birthday.

METHODS

one hundred and eighteen consecutive patients with "pure" CVU underwent history and examination, measurement of ankle-brachial pressure index (ABPI) and duplex ultrasound examination of the affected limb. Pure venous ulcers were defined as those of >4 weeks duration in the presence of venous reflux (>0.5) and in association with an ankle: brachial pressure index of >0.8.

RESULTS

patients in Group 1 (n = 54, 46%) were more likely to be male (32/54 [59%] vs 14/64 [23%], p < 0.001 chi(2)), to have a higher median (interquartile [IQR]) body mass index (32 [27-39] vs 27 [23-34], p = 0.003, Mann-Whitney U [MWU]), to have a history of deep venous thrombosis (23/54 [43%] vs 16/64 [25%], p = 0.04 chi(2)) and of ipsilateral long bone fracture (13/54 [24%] vs 5/64 [8%], p = 0.01, chi(2)), to have previously undergone venous surgery (27/54 [50%] vs 19/64 [30%] a median (IQR) of 11.5 (6.5-19) and 10 (2-20) years earlier respectively, and to have worse disease in terms of the duration of present ulcer (12 (6-36) vs 8.5 [3-18] months, p = 0.035 MWU), the total duration of ulcer disease (216 [72-360] vs 48 [12-120] months, p < 0.001 MWU), and the number of episodes of ulceration (3 [2-7] vs 1 [1-3], p = 0.002 MWU). There was no significant difference between the two groups in the pattern and severity of venous reflux with 46/54 (85%) of Group 1 and 54/64 (84%) of Group 2 patients having surgically correctable superficial venous reflux.

CONCLUSION

patients who develop CVU before their 50th birthday appear to represent a distinct group in terms of aetiology, natural history and prognosis. The importance of thrombo-embolic prophylaxis in the prevention, and the detection and correction of superficial venous reflux in the treatment, of such ulcers is re-emphasised.

Pathogenesis of varicose veins

BACKGROUND

varicose veins are present in up to 40% of the population. They may be associated with considerable morbidity. Around 70% of patients with chronic venous insufficiency have evidence of superficial venous incompetence on duplex imaging.

METHODS

in this publication we review the evidence available regarding the pathogenesis of varicose veins.

RESULTS

a number of theories have been suggested. The present data suggests that abnormalities in the venous endothelium and smooth muscle cells result in vein wall dilatation with secondary valvular incompetence. However, there is also evidence to support acquired venous valve failure. Congenital venous valve abnormalities have not been well studied.

CONCLUSION

further work is required on this relatively neglected topic. The use of improved imaging such as high-resolution ultrasound is likely to significantly improve our understanding of venous valve function and pathology.

Thrombophilia and chronic venous ulceration

It is known that thrombophilia (TP) is a risk factor for deep venous thrombosis (DVT), and that DVT predisposes to chronic venous ulceration (CVU). However, the relationship between TP and CVU has not been well studied. Review of the literature reveals that the prevalence of TP in CVU patients is high--similar to the prevalence found in patients with a history of DVT. This is despite many patients with CVU having no clear history, or duplex evidence of previous DVT. TP may predispose to CVU by leading to macro- or micro-vascular thrombosis. This association raises several issues regarding the investigation, prevention and management of patients with venous disease.

Endovenous obliteration with radiofrequency-resistive heating for greater saphenous vein insufficiency: a feasibility study

PURPOSE

To assess the feasibility, safety, and clinical utility of ultrasound (US)- and fluoroscopy-guided endovenous saphenous vein obliteration with radiofrequency (RF)-resistive heating in the treatment of primary venous insufficiency.

MATERIALS AND METHODS

Thirty legs of 27 patients with mild to moderate varicose veins and primary greater saphenous vein (GSV) insufficiency diagnosed with duplex US were treated. An endovenous catheter was inserted via US-guided percutaneous puncture or a skin incision. Fluoroscopy and US were used to locate the electrodes at the saphenofemoral junction. GSVs were occluded with RF-resistive heating. Local phlebectomies or sclerotherapy were performed in all procedures to treat varicose veins and teleangiectases. Persistence of vein occlusion and complications potentially attributable to endovenous treatment were assessed at 1 week, 6 weeks, 3 months, 6 months, and 1 year.

RESULTS

The mean follow-up time was 9.6 months (SD, 3.8 mo). By the time of the last follow-up visit, occlusion of the treated segment of the GSV had been achieved in 22 legs (73.3%). Persisting patency or recanalization of the GSV was detected in eight legs (26.7%). One patient (3.3%) had varicosity-related symptoms, and three treated legs (10%) had recurrent or new varicosities. Postoperative complications included saphenous nerve paresthesia in three legs (10%) and thermal skin injury in one limb (3.3%).

CONCLUSION

Endovenous obliteration employing RF-resistive heating is a relatively safe and promising minimally invasive technique for the treatment of primary GSV insufficiency.

The effect of long saphenous vein stripping on quality of life

PURPOSE

Long saphenous vein (LSV) stripping in the treatment of varicose veins may reduce the recurrence of varices but may also increase morbidity rates. The effect of stripping on health-related quality of life (HRQoL) is unknown. The aim of this study was to examine the effect of LSV surgery, with and without successful stripping, on HRQoL.

METHODS

This prospective study comprises 102 consecutive patients who underwent varicose vein surgery that included attempted stripping of the LSV to the knee. HRQoL was assessed before surgery and at 4 weeks, 6 months, and 2 years after surgery with the Aberdeen varicose vein severity score (AVSS; disease-specific) and the Short-Form 36 (SF-36; generic). Patients defined as stripped were those in whom complete thigh stripping to the knee was confirmed with postoperative duplex scanning at 2 years. Patients defined as incompletely stripped were those in whom any LSV remnant was found in the thigh after surgery. Deep venous reflux (DVR) was defined as reflux of 0.5 seconds or more in at least the popliteal vein.

RESULTS

Sixty-six of 102 patients (65%) provided complete HRQoL data at all four time points. At baseline, there was no significant difference between patients who were stripped (n = 25) and incompletely stripped (n = 41) in terms of AVSS, SF-36, age, gender, DVR, or CEAP grade. Significantly more patients in the incompletely stripped group underwent surgery for recurrent disease (29/41, 71%, versus 8/25, 32%; P =.002, with chi(2) test). Both groups gained significant improvements in AVSS scores for as much as 2 years. After adjustment for recurrent disease, stripping conferred additional benefit in terms of AVSS at 6 months (median [interquartile range]) (9 [4 to 16] versus 15 [9 to 24]; P =.031) and 2 years (7 [2 to 10] versus 9 [5 to 15]; P =.014), which was statistically significant in patients without preoperative DVR but not significant in patients with preoperative DVR. SF-36 scores were not affected by stripping.

CONCLUSION

LSV surgery leads to a significant improvement in disease-specific HRQoL for as much as 2 years. In patients without DVR, stripping to the knee confers additional benefit.

Chronic venous insufficiency: worldwide results of the RELIEF study. Reflux assEssment and quaLity of lIfe improvEment with micronized Flavonoids

Chronic venous insufficiency (CVI) results in considerable morbidity and may seriously affect patients' quality of life. The RELIEF (Reflux assEssment and quaLity of life improvEment with micronized Flavonoids) Study was a prospective controlled study designed to assess differences in the severity and in the evolution of symptoms and signs of CVI according to presence or not of venous reflux. Patients were thus separated into 2 comparative groups: those presenting venous reflux and those without venous reflux. The design of the study was multicentric and international, carried out in 23 countries over 2 years, in which 5,052 symptomatic patients assigned to classes C0 to C4 (on the basis of CEAP clinical classification) were enrolled. Patients were treated with micronized purified flavonoid fraction (MPFF), consisting of 450 mg of micronized diosmin and 50 mg of flavonoids expressed in hesperidin over 6 months. In order to document changes in the quality of life of these patients during MPFF treatment, a new validated Quality of Life Questionnaire specific to CVI (CIVIQ) was used. The study also set out to gather epidemiologic data including the prevalence of venous reflux in symptomatic patients. The RELIEF study provided important information about the epidemiology and clinical manifestations of CVI. Of particular interest was the observation that venous reflux was found to be absent in 57% of patients diagnosed as suffering from CVI belonging to CEAP classes C0 to C4. A positive relationship between symptoms of CVI (pain, leg heaviness, sensation of swelling, and cramps) and presence of venous reflux was found in the RELIEF study: symptoms were more frequent and more severe at presentation in patients with venous reflux. Moreover, during MPFF treatment, all symptoms showed a greater decrease in the group without venous reflux compared with the other group. This difference in the evolution of symptoms between the 2 groups was significant for pain, sensation of swelling, and cramps. Regarding leg heaviness and signs such as edema (assessed by leg circumference), patients improved equally independently of the presence or not of venous reflux. The significant and progressive improvement in the signs of CVI was reflected in significant changes in the clinical class of the CEAP classification, ie, from more severe to less severe stages. Continuous clinical improvement was found throughout the study and after treatment with MPFF for 6 months, the clinical scores of all symptoms and signs had significantly decreased (p=0.0001 versus DO) in both groups. This improvement was also associated with a significant and continuous progression in the quality of life scores of all patients. Age of patients, average time since diagnosis, and presence of venous reflux increased with the severity of the disease. The relationship shown in this study between these parameters and clinical CEAP classification reflects the progressive nature of CVI. Despite obvious symptoms of CVI, a very low percentage (21.8%) of the "intention-to-treat" (ITT) population had previously been treated. This was the case whether venous reflux was present or not.

Randomised trial of pre-operative colour duplex marking in primary varicose vein surgery: outcome is not improved

OBJECTIVE

the ability of colour duplex to accurately locate incompetent venous sites has been widely published; its value in pre-operative marking in simple primary varicose vein surgery is evaluated in this study.

DESIGN OF STUDY

prospective randomised controlled trial.

SETTING

regional vascular service, hospital patients.

SUBJECTS

consecutive patients (149) undergoing primary varicose vein surgery where the only difference was one group of patients received duplex marking prior to surgery. Six weeks and 12 months post-operatively all patients had a colour duplex scan to determine the accuracy of surgery and the presence of residual/recurrent varicose veins and completed the Aberdeen, SF-36, and EuroQol quality of life questionnaires.

INTERVENTIONS

varicose vein surgery.

MAIN OUTCOME MEASURES

Duplex evidence of venous incompetence, quality of life measures using the SF-36 and Aberdeen Varicose Veins Questionnaire.

RESULTS

pre-operative marking of primary varicose veins by skilled duplex ultrasonography does not improve the accuracy or recurrence rate following surgery. Quality of life improved significantly following surgery in both groups, however there was no difference in this improvement between the groups.

CONCLUSION

the trial has not demonstrated any additional benefit of pre-operative colour duplex marking over that of clinical and hand held Doppler marking in terms of satisfactory varicose vein surgery performance at 6 weeks or 12 months in patients with primary varicose veins of the long saphenous system. It role in the short saphenous system is less clear.

Symptoms in individuals with small cutaneous veins

The clinical relevance of small cutaneous veins (SCV) is still being discussed. In the Duesseldorf/Essen civil servants study, the prevalence of SCV and the individual symptoms and age-dependent changes were analysed. This cross-sectional study recruited 9935 employees; 9100 could be finally evaluated for this analysis. All volunteers were asked to fill out the questionnaire and were clinically examined. Primarily the clinical findings were documented, adapted to the Basel Study and later modified according to the CEAP classification: (a) class 0 - no visible or palpable clinical signs of venous disease, (b) class 1 - small cutaneous veins, (c) class 1 - reticular veins, (d) class 2 - varicose veins. In all, 64% of the volunteers had no signs of venous disease (class 0: age 41+/-10 years); 10% had small cutaneous veins (class 1: age 44+/-10 years). SCV was more frequent in females (25%) than in males (6%). Only 5% of those with SCV had already consulted a physician. A striking result was that individuals with SCV generally complained about more leg symptoms, of which 'leg swelling' and 'muscle cramps during the night' were the most frequent. 'Continual leg swelling' was reported by 24% of individuals with SCV as opposed to 10% of those without. 'Leg cramps' and 'restless legs' also were more often documented in individuals with SCV (29% vs 22% and 10% vs 7%). These findings were all statistically significant (p<0.001). After adjusting for age and sex, though, there were few or no differences between groups (leg swelling: odds ratio (OR) 1.3; 95% confidence interval (95% CI) 1.1-1.6 and cramps: OR 1.1; 95% CI 0.9-1.3). A gender separate estimation of the rates showed that females suffer more often from any symptom. Regarding 'leg cramps', 'restless legs' and 'itching', the OR were not different for females and males. For 'leg swelling' the age-adjusted OR were significant for women (OR 1.4; 95% Cl 1.1-1.7) compared with men (OR 1.1; 95% Cl 0.7-2). Individuals with SCV seem to have more symptoms compared with healthy people. However, this analysis shows that age and sex are the most relevant explanations for these symptoms.

Injection sclerotherapy for varicose veins

BACKGROUND

Injection sclerotherapy for varicose veins has been used widely since 1963, following popularisation of the technique by Fegan. The treatment aims to obliterate the lumen of varicose veins or thread veins, however, there is limited evidence regarding its efficacy.

OBJECTIVES

To determine whether sclerotherapy is effective in terms of symptomatic improvement and cosmetic appearance; has an acceptable complication rate; and to define rates of symptomatic or cosmetic varicose vein recurrence following sclerotherapy.

SEARCH STRATEGY

Publications describing randomised controlled trials (RCTs) of injection sclerotherapy for varicose veins (excluding comparisons with surgery) were sought through EMBASE and MEDLINE (from inception to March 2001) and hand-searching relevant journals, using the search strategy described by the Cochrane Peripheral Vascular Diseases Review Group. Bibliographies of papers identified were examined for further RCTs. Manufacturers of sclerosants were contacted for further trial information.

SELECTION CRITERIA

RCTs of injection sclerotherapy versus graduated compression stockings or 'observation', or comparing different sclerosants, doses and post-compression bandaging techniques on patients with symptomatic and/or cosmetic varicose veins or thread veins were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Ten studies were included in the analysis. These compared: sodium tetradecyl sulphate (STD) versus an alternative sclerosant; sclerosant with or without local anaesthetic; application of Molefoam versus Sorbo pads to injection sites; elastic compression bandaging versus conventional bandaging; and short-term bandaging versus standard bandaging. Data were abstracted by both authors.

MAIN RESULTS

No RCTs compared sclerotherapy to graduated compression stockings or other non-surgical treatments. Two studies compared STD to alternative sclerosants and found no significant differences in outcome or complication rates. Adding local anaesthetic to sclerosant reduced the pain from injection (one study) but had no other effects. Comparison of Molefoam and Sorbo pad pressure dressings found no difference in outcome for erythema (redness) or successful sclerosis. The degree and duration of elastic compression had no significant effect on varicose vein recurrence rates, cosmetic appearance or symptomatic improvement. Increased compression prevented slipping of dressings but caused increased discomfort, as did increasing duration of compression.

REVIEWER'S CONCLUSIONS

Evidence from RCTs suggests that type of sclerosant, local pressure dressing, degree and length of compression have no significant effect on the efficacy of sclerotherapy for varicose veins. This supports the current place of sclerotherapy in modern clinical practice, which is usually limited to treatment of recurrent varicose veins following surgery, and thread veins. A comparison of surgery versus sclerotherapy would be valuable.

Do varicose veins affect quality of life? Results of an international population-based study

PURPOSE

This study assessed the impact of varicose veins (VV) on quality of life (QOL) and patient-reported symptoms.

METHODS

A cross-sectional population-based study was held in 166 general practices and 116 specialist clinics for venous disorders of the leg in Belgium, Canada (Quebec), France, and Italy. Study subjects included a sample of 259 reference patients without VV (CEAP class 0 or 1) and 1054 patients with VV who were classified as having VV alone (367; 34.8%), VV with edema (125; 11.9%), VV with skin changes (431; 40.9%), VV with healed ulcer (100; 9.5%), and VV with active ulcer (31; 2.9%). The main outcome measure was generic and disease-specific QOL, as measured by means of the Short-Form Health Survey-36 (SF-36) and the VEINES-QOL scale, and patient-reported symptoms as measured by the VEINES-SYM scale.

RESULTS

In patients with VV, age-standardized mean SF-36 physical (PCS) and mental (MCS) scores were 45.6 and 46.1 in men and 44.2 and 43.2 in women, respectively, compared with population norms of 50. PCS scores decreased according to increasing severity of concomitant venous disease, with the lowest mean scores of 37.3 and 35.5 found in patients with VV and active ulcer. However, adjusted analyses showed no statistically significant differences between patients with VV alone and patients without VV for PCS (0.0), MCS (1.0), VEINES-QOL (-0.1), or VEINES-SYM (0.0) scores. In comparison with patients without VV, the largest differences were seen in patients with VV and edema (PCS, VEINES-QOL, and VEINES-SYM score differences of -1.8, -2.5, and -2.9, respectively) and in patients with VV and ulceration (differences of -3.3, -3.4, and -2.7, respectively). The high prevalence of major symptoms of venous disorders in patients in CEAP class 0 or 1 being treated for venous disorders (76.1% of patients had heaviness, aching legs, or swelling) might have contributed to the impairment of QOL in the reference group.

CONCLUSION

Results indicate that impairment in physical QOL in patients with VV is associated with concomitant venous disease, rather than the presence of VV per se. Findings concerning QOL in patients with VV can only be reliably interpreted when concomitant venous disease is taken into account. In patients with VV alone, the objectives of cosmetic improvement and the improvement of QOL should be considered separately.

Lifestyle risk factors for lower limb venous reflux in the general population: Edinburgh Vein Study

BACKGROUND

Varicose veins occur commonly in the general population but the aetiology is not well established. Varicosities are associated frequently with reflux of blood in the leg veins due to valvular incompetence. Our aim was to determine in the general population which lifestyle factors were related to reflux and thus implicated in the aetiology of varicose veins.

METHODS

In the Edinburgh Vein Study, 1566 men and women aged 18-64 years were sampled randomly from the general population in the city of Edinburgh, Scotland, and had duplex scans to measure reflux in eight venous segments in each leg. A self-administered questionnaire enquired about occupation, mobility at work, smoking, obstetric history, dietary fibre intake and bowel habit. A bowel record form was completed subsequently.

RESULTS

In women, venous reflux was associated with decreased sitting at work (odds ratio [OR] = 0.76, 95% CI : 0.61-0.94), previous pregnancy (OR = 1.20, 95% CI : 0.93-1.54), and a lower prior use of oral contraceptives (OR = 0.84, 95% CI : 0.66-1.06). Mean body mass index was greater in women with superficial reflux compared to those with no reflux: 26.2 kg/m(2) (95% CI : 25.5-27.0) versus 25.2 kg/m(2) (95% CI : 24.8-25.6). On age adjustment, sitting at work remained related to reflux (OR = 0.78, 95% CI : 0.63-0.98) and prior use of oral contraceptives to superficial reflux (OR = 0.71, 95% CI : 0.50-1.01). In age-adjusted analyses in men, height was related to reflux, (OR = 1.13, 95% CI : 1.02-1.26) and straining at stool was related to superficial reflux (OR = 1.94, 95% CI : 1.12-3.35). No associations were found in either sex between reflux and social class, lifetime cigarette consumption, dietary fibre intake and intestinal transit time.

CONCLUSIONS

This population study did not identify strong and consistent lifestyle risk factors for venous reflux although previous pregnancy, lower use of oral contraceptives, obesity and mobility at work in women and height and straining at stool in men may be implicated.

Surgical Workload Generated by a Single-Visit Venous Clinic

Objective:

To determine the management of patients attending a single-visit venous clinic.

Design:

Observational study.

Setting:

District general hospital.

Patients:

Two hundred and sixty-nine patients who attended over 1 year.

Intervention:

Clinical assessment was carried out with continuous wave Doppler ultrasound examination in all cases and duplex ultrasound examination in selected patients, followed by standard appropriate management.

Main outcome measures:

Patients were classified according to their clinical status under the CEAP classification (clinical, aetiological, anatomical, pathophysiological). This was related to the chosen form of management (advice only, compression hosiery, compression bandaging, injection sclerotherapy, superficial venous surgery).

Results:

A much higher proportion of patients with mild or moderate disease (CEAP 2 or 3) undergo operation (109/146, 75%) than those with severe disease (CEAP 4–6), in whom operation is less often appropriate (37/106, 35%).

Conclusions:

Most of the operative workload is generated by patients with mild or moderate disease; patients with severe disease are more often treated conservatively.

The relationship between heart problems and mortality in different social classes

The aim of this study is to analyze how relative mortality risk varies between persons with and without heart problems in different social classes. Cox proportional hazards regression was used to analyze relative mortality risk for the period 1968-1996 for a Swedish nationally representative sample of 4585 persons born between 1892 and 1942, and interviewed 1968. Survivors from the original sample were also interviewed in 1974, 1981 and 1991 or 1992. "Heart problems" is defined as the presence of three mild or one severe symptom associated with circulatory problems. Social class is based on occupation. The relative mortality risk varied significantly between social classes and between persons with and without heart problems, among both men and women. These differences were smaller among women than among men. The main results are that there are significant additive interactions between social class and heart problems among men. Men from lower social classes have a more elevated mortality risk than men from higher social classes when they have a heart problem. Among white-collar workers the coefficient of the difference between men with and without heart problems was 0.53. The corresponding difference was significantly larger among workers (1.59, P = 0.01), thus demonstrating an additive interaction. The difference was even greater (1.86) among "unclassifiable" men--those who could not report an occupation that could be coded into a social class, mainly because they were long-term unemployed or on early-retirement pensions. Among women, the mortality difference between white-collar workers with and without heart problems was 0.85. None of the mortality differences between those with and without heart problems in other social classes differed significantly from those of white-collar workers. The mortality difference between women with and without heart problems was, however, large (2.34) among the "unclassifiable". This difference is even larger than the corresponding difference among men.

Treatment of varicose veins: proximal saphenofemoral ligation comparing adjunctive varicose phlebectomy with sclerotherapy at a military medical center

There is no consensus as to the single best approach to the treatment of varicose veins. There has been a trend toward less invasive procedures to reduce the number of incisions and provide more selective ablation of varicosities. Ultimately, therapeutic decisions have depended on surgeon preference and the patient population. The active duty military population presents a unique challenge in the treatment of varicose veins. This mobile and active population requires a treatment method that provides maximum relief with the lowest possible morbidity and rapid recovery. The authors previously reported their experience with 104 patients who underwent saphenofemoral ligation combined with perforator point ligation and staged sclerotherapy. This group was compared to 103 patients who underwent saphenofemoral ligation, point perforator ligation, and stab avulsion phlebectomy as a single procedure. Follow-up for the sclerotherapy group included patient satisfaction surveys and documentation of recurrent varicosities. All ambulatory phlebectomy patients responded positively with respect to symptomatic and cosmetic results. Overall satisfaction was favorable and there was no significant difference in patient satisfaction between the ambulatory phlebectomy and sclerotherapy groups. Twelve per cent of the sclerotherapy patients developed true recurrences or new varicosities compared to 11% in the ambulatory phlebectomy group. The most common complication was superficial thrombophlebitis (20% ambulatory phlebectomy, 16% sclerotherapy) which was mild in all cases. All but three patients in the ambulatory phlebectomy group returned to work within 7 days and 75% returned to full duty within 72 hours. Completion of therapy was accomplished in a much shorter period for the ambulatory phlebectomy group. Overall patient satisfaction was achieved for both ambulatory phlebectomy and sclerotherapy patients. Completion of therapy was achieved in a shorter period with fewer clinic visits in the ambulatory phlebectomy group and this has become our procedure of choice for active duty military patients.

The impact of isolated lesser saphenous vein system incompetence on clinical signs and symptoms of chronic venous disease

PURPOSE

The purpose of this study was to determine the patterns of isolated lesser saphenous vein (LSV) system incompetence and correlate the distribution and extent of such reflux with symptoms and signs of chronic venous disease (CVD).

METHODS

During a 3-year period, 2254 limbs in 1682 patients with signs and symptoms of CVD were evaluated with color flow duplex scanning. Extremities with isolated reflux in the LSV system were selected for this study. Limbs with perforating venous reflux connected to this system only were also included. Limbs that had marked reflux in the greater saphenous or deep vein, that had a documented history of deep venous thrombosis, and that previously underwent surgery or sclerotherapy were excluded. The clinical severity of the limbs was graded with the CEAP classification system.

RESULTS

There were 226 limbs in 200 patients with reflux in the LSV system; 61% were female patients with a mean age of 49 years (range, 18-82 years). There were 174 patients (87%) with unilateral and 26 with bilateral disease, and 41% of the limbs belonged in CVD class 2, 26% in class 3, 12% in class 4, 3.5% in class 5, and 3% in class 6. Classes 0 and 1 were present in 14.5% of the limbs. Symptoms were present in 139 limbs (61.5%). Some degree of ache or burning sensation was the most frequent symptom (41%), followed by itching (32%), heaviness (29%), cramps (24%), and restless limbs (18%). Reflux in the main trunk of the LSV was the most prevalent (177 limbs [78%]), followed by the saphenopopliteal junction (146 limbs [64.6%]), the vein of Giacomini (39 limbs [17%]) and the gastrocnemial vein (23 limbs [10%]). Reflux involving both the saphenopopliteal junction and the LSV was seen in 50% of limbs, but almost any other combination of reflux was present, which indicated the complexity of this system. Perforator vein incompetence was detected in 56 limbs (25%). We found 83 perforator veins, resulting in a mean of 1.5 veins per limb. Both the number of incompetent perforator veins and the extent of superficial reflux correlated with clinical severity. Four main types of termination of the LSV were identified with at least nine variations. The LSV was duplicated for at least half of its length in five limbs (2.2%). Nonsaphenous reflux was detected in seven limbs (3.1%). Superficial vein thrombosis in the LSV system was found in eight limbs (3.5%), and in the gastrocnemial vein it was found in four (1.8%).

CONCLUSIONS

Isolated LSV system incompetence can cause the entire range of signs and symptoms of CVD. Clinical deterioration is associated with a longer extent of reflux and perforator incompetence. Classes 2 to 4 are the most frequent clinical presentations, whereas classes 5 and 6 are uncommon. The complex anatomy of this system and the great variation in the patterns of reflux warrant the use of color flow duplex scanning before planning treatment.

The relationship between lower limb symptoms and superficial and deep venous reflux on duplex ultrasonography: The Edinburgh Vein Study

BACKGROUND

Previous work from this group has demonstrated the relationships between lower limb symptoms and the presence and severity of trunk varicose veins as seen on clinical examination to be generally weak, symptom specific, and gender dependent.

OBJECTIVE

This study was undertaken to investigate the relationships in the general population between lower limb symptoms and the presence of superficial or deep venous reflux.

METHODS

A cross-sectional study was made of an age-stratified random sample of 1566 subjects (699 men and 867 women) aged 18 to 64 selected from 12 general practices in Edinburgh, Scotland. Subjects completed a self-administered questionnaire regarding symptoms (heaviness/tension, a feeling of swelling, aching, restless legs, cramps, itching, tingling) and underwent duplex ultrasound examination of the superficial and deep venous systems of both legs. Reflux of 0.5 seconds or greater was considered pathologic. Deep venous reflux was defined as reflux in at least the popliteal vein.

RESULTS

There was a significant positive relationship between isolated superficial reflux and the presence of heaviness/tension (P <.025, both legs) and itching (P =.002, left leg) in women. Isolated superficial reflux in men was not significantly positively associated with any symptom. Isolated deep venous reflux was not significantly related to any symptom in either leg in either sex. Combined reflux was related to a feeling of swelling (P =.018, right leg; P =.0022, left leg), cramps (P =.0049, left leg) and itching (P =.0043, left leg) in men, and aching (P =.03, right leg) and cramps (P =.026, left leg) in women.

CONCLUSION

In the general population, only certain lower limb symptoms were related to the presence of reflux on duplex ultrasound scanning. The strongest relationships were observed in the left legs of men with combined superficial and deep reflux.

High endogenous estradiol is associated with increased venous distensibility and clinical evidence of varicose veins in menopausal women

OBJECTIVE

The purpose of this study was to determine if there is an association between elevated sex hormones (ie, serum estradiol, sex hormone binding globulin [SHBG], testosterone) and increased venous distension and clinical evidence of varicose veins in menopausal women.

METHODS

Participants were 104 healthy volunteer menopausal women, aged 48 to 65 years, who were not undergoing hormonal treatment. Of these 104, 14 were excluded from analyses because their estradiol levels were compatible with a premenopausal condition (4), because they had missing values for insulin concentration (5), and because they did not show up at venous vessel examination (5). Patients underwent a physical examination to determine the presence of varicose veins; a venous strain-gauge plethysmographic examination to compute instrumental measures of venous distensibility; and laboratory analyses of blood so serum testosterone, estradiol, SHBG, glucose, and insulin could be measured. There were also prevalence ratios and odds ratios used to test the presence of an association between biochemical and instrumental variables.

RESULTS

Serum levels of estradiol in the upper tertile of the frequency distribution were significantly associated with clinical evidence of varicose veins (prevalence odds ratios 3.6; 95% CI 1.1-11.6) and with increased lower limb venous distensibility (prevalence odds ratios 4.4; 95% CI 1.2-15.5). No association was found for SHBG and testosterone.

CONCLUSIONS

Our finding that high serum levels of estradiol are associated with clinical evidence of varicose veins and instrumental measurements indicating increased venous distensibility in menopausal women suggests that endogenous estrogens may play a role in the development of this very common venous vessel abnormalities.