Chronic venous disorders: Correlation between visible signs, symptoms, and presence of functional disease

Superficial Venous Disease-An Updated Review

BACKGROUND

This review article provides an updated review of a relatively common pathology with various manifestations. Superficial venous diseases (SVDs) are a broad spectrum of venous vascular disease that predominantly affects the body's lower extremities. The most serious manifestation of this disease includes varicose veins, chronic venous insufficiency, stasis dermatitis, venous ulcers, superficial venous thrombosis, reticular veins, and spider telangiectasias.

METHODS

The anatomy, pathophysiology, and risk factors of SVD were discussed during this review. The risk factors for developing SVD were related to race, age, sex, lifestyle, and certain genetic conditions as well as comorbid deep vein thrombosis. Various classification systems were listed, focusing on the most common one-the revised Clinical-Etiology-Anatomy-Pathophysiology classification. The clinical features including history and physical examination findings elicited in SVD were outlined.

RESULTS

Imaging modalities utilized in SVD were highlighted. Duplex ultrasound is the first line in evaluating SVD but magnetic resonance imaging and computed tomography venography, plethysmography, and conventional venography are feasible options in the event of an ambiguous venous duplex ultrasound study. Treatment options highlighted in this review ranged from conservative treatment with compression stockings, which could be primary or adjunctive to pharmacologic topical and systemic agents such as azelaic acid, diuretics, plant extracts, medical foods, nonsteroidal anti-inflammatory drugs, anticoagulants and skin substitutes for different stages of SVD. Interventional treatment modalities include thermal ablative techniques like radiofrequency ablationss, endovenous laser ablation, endovenous steam ablation, and endovenous microwave ablation as well as nonthermal strategies such as the Varithena (polidocanol microfoam) sclerotherapy, VenaSeal (cyanoacrylate) ablation, and Endovenous mechanochemical ablation. Surgical treatments are also available and include debridement, vein ligation, stripping, and skin grafting.

CONCLUSIONS

SVDs are prevalent and have varied manifestations predominantly in the lower extremities. Several studies highlight the growing clinical and financial burden of these diseases. This review provides an update on the pathophysiology, classification, clinical features, and imaging findings as well as the conservative, pharmacological, and interventional treatment options indicated for different SVD pathologies. It aims to expedite the timely deployment of therapies geared toward reducing the significant morbidity associated with SVD especially varicose veins, venous ulcers, and venous insufficiency, to improve the quality of life of these patients and prevent complications.

Assessment of lower extremity venous insufficiency and lipedema and their association with knee symptoms, functions, and quality of life in patients with knee osteoarthritis

OBJECTIVE

To evaluate the effects of the venous insufficiency (VI) or lipedema on the symptoms, functions, and quality of life (QoL) of patients with knee osteoarthritis (OA).

METHODS

96 patients with stage 3/4 knee OA were included in the study. Patients were grouped as OA (n = 35), VI + OA (n = 35), and lipedema + OA (n = 26). Range of motion (ROM), Visual Analogue Scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), short-form (SF-36), and 6-minute walking test (6MWT) were evaluated.

RESULTS

WOMAC stiffness score was significantly higher in the VI group than the other groups (p < .05). VAS resting, WOMAC pain, function, and total scores were significantly higher in the lipedema + OA and VI + OA groups than the OA group (p < .05). SF-36-physical role limitation was significantly lower in the lipedema and VI groups (p < .05).

CONCLUSION

VI or lipedema accompanying knee OA increases the existing disability due to OA by negatively affecting patients regarding pain, QoL, and physical functioning.

Risk factors for venous ulceration in patients with varicose veins of lower extremities

The aim of this case-control study was to explore the potential risk factors for venous ulceration in patients with varicose veins of lower extremities and to establish a simplified diagnostic score model. Seventy subjects with varicose veins of lower extremities and venous ulceration were compared with 1164 controls with varicose veins of lower extremities and no history of venous ulceration. Stepwise multivariate logistic regression analysis was used to identify the risk factors for venous ulceration. The steps in developing the diagnostic score model were based on the Framingham Heart study. The area under the receiver operating characteristic curve (AUC) was calculated to assess the diagnostic ability of the diagnostic score model. Multivariate analysis showed that men, overweight, obesity, longer duration varicose veins, deep venous valve insufficiency, low lymphocyte counts, and high fibrinogen content were independently associated with an increased risk of venous ulceration. The AUC for the diagnostic score model was 0.75, which indicated good discriminatory ability. Special attention should be paid to the high-risk group of patients with lower extremity varicose veins. The diagnostic score model might be a useful screening tool for clinicians, policy makers, and patients.

A Narrative Review of Advancements in Understanding and Treating Varicose Veins

Chronic venous disease, with varicose veins as its archetypal manifestation, stands as a pervasive and intricate health quandary, encompassing a vast array of contributing factors. Age, genetics, obesity, pregnancy, and prolonged immobility weave a complex tapestry, underscoring the omnipresence of this ailment. Its societal and economic footprint is undeniably formidable, as diverse classifications underscore its multifaceted character. The intricate interplay of chronic venous disease with diabetes mellitus and neuropathy compounds the challenge, fostering soaring healthcare expenditures and a palpable erosion of quality of life, particularly among women harboring cardiometabolic risk factors. Despite research shedding light on heightened susceptibility within certain demographics, the enigmatic determinants orchestrating the transition from mild to severe chronic venous disease continue to elude us. Varicose veins, marked by the presence of dilated and tortuous subcutaneous vessels, precipitate both physical discomfort and cosmetic concerns, frequently necessitating meticulous clinical evaluation coupled with ultrasound studies to secure a precise diagnosis. Treatment strategies are strategically crafted to ameliorate distressing symptoms, enhance aesthetic concerns, and forestall potential complications. Nevertheless, the prognostication of chronic venous disease remains ensconced in a degree of ambiguity, hinting at the vast terrain yet to be charted in this medical domain. The quest to fathom the intricacies of this condition uncovers an ever-evolving panorama where conservative interventions play an indispensable role in managing mild cases, while interventional procedures like endovenous laser ablation and sclerotherapy step onto the stage for patients grappling with severe symptoms, thus treading the fine line between efficacy and invasiveness. Moreover, a meticulous economic analysis underscores the cost-effectiveness of various therapeutic modalities, thereby bolstering the imperative of a patient-centered approach. As we navigate the labyrinthine complexities of chronic venous disease and varicose vein management, we are inexorably drawn to the pivotal role of customized treatment approaches, as well as the dynamic interplay between scientific progress, patient preferences, and therapeutic innovations in the relentless pursuit of optimized outcomes and an enhanced quality of life.

Variation in sociodemographic, clinical and functional characteristics of patients with chronic venous insufficiency in a single public health center

OBJECTIVES

Describe and analyze the sociodemographic, clinical and functional characteristics of individuals with chronic venous insufficiency (CVI) and compare the clinical severity with levels of mobility.

METHODS

Exploratory cross-sectional study in a single public health center. The study cohort comprised 99 individuals.

INTERVENTIONS

Clinical, sociodemographic and physical activity level questionnaires were applied; we also evaluated ankle amplitude and sural triceps function. Descriptive statistics, independent t test and one-way ANOVA with post hoc Least Significant Difference (LSD) were performed.

RESULTS

Ninety-nine participants (87.9% woman) with an average age with an average age of 60.6 ± 14 years who where recruited to the study. The cohort was composed of individuals were moderately active, 80% exhibited symptoms of the disease and approximately 40% reported reduced mobility. Individuals who had reduced mobility and less physical activity showed reduced ankle amplitude and muscle function (p <0.05).

CONCLUSION

CVI impacts on functional capacity, even in individuals with less severe disease.

Patterns of flow drainage from varicose veins originating in the incompetent great saphenous vein

Background

Chronic venous insufficiency affects the lives of many people and therefore constitutes a public health problem. Knowledge of the drainage patterns of reflux from varicose veins secondary to incompetent saphenous veins is essential to define the best therapeutic management.

Objectives

To determine the reflux drainage patterns from varicose veins originating in incompetent GSV, the prevalence of perforating veins (PV), and their relationships with symptoms.

Methods

55 ultrasound reports were analyzed to determine the drainage patterns of reflux from the GSV, location and diameter of PV drainage, and staging of symptoms.

Results

In 64% of the sample, reflux from varicose veins drained to PVs, in 4% reflux drained to the GSV itself, in another 4% drainage was to the small saphenous vein, and in 29% drainage was to varicose trunk veins in which no direct communication with the deep system could be identified. No associations were observed between symptoms and reflux drainage patterns or PV diameters.

Conclusions

For this sample, PVs were responsible for draining flow from varicose veins in 64% of cases. Neither PV diameters nor GSV reflux patterns were associated with severity of symptoms.

Women benefit from endovenous ablation with fewer complications: Analysis of the Vascular Quality Initiative Varicose Vein Registry

OBJECTIVE

To evaluate the association between gender and long-term clinician-reported and patient-reported outcomes after endovenous ablation procedures.

METHODS

This retrospective cohort study of prospectively collected data from the Vascular Quality Initiative's Varicose Vein Registry included patients undergoing endovenous ablation procedures on truncal veins with or without treatment of perforating veins between 2015 and 2019. A univariate analysis included comparisons of preprocedural, postprocedural, and periprocedural change in Venous Clinical Severity Score (VCSS) and total symptom score by gender. Rates of complications including deep vein thrombosis, endovenous heat-induced thrombosis, leg pigmentation, blistering, paresthesia, incisional infection, and any postprocedural complications were reported by gender. Multivariable analysis leveraged linear regression to examine how gender affected the relationships between patient characteristics, complication rates, and periprocedural change in VCSS score and total symptom score.

RESULTS

Of 9743 patients who met the inclusion criteria, 3090 (31.7%) were men and 6653 (68.2%) were women. The perioperative change in VCSS score was greater for men than women (average -4.46 for men vs -4.13 for women; P < .0001). Perioperative change in total symptom score was greater for women than for men (average -10.64 for women vs -9.64 for men; P < .0001). Women had lower incidence of any leg complication (6.1% vs 8.6%; P = .001) endovenous heat-induced thrombosis (1.1% vs 2.2%; P = .002), and infection (0.4% vs 0.7%; P = .001). In multivariable analysis, among patients with a body mass index of more than 40, presence of deep reflux, and preoperative Clinical, Etiologic, Anatomic, and Physiologic classification of 2, women had a greater periprocedural change in VCSS score than men.

CONCLUSIONS

Women benefited from endovenous ablation similarly as men, with a lower incidence of postprocedural complications. Gender may be useful for patient selection and counseling for endovenous ablation, with particular usefulness among patients with a high body mass index, presence of deep reflux, and preoperative Clinical, Etiologic, Anatomic, and Physiologic classification of 2.

Factors associated with chronic venous disease: study in 1,136 patients treated for varicose veins of the lower limbs in a specialized clinic

Background

Varicose veins are a highly prevalent condition in the general population, generating variable reasons for consultation that can alter the patient's quality of life, with prevalence and associated factors that vary in different series.

Objectives

To describe the epidemiological profile of patients who consulted for varicose veins by evaluating main symptoms and associated variables.

Methods

Between 2019 and 2020, 1,136 patients attending vascular surgery consultation in a specialized outpatient center were evaluated. Demographic variables, presented symptoms, complications, and associated factors, such as body mass index, parity and family history, were recorded.

Results

A total of 1136 patients were evaluated (79.8% women and 20.2% men), with a mean age of 53.51 years. The presence of symptoms was similar in men and women; the most frequent complications were ulcer, varicorrhage, and superficial venous thrombosis. Most patients showed CEAP 1, 2 and 3 (n = 909) and more than half were overweight or obese (n = 679) with a predominance of those classified as C4. Sixty-nine per cent had a positive family history of varicose veins. There was no difference between severity of varicose veins and time working in the standing or sitting position, but there was a greater presence of C5 or C6 ulcer among patients standing for more than 4 hours.

Conclusions

Describing the characteristics of patients with varicose veins helps to understand the disease and to focus efforts towards those who are more susceptible. The results of this research are similar to those found in other populations.

Earth’s gravity field and prevalence of varicose veins and chronic venous disease: Systematic review

Aim

This study examines the influence of Earth’s gravity field on the prevalence of varicose veins in geophysical area.

Material and Methods

We performed a systematic review (OVID and Google Scholar) of studies focusing on prevalence of varicose veins to determine the influence of Earth’s gravity field—GRACE GGM05S gravity model—on the disease prevalence. PROSPERO: CRD42021279513.

Results

81 studies met inclusion and quality criteria. Areas with stronger gravity have significantly higher prevalence of varicose veins with adjustment for age, gender and body mass index (BMI) ( p-values < 0.02). Adjusted for age, prevalence of varicose veins in areas with gravity field +20 mGal and more is 1.37 time higher than in areas with gravity field less than +20 mGal, p-value 0.005 (95% CI: −12.5 to −2.4): mean disease prevalence for gravity field +20 mGal and more—27.5% (mean age, 40.1 years; mean gravity field, +27.1 mGal; 63.9% females, 37 studies, 123,164 participants) vs mean disease prevalence for gravity field less than +20 mGal – 20.1% (mean age, 42.2 years; mean gravity field, +5.7 mGal; 56.8% females, 44 studies, 205,925 participants). Older age is the main risk factor for varicose veins ( p-values < 0.005). Female gender and high BMI are insignificantly associated with high prevalence of varicose veins ( p-values > 0.4 for gender, p-values > 0.2 for BMI).

Conclusion

Stronger gravity field is significantly associated with higher prevalence of varicose veins—risk factor. The potential mechanism of this phenomenon is that high gravity field alters systemic venous return, pooling blood and fluid in the peripheral, gravity-dependent regions of the body in upright humans constantly living in the defined geophysical area.

Current Best Practice in the Management of Varicose Veins

This article outlines the current best practice in the management of varicose veins. “Varicose veins” traditionally means bulging veins, usually seen on the legs, when standing. It is now a general term used to describe these bulging veins, and also underlying incompetent veins that reflux and cause the surface varicose veins. Importantly, “varicose veins” is often used for superficial venous reflux even in the absence of visible bulging veins. These can be simply called “hidden varicose veins”. Varicose veins usually deteriorate, progressing to discomfort, swollen ankles, skin damage, leg ulcers, superficial venous thrombosis and venous bleeds. Patients with varicose veins and symptoms or signs have a significant advantage in having treatment over conservative treatment with compression stockings or venotropic drugs. Small varicose veins or telangiectasia without symptoms or signs can be treated for cosmetic reasons. However, most have underlying venous reflux from saphenous, perforator or local “feeding veins” and so investigation with venous duplex should be mandatory before treatment. Best practice for investigating leg varicose veins is venous duplex ultrasound in the erect position, performed by a specialist trained in ultrasonography optimally not the doctor who performs the treatment. Pelvic vein reflux is best investigated with transvaginal duplex ultrasound (TVS), performed using the Holdstock-Harrison protocol. In men or women unable to have TVS, venography or cross-sectional imaging is needed. Best practice for treating truncal vein incompetence is endovenous thermal ablation. Increasing evidence suggests that significant incompetent perforating veins should be found and treated by thermal ablation using the transluminal occlusion of perforator (TRLOP) approach, and that incompetent pelvic veins refluxing into symptomatic varicose veins in the genital region or leg should be treated by coil embolisation. Bulging varicosities should be treated by phlebectomy at the time of truncal vein ablation. Monitoring and reporting outcomes is essential for doctors and patients; hence, participation in a venous registry should probably be mandatory.

Factors associated with chronic venous disease: study in 1,136 patients treated for varicose veins of the lower limbs in a specialized clinic

Abstract Background Varicose veins are a highly prevalent condition in the general population, generating variable reasons for consultation that can alter the patient’s quality of life, with prevalence and associated factors that vary in different series. Objectives To describe the epidemiological profile of patients who consulted for varicose veins by evaluating main symptoms and associated variables. Methods Between 2019 and 2020, 1,136 patients attending vascular surgery consultation in a specialized outpatient center were evaluated. Demographic variables, presented symptoms, complications, and associated factors, such as body mass index, parity and family history, were recorded. Results A total of 1136 patients were evaluated (79.8% women and 20.2% men), with a mean age of 53.51 years. The presence of symptoms was similar in men and women; the most frequent complications were ulcer, varicorrhage, and superficial venous thrombosis. Most patients showed CEAP 1, 2 and 3 (n = 909) and more than half were overweight or obese (n = 679) with a predominance of those classified as C4. Sixty-nine per cent had a positive family history of varicose veins. There was no difference between severity of varicose veins and time working in the standing or sitting position, but there was a greater presence of C5 or C6 ulcer among patients standing for more than 4 hours. Conclusions Describing the characteristics of patients with varicose veins helps to understand the disease and to focus efforts towards those who are more susceptible. The results of this research are similar to those found in other populations.

Popliteal Vein Compression, Obesity, and Chronic Venous Disease

BACKGROUND

Obesity is a known risk factor for the development of chronic venous disease (CVD). However, some obese patients with lower limb skin changes suggestive of venous disease do not demonstrate venous reflux or obstruction. Popliteal vein compression (PVC) caused by knee hyper-extension during standing has been postulated by others to be more common in the obese due to the increased adipose content of the popliteal fossa. This compression may contribute to the development of venous disease.

OBJECTIVE

To examine the prevalence of PVC in obese and non-obese subjects, with and without venous disease.

METHODS

Participants were recruited across the range of clinical CEAP classifications and body mass. Those referred for venous studies had full venous ultrasound assessments. To assess for PVC, the popliteal vein was assessed via B-mode ultrasound whilst the subject stood and performed two manoeuvres: knee hyper-extension and a bilateral toe stand. Video clips of each manoeuvre were analysed offline.

RESULTS

There were 309 limbs (158 subjects), of which 131 were non-obese (BMI 26±3 kg/m²) and 178 obese (BMI 43±8 kg/m²). PVC with toe stand was more common in obese limbs (89% vs. 64%, P<0.001). It occurred mainly in the distal popliteal vein, associated with contraction of the gastrocnemius muscles. PVC with knee hyper-extension was also more frequent in obese limbs (39% vs. 10%, P<0.0001), and was distinct as it occurred more proximally in the popliteal vein. PVC with knee hyper-extension was significantly more frequent in all obese C classes of obese patients, most notably in the obese with C4-6 CVD (41% vs. 4%, P<0.0001) and was associated with more severe VCSS (median 8 (range: 0-19) vs. 5 (0-21), P = 0.034). There were 19 limbs with skin changes (C4-6) with no venous reflux or obstruction on ultrasound; exclusively obese limbs. These limbs, designated CEAP Pn limbs, were in older, shorter participants with a higher BMI than their counterparts demonstrating reflux, and they also had more frequent PVC with knee hyper-extension (63% vs. 37%, P=0.036).

CONCLUSIONS

PVC with toe stand and knee hyper-extension are both functional effects and more common in obese limbs. PVC(toe stand) is likely associated with normal functioning of the calf muscle pump. While PVC(lock) may contribute to CVD in some obese limbs, the demonstration of PVC(lock) alone is insufficient evidence for direct intervention.

Management of Lower Extremity Pain from Chronic Venous Insufficiency: A Comprehensive Review

PURPOSE OF REVIEW

Chronic venous insufficiency is found to some extent in a large proportion of the world's population, especially in the elderly and obese. Despite its prevalence, little research has been pursued into this pathology when compared to similarly common conditions. Pain is often the presenting symptom of chronic venous insufficiency and has significant deleterious effects on quality of life. This manuscript will describe the development of pain in chronic venous insufficiency, and will also review both traditional methods of pain management and novel advances in both medical and surgical therapy for this disease.

RECENT FINDINGS

Pain in chronic venous insufficiency is a common complication which remains poorly correlated in recent studies with the clinically observable extent of disease. Although lifestyle modification remains the foundation of treatment for pain associated with chronic venous sufficiency, compression devices and various pharmacologic agents have emerged as safe and effective treatments for pain in these patients. In patients for whom these measures are insufficient, recently developed minimally invasive vascular surgical techniques have been shown to reduce postsurgical complications and recovery time, although additional research is necessary to characterize long-term outcomes of these procedures. This review discusses the latest findings concerning the pathophysiology of pain in chronic venous insufficiency, conservative and medical management, and surgical strategies for pain relief, including minimally invasive treatment strategies.

Classification of reflux patterns in patients with great saphenous vein insufficiency and correlation with clinical severity

PURPOSE

This study aims to establish a clinically applicable classification of reflux patterns in patients with great saphenous vein insufficiency and to evaluate the relationship between this classification, the demographics, and severity of clinical findings.

METHODS

This is a retrospective study from prospectively collected data of 503 patients who had the complaint of varicose vein. All patients had complete physical examination and their medical history was recorded. Lower limbs of all patients were examined with Doppler ultrasonography. A total of 787 limbs with great saphenous vein insufficiency were included in the analysis. The reflux patterns of great saphenous vein insufficiency were classified into 4 types as: type 1, great saphenous vein reflux without involvement of malleolar region and saphenofemoral junction (SFJ); type 2, reflux involving malleolar region with competent SFJ; type 3, reflux involving SFJ with competent malleolar region; and type 4, reflux involving both the SFJ and the malleolar region. We evaluated the association between the classification of great saphenous vein insufficiency and age, sex, body mass index (BMI), disease duration, clinical, etiological, anatomical and pathophysiological elements (CEAP) classification and venous clinical severity score (VCSS).

RESULTS

The mean age of the patients was 45.3±11.7 years, with a male-to-female ratio of 2:3. The most common reflux pattern in patients with great saphenous vein insufficiency was type 3 (48.9%), while 14.8% of patients had type 1, 10.4% had type 2, and 25.7% had type 4. Patients with type I reflux pattern were younger in age (p = 0.002), had lower BMI (p = 0.002), fewer number of children (p = 0.008), as well as milder clinical severity score (p = 0.002) compared to other reflux types. Duration of disease symptoms was not significantly correlated with the reflux patterns, but VCSS increased with the involvement of malleolar region as in type 2 compared to type 1 (2.82±1.67 vs. 2.74±2.31), and further increased with the involvement of SFJ as in type 3 (4.13±2.92 vs. 2.82±1.67). Patients with diffuse reflux pattern (type 4) had the most severe clinical presentation (4.59±2.9).

CONCLUSION

We developed a clinically applicable classification of reflux patterns in patients with great saphenous vein insufficiency based on the involvement of malleolar region and/or SFJ. We showed an association between weight, BMI, VCSS, CEAP classification and the extent of insufficiency.

Venous leg symptoms, ecchymosis, and coldness in patients with peripheral varicose vein: A multicenter assessment and validation study (VEIN-VIOLET study)

OBJECTIVES

We aimed to evaluate peripheral varicose vein symptoms including ecchymosis and coldness by using the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms (VEINES-QoL/Sym) questionnaire.

METHODS

A total of 1120 patients were enrolled to the analysis after the exclusion of 199 patients who did not match the inclusion criteria. Patients were asked to answer the VEINES-Sym questionnaire and questions about ecchymosis and coldness. Scores of ecchymosis and coldness were calculated similar to VEINES-Sym questionnaire. Classifications of peripheral varicose vein were made according to the clinical part of clinical, etiological, anatomical, and pathophysiological classification system and patients with grade 2 or higher were considered as positive for peripheral varicose vein.

RESULTS

Frequency of symptoms present in the VEINES-Sym instrument, ecchymosis and coldness were significantly higher in patients with peripheral varicose vein. Mean score of each symptom was significantly lower in peripheral varicose vein patients including scores of ecchymosis and coldness. Logistic regression analysis revealed that presence of hemorrhoids and all symptoms in VEINES-Sym questionnaire except restless leg were significantly and independently associated with peripheral varicose vein. Besides, ecchymosis (odds ratio: 2.04, 95% confidence interval: 1.34-3.08, p = 0.008) but not coldness was significantly and independently associated with peripheral varicose vein. There was also significant correlation of VEINES-Sym score with ecchymosis (r = 0.43, p < 0.001) and coldness (r = 0.47, p < 0.001).

CONCLUSIONS

Venous leg symptoms present in VEINES-Sym questionnaire except restless legs, presence of hemorrhoids and ecchymosis are significantly and independently associated with peripheral varicose vein. Not only ecchymosis but also coldness has shown an independent association with total VEINES-Sym score.

Global Epidemiology of Chronic Venous Disease: A Systematic Review with Pooled Prevalence Analysis

OBJECTIVE

To provide an updated estimate of the global prevalence of CVD and to comprehensively evaluate risk factors associated with this condition.

BACKGROUND

Chronic Venous Disease (CVD) is an important cause of morbidity internationally, but the global burden of this condition is poorly characterised. The burden of CVD must be better characterised to optimise service provision and permit workforce planning to care for patients with different stages of CVD.

METHODS

A systematic search in Ovid MEDLINE and Embase (1946 - 2019) identified 1271 articles. Full-text, English language articles reporting on the epidemiology of CVD in a general adult population were included. Data extraction was performed by two independent reviewers, in accordance with a pre-registered protocol (PROSPERO: CRD42019153656). STATA and Review Manager were used for quantitative analysis. A crude, unadjusted pooled prevalence was calculated for each Clinical (C) stage in the Clinical, Etiologic, Anatomic, Pathophysiologic (CEAP) classification and across different geographical regions. Qualitative analysis was performed to evaluate associated risk factors in CVD.

RESULTS

32 articles across 6 continents were identified. 19 studies were included in the overall pooled prevalence for each Clinical (C) stage; pooled estimates were: C0 s: 9%, C1: 26%, C2: 19%, C3: 8%, C4: 4%, C5: 1%, C6: 0·42%. The prevalence of C2 disease was highest in Western Europe and lowest in the Middle East and Africa. Commonly reported risk factors for CVD included: female gender (OR 2·26, 95% CI 2·16-2·36, p < 0.001), increasing age, obesity, prolonged standing, positive family history, parity and Caucasian ethnicity. There was significant heterogeneity across the included studies.

CONCLUSIONS

CVD affects a significant proportion of the population globally however there is significant heterogeneity in existing epidemiological studies.

Determining Risk Factors for Endovenous Heat-induced Thrombosis after Radiofrequency Ablation

BACKGROUND

The objective of this study was to evaluate risk factors, incidence, management, and outcome of endovenous heat-induced thrombosis (EHIT) related to radiofrequency ablation (RFA).

METHODS

This was a single-center retrospective analysis of patients over the age of 18 who underwent RFA between 2016 and 2019. Demographics, comorbidities, medications, severity scores, vascular anatomy, procedural details, and outcome data were collected. EHIT-related data included occurrence, grade, laterality, management, and outcome.

RESULTS

During the study period, 672 RFA procedures were performed at our institution. Of these, 642 (median age 57 (21-93), 62.3% female) met study inclusion criteria. EHIT was observed in 43 (6.6%) cases. Concurrent left common femoral vein (CFV) or right femoral vein (FV) incompetence was found to be more prevalent in the EHIT group (P = 0.024 and P = 0.011, respectively). Compared with performing RFA alone, concurrent performance of stab phlebectomy and sclerotherapy with RFA on the left side was found to be associated with possible increased risk for EHIT (P = 0.021). Furthermore, patients with diabetes mellitus (DM) (P = 0.05) and those with median diameter of the treated left vein of 1.2 cm (P = 0.02) were more likely to have a higher EHIT grade (III and IV) than those without DM and those with smaller vein diameter, respectively. Management included aspirin (44%), anticoagulant (28%), both (10%), or neither (18%). EHIT either resolved or regressed (64%), did not change (5%), or propagated (8%) at follow-up.

CONCLUSIONS

Left CFV or right FV incompetence was found to be more prevalent in the total EHIT group. Furthermore, DM and the median size of the treated vein on the left (1.2 cm) were more prevalent in the high (III-IV) versus low grade (I-II) EHIT group. More than 50% of EHIT improved (regressed or resolved) at follow-up regardless of the management option. Further analysis with larger patient samples are needed to confirm the association between these variables and the development of EHIT.

Anthropometric, Biochemical, and Food Consumption Parameters are Associated with Venous Leg Ulcer Area and Duration

OBJECTIVE

To describe the dietary habits and anthropometric and biochemical parameters of patients with active venous leg ulcers and to verify the association of these variables with wound duration and area.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study conducted with 33 participants diagnosed with venous leg ulcers in outpatient care.

MAIN OUTCOME MEASURES

Socioeconomic data, anthropometric parameters, biochemical parameters, food consumption, and wound characteristics were analyzed by an interprofessional team.

MAIN RESULTS

Participants were an average of 58 ± 13 years, 57.6% women, 84.8% overweight, and had a median wound duration of 10 months (range, 1-192 months) and an average wound area of 5 cm (range, 0.22-61.1 cm). Diets were typically hypocaloric and hypoproteic, with a low amount of vitamin A and magnesium. Wound duration was negatively associated with polyunsaturated fat intake (P = .032), whereas wound area was significantly associated with lipid intake (P = .002) and C-reactive protein (P = .040).

CONCLUSIONS

Patients with active venous leg ulcers were overweight (leading to systemic inflammation) and had low consumption of calories, protein, and micronutrients that could support cicatrization. Wound area was associated with a high-fat diet, whereas wound duration was negatively associated with polyunsaturated fat intake.

Distribution of working position among workers with varicose veins based on the National Health Insurance and National Employment Insurance data

Background

This study aimed to determine the effect of specific working postures on the development of varicose veins (VV). By using Korea's National Health Insurance (NHI) and National Employment Insurance (NEI) data, we analyzed the general characteristic and difference in proportions of VV cases according to occupational working posture.

Methods

From the NEI and NHI data, participant demographics, such as gender, age, body mass index, and number of workers in specific occupations or industries were obtained. We classified the 240 occupations into blue-collar (BC) and white-collar (WC) occupations and subdivided them into standing, sitting, and walking groups according to the dominant working posture.

Results

The number of VV patients per 100,000 individuals increased with age, with a higher number of women than men and a higher number of patients in the BC than WC groups. For the BC group, the proportion of VV cases was the highest in the standing group, followed by the walking and sitting groups, but there was no significant difference between standing and walking groups in man. For the WC group, the standing group had a higher proportion of VV cases than the sitting group, but there was no significant difference between the standing and sitting group in man. In the BC group, the proportion of VV cases was the highest among medical and welfare-related elementary workers, bakers and cookie makers, automobile assemblers, cleaning and guarding-related elemental workers, and nurses and dental hygienists. In the WC group, the proportion of VV cases was the highest among food/lodging/tourism/entertainment/sports-related managers, environment/cleaning/protective services-related managers, finance and insurance clerks, accounting book-keeping clerks, and social welfare and counseling professionals.

Conclusions

This study was performed to determine the characteristics of VV with different working posture among Korean workers. It is expected to be the basis of further studies on occupational musculoskeletal diseases.

Differences in pain, fatigue, and quality of life in patients with chronic venous insufficiency based on physical activity level

Background

This study aims to compare the effect of different physical activity levels on pain, fatigue, and quality of life in patients with chronic venous insufficiency.

Methods

Between October 2018 and February 2019, a total of 69 patients (4 males, 65 females; mean age 50 years; range, 19 to 73 years) who were diagnosed with chronic venous insufficiency and consulted for physiotherapy were included in the study. The physical activity level of the patients was determined using the International Physical Activity Questionnaire in three groups as light, moderate, or vigorous. Fatigue, pain, and QoL were assessed using the Fatigue Severity Scale, visual analog scale (during the night, activity, and rest), and Venous Insufficiency Epidemiological and Economic Study Quality/Symptom Scale, respectively.

Results

Of a total of 69 patients, 17 were in the light-intensity physical activity group, 32 in the moderate-intensity physical activity group, and 20 in the vigorous-intensity physical activity group. Perceived pain during activity and fatigue were significantly different between the light- and moderate-intensity physical activity groups (p<0.05). There was no significant difference in pain, fatigue, and quality of life scores between the vigorous-intensity physical activity group and the other two groups (p>0.05).

Conclusion

Our study results suggest that a moderate level of physical activity may be helpful to overcome symptoms such as pain and fatigue in patients with chronic venous insufficiency and to improve quality of life.

Influence of polidocanol ultrasound-guided foam sclerotherapy on quality of life in lower extremity chronic venous disease: initial results

Chronic Venous Insufficiency (CVI) is not only detrimental to patients' Quality of Life (QoL) but also places a considerable burden on public health resources. Ultrasound guided foam sclerotherapy (USFS) is a good treatment option, but its effect on patients' QOL is still unclear. This article presents the results from the first 27 patients in a prospective, longitudinal, non-controlled study for evaluation of the clinical and QOL impact of USFS treatment for CEAP C4 to C6 grade CVI with contraindications for open surgery. Clinical symptoms were measured with the Venous Clinical Severity Score (VCSS) and QOL by the Assessment of Burden Chronic Disease - Venous questionnaire (ABC-V). We observed 22.2% reductions in VCSS (p<0.001) in the first week after the procedure, and a 37.8% reduction in ABC-V scores (p=0.03) over the first 3 months.

Chronic venous disease: from symptoms to microcirculation

The recently published European Venous Forum (EVF) Guidelines 2018 update on the management of chronic venous disorders of the lower limbs has focused on several new aspects: a new place for early symptoms, new data on microcirculation alterations, and a re-evaluation of veno-active drugs (VADs), based on new criteria. The symposium "Chronic Venous Disease (CVD): From Symptoms to Microcirculation", held at the annual meeting of the EVF on 28 June 2018 in Athens, Greece, highlighted this perspective by answering three questions: What do symptoms mean and how do they influence our choice of investigations? Is there a link between symptoms and microcirculation alterations? How to choose the right VAD for the right patient based on the updated EVF guidelines? The answers given led the speakers to three conclusions: early symptoms reveal the initial stage of CVD and patients with C0S disease should be properly diagnosed, investigated, and treated; damage to the microcirculation is likely to be the first evidence of the onset of venous disease; Ruscus+HMC+VitC has proven efficacy in randomized controlled trials, and has been given a strong recommendation (Grade 1A) by the 2018 EVF guidelines for treatment of pain, heaviness, feeling of swelling, paresthesia, and edema, and should be considered as one of the preferred treatments to relieve these symptoms in CVD patients.

Evaluation of Peak Reflux Velocities with Vector Flow Imaging and Spectral Doppler Ultrasound in Varicose Veins

Purpose Spectral Doppler ultrasound (SDUS) is used for quantifying reflux in lower extremity varicose veins. The technique is angle-dependent opposed to the new angle-independent Vector Flow Imaging (VFI) method. The aim of this study was to compare peak reflux velocities obtained with VFI and SDUS in patients with chronic venous disease, i. e., pathological retrograde blood flow caused by incompetent venous valves. Materials and Methods 64 patients with chronic venous disease were scanned with VFI and SDUS in the great or the small saphenous vein, and reflux velocities were compared to three assessment tools for chronic venous disease. A flow rig was used to assess the accuracy and precision of the two methods. Results The mean peak reflux velocities differed significantly (VFI: 47.4 cm/s vs. SDUS: 62.0 cm/s, p<0.001). No difference in absolute precision (p=0.18) nor relative precision (p=0.79) was found. No correlation to disease severity, according to assessment tools, was found for peak reflux velocities obtained with either method. In vitro, VFI was more accurate but equally precise when compared to SDUS. Conclusion Both VFI and SDUS detected the pathologic retrograde flow in varicose veins but measured different reflux velocities with equal precision. VFI may play a role in evaluating venous disease in the future.

Surgical Scarring after Arterial Bypass, an Etiology of Venous Hypertension

Venous ulcers can be a chronic debilitating condition with a high rate of recurrence. Herein, we describe a case of a patient who successfully underwent an arterial bypass for rest pain but returned with lower extremity swelling and venous ulcers. Venography demonstrated a focal common femoral vein stenosis due to scarring from the surgical exposure. This was treated with endovenous stenting and resulted in resolution of the swelling and ulceration.

Prevention and treatment of the post-thrombotic syndrome

Post thrombotic syndrome (PTS) is a common chronic complication of deep vein thrombosis of the leg (DVT). Treatment options are limited therefore emphasis is placed on its prevention. Several risk factors have been recognized, but were so far not used for risk stratification or translation into prediction models. Early interventions did not yet result in more successful preventive treatment strategies; for the acute phase of DVT there is equipoise on the value of elastic compression, as well as on catheter directed thrombolysis. There are no drugs specifically targeted at PTS prevention. The use of anticoagulant medication such as direct oral anticoagulants (DOACs) might decrease PTS incidence, but this needs to be corroborated. Both research into more effective treatment options as well as future PTS management may benefit from a uniform diagnostic strategy and the use of prediction rules to better allocate treatment and thereby increase treatment efficacy.

The Significance of Pain in Chronic Venous Disease and its Medical Treatment

Chronic venous disease (CVeD) is a highly prevalent condition in the general population, and it has a significant impact on quality of life. While it is usually manifested by obvious signs, such as varicose veins and venous ulcers, other symptoms of the disease are less specific. Among the other symptoms, which include heaviness, swelling, muscle cramps and restless legs, pain is the symptom that most frequently compels CVeD patients to seek medical aid. However, there is a substantial discrepancy between pain severity and clinically detectable signs of CVeD, questioned by several opposing studies. Further evaluation is needed to clarify this subject, and to analyse whether pain development predicts objective CVeD progression. General management of CVeD starts with advising lifestyle changes, such as lowering body mass index and treating comorbidities. However, the mainstay of treatment is compression therapy, with the additional use of pharmacological substances. Venoactive drugs proved to be the drugs of choice for symptom alleviation and slowing the progression of CVeD, with micronized purified flavonoid fraction being the most effective one. Interventional therapy is reserved for advanced stages of the disease.

Radiofrequency Thermal Ablation Heat Energy Transfer in an Ex-Vivo Model

Little work has been done to consider the temperature changes and energy transfer that occur in the tissue outside the vein with ultrasound-guided vein ablation therapy. In this experiment, a ex-vivo model of the human calf was used to analyze heat transfer and energy degradation in tissue surrounding the vein during endovascular radiofrequency ablation (RFA). A clinical vein ablation protocol was used to determine the tissue temperature distribution in 10 per cent agar gel. Heat energy from the radiofrequency catheter was measured for 140 seconds at fixed points by four thermometer probes placed equidistant radially at 0.0025, 0.005, and 0.01 m away from the RFA catheter. The temperature rose 1.5°C at 0.0025 m, 0.6°C at 0.005 m, and 0.0°C at 0.01 m from the RFA catheter. There was a clinically insignificant heat transfer at the distances evaluated, 1.4 ± 0.2 J/s at 0.0025 m, 0.7 ± 0.3 J/s at 0.0050 m, and 0.3 ± 0.0 J/s at 0.01 m. Heat degradation occurred rapidly: 4.5 ± 0.5 J (at 0.0025 m), 4.0 ± 1.6 J (at 0.0050 m), and 3.9 ± 3.6 J (at 0.01 m). Tumescent anesthesia injected one centimeter around the vein would act as a heat sink to absorb the energy transferred outside the vein to minimize tissue and nerve damage and will help phlebologists strategize options for minimizing damage.

A Case of Superficial Femoral Arteriovenous Fistula and Severe Venous Stasis Ulceration, Managed with an Iliac Extender Prosthesis

Most femoral artery arteriovenous fistulas occur as a result of percutaneous interventions. However, arteriovenous fistulas can occur in the setting of trauma, with resultant consequences such as heart failure, steal syndrome, or venous insufficiency. Indications for endovascular repair in this setting are limited to patients who are at too high risk for anesthesia, have a hostile groin, or would not survive significant bleeding. We report the case of a traumatic femoral arteriovenous fistula, causing severe venous insufficiency and arteriomegaly, in a 58-year-old male, with history of traumatic gunshot wound complicated by popliteal DVT. Surgical options for arteriovenous fistula include open and endovascular repair but this patient's fistula was more suitable for endovascular repair for reasons that will be discussed.

Variação anatômica venosa rara em membros inferiores

A anatomia do sistema venoso dos membros inferiores é uma das mais complexas no corpo humano. Devido a essa condição, é de extrema importância saber identificar variações que possam acometê-la, como as malformações congênitas. Em casos de agenesia de veias profundas, como uma malformação vascular rara, o quadro clínico pode manifestar-se com insuficiência venosa crônica, que pode evoluir com edema, hiperpigmentação e úlcera de membro inferior. Assim, em muitos casos, torna-se uma doença incapacitante e de difícil tratamento. Apresenta-se um caso de agenesia de segmento venoso femoropoplíteo no membro inferior direito em paciente de 36 anos de idade, que cursou com edema e varizes de grosso calibre no membro acometido.

Functional chronic venous disease: A systematic review

Objectives

Functional chronic venous disease is an underestimated syndrome quite present in the general population. It affects up to 20% of the general population and is based on the presence of venous symptoms without instrumental evidence of anatomic and morphologic damage. The aim of this review article is to provide the reader with the most updated information on this phenomenon.

Methods

Medline and Scopus databases were searched without time limit using the key-word: ‘Functional chronic venous disease of legs’, C0s patients. We decided to include all the studies conducted about functional chronic venous disease. Randomised trials, cohort studies and reviews were contemplated in order to give a breadth of clinical data. Only publications in English were considered. We excluded all the studies with insufficient statistical analysis, possible biases and contradictions, not clear end-points, inconsistent or arbitrary conclusions.

Results

Of the 326 records found, after removal of 68 duplicates, 143 matched our inclusion criteria. After reading the full-text articles, 133 manuscripts were excluded. Ten full text articles were assessed for eligibility and four studies were excluded because of the following reasons: (a) no specific or important content and (b) insufficient data; the final set included six articles.

Conclusions

Functional chronic venous disease is a complex syndrome and further evidences are needed in order to assess the pathophysiology, the morbidity and the correct treatment of this venous dysfunction.

Sex differences in symptom severity and clusters in patients with stage C4 and stage C5 chronic venous disease

BACKGROUND

Multiple symptoms associated with chronic venous disease (CVD) are poorly understood, under-recognized, and ill-managed.

AIMS

The aim of this study was to determine whether there are differences in symptoms and symptom clusters between men and women with stage C4 and stage C5 CVD.

METHODS

Data were collected via interviews with 264 patients using a demographic survey and an 11-item VEINES-SYM questionnaire.

ANALYSIS

An intrinsic scoring algorithm was developed to calculate the overall t scores for each item by sex. Exploratory factor analysis identified symptom clusters using oblique rotation to account for correlations between factors.

RESULTS

The average age was 61.7 years; 54.5% of the patients were women, 58% were African American or black, and 60.6% had diabetes. The top three symptoms for women in order of frequency were achy legs, swelling, and pain; for men, these were swelling, achy legs, and heavy legs. For the total group, two symptom clusters emerged: distressful and discomfort. There was no statistically significant difference in factor score between the sexes. Different factor loadings for symptom clusters were observed: women reported hurting and annoying clusters; and men reported nagging and irritating clusters.

CONCLUSION

The data suggest differences in CVD symptoms and clusters by sex. Symptoms in the two clusters were different; however, there was consistency in the factors associated with each cluster. Co-morbid conditions and sex differences in pain responses may play a part in symptom presentation. This study supports the need for increased sex-delineated clinical assessment and consideration of the potential differences between the sexes in the management of CVD symptoms.

Meta-analytic approaches to determine gender differences for delayed healing in venous leg ulcers

Objective The aim of this analysis was to perform a meta-analysis evaluating gender difference of delayed healing risk in patients with venous leg ulcers. Methods We searched the PubMed and Web of Knowledge from their inception to 4 July 2015. The meta-analysis of pooled odds ratio and 95% confidence interval for venous leg ulcers healing risk were calculated. Results Twelve studies with 4453 patients were included in the meta-analysis. The pooled odds ratio for healing rate stratified by gender was 1.055 (95% CI 0.955-1.165; Z = 1.05, p = 0.292) by fix-effects model. The Begg's test (z = 2.67, p = 0.007), the Egger's test (t = 4.00, p = 0.003), and asymmetric funnel plot suggested there was significant publication bias. Subgroup analysis showed the pooled odds ratios were 1.048 (95% CI 0.945-1.162; Z = 0.88, p = 0.376) in prospective studies and 1.439 (95% CI 0.757-2.736; Z = 1.11, p = 0.266) in retrospective studies. Sensitivity analyses by only pooled adjusted odds ratios showed the pooled odds ratio was 1.049 (95% CI 0.946-1.163; Z = 0.91, p = 0.365), which indicated the results of meta-analysis were robust. Meta-regression analysis showed the healing rate odds ratio stratified by gender was not related with healing rate (t = 0.73, p = 0.484). Conclusion Our meta-analysis indicates that no gender difference existed for delayed healing in venous leg ulcers. Our results may be also useful in developing a risk score for failure of venous leg ulcers to heal.

Relationship Between Pain and CEAP C Categories of Chronic Venous Disease

In this study, we investigated whether the occurrence and intensity of leg pain are related to C class of the clinical, etiological, anatomical, and pathophysiological (CEAP) classification for chronic venous disease (CVeD). This cross-sectional study, conducted in Serbia, included 2841 patients: 2027 (71.3%) women and 814 (28.7%) men with CVeD diagnosed by general practitioners. For the first time, the Numeric Rating Scale of 0 to 5 units was used to assess the intensity of pain. For the analysis, univariate and multivariate logistic and linear regressions were applied. Pain in the legs was reported by 90.5% of the patients. The occurrence of pain significantly (P < .001) increased with increasing C class. Of the patients who reported pain in the legs, 42.0% had moderate pain, 23.7% had moderate to severe pain, 22.8% had light pain, 11.2% had severe pain, and 0.3% had very severe pain. Severity of pain differed significantly (P < .001) according to C class. Light and moderate pain gradually decreased and severe pain gradually increased from C0 to C6 class. These associations remained significant after adjustment for age, body mass index, and family history of CVeD.

Symptoms in patients with skin changes due to chronic venous insufficiency often lead to emergency care service: an Italian observational study

Chronic venous insufficiency (CVI) is the most advanced form of chronic venous disease (CVD), and is often associated with skin changes such as hyperpigmentation, eczema, lipodermatosclerosis and venous skin ulceration that cause discomfort, pain, sleep disturbances, absenteeism in the workplace, disability and deteriorated quality of life (QoL). The purpose of this study is to evaluate the prevalence of CVI and skin changes in patients who turn to Continuous Assistance Services due to the presence of disturbing symptoms of their condition. Data were evaluated by consulting the medical records, during a 16-month period, available with three Continuous Assistance Services of the Italian territory. The overall population of the referring centres consisted of 1186 patients [739 females (62·31%) and 447 males (37·69%)]. Seventy-nine patients (6·66%) consulted the emergency unit for venous symptoms related to CVD. Patients with more severe disease (CVI, categories C4-C6) represented the majority accounting for 60·75%, while patients with moderate disease (C3) accounted for 35·44% and patients with mild disease (C1-C2 stages) accounted for 3·79%. The main finding of this study is that despite CVI not being a disease that commonly requires medical emergency/urgency intervention, patients with CVI, especially in advanced stage with skin changes, may turn to Continuous Assistance Service for treating bothersome symptoms related to their condition.

Association of Venous Disorders with Leg Symptoms: Results from the Bonn Vein Study 1

OBJECTIVES

The aim was to study the association between venous disorders and leg symptoms in the population based cross sectional Bonn Vein Study 1 (BVS1).

METHODS

A total of 1,350 men and 1,722 women aged 18-79 years were enrolled into BVS1. Chronic venous insufficiency (CVI), varicose veins (VVs), and clinical classes (C-classes/CEAP [Clinical, Etiological, Anatomical, and Pathophysiological]) were determined by clinical and duplex investigation. Leg symptoms (heaviness, tightness, swelling, pain after standing or sitting, pain while walking, muscle cramps, itching, and restless legs) were assessed in a standardized interview. For 2,624 subjects (48.7% male) with complete information on venous disorders, relevant characteristics and information on at least one leg symptom, multivariate logistic regression analysis was performed.

RESULTS

More women (929/63.0%) reported at least one leg symptom within the last 4 weeks than men (560/48.7%). Prevalence of reported symptoms increased with age (45.4% of the 18-29 year olds, 73.9% of the 70-79 year olds). Leg symptoms were more frequent in obese and underweight subjects. As confirmed by clinical and duplex examination 22.6% had VV and 15.8% had CVI. VV (OR: 1.4; CI: 1.1-1.7) and CVI (OR: 1.8; CI: 1.3-2.3) were significantly associated with reporting at least one leg symptom. In particular, there was a positive association of VV and CVI with itching, feeling of heaviness, tightness, swelling, and pain after standing or sitting. C2-C6 showed a statistically significant association with feeling of heaviness, tightness, swelling, and itching, while for pain on walking and muscle cramps this was shifted towards C classes C3-C6 and C3-C4, respectively.

CONCLUSIONS

Venous disorders show significant associations with several leg symptoms. Itching, feeling of heaviness, or tightness seem to be more closely related than other symptoms. The associations between C classes and symptoms seem to be restricted to classes C2 or higher.

The influence of age and gender on venous symptomatology. An epidemiological survey in Belgium and Luxembourg

Aim

The aim of this study is to measure the incidence of the symptoms in patients with chronic venous disease (CVD) and to look for the influence of age on the severity of symptoms for both genders.

Materials and methods

A survey was carried out in Belgium and Luxembourg between May and September 2013. Patient recruitment was done by 406 general practitioners (GPs). Each GP screened 10–20 consecutive patients older than 18 years. Inquiries were made regarding the presence of symptoms and possible signs of CVD. Patients with diagnosed CVD filled out a questionnaire including a quality of life score (CIVIQ-14). These data were converted into a CIVIQ Global Index Score (GIS). Statistical analysis was performed in order to calculate the effect of age and gender on the number of symptoms and the estimated probabilities of having CVD.

Results

Totally 6009 patients were included in this survey. The mean age was 53.4 years. Of all, 61.3% of the patients have CVD (C1-C6). Of all, 64.7% of patients were symptomatic. Age and female gender were major risk factors for developing CVD. Most common symptoms were ‘heavy legs’ (70.4%), pain (54.0%), and sensation of swelling (52.7%). The number of symptoms increases with age ( p < 0.001). Female patients have significantly more symptoms in comparison with male patients in all age groups. In both females and males, age is negatively correlated with GIS score ( p < 0.001). The estimated probability of having CVD was significantly higher for woman compared to men and increases with age for both gender.

Conclusion

CVD is a very common progressive disease with age as a major risk factor. Increasing age results in a higher C-classification, more symptoms, and a lower GIS score (quality of life). Female gender interacts significantly with age and results in a more advanced stage of CVD.

Is vein damage the only cause of clinical signs of lower limb chronic venous insufficiency?

Background:Venous insufficiency is a very prevalent disease. Some decades ago a group of patients was identified that had symptoms of venous insufficiency, but no visible anatomic abnormalities. Studies showed that this subset had reduced venous tone, and their condition became known as hypotonic phlebopathy.Objective:To investigate prevalence, age group and variations in body mass index (BMI) among patients with hypotonic phlebopathy.Methodology:A total of 1,960 limbs were examined in 1,017 patients who had been referred for complaints compatible with venous insufficiency. Patients with BMI ≥ 30 were defined as obese. The patients were examined using color Doppler ultrasonography to detect presence or absence of reflux in veins of the lower limbs and were then distributed into two groups as follows: patients with CEAP ≤ 1 and no reflux, diagnosed with hypotonic phlebopathy; or patients with CEAP ≥ 2 and reflux.Results:The study sample comprised 89.7% women and 10.3% men with a mean age of 44.9 years. Hypotonic phlebopathy was more common among the women (p = 0.0001). Obese women were more likely than women who were not obese to have venous symptom etiology involving trunk lesions (p = 0.0017). Among the men, obesity was unrelated to etiology of symptoms (p = 0.5991). Symptomology was more likely to be related to trunk vein damage among older age groups than among younger age groups (p-valor <0.0001).Conclusions:Hypotonic phlebopathy was very prevalent, particularly among young women who were not obese.

A study to evaluate patterns of superficial venous reflux in patients with primary chronic venous disease

Objective

This study assessed patterns of superficial reflux in patients with primary chronic venous disease.

Methods

Retrospective review of all patient venous duplex ultrasonography reports at one institution between 2000 and 2009. Legs with secondary, deep or no superficial reflux were excluded.

Results

In total, 8654 limbs were scanned; 2559 legs from 2053 patients (mean age 52.3 years) were included for analysis. Great saphenous vein reflux predominated (68%), followed by combined great saphenous vein/small saphenous vein reflux (20%) and small saphenous vein reflux (7%). The majority of legs with competent saphenofemoral junction had below-knee great saphenous vein reflux (53%); incompetent saphenofemoral junction was associated with combined above and below-knee great saphenous vein reflux (72%). Isolated small saphenous vein reflux was associated with saphenopopliteal junction incompetence (61%), although the majority of all small saphenous vein reflux limbs had a competent saphenopopliteal junction (57%).

Conclusion

Superficial venous reflux does not necessarily originate from a saphenous junction. Large prospective studies with interval duplex ultrasonography are required to unravel the natural history of primary chronic venous disease.

Leg discomfort: beyond the joints

Although simple characterization of discomfort as cramps, heaviness, shooting pains, and so forth can be misleading, history and examination are key to accurate diagnosis. Absence of both dorsalis pedis and posterior tibial pulses strongly suggests peripheral arterial disease (PAD), and the presence of either pulse makes PAD less likely. Hydroxymethylglutaryl coenzyme A reductase inhibitors (statins) are a common cause of lower extremity myalgias. Restless legs syndrome causes nocturnal discomfort but must be distinguished from confounding“mimics." Neurologic causes of leg symptoms include lumbar spinal stenosis, radiculopathy, distal symmetric polyneuropathy, and entrapment neuropathy. Many common causes of leg discomfort can be managed conservatively.

Radiofrequency Ablation as First-line Treatment of Varicose Veins

Endovascular radiofrequency ablation is a minimally invasive method to safely treat symptomatic refluxing varicose veins. A retrospective chart review was used to determine patient demographics, disease severity, treatment algorithm, and outcome in patients who underwent radiofrequency ablation of symptomatic refluxing veins that had failed conservative management. Statistical analysis was done using GraphPad Demo Version (San Diego, CA). Two hundred forty-one limbs in 179 patients (average age, 53 years; 73% females, 27% males) were treated. Preprocedure Clinical Etiological Anatomic and Pathologic (CEAP) scores were C2s: 236, C3s: 4, and C5s:1. Procedures were performed in the office using tumescent anesthetic; all patients could ambulate immediately after the procedure. Postprocedure total occlusion (TO) rate was seen in 93 per cent of limbs (223 limbs) at 3 months and 91 per cent of limbs (220 limbs) at 12 months posttreatment. No relationship was found between patients who did not have total occlusion and age, sex, diameter of veins, CEAP scores, preoperative reflux time, and volume of tumescent anesthetic ( P > 0.05). The VNUS procedure is an in-office, minimally invasive procedure with a low complication rate and quick recovery. Total occlusion rates are high and there is improvement in disease severity after treatment.

Teleconsultation in vascular surgery: a 13 year single centre experience

The University Hospital of Zurich has provided an email-based medical consultation service for the general public since 1999. We examined the enquiries in a 13-year period to identify those related to vascular surgery (based on 22 ICD-10 codes specific for vascular surgery). There were 40,062 questions, of which 643 (2%) were selected by ICD-10 codes. After exclusion of diagnoses not relevant to vascular surgery, 139 questions remained, i.e. an average rate of about one per month. The mean age of the users was 43 years (range 19-88). Most users (61%) were women. The majority of users asked questions about their own health problems (79%) with varicose veins and spider veins accounting for 63% of all questions. Arterial diseases accounted for 30%. The patient's intention in contacting the service was to obtain advice on treatment options (37%), information about a diagnosis or symptoms (27%), or a second opinion (15%). The online service responded with detailed information and advice (87%) and suggested a referral to the family doctor or a specialist in 75%. Most patients (82%) rated the service overall as good or very good. It appears likely that telemedicine and in particular email teleconsultations will increase in vascular surgery in the future.