Pathophysiology and Genetic Associations of Varicose Veins: A Narrative Review

Varicose veins (VVs) have a high prevalence worldwide and have become a major medical burden. Their pathophysiology involves a complex interplay of inflammation and tissue remodeling, and current treatment is limited by its impact on the pathophysiological mechanisms. In addition, despite clear environmental factors, family history is an important risk factor, suggesting a genetic component to the risk of developing VVs. Our understanding of the pathogenesis of these diseases has benefited greatly from the expansion of population genetic studies, from pioneering family studies to large genome-wide association studies; we now find multiple risk loci for each venous disease. This review considers the pathophysiology of VVs, highlighting the current state of genetic knowledge. We also propose future directions for research.

The impact of invasive treatment of superficial venous insufficiency of the lower extremities on cardiac functions

OBJECTIVE

The aim of the study was to investigate the effect of invasive treatment for chronic venous insufficiency (CVI) on cardiac hemodynamics.

METHODS

Fifty three patients diagnosed with saphenofemoral junction or great saphenous vein insufficiency in a level above C3 according to Clinical-Etiology-Anatomy-Pathophysiology classification were included in the study. All the patients underwent 2D echocardiography before and 3 months after the invasive treatment.

RESULTS

In postinvasive treatment echocardiographic assessment, significant decreases in right ventricular end-diastolic diameter (p = 0.006), TAPSE (p = 0.006), tricuspid E wave velocity (p = 0.004), tricuspid E/A ratio (p < 0.001), sPAB (p = 0.017), tricuspid lateral s' wave velocity (p = 0.004), and right ventricular free wall longitudinal strain rate (p = 0.011) were observed.

CONCLUSIONS

The invasive treatment of superficial venous insufficiency of the lower extremities may lead to reduction in the increased venous return in the supine position subclinically.

The influence of different sub-bandage pressure values in the prevention of recurrence of venous ulceration-A ten year follow-up

OBJECTIVE

The aim of this study was to establish the efficacy of three different strengths of compression systems in the prevention of venous leg ulcer (VLU) recurrences during a 10-year follow up period.

METHODS

An open, prospective, randomized, single-center study included 477 patients (240 men, 237 women; mean age 59 years). Patients were randomized into three groups: Group A) 149 patients (allocated to wear elastic stocking 18-25 mmHg). Group B) 167 patients (wearing compression device exerting 25-35 mmHg), and Group C) 161 patients (treated with multilayer compression system exerting 35-50 mmHg).

RESULTS

Overall, 65% (234/360) of patients had recurrent VLU within 10 years. Recurrence occurred in 120 (96%) of 125 in group A, in 89 (66.9%) of 133 patients in group B and in 25 (24.5%) of 102 patients in group C (p < 0.05).

CONCLUSION

Compression systems with the higher compression class provide lower recurrence rate.

Association between cardiac conditions with venous leg ulcers in patients with chronic venous insufficiency

INTRODUCTION

Venous leg ulcers (VLUs) are the final stage of chronic venous insufficiency. This study aims to characterize the association between cardiovascular diseases and VLU.

METHODS

A multicentric case-control study analyzed 17,788 patients between 2015 and 2020. Cases were matched (1:2) by age and sex, and odds ratios (OR) were analyzed with conditional logistic regressions adjusted by risk factors.

RESULTS

The prevalence of VLU was 15.2%. 2390 cases were analyzed. Diseases found to be associated with VLU were atrial fibrillation (OR, 1.21; 95% CI: 1.03-1.42), pulmonary hypertension (OR, 1.45; 95% CI: 1.06-2.00), right heart failure (OR, 1.27; 95% CI: 1.13-1.43), peripheral artery disease (OR, 2.21; 95% CI: 1.90-2.56), and history of pulmonary embolism (OR, 1.45; 95% CI: 1.06-2.00).

CONCLUSIONS

Certain cardiovascular conditions showed an association with VLU. Further studies are warranted to evaluate the effect that treating concomitant cardiovascular diseases might exert on the natural history of venous leg ulcers.

Cardiac response to changes in central venous sonomorphology: Mechanism of impaired heart relaxation in patients with varicose veins of lower extremities

Aim

This study examines the interactions between central venous and cardiac sonomorphologies to explain the mechanism of impaired heart relaxation in patients with varicose veins of lower extremities.

Material and Methods

Part 1: We performed retrospective analysis of influences of inferior vena cava (IVC) diameters on tricuspid and mitral inflow and annular velocities in 64 patients with primary varicose veins. Part 2: We compared IVC diameters and IVC collapsibility index (IVC CI) in patients with varicose veins with normal values.

Results

We found a significant positive influence of an increase in maximal expiratory and minimal inspiratory IVC diameters on mitral and tricuspid early annular velocities or e′-waves ( p-values < .008), inflow velocities or E-waves ( p-values < .05) and early to late inflow E/A ratios ( p-values < .01). Less influenced by the changes in venous biometry ( p-values > .05) were late mitral and tricuspid inflow, annular and systolic velocities (A-, a′-, s-waves). Expiratory and inspiratory diameters in patients with varicose veins were significantly smaller ( p-values < .05 expiratory; < .0001 inspiratory), and IVC CI was significantly higher ( p-values < .0001) than the normal values.

Conclusion

Chronic venous disease impairs the function and the morphology of the entire inferior caval system and the heart. Impaired relaxation of the heart in patients with varicose veins is the result of two factors: (1) impaired venous return resulting in the low central venous pressure and the low early diastolic cardiac inflow; (2) structural changes in the heart resulting in the compensatory increased late diastolic cardiac inflow. Increase in central venous pressure (IVC diameters) and early diastolic cardiac inflow (E-waves), accompanied by unchanged myocardial response (e′-wave) can serve as marker for return to normal physiology.

Clinical Efficacy of Endovenous Radiofrequency Ablation (RFA) for Superficial Varicose Veins of the Lower Extremities

Objective

To investigate the clinical efficacy of intravenous radiofrequency ablation (RFA) in the treatment of patients with superficial varicose veins of lower extremities.

Methods

From January 1, 2021, to January 1, 2022, 62 patients with superficial lower extremity varicose veins were selected and divided into two groups according to the treatment plan. 31 patients underwent high saphenous vein ligation and dissection as control. Thirty-one patients received RFA treatment as the experimental group. The operation-related indicators, clinical efficacy, and postoperative complications were compared.

Results

The intraoperative blood loss in the experimental group was significantly less than that in the control group. The clinical efficacy of the experimental group was significantly better than that of the control group. The incidence of postoperative complications in the experimental group was lower than that in the control group.

Conclusion

RFA has a good clinical effect in the treatment of patients with superficial lower extremity varicose veins, with less postoperative complications, and has a high therapeutic value.

Respiratory changes in biometry of suprarenal inferior vena cava in patients with varicose veins of lower extremities

AIM

This study examines respiratory biometry of inferior vena cava in patients with varicose veins of lower extremities.

MATERIAL AND METHODS

We performed retrospective analysis of clinical and ultrasound data of 67 patients with primary varicose veins.

RESULTS

The largest expiratory (mean 16.2 mm, p-value 0.09) and inspiratory (mean 8.2 mm, p-value 0.02) inferior vena cava diameters were in C3 Clinical Etiological Anatomical Pathophysiological clinical class; the smallest expiratory diameters (mean 13.1 mm, p-value 0.5) were in C6 class; the smallest inspiratory diameters (mean 4.6 mm, intercept) were in C2 class. C2 class was associated with highest inferior vena cava collapsibility index (mean 68.2%, intercept); C6 class was associated with lowest collapsibility index (mean 48.3%, p-value 0.04).Recurrent varices in comparison with previously untreated were associated with smaller inspiratory diameters of inferior vena cava (mean 4.4 mm, p-value 0.005), smaller expiratory diameters (mean 13.4 mm, p-value 0.06) and higher collapsibility index (mean 68.5%, p-value 0.005). Patients with recurrent and bilateral varicose veins had identical respiratory biometry of inferior vena cava.Older age was associated with smaller inferior vena cava diameters (p-value <0.01).

CONCLUSION

Clinical presentation of varicose veins is associated with different respiratory biometry of suprarenal inferior vena cava. C6 clinical class in comparison with C2 clinical class is associated with lower central venous compliance possible due to the narrowing of inferior vena cava. Smaller inferior vena cava diameters and higher collapsibility index in recurrent subgroup in comparison with previously untreated can be a sign of the significantly altered pressure gradient between the systemic capillaries and the right heart and impaired peripheral venous return. Narrowing of inferior vena cava with age can be a sign of more profound changes in systemic venous return with age in patients with varicose veins in comparison to those without chronic venous disease.