Factors associated with lack of clinical improvement after vein ablation in the vascular quality initiative

BACKGROUND

Insurance companies have adopted variable and inconsistent approval criteria for chronic venous disease (CVD) treatment. Although vein ablation (VA) is accepted as the standard of care for venous ulcers, the treatment criteria for patients with milder forms of CVD remain controversial. This study aims to identify factors associated with a lack of clinical improvement (LCI) in patients with less severe CVD without ulceration undergoing VA to improve patient selection for treatment.

METHODS

We performed a retrospective analysis of patients undergoing VA for CEAP C2 to C4 disease in the Vascular Quality Initiative varicose veins database from 2014 to 2023. Patients who required intervention in multiple veins, had undergone prior interventions, or presented with CEAP C5 to C6 disease were excluded. The difference (Δ) in venous clinical severity score (VCSS; VCSS before minus after the procedure) was used to categorize the patients. Patients with a ΔVCSS of ≤0 were defined as having LCI after VA, and patients with ≥1 point decrease in the VCSS after VA (ΔVCSS ≥1) as having some benefit from the procedure and, therefore, "clinical improvement." The characteristics of both groups were compared, and multivariable regression analysis was performed to identify factors independently associated with LCI. A second analysis was performed based on the VVSymQ instrument, which measures patient-reported outcomes using five specific symptoms (ie, heaviness, achiness, swelling, throbbing pain, and itching). Patients with LCI showed no improvement in any of the five symptoms, and those with clinical improvement had a decrease in severity of at least one symptom.

RESULTS

A total of 3544 patients underwent initial treatment of CVD with a single VA. Of the 3544 patients, 2607 had VCSSs available before and after VA, and 420 (16.1%) had LCI based on the ΔVCSS. Patients with LCI were more likely to be significantly older and African American and have CEAP C2 disease compared with patients with clinical improvement. Patients with clinical improvement were more likely to have reported using compression stockings before treatment. The vein diameters were not different between the two groups. The incidence of complications was overall low, with minor differences between the two groups. However, the patients with LCI were significantly more likely to have symptoms after intervention than those with improvement. Patients with LCI were more likely to have technical failure, defined as vein recanalization. On multivariable regression, age (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.00-1.02) and obesity (OR, 1.47; 95% CI, 1.09-2.00) were independently associated with LCI, as was treatment of less severe disease (CEAP C2; OR, 1.82; 95% CI, 1.30-2.56) compared with more advanced disease (C4). The lack of compression therapy before intervention was also associated with LCI (OR, 6.05; 95% CI, 4.30-8.56). The analysis based on the VVSymQ showed similar results.

CONCLUSIONS

LCI after VA is associated with treating patients with a lower CEAP class (C2 vs C4) and a lack of compression therapy before intervention. Importantly, no significant association between vein size and clinical improvement was observed.

Diagnosis of chronic iliac venous obstruction

Stenting has become the first line of treatment for symptomatic chronic iliofemoral venous obstruction in patients with quality-of-life-impairing clinical manifestations who have failed conservative therapy. Patient selection for such intervention is, however, dependent on clear identification of relevant clinical manifestations and subsequent testing to confirm the diagnosis. In this regard, the physician engaged in management of such patients needs to be well-aware of symptoms and signs of chronic iliofemoral venous obstruction, and instruments used to grade chronic venous insufficiency and determine quality of life, in addition to diagnostic tests available and their individual roles. This review serves to provide an overview of the diagnosis of chronic iliofemoral venous obstruction and patient selection for stenting.

An Evidence Map of Clinical Practice Guideline Recommendations and Quality on Venous Leg Ulcer

Significance: Venous leg ulcers (VLUs) are the most common venous disease, mainly presenting as open skin lesions on the legs or feet and are an important concern in clinical care settings. Recent Advances: Comprehensive tactics were employed to search electronic databases PubMed, Embase, guideline databases, and society websites were searched for Clinical Practice Guidelines (CPGs) on VLU care. The basic information, recommendations for the VLUs, methodological quality, and reporting quality of VLU's CPGs were extracted and captured in Excel. The quality of each CPG was independently assessed by four researchers using AGREE II instrument and the RIGHT checklist. Critical Issues: This study included 19 CPGs with a combined 23 recommendations. The assessment of VLUs was summarized based on the recommendations of VLUs in 11 major items; six on VLU's diagnosis and six on therapeutic strategies of VLUs. The identified CPGs were of mixed quality, and the highest score based on the scope and purpose was 82.85 ± 11.66, whereas the lowest mean score based on the editorial independence by AGREE II was 59.93 ± 21.50. Regarding the RIGHT checklist, field one (basic information) had the highest reporting rate (84.33%), whereas field five (review and quality assurance) had the lowest quality of CPGs (41.11%). Future Directions: This evidence map provided new perspectives in the presentation of evidence. In addition, the evidence map collected and evaluated the characteristics of published CPGs. Thus, the evidence map enhances our knowledge and promotes the development of trustworthy CPGs for VLUs.

Brazilian guidelines on chronic venous disease of the Brazilian Society of Angiology and Vascular Surgery

The Brazilian Society of Angiology and Vascular Surgery has set up a committee to provide new evidence-based recommendations for patient care associated with chronic venous insufficiency. Topics were divided in five groups: 1. Classification, 2. Diagnosis, 3. Conservative or non-invasive treatment, 4. Invasive treatment and 5. Treatment of small vessels. This last series is closely related to the activities of Brazilian angiologists and vascular surgeons, who are heavily involved in the treatment of small superficial veins. These guidelines are intended to assist in clinical decision-making for attending physicians and health managers. The decision to follow a guideline recommendation should be made by the responsible physician on a case-by-case basis taking into account the patient's specific condition, as well as local resources, regulations, laws, and clinical practice recommendations.

Venous Clinical Severity Score has a suboptimal ability to detect improvement after iliac vein stenting across three years of follow-up

OBJECTIVE

Venous Clinical Severity Score (VCSS) is currently the gold standard for measuring the severity of chronic venous disease, especially in patients with chronic proximal venous outflow obstruction (PVOO) secondary to non-thrombotic iliac vein lesions. Change in VCSS composite scores is often used to quantitatively measure the degree of clinical improvement after venous interventions. This study sought to assess the discriminative ability, sensitivity, and specificity of change in VCSS composites for detecting clinical improvement after iliac venous stenting.

METHODS

A registry of 433 patients who underwent iliofemoral vein stenting for chronic PVOO from August 2011 to June 2021 was retrospectively analyzed. These 433 patients had follow-up exceeding 1 year after the index procedure. Change in VCSS composite and clinical assessment scores (CAS) were used to quantify improvement after venous interventions. CAS is an assessment by the operating surgeon based on patient self-reporting to assess the degree of improvement at each clinic visit compared with before the index procedure longitudinally across the treatment course of a patient. Patients are rated as worse (-1), no change (0), mildly improved (+1), significantly improved (+2), and asymptomatic/complete resolution (+3) at every follow-up visit as compared with their disease severity prior to the procedure based on patient self-report. This study defined improvement as CAS >0 and no improvement as CAS ≤0. VCSS was then compared with CAS. Receiver operative characteristic curve and area under the curve (AUC) were used to evaluate change in VCSS composite for its ability to discriminate between improvement and no improvement after intervention at each year of follow-up.

RESULTS

Change in VCSS was a suboptimal measure for discriminating clinical improvement (1-year AUC, 0.764; 2-year AUC, 0.753; 3-year AUC, 0.715). Across all three time points, a change in VCSS threshold of +2.5 maximized the sensitivity and specificity of the instrument to detect clinical improvement. At 1 year, change in VCSS at this threshold was able to detect clinical improvement at a sensitivity of 74.9% and specificity of 70.0%. At 2 years, VCSS change had a sensitivity of 70.7% and specificity of 66.7%. At 3 years of follow-up, VCSS change had a sensitivity of 76.2% and specificity of 58.1%.

CONCLUSIONS

Across 3 years, change in VCSS exhibited a suboptimal ability to detect clinical improvement in patients undergoing iliac vein stenting for chronic PVOO with considerable sensitivity but variable specificity at a threshold of 2.5.

Editor's Choice - Clinical Efficacy of Venastent - A Novel Iliac Vein Stent for Non-Thrombotic Iliac Vein Lesions: A Multi-Centre Randomised Controlled Trial

OBJECTIVE

To determine the efficacy of Venastent - a novel iliac vein stent for non-thrombotic iliac vein lesions (NIVLs).

METHODS

From October 2018 to January 2021, 256 NIVL patients were recruited at 19 Chinese hospitals. A randomised controlled trial was conducted to compare the efficacy of the new iliac vein stent-Venastent (Tianhong China) with Zilver stent (Cook USA). All patients were allocated randomly to two groups: the experimental group patients used Venastent, while the control group received the Zilver stent. The trial was registered in Chinese Clinical Trial Registry (ChiCTR2200057851).

RESULTS

A total of 123 patients in the experimental group and 122 patients in the control group had a full set of data collected (p = ns). The technical success rate was 100% (n = 245/245). The patency rate was 100% (n = 123/123) in the experimental group and 98.4% (n = 120/122) in control group one year after operation (p = ns). The lower extremity swelling remission rate was 79.1% (n = 87/110) in the experimental group and 78.4% (n = 91/116) in the control group (p = ns). The lower extremity pain relief rate was 68.8% (n = 50/80) in the experimental group and 77.2% (n = 71/92) in the control group (p = ns). The ulcer healing rate was 90% (n = 18/20) in the experimental group and 87% (n = 20/23) in the control group (p = ns). There was no difference in stent re-stenosis or clinical remission between the two groups.

CONCLUSION

The new iliac vein stent, Venastent, had a comparable high patency rate and safety profile as the Zilver stent (Cook) in NIVLs patients. Venastent significantly reduced symptoms of chronic venous disease.

Pilot Trial of Neuromuscular Stimulation in Human Subjects with Chronic Venous Disease

Introduction

Neuromuscular stimulation (NMES) has been shown to improve peripheral blood flow in healthy people. We investigated the effect of bilateral leg NMES on the symptoms of chronic venous disease.

Methods

Forty subjects were recruited from four groups: healthy, superficial insufficiency, deep insufficiency, and deep obstruction. Haemodynamic venous measurements were taken from the right femoral vein with ultrasound, laser Doppler fluximetry from the left hand and foot. Devices were then worn for 4–6 hours per day, for 6 weeks. Haemodynamic measurements were repeated at week 6. Quality of life questionnaires were taken at week 0, 6 and 8.

Results

The mean age was 48.7, BMI 28.6kg/m2, and maximum calf circumference 39.0 cm. Twenty-four subjects were men. NMES increased femoral vein peak velocity, TAMV and volume flow by 55%, 20%, 36% at 20 minutes (all p<0.05), which was enhanced at week 6 (PV and TAMV p<0.05). Mean increases in arm and leg fluximetry were 71% and 194% (both p<0.01). Leg swelling was reduced by mean 252.7 mL (13%, p<0.05) overall; 338.9 mL (16%, p<0.05) in venous disease. For those with venous pathology, scores for disease specific and generic quality of life questionnaires improved. Those with C4-6 disease benefitted the most, with improvements in VDS score of 1, AVVQ of 6, and SF-12 of 10.

Conclusion

NMES improves venous haemodynamic parameters in chronic venous disease, which is enhanced by regular use. NMES reduces leg oedema, improves blood supply to the skin of the foot, and may positively affect quality of life.

Clinical Trials

This trial was registered with www.clinicaltrials.org.uk (NCT02137499).

Treatment of chronic venous disorder: A comprehensive review

Chronic venous disorder (CVD) is highly prevalent vascular disorder affecting up to 45% of the general population, with clinical manifestations ranging from teleangiectasias to venous leg ulcers (VLUs). We examined the currently available data in order to provide an updated, comprehensive review on treatment options of CVD. We searched MEDLINE, Cochrane, Scopus, EMBASE, ClinicalTrials, and OpenGrey databases for relevant articles in English published until November 2020. Compression treatment is the mainstay of conservative treatment. Pharmacological treatment can provide significant symptomatic relief and hence it should be considered as part of conservative treatment. Transcutaneous Lacer treatment (TCL) is a safe and effective alternative option to sclerotherapy for treatment of C1 stage. High ligation and stripping (HL/S), ultrasound-guided foam sclerotherapy (UGFS), endovenous thermal ablation (EVTA) systems and non thermal non tumescent ablation (NTNT) systems are safe and efficacious first-line options for treatment of saphenous insufficiency. Interventional treatment of co-existing incompetent perforator veins (IPVs) is not supported by contemporary evidence. Regarding deep venous insufficiency (DVI), treatment of symptomatic femoroiliocaval occlusive venous disease refractory to conservative treatment with percutaneous transluminal venoplasty stenting has produced encouraging results.

Randomized clinical trial of radiofrequency-induced thermotherapy combined with transilluminated powered phlebectomy versus high ligation and stripping for the treatment of lower limb varicose veins

OBJECTIVE

The objective of this study was to evaluate the efficacy and safety of radiofrequency-induced thermotherapy (RFiTT) combined with transilluminated powered phlebectomy (TIPP) in the treatment of lower limb varicose veins (VVs) in comparison with high ligation and stripping (HLS) combined with TIPP.

METHODS

The patients with lower limb VVs were randomly assigned to RFiTT combined with TIPP or HLS combined with TIPP. The primary end point was total closure rate of the great saphenous vein at 12 months. Secondary end points included Venous Clinical Severity Score and 14-item Chronic Venous Insufficiency Questionnaire score changes at 12 months and perioperative complications.

RESULTS

The total closure rate of the great saphenous vein at 12 months was slightly lower in the RFiTT group (90.9% [90/99]) than in the HLS group (97.0% [98/101]) but not statistically significant (χ² = 0.068; P = .08). Operation time, intraoperative blood loss, duration in hospital, duration in bed, and resumption of activities were statistically significantly better with RFiTT than with HLS. There were no significant differences between the groups in deep venous thrombosis, phlebitis, hematomas, pain, and infection. However, skin pigmentation and paresthesia were statistically significantly better with RFiTT than with HLS. At 12 months, both groups showed similar improvement from baseline in Venous Clinical Severity Score (1.28 ± 0.57 in the RFiTT group vs 1.33 ± 0.61 in the HLS group) and 14-item Chronic Venous Insufficiency Questionnaire score (67.32 ± 1.29 in the RFiTT group vs 67.45 ± 1.32 in the HLS group); however, neither group was superior to the other.

CONCLUSIONS

RFiTT combined with TIPP is an effective treatment method for lower limb VVs and had a more satisfactory clinical outcome in surgical data, skin pigmentation, and paresthesia than HLS at the 12-month follow-up.

Venovo venous stent in the treatment of non-thrombotic or post-thrombotic iliac vein lesions – short-term results from the Arnsberg venous registry

Abstract. Background: We sought to determine the patency and clinical symptom relief of the Venovo venous stent in the endovascular treatment of non-thrombotic (NIVL) or post-thrombotic venous obstruction (PTO) of the iliofemoral track over a period of 6 months. Patients and methods: A total of 80 patients (45 female, mean age 57 years) treated in 2016 and 2017 were included in the Arnsberg venous registry. Clinical improvement was determined by the revised venous clinical severity score (rVCSS) as well as the clinical, etiologic, anatomic and pathophysiologic (CEAP) score. Primary and secondary stent patency was evaluated using duplex ultrasound. Results: Overall 6-months patency rates were 98 % for primary and 100 % for secondary patency. For NIVL primary patency was 97 %, whereas for PTO primary patency was 96 %. Early stent re-occlusion occurred in 3 patients within 34, 59 and 156 days after intervention. Two of these patients were successfully treated by endovascular mechanical thrombectomy and stent in stent implantation. Clinical improvement with a gain of ≥ 2 rVCSS levels was observed in 51 %. CEAP scores decreased from 4.3 to 2.7. Conclusions: In this first time report the novel Venovo venous stent showed adequate patency rates associated with reasonable clinical improvement and low device-related complications throughout a 6-months-follow-up in both NIVL and PTO.

Eight-year follow-up of a randomized clinical trial comparing ultrasound-guided foam sclerotherapy with surgical stripping of the great saphenous vein

BACKGROUND

This was an 8-year follow-up of an RCT comparing ultrasound-guided foam sclerotherapy (UGFS) with high ligation and surgical stripping (HL/S) of the great saphenous vein (GSV).

METHODS

Patients were randomized to UGFS or HL/S of the GSV. The primary outcome was the recurrence of symptomatic GSV reflux. Secondary outcomes were patterns of reflux according to recurrent varices after surgery, Clinical Etiologic Anatomic Pathophysiologic (CEAP) classification, Venous Clinical Severity Score (VCSS) and EuroQol Five Dimensions (EQ-5D™) quality-of-life scores.

RESULTS

Of 430 patients originally randomized (230 UGFS, 200 HL/S), 227 (52·8 per cent; 123 UGFS, 103 HL/S) were available for analysis after 8 years. The proportion of patients free from symptomatic GSV reflux at 8 years was lower after UGFS than HL/S (55·1 versus 72·1 per cent; P = 0·024). The rate of absence of GSV reflux, irrespective of venous symptoms, at 8 years was 33·1 and 49·7 per cent respectively (P = 0·009). More saphenofemoral junction (SFJ) failure (65·8 versus 41·7 per cent; P = 0·001) and recurrent reflux in the above-knee GSV (72·5 versus 20·4 per cent; P = 0·001) was evident in the UGFS group. The VCSS was worse than preoperative scores in both groups after 8 years; CEAP classification and EQ-5D® scores were similar in the two groups.

CONCLUSION

Surgical stripping had a technically better outcome in terms of recurrence of GSV and SFJ reflux than UGFS in the long term. Long-term follow-up suggests significant clinical progression of venous disease measured by VCSS in both groups, but less after surgery. Registration number: NCT02304146 (http://www.clinicaltrials.gov).

Expert review on the VenaSeal® system for endovenous cyano-acrylate adhesive ablation of incompetent saphenous trunks in patients with varicose veins

INTRODUCTION

The treatment of incompetent truncal veins has been innovated by the introduction of minimally invasive non-thermal non-tumescent (NTNT) techniques. One of these consists of the use of cyanoacrylate glue to occlude the vein lumen by means of the VenaSeal device. Areas covered: This expert-review aims to evaluate NTNT ablation of incompetent saphenous trunks using the VenaSeal device. Expert commentary: Cyanoacrylate adhesive embolization of incompetent truncal veins using the VenaSeal device is a safe and efficacious innovative technique. Further studies are needed to evaluate anatomical and clinical outcomes at long term.

Long-segment hypoplasia of great saphenous vein with posterior accessory saphenous vein as a connecting vein: a case report

Aplasia or hypoplasia of great saphenous vein (GSV) is relatively common. Most of them are segmental and localized around the knee. They rarely extend to the inguinal area, yet in case of this, the anterior accessory saphenous vein (AASV) is the most common connecting vein. We report a case of a 22-year-old male who underwent surgery for pain and heaviness of the right calf. He had the hypoplasia of right GSV extended from below the popliteal crease to near the saphenofemoral junction with posterior ASV (PASV) as a connecting vein. Significant reflux was observed in PASV and GSV which are proximal to PASV. High ligation and stripping was performed, and symptoms improved after surgery. In this report, the author discussed a rare case of long-segment hypoplasia of GSV with PASV as a connecting vein.

Evaluation of inflammatory cell biomarkers in chronic venous insufficiency

Objective

Inflammation has been implicated as a factor that may contribute to chronic venous insufficiency. The purpose of this study is to compare readily available inflammatory cell biomarkers, with an emphasis on neutrophil count, lymphocyte count, and neutrophil lymphocyte ratio, in patients with chronic venous insufficiency. We hypothesized that circulating leukocyte counts would be higher in the peripheral blood of patients with severe compared to mild chronic venous insufficiency.

Methods

We performed a retrospective medical record review of patients discharged from Ruby Memorial Hospital (Morgantown, WV, USA) with a primary diagnosis of chronic venous insufficiency. Patients were organized into two groups—mild and severe chronic venous insufficiency—based on the Clinical, Etiologic, Anatomic, and Pathophysiological classification system, and inflammatory cell counts were compared between groups.

Results

We observed a significantly higher neutrophil count ( p = .002) and neutrophil-lymphocyte ratio ( p = .005) in patients with severe chronic venous insufficiency compared to mild. Further, the neutrophil–lymphocyte ratio may be a useful predictor of chronic venous insufficiency severity.

Conclusions

We reported significant differences in inflammatory cell biomarkers between mild and severe chronic venous insufficiency, as well as provided support for the use of the neutrophil–lymphocyte ratio as a predictor of chronic venous insufficiency severity. These results may provide clinicians with additional insight to manage chronic venous insufficiency in patients and provide a framework for the development of novel treatment options targeting the immune system in chronic venous insufficiency.

The relation between clinical scores and quality-of-life in long-term follow-up

INTRODUCTION

Quality-of-life and severity scores are both popular measures in medicine. For deep venous obstruction, the VEINES-QOL/Sym and venous clinical severity score (VCSS) are widely used. Combining a patient-reported outcome with a clinical severity score should give a more sensitive outcome for treatment results. To establish and compare their suitability for deep venous disease, we compared the outcomes of both scores in a group of patients who were interventionally treated for deep venous disease.

METHODS

The venous clinical severity scores and VEINES-QOL/Sym scores of a group of patients who had received interventional treatment for deep venous obstruction more than 12 months ago were compared at T0 and T12.

RESULTS

Both the Spearman's rho and Pearson's r show a very weak, negative correlation (statistically significant (p ≤ 0.05)), between the venous clinical severity score and VEINES-QOL at T12 and between the venous clinical severity score and the VEINES-SYM at both T0 and T12. T0 VCSS-VSYM: rho = -0.219 (p = 0.052), r = -0.236 (p = 0.037), T12 VCSS-VQOL: rho = -0.459 (p = 0.007), r = -0.379 (p = 0.030), T12 VCSS-VSYM: rho = -0.463 (p = 0.007), r = -0.432 (p = 0.012). This negative correlation was not statistically (p ≥ 0.05) confirmed for T0 VCSS-VSYM.

CONCLUSION

The physician-scored venous clinical severity score of patients treated for deep venous obstruction does not correlate well with their self-reported quality-of-life and symptom scores.

Comparing 1470- and 980-nm diode lasers for endovenous ablation treatments

The purpose of this study was to compare the effectiveness of 1470- and 980-nm lasers with regard to power output, complications, recanalization rates, and treatment response. We prospectively evaluated the effectiveness of endovenous laser ablation (EVLA) in a total of 152 great and small saphenous veins from 96 patients. Lasers were randomly used based on the availability of the units. Patients were clinically evaluated for Clinical Etiologic Anatomic Pathophysiologic (CEAP) stage and examined with Doppler ultrasound. Treatment response was determined anatomically by occlusion of the vein and clinically by the change in the venous clinical severity score (VCSS). Seventy-eight of the saphenous veins underwent EVLA with a 980-nm laser and 74 underwent EVLA with a 1470-nm laser. Treatment response was (68) 87.2 % in the 980-nm group and (74) 100 % in the 1470-nm group (p = 0.004). The median VCSS decreased from 4 to 2 in the 980-nm group (p < 0.001) and from 8 to 2 (p < 0.001) in the 1470-nm group. At 1-year follow-up, seven veins treated with 980 nm and two veins treated with 1470 nm were recanalized (p = 0.16); the average linear endovenous energy density (LEED) was 83.9 (r, 55-100) J/cm and 58.5 (r, 45-115) J/cm, respectively (p < 0.001). Postoperative minor complications occurred in 23 (29.4 %) limbs in the 980-nm group and in 19 (25.6 %) limbs of the 1470-nm group (p = 0.73). EVLA with the 1470-nm laser have less energy deposition for occlusion and better treatment response.

Quality-of-life in interventionally treated patients with post-thrombotic syndrome

Introduction

New developments in the treatment of complex deep venous disease have become available in the last decade. Besides analysing patencies as a surrogate outcome for these treatments we analysed the Quality-of-Life (QoL) changes for successful and failed deep venous treatments.

Materials and methods

Patients with proven venous occlusive disease, referred to our department of Venous Surgery at the Maastricht University Medical Centre, were included. After inclusion patients were treated by percutaneous transluminal angioplasty and stenting and when indicated endophlebectomy with an arteriovenous fistula. QoL was assessed with the disease specific VEINES-QOL/Sym and the generic Short-Form (SF)-36 questionnaires preoperatively at baseline and post-operatively after 3, 12 and 24 months.

Results

One hundred fifty-three interventions were analysed, showing a primary, assisted primary and secondary patency of respectively 65%, 78% and 89% at 24 months. The VEINES-QOL and Sym scores improved at 3, 12 and 24 months. The overall improvement at 24 months is 22.7 for QoL and 18.18 for Sym with respective p values of 0.013 and 0.016. The improvement of the VEINES-QOL and Sym scores after a successful (patent) treatment remained highly significant (QoL: p < 0.001, Sym: p = 0.004). Also the generic QoL (Short-Form 36v2) shows significant improvement after 12 months for physical functioning ( p = 0.004) and role physical ( p = 0.004) scales.

Conclusions

The overall patencies of interventions for deep venous pathology are exceptionally good after two years. Concomitantly the VEINES-Sym and VEINES-QOL scores improve significantly for 3, 12, and 24 months when compared to the baseline (T0) after treatment. Successful interventions showed, as expected, a significant greater QoL improvement between T0 and T3, T12, T24 for both VEINES-QOL and VEINES-Sym scores when compared to the failed interventions. The one-year linear improvement of two SF-36 scales (PF and RP) is also significant.

Health-related quality-of-life scales specific for chronic venous disorders of the lower limbs

OBJECTIVE

We conducted a systematic review of the literature about quality-of-life (QOL) scales in chronic venous disorders (CVDs) comprising leg ulcers to identify the respective advantages and deficits of existing tools.

METHODS

A research protocol was built following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and the PICO (population, intervention, comparator, and outcome) criteria. The following databases were screened: MEDLINE, SCOPUS, EMBASE, CINHAL, and Cochrane. Psychometric and linguistic validation studies in English were included, as were clinical trials that have used QOL scales in CVDs. The data search was up to date as of October 31, 2013.

RESULTS

Inclusion criteria were met in 103 of the 511 recorded references, in which 10 scales were identified: two for the full spectrum of CVDs, three for patients with CVDs without leg ulceration, four for leg ulcers, and one exclusively for patients with varicose veins. Among them, the ChronIc Venous Insufficiency Questionnaire (CIVIQ), Aberdeen Varicose Vein Questionnaire (AVVQ), and VEnous INsufficiency Epidemiological and Economic Study on Quality of Life (VEINES-QOL) scales were the most highly used according to the literature, and CIVIQ and VEINES-QOL were the most extensively validated scales and had the longest iterative validation process. A total of 31 psychometric and linguistic validations of the 10 QOL scales and 66 clinical trials that have used these scales were identified. The validation studies were based on acceptability, content validity, construct validity, reliability, and responsiveness. The clinical trials were composed of 25 randomized controlled trials and 41 observational studies. Only the randomized controlled trials are considered in the present article.

CONCLUSIONS

This systematic review confirmed that CVDs have an important effect on QOL. The majority of the studies addressed the application rather than the validation of the 10 identified scales. Two scales, CIVIQ and VEINES-QOL, emerged as being thoroughly validated instruments, although factorial stability was not demonstrated for the VEINES-QOL. Our findings confirm a paucity of validation studies.

An overview of the most commonly used venous quality of life and clinical outcome measurements

BACKGROUND

Modern medicine should no longer rely solely on technical success to evaluate treatments. The treatment of venous disease has seen many new developments, insights, and treatment modalities. Combining clinical scores with quality of life (QoL) outcome measurements is becoming the new norm for evaluation of treatments. Many different outcome assessment instruments are currently available, indicating a lack of consensus.

METHODS

We set out to find the most reliable and comprehensive scoring instrument for clinical and QoL measurement in venous disease. In this review, we focus on the eight most widely used instruments. For clinical assessment, these are the Clinical, Etiologic, Anatomic, and Pathologic (CEAP) classification, Villalta scale, and Venous Clinical Severity Score (VCSS); for generic QoL, the 36-Item Short Form Health Survey (SF-36) and EQ-5D questionnaires; and for disease-specific QoL, the Aberdeen Varicose Vein Questionnaire (AVVQ), Chronic Venous Insufficiency Questionnaire (CIVIQ), and VEnous INsufficiency Epidemiological and Economic Study on Quality of Life/Symptoms (VEINES-QOL/Sym) questionnaire. Each instrument is reviewed.

CONCLUSIONS

For the accurate evaluation of treatment outcomes, socioeconomic, QoL, and clinical aspects must be assessed. None of the available disease-specific instruments is suited to use in uniform outcome measurement for the whole spectrum of venous disease. A new combined QoL and clinical instrument is needed to validly assess and compare the outcomes of venous treatments. The VEINES-QOL/Sym is currently the most valid instrument to assess disease-specific QoL.

How specific are venous symptoms for diagnosis of chronic venous disease?

Objective

The objective of this study is to evaluate whether and which ‘venous’ symptoms are characteristic for patients affected with chronic venous disease compared to patients with other diseases of the lower limbs (e.g. arthrosis, peripheral arterial disease, spinal disc herniation).

Methods

A cross-sectional study was performed to compare the frequency of venous symptoms among 76 patients with chronic venous disease and reflux and 74 patients with other diseases of the legs without reflux. The VEINES-Sym of the VEINES-QOL/Sym questionnaire was used to evaluate the frequency of symptoms. Demographic, clinical classification and ultrasound findings were also noted.

Results

A total of 122 patients were included for analysis (response rate of 87%). Presence of venous symptoms was slightly more often reported in the chronic venous disease group than in the non-chronic venous disease group, but differences were small and statistically non-significant. Severity of chronic venous disease as classified by the CEAP classification was not associated with higher proportions of patients reporting symptoms than in non-chronic venous disease patients, except for swelling ( p = .016) and itching ( p = .007) in C3-C6 patients. The largest difference between the chronic venous disease and non-chronic venous disease group was observed for the time of the day at which symptoms were most intense; patients with chronic venous disease were more likely to experience symptoms at the end of the day ( p < .001).

Conclusions

The small differences in prevalence of reported ‘venous’ symptoms between chronic venous disease patients and patients with other diseases of the legs suggest that these symptoms may be less specific for patients with chronic venous disease and refluxing veins than is usually assumed.

Bandages or double stockings for the initial therapy of venous oedema? A randomized, controlled pilot study

OBJECTIVE/BACKGROUND

Treatment for leg oedema conventionally starts with compression bandaging followed by elastic stockings once swelling is reduced. The aim was to investigate if a kit consisting of a liner and outer stocking, each exerting 20 mmHg of pressure, would be equally effective in achieving and maintaining volume reduction compared with short-stretch bandaging (2 weeks) followed by a class II (23-33 mmHg) stocking (2 weeks).

METHODS

Forty legs (28 patients) with chronic venous oedema were randomised to either short-stretch bandages applied weekly for 2 weeks, followed by an elastic stocking for 2 weeks (group A) or a light stocking ("liner") for 1 week followed by superimposing a second stocking for 3 weeks (group B). Interface pressures and leg volumes were measured weekly.

RESULTS

Despite differences in the pressure (median ± interquartile range) applied (bandage: 67 mmHg [55.7-73.0] vs. liner 24.5 mmHg [21.2-26.5]) volume reduction after 1 week was equal (12.8% [8.7-16.5] and 13.0% [10.4-20.6]). After 2 weeks (group A: 17.8% [10.6-20.0] vs. group B 16.2% [13.0-25.4]) and 4 weeks (group A: 17.3% [9.6-22.8] vs. group B: 17.0% [13.1-24.1]) volume reductions remained identical.

CONCLUSIONS

The initial improvement in leg volume (1 week) was independent of the pressure applied and the reduction was maintained by superimposing a second stocking. This offers a simple alternative for managing leg oedema with reduced staffing costs.