The CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification is an internationally accepted standard for describing patients with chronic venous disorders and it has been used for reporting ...clinical research findings in scientific journals. Developed in 1993, updated in 1996, and revised in 2004, CEAP is a classification system based on clinical manifestations of chronic venous disorders, on current understanding of the etiology, the involved anatomy, and the underlying venous pathology. As the evidence related to these aspects of venous disorders, and specifically of chronic venous diseases (CVD, C2-C6) continue to develop, the CEAP classification needs periodic analysis and revisions. In May of 2017, the American Venous Forum created a CEAP Task Force and charged it to critically analyze the current classification system and recommend revisions, where needed. Guided by four basic principles (preservation of the reproducibility of CEAP, compatibility with prior versions, evidence-based, and practical for clinical use), the Task Force has adopted the revised Delphi process and made several changes. These changes include adding Corona phlebectatica as the C4c clinical subclass, introducing the modifier “r” for recurrent varicose veins and recurrent venous ulcers, and replacing numeric descriptions of the venous segments by their common abbreviations. This report describes all these revisions and the rationale for making these changes.
Display omitted
Chronic venous disease (CVD) is a debilitating condition with a prevalence between 60-70%. The disease pathophysiology is complex and involves genetic susceptibility and environmental factors, with ...individuals developing visible telengiectasias, reticular veins, and varicose veins. Patient with significant lower extremity symptoms have pain, dermal irritation, swelling, skin changes, and are at risk of developing debilitating venous ulceration. The signature of CVD is an increase in venous pressure referred to as venous hypertension. The various symptoms presenting in CVD and the clinical signs that are observed indicate that there is inflammation, secondary to venous hypertension, and it leads to a number of inflammatory pathways that become activated. The endothelium and glycocalyx via specialized receptors are critical at sensing changes in shear stress, and expression of adhesion molecules allows the activation of leukocytes leading to endothelial attachment, diapedisis, and transmigration into the venous wall/valves resulting in venous wall injury and inflammatory cells in the interstitial tissues. There is a complex of cytokines, chemokines, growth factors, proteases and proteinases, produced by activated leukocytes, that are expressed and unbalanced resulting in an environment of persistent inflammation with the clinical changes that are commonly seen, consisting of varicose veins to more advanced presentations of skin changes and venous ulceration. The structural integrity of protein and the extracellular matrix is altered, enhancing the progressive events of CVD. Work focusing on metabolic changes, miRNA regulation, inflammatory modulation and the glycocalyx will further our knowledge in the pathophysiology of CVD, and provide answers critical to treatment and prevention.
The most frequently used treatment options for great saphenous vein incompetence are high ligation with stripping (HL+S), endovenous thermal ablation (EVTA), mainly consisting of endovenous laser ...ablation (EVLA) or radiofrequency ablation, and ultrasound guided foam sclerotherapy (UGFS). The objective of this systematic review and meta-analysis was to compare the long-term efficacy of these different treatment modalities.
A systematic literature search was performed. Randomised controlled trials (RCTs) with follow-up ≥ 5 years were included. Pooled proportions of anatomical success, which was the primary outcome, rate of recurrent reflux at the saphenofemoral junction (SFJ), and mean difference in venous clinical severity score (VCSS) were compared using a z test or Student t test. Quality of life data were assessed and described.
Three RCTs and 10 follow-up studies of RCTs were included of which 12 were pooled in the meta-analysis. In total, 611 legs were treated with EVLA, 549 with HL+S, 121 with UGFS, and 114 with HL+EVLA. UGFS had significantly lower pooled anatomical success rates than HL+S, EVLA, and EVLA with high ligation: 34% (95% CI 26–44) versus 83% (95% CI 72–90), 88% (95% CI 82–92), and 88% (95% CI 17–100) respectively; p ≤ .001. The pooled recurrent reflux rate at the SFJ was significantly lower for HL+S than UGFS (12%, 95% CI 7–20, vs. 29%, 95% CI 21–38; p ≤ .001) and EVLA (12%, 95% CI 7–20, vs. 22%, 95% CI 14–32; p = .038). VCSS scores were pooled for EVLA and HL+S, which showed similar improvements.
EVLA and HL+S show higher success rates than UGFS 5 years after GSV treatment. Recurrent reflux rates at the SFJ were significantly lower in HL+S than UGFS and EVLA. VCSS scores were similar between EVLA and HL+S.
This trial of varicose-vein treatments showed no substantial differences in quality of life 6 months after ultrasound-guided foam sclerotherapy, endovenous laser ablation, or surgery, but ...disease-specific quality of life was slightly worse after foam treatment than after surgery.
Ultrasound-guided foam sclerotherapy and thermal ablation techniques such as endovenous laser ablation have become widely used alternatives to surgery for the treatment of varicose veins. Previous randomized trials and meta-analyses have shown these treatments to be effective in terms of short-term technical success and clinician-reported outcomes.
1
–
19
Clinical practice guidelines recommend the use of patient-reported quality of life to assess the outcomes of treatment of varicose veins.
20
Quality of life was a primary outcome measure in two small randomized trials that compared surgery and endovenous laser ablation,
5
,
9
but to our knowledge, it has not been assessed as a primary . . .
Varicose Veins: Diagnosis and Treatment Raetz, Jaqueline; Wilson, Megan; Collins, Kimberly
American family physician,
06/2019, Letnik:
99, Številka:
11
Journal Article
Recenzirano
Varicose veins are twisted, dilated veins most commonly located on the lower extremities. The exact pathophysiology is debated, but it involves a genetic predisposition, incompetent valves, weakened ...vascular walls, and increased intravenous pressure. Risk factors include family history of venous disease; female sex; older age; chronically increased intra-abdominal pressure due to obesity, pregnancy, chronic constipation, or a tumor; and prolonged standing. Symptoms of varicose veins include a heavy, achy feeling and an itching or burning sensation; these symptoms worsen with prolonged standing. Potential complications include infection, leg ulcers, stasis changes, and thrombosis. Conservative treatment options include external compression; lifestyle modifications, such as avoidance of prolonged standing and straining, exercise, wearing nonrestrictive clothing, modification of cardiovascular risk factors, and interventions to reduce peripheral edema; elevation of the affected leg; weight loss; and medical therapy. There is not enough evidence to determine if compression stockings are effective in the treatment of varicose veins in the absence of active or healed venous ulcers. Interventional treatments include external laser thermal ablation, endovenous thermal ablation, endovenous sclerotherapy, and surgery. Although surgery was once the standard of care, it largely has been replaced by endovenous thermal ablation, which can be performed under local anesthesia and may have better outcomes and fewer complications than other treatments. Existing evidence and clinical guidelines suggest that a trial of compression therapy is not warranted before referral for endovenous thermal ablation, although it may be necessary for insurance coverage.
The aim was to establish the prevalence of chronic venous disease (CVD) and its risk factors in the general population.
This was a population based, cross sectional study. In total, 703 residents ...aged > 18 years from the rural community of Kryukovo (Central Russia) were enrolled. Medical history was taken and clinical examination performed, documenting venous signs/symptoms. The CEAP classification of the most affected limb was used. Duplex ultrasound was performed to register morphological changes and reflux in deep and superficial veins.
There were 63% women and 37% men (mean age 53.5 years). CVD was found in 69.3%. Of all participants 4.7% were C0S and 34.3% were C1. Chronic venous insufficiency (C3–C6) was found in 8.2% and venous ulcers (C5–C6) in 1.1%. Venous pain, heaviness, fatigue, itching, and the sensation of swelling were documented in 14.8%, 36.3%, 32.8%, 7.0% and 29.1% of patients respectively. Family history was the significant risk factor for both CVD (hazard ratio HR 1.3) and primary varicose vein disease (HR 1.6; p < .01). Female sex was a risk factor only for CVD (HR 1.3; p < .01) but not for varicose veins. Age was a risk factor for CVD (HR 1.01) and for varicose veins (HR 1.02; p < .01). For women, number of births (HR 1.05; p < .05) and menopause (HR 1.3; p < .01) were risk factors for CVD. Menopause was a risk factor for varicose veins (HR 2.0; p < .05).
This study provides data on the prevalence of CVD, venous abnormalities and risk factors in Russia. The results contribute to already established data, giving a more complete outlook on the global prevalence of CVD.
Abstract Objectives To determine the relationship between lower limb symptoms and generic health-related quality of life (HRQL) in patients with varicose veins (VV). Methods 284 patients on the ...waiting list for VV treatment completed the Short Form-12 (SF12) and a questionnaire asking about the presence of lower limb symptoms commonly attributed to venous disease (pain or ache, itching, tingling, cramp, restless legs, a feeling of swelling, and heaviness). Results Median age was 57 years (interquartile range 45–67); 100 (35%) were male, and 182 (64%) had CEAP clinical grade 2 or 3 disease. Jonckheere–Terpstra test for trend revealed that both physical ( P < .0005) and mental ( P = .001) HRQL worsened as the reported number of symptoms increased. Patients reporting tingling ( P = .016, Mann–Whitney U test), cramp ( P = .001), restless legs ( P < .0005), swelling ( P < .0005), and heaviness ( P < .0005) had a significantly worse physical HRQL than those who did not. Mental HRQL was also significantly worse in patients with tingling ( P = .010), cramp ( P = .008), restless legs ( P = .040), swelling ( P = .001), and heaviness ( P = .035). These significant relationships remained, and pain was also correlated with worse physical HRQL ( P = .011), when linear regression was performed to control for CEAP clinical grade, age and sex. Conclusions Physical and mental HRQL is significantly worse in VV patients with lower limb symptoms irrespective of the clinical stage of disease. This observation confirms that VV are not primarily a cosmetic problem and that NHS rationing of treatment to those with CEAP C4-6 disease excludes many patients who would benefit from intervention in terms of HRQL. Generic HRQL instruments also allow comparison with interventions for other chronic conditions.
The Vein Consult Program is an international, observational, prospective survey aiming to collect global epidemiological data on chronic venous disorders (CVD) based on the CEAP classification, and ...to identify CVD management worldwide. The survey was organized within the framework of ordinary consultations, with general practitioners (GPs) properly trained on the use of the CEAP classification.
Screening for CVD was to be performed by enrolling in the survey all consecutive outpatients >18 years whatever the reason for consultation, to record patient's data and classify them according to the CEAP, from the stage C0s to C6. The program enrolled 6232 GPs 91545 subjects were analysed. Their mean age was 50.6±16.9 years, younger patients being in the Middle East and older ones in Europe, and the proportion of women was higher than that of men.
The worldwide prevalence of CVD was 83.6%: 63.9% of the subjects ranging C1 to C6, and 19.7% being C0s subjects. C0s patients were more frequently men whatever the age and the geographical zone. C1-C3 appeared to be more frequent among women whatever the country but the rate of severe stages (C4-C6) did not differ between men and women. GPs consider CVD subjects as patients eligible to specialist referral beginning from C2 but some geographical disparities were observed.
The VCP survey provides reliable results on CVD global epidemiology and shows that CVD affects a significant part of the populations worldwide, underlining the importance of adequate screening for CVD and training of both GPs and specialist physicians.
Abstract Background Great saphenous vein (GSV) incompetence is involved in the majority of cases of varicose disease. Standardised pre-interventional assessment is required to analyse the relative ...merit of treatment modalities. We weighed GSV diameter measurement at the sapheno-femoral junction (SFJ) against measurement at the proximal thigh 15 cm distal to the groin (PT), established a conversion factor and applied it to selected literature data. Methods Legs with untreated isolated GSV reflux and varices limited to its territory and control legs were studied clinically, with duplex ultrasound and photoplethysmography. GSV diameters were measured at both the SFJ and the PT. A conversion factor was calculated and used to compare published data. Results Of 182 legs, 60 had no GSV reflux (controls; group I), 51 had above-knee GSV reflux only (group II) and 71 had GSV reflux above and below knee (group III). GSV diameters in group I measured 7.5 mm (±1.8) at the SFJ and 3.7 mm (±0.9) at the PT. In groups II and III, they measured 10.9 mm (±3.9) at the SFJ and 6.3 mm (±1.9) at the PT ( p < 0.001 each). Measurement at the PT revealed higher sensitivity and specificity to predict reflux and clinical class. Good correlation between sites of measurement ( r = 0.77) allowed a conversion factor (SFJ = 1.767 * PT, PT = 0.566*SFJ) to be applied to pre-interventional data of published studies. Conclusions GSV diameter correlates with clinical class, measurement at the PT being more sensitive and more specific than measurement at the SFJ. Applying the conversion factor to published data suggests that some studies included patients with minor disease.
Varicose veins affect one-third of Western society, with a significant subset of patients developing venous ulceration, costing $14.9 billion annually in the USA. Current management consists of ...either compression stockings, or surgical ablation for more advanced disease. Most varicose veins patients report a positive family history, and heritability is ~17%. We describe the largest two-stage genome-wide association study of varicose veins in 401,656 individuals from UK Biobank, and replication in 408,969 individuals from 23andMe (total 135,514 cases and 675,111 controls). Forty-nine signals at 46 susceptibility loci were discovered. We map 237 genes to these loci, several of which are biologically plausible and tractable to therapeutic targeting. Pathway analysis identified enrichment in extracellular matrix biology, inflammation, (lymph)angiogenesis, vascular smooth muscle cell migration, and apoptosis. Using a polygenic risk score (PRS) derived in an independent cohort, we demonstrate its predictive utility and correlation with varicose veins surgery.
PDF
