thesis topics on varicose veins

Varicose veins : epidemiology and outcomes

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• Kurz, Xavier.
• Abenhaim, L. (Supervisor)
• Varicose veins are among the most prevalent medical conditions in western populations, with a prevalence estimated at 25--35% in women and 10--20% in men. Until now, few studies have regarded varicose veins as a distinct clinical entity and have investigated specific risk factors. Their consequences for the patients have not been adequately investigated. The main objective of this thesis was to examine the association between varicose veins and specific risk indicators and outcomes, taking into account the effects of more severe venous disorders often found in combination with varicose veins. This work is based on the VEnous INsufficiency Epidemiological and economical Study (VEINES), a one-year cohort study on venous disorders carried out in Belgium, France, Italy and Quebec. It included 1531 patients sampled among 5688 consecutive patients consulting a physician for a venous disorder. A sub-sample of 150 patients were referred to specialists for clinical examination and duplex investigation of venous incompetence. This study illustrated the problems of the diagnosis and classification of varicose veins, with a specificity of 45% for the diagnosis made by general practitioners. In a case-control analysis, the strongest risk indicators of varicose veins were pregnancy, age and family history. No association was found with other hypothesised determinants (obesity, smoking, history of thrombophlebitis, blood group A). Results of duplex studies support the hypothesis of a distal onset of venous reflux and varicose veins. Using a classification of varicose veins proposed to take account the concomitant presence of other signs of venous disease, varicose veins alone had no impact on a symptom score and on generic (SF-36) and disease-specific quality of life scores. The results suggest that symptoms and presence of varicose veins are independent outcomes, which has implications for clinical practice. A detailed analysis of health service utilisation performed in Belgium also showed that both are independent predictors of resource use.
• Health Sciences, Medicine and Surgery.
• McGill University
•  https://escholarship.mcgill.ca/concern/theses/rv042v600
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• Department of Epidemiology, Biostatistics and Occupational Health
• Doctor of Philosophy
• Theses & Dissertations

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Clinical Presentation of Varicose Veins

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• Published: 25 May 2021
• Volume 85 , pages 7–14, ( 2023 )

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• Shantonu Kumar Ghosh   ORCID: orcid.org/0000-0002-2842-9023 1 ,
• Abdullah Al Mamun 2 &
• Alpana Majumder 3  

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Varicose vein is one type of venous insufficiency that presents with any dilated, elongated, or tortuous veins caused by permanent loss of its valvular efficiency. Destruction of venous valves in the axial veins results in venous hypertension, reflux, and total dilatation, causing varicosities and transudation of fluid into subcutaneous tissue. The first documented reference of varicose veins was found as illustrations on Ebers Papyrus dated 1550 B.C. in Athens. Evidence of surgical intervention was found in the 1860s. However dramatic advances of varicose vein management occurred in the latter half of twentieth century. Varicose veins affect from 40 to 60% of women and 15 to 30% men. Multiple intrinsic and extrinsic factors including age, gender, pregnancy, weight, height, race, diet, bowel habits, occupation, posture, previous DVT, genetics, and climate are considered to be the predisposing factors for formation of varicose vein. Other reported factors are hereditary, standing occupation, chair sitting, tight underclothes, raised toilet seats, lack of exercise, smoking, and oral contraceptives. Common symptoms are unsightly visible veins, pain, aching, swelling, itching, skin changes, ulceration, thrombophlebitis, and bleeding. The signs of varicose vein disease are edema, varicose eczema or thrombophlebitis, ulcers (typically found over the medial malleolus), hemosiderin skin staining, lipodermatosclerosis (tapering of legs above ankles, an “inverted champagne bottle” appearance), and atrophie blanche. Varicose vein is classified according to CEAP classification, the components of which are clinical, etiological, anatomy, and pathophysiology. The revised CEAP classification was published on 2020 based on four principles which were preservation of the reproducibility of CEAP, compatibility with prior versions, evidence-based medicine, and practicality.

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Introduction

Varicose veins constitute a progressive disease, and remission of the disease does not occur, except after pregnancy and delivery. During its course, the disease produces complication; most frequent are superficial thrombophlebitis, acute bleeding originating in one of the thin-walled varices, eczema, and, finally, skin ulceration [ 1 ].

The first documented reference of varicose veins was found as illustrations on Ebers Papyrus dated 1550 B.C. in Athens [ 2 ]. First patient who underwent operation for his varicose vein appears to be Canus Marius, the Roman tyrant. Greek philosopher Hippocrates (460–377 B.C.) described the use of compressive bandages and was advisor of small punctures in varicose veins. Aurelius Cornelius Celsus 25 B.C.–A.D.50) used linen bandages and plasters for leg ulcers. He treated them by exposure followed by avulsion with a blunt hook. Claudius Galen (A.D. 130–200) developed a method of bandaging which held the wound edges together. Galen’s theory of circulation remained standard theory for next 1400 years. William Harvey (1578–1657) proposed the theory of unidirectional blood circulation [ 3 ]. Giovanni Rima (1777–1843) introduced midthigh ligation of the saphenous vein.

The era of vascular intervention for varicose veins was modernized by Friedrich Trendelenburg, in the 1860s, who not only popularized his eponymous Trendelenburg test for saphenous reflux but also performed great saphenous vein (GSV) ligation by making a transverse upper thigh incision to ligate and divide the proximal GSV [ 1 ]. William Moore, an Australian surgeon, moved the site of ligation cephalad to the sapheno-femoral junction [ 1 ]. Ligation of the sapheno-femoral junction as it is practiced today was first described by John Homans in his paper in 1916 [ 1 ]. The Mayo Brothers, postulating that there would be additional benefit in removing the saphenous vein, pursued excision of the GSV through an incision extending from the groin to below the knee. This technique was initially improved by the use of an external “ring vein enucleator” [ 1 ]. The final technologic leap was introduction of the intraluminal stripper by Babcock [ 1 ]. The latter half of the twentieth century saw dramatic advances in diagnostic testing; however, surgical treatment of varicose veins benefited from only modest refinements after this innovation.

The twenty-first century has begun with a resurgence of interest and innovation in venous disease. Although sclerotherapy and endovenous thermal ablation occupy preeminent roles in the contemporary management of superficial venous disease, surgical approaches remain relevant when applied appropriately and executed expertly [ 4 ].

Epidemiology

It is generally agreed that varicose veins affect from 40 to 60% of women and 15 to 30% men [ 5 ]. In a study published on 1994, it was found that half of the adult population had minor stigmata of venous disease (women 50–55%; men 40–50%), but fewer than half of these will have visible varicose veins (women 20–25%; men 10–15%) [ 6 ]. However, more recently, large population studies such as Edinburgh Vein Study demonstrated an age-adjusted prevalence of truncal varices of 40% in men and 32% in women [ 7 ].

Varicose vein is one type of venous insufficiency which falls under the broad heading superficial venous disease [ 8 ]. In Western populations, the incidence of varicose veins varies with the definition applied. Most investigators favor the definition of Arnoldi, who said that varicosities are “any dilated, elongated, or tortuous veins, irrespective of size” [ 9 ] (Fig. 1 ).

Development of varicose veins: healthy vein (1) and varicose vein (2)

The definition of Arnoldi is particularly useful because it presents a unifying concept for reticular varicosities, telangiectasias, and major varicose veins. Since all three are elongated, dilated, and have incompetent valves, they probably have a common origin and respond to the same physical forces and acquired influences [ 5 ]. The dilation and elongation implies that these abnormal veins have been responsive to effects of pressure. The dilation of a vein and valve annulus stretches beyond the capability of its leaflets to close together. Dodd and Cockett defined varicose veins, saying “a varicose vein is one which has permanently lost its valvular efficiency” [ 10 ] (Fig. 2 ). It was pressure over a course of time that causes a varix to become elongated, tortuous, pouched, and thickened.

Varicose veins develop from valvular incompetence, resulting in dilation of the superficial venous system

Risk Factors

Among the theories that have been proposed to explain the cause of varicose veins is the hypothesis regarding weakness in the vein wall. Significantly reduced vein wall elasticity has suggested that the role of venous valves in development of varicose veins is secondary to changes in the elastic properties of the vein wall [ 11 ]. Estrogens, progestogens, or their associative action facilitate varicose vein development in individuals with factors which predispose them to vascular disorders (familial history, prolonged standing, obesity, and sedentary). They also aggravate the superficial venous state in these patients [ 12 ]. Wearing of tight undergarments produces proximal limb venous hypertension. A low-fiber diet predisposes to constipation and increased abdominal straining. Raised toilet seats prevent squatting during defecation. All these theories are related to venous hypertension, which itself is linked to development of venous insufficiency.

Common Predisposing Factors for Formation of Varicose Vein

Multiple intrinsic and extrinsic factors including age, gender, pregnancy, weight, height, race, diet, bowel habits, occupation, posture, previous DVT, genetics, and climate are the predisposing factors for formation of varicose vein [ 2 ]. Other factors documented in various studies are hereditary, standing occupation, chair sitting, tight underclothes, raised toilet seats, lack of exercise, smoking, and oral contraceptives.

Pathogenesis

Destruction of venous valves in the axial veins results in venous hypertension, reflux, and total dilatation, causing varicosities and transudation of fluid into subcutaneous tissue [ 2 ].

Development of Varicose Vein

All leg veins are equipped with valves at regular intervals. Together with the leg muscles and the pump function of the heart, these valves ensure that blood flows back to the heart against the force of gravity. Activating the leg muscles, for example by walking, compresses the deep veins lying between the muscles and forces the blood out of them. Healthy valves ensure that the blood flows in only one direction towards the heart and prevent any backflow to the feet. Most of the blood returns to the heart in the deep vein system. The superficial veins merely have a supporting role in blood transport, although they often develop into varicose veins. When superficial veins enlarge because of hereditary connective tissue weakness, the valves do not expand at the same time. This disrupts valve function, as the valves are no longer big enough to close the dilated vein (Fig. 2 ). As a result, there is a constant backflow to the feet that causes the vein to enlarge even further and varicose veins to develop (Fig. 3 ).

Overview of the positions of the different types of varicose veins in and under the skin

Saphena Varix

A saphena varix is a dilatation of the saphenous vein at the sapheno-femoral junction in the groin. As it displays a cough impulse, it is commonly mistaken for a femoral hernia; suspicion should be raised in any suspected femoral hernia if the patient has concurrent varicosities present in the rest of the limb. These can be best identified via duplex ultrasound and management is via high saphenous ligation.

Classifications

Ceap classification—creation.

CEAP was suggested by John Porter in 1993 at the American Venous Forum. A consensus conference was held at the Sixth Annual Meeting of AVF in February, 1994. An international ad hoc committee chaired by Andrew Nicolaides with representatives from Australia, Europe, and the USA developed the first CEAP consensus document in 1994—“CEAP classification” [ 13 ]. It was accepted around the World by venous authorities of Europe, America and Asia. It was published in 11 languages in 5 continents. CEAP was updated in 1996 and revised in 2004 [ 13 ] (Table 1 and Table 2 ).

Since its introduction, CEAP has been demonstrated to be an excellent discriminative instrument and has become an accepted reporting standard for CVD research [ 14 ]. With time management of venous diseases has progressed, and many new modalities have been introduced which became popular in many fields. Over the years, criticisms of the instrument have included a lack of precise definitions resulting in a lack of reproducibility in assigning patients to specific clinical classes [ 15 , 16 ]. In the 16 years since the last revision, an enhanced understanding of aspects of venous disease has identified gaps in the ability of CEAP to separately group patients with unique clinical attributes [ 17 ]. The necessity of further revision of CEAP was due with the advancement of phlebology. To address these advances, a taskforce was created for necessary revisions of CEAP classification. This task force comprised an international group of experts, as well as an advisory group of those who were involved in the creation and previous revision of the CEAP classification. Following a modified Delphi process, the task force adopted the following four “guiding principles”: preservation of the reproducibility of CEAP, compatibility with prior versions, evidence based medicine, and practicality. The revised CEAP remains a descriptive classification [ 18 ].

Changes in CEAP 2020

The CEAP 2020 taskforce adopted the following changes [ 19 ] (Table 3 ).

Clinical Domain

Revision in the “C” domain was done for the better understanding of the natural history between the subclasses. Corona phlebectatica appears to be a predictor of venous ulcer similar to other advanced skin changes and was placed as a subclass C4c in the class C4. The tendency of recurrence of varicose vein and venous ulcer was reflected by “r” in the revised CEAP. C2r indicates recurrent varicose vein, and C6r indicates recurrent venous ulcer.

Etiology Domain

Previously those patients who had no venous abnormality were classified as “En” (none). According to the modified CEAP, patients with clinical signs typically associated with venous disease will come under this subclass, if no other typical venous etiology is found. After the last revision of CEAP, the diverse of causality and development of newer treatment techniques raised the necessity to revise the secondary chronic venous disease (CVDs). To make it easily understandable, “Es” was separated into intravenous (Esi) and extravenous (Ese). The subclass “Esi” includes post-thrombotic changes, traumatic arteriovenous fistulas, primary intravenous sarcoma, or other luminal changes inside the vein. Unlike “Esi,” “Esc” does not reflect on conditions due to venous wall or valve damage, rather due to conditions affecting venous hemodynamics. It may be systemic (e.g., obesity and congestive heart failure) or locally by extrinsic compression (e.g., extravenous tumor and local perivenous fibrosis), or, at a distance, by muscle pump dysfunction due to motor disorders (paraplegia, arthritis, chronic immobility, and frozen ankle) [ 18 ].

Anatomy Domain

Previously 18 numerical designations were used to describe the venous segments of abdomen, pelvis, and lower extremities. Now it has been described by abbreviations which is more practical and easier for professional communication and publications. Anterior accessory saphenous vein was also included in the list of anatomical segments.

Pathophysiology Domain

The “P” component of CEAP was kept unchanged.

Venous Severity Scoring

The CEAP scoring was limited by several factors and was not popular. Rather it was found that severity scoring system based on CEAP was more desirable for research and daily practice. In 2000, the American Venous Forum (AVF), Ad Hoc Committee on Venous Outcomes Assessment, proposed the three-part Venous Severity Score: Venous Clinical Severity Score (VCSS), Venous Segmental Disease Score (VSDS), and Venous Disability Score (VDS)—a modification of the original CEAP disability score [ 20 ]. These scorings had been used to evaluate the severity of venous disease and to provide standardized evaluation of treatment effectiveness.

Venous Clinical Severity Score

The VCSS system includes 10 clinical descriptors (pain, varicose veins, venous edema, skin pigmentation, inflammation, induration, number of active ulcers, duration of active ulceration, size of ulcer, and compressive therapy use), scored from 0 to 3 (absent, mild, moderate, severe; total possible score, 30) that may be used to assess changes in response to therapy [ 21 ]. The revised VCSS score was published in 2010 and is currently being evaluated in studies for its validity and reliability.

Venous Segmental Disease Score

Venous Segmental Disease Score combines the anatomic and pathophysiologic components of CEAP. Major venous segments are graded according to presence of reflux and/or obstruction. It is entirely based on venous imaging, primarily duplex scan but also phlebographic findings. This scoring scheme weights 11 venous segments for their relative importance when involved with reflux and/or obstruction, with a maximum score of 10 [ 20 ].

Venous Disability Score

This modification to the original CEAP disability score substitutes prior normal activity level for the patient rather than ability to complete an 8-h workday.

Clinical Features

The common symptoms of varicose veins are unsightly visible veins, pain, aching, swelling (often worse on standing or at the end of the day), itching, skin changes, ulceration, thrombophlebitis, and bleeding. Edema, varicose eczema or thrombophlebitis, ulcers (typically found over the medial malleolus), hemosiderin skin staining, lipodermatosclerosis (tapering of legs above ankles, an “inverted champagne bottle” appearance), and atrophie blanche are common signs. Treatment should be considered when the patient is complaining of aching pain, leg heaviness, easy leg fatigue, superficial thrombophlebitis, external bleeding, ankle hyperpigmentation, lipodermatosclerosis, atrophie blanche, and venous leg ulcer.

Complications

Most common complications of varicose vein include aching pain, leg heaviness, and easy leg fatigue. Other complications are superficial thrombophlebitis, ankle hyperpigmentation, lipodermatosclerosis, atrophie blanche, and venous ulcer. Complications that require urgent management are superficial bleeding and superficial venous thrombosis. Rarely superficial venous thrombus may propagate to deep venous system.

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Shantonu Kumar Ghosh

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Ghosh, S.K., Al Mamun, A. & Majumder, A. Clinical Presentation of Varicose Veins. Indian J Surg 85 (Suppl 1), 7–14 (2023). https://doi.org/10.1007/s12262-021-02946-4

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Received : 16 April 2021

Accepted : 13 May 2021

Published : 25 May 2021

Issue Date : February 2023

DOI : https://doi.org/10.1007/s12262-021-02946-4

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A Comprehensive Review on Varicose Veins: Preventive Measures and Different Treatments

Affiliations.

• 1 Department of Food Technology and Nutrition, School of Agriculture, Lovely Professional University, Phagwara, Punjab, India.
• 2 Department of Biotechnology, Chandigarh group of Colleges Landran, Mohali, Punjab, India.
• 3 Indian Institute of Food Processing Technology, Thanjavur, Tamilnadu, India.
• 4 Department of Pharmacy, Goa College of Pharmacy, Panaji, Goa, India.
• PMID: 34242131
• DOI: 10.1080/07315724.2021.1909510

The purpose of this article was to review the different preventive measures and treatments for varicose veins disease. Varicose veins are tortuous, enlarged veins that are usually found in the lower extremities damages blood vessels leading to its painful swelling cause's blood clots, affecting people over increasing prevalence with age and affects the proficiency, productivity, and life quality of a person. Prolonged standing and obesity are the major reason for varicose vein disease. The mechanisms, prevention, risk factors, complications, and treatment of varicose veins are explained in this review. Various types of treatments such as endovascular, surgical, and herbal treatments improve quality of life and reduce the secondary complications of varicose veins. Besides these methods of treatments, varicose vein disease can be prevented by doing regular yoga/exercise and consumption of several fruits and vegetables such as Grapes, blackberries, avocados, ginger, and rosemary. Typically, varicose veins can be a benign process with several problems that can influence the life quality of an individual that can lead to potentially life-threatening complications. However, there are numerous surgical, endovascular, and chemical treatments that improve quality of life and decrease secondary complications of varicose veins. Patients with varicose veins should take an antioxidant medicament from the flavonoid groups to reduce the arterial blood pressure value, risk of atherosclerosis development, prevent thrombotic incidents.Key teaching pointsChronic venous disease is a pathological state of vein circulatory systems of the lower limbsProlonged standing and obesity are the major reason for varicose vein diseaseEndovascular, surgical, and herbal treatments improve quality of life and reduce the secondary complications of varicose veinsVenoactive drugs such as flavonoids, saponins, and others have a therapeutic effect on chronic venous disordersPhlebotropic drugs are semi-synthetic substances widely used in different states of chronic venous insufficiencyFood rich in phytoconstituents are more effective in varicose veins.

Keywords: Varicose vein; foam sclerotherapy; herbs.

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Varicose veins: a clinical study

2017, International Surgery Journal

Background: Varicose veins are a common condition affecting the lower limbs. Apart from being a cosmetic problem, it can have some serious complications if not treated in time. Multiple modes of surgical management exist for the disease. Complications of the surgery are troublesome and difficult to treat.Methods: This is a prospective study done in inpatients of SDM college of Medical Sciences, Dharwad, Karnataka, India. A total of 70 patients were included in this study and various general, demographic, clinical and surgical data outcomes were studied over a period of 4 years.Results: In our study of 70 patients we found the mean age of the study population to be 45.6% with a range of 21 to 70 years. Male patients (80%) outnumbered the females (20%). Among the 70 limbs studied, 30 (42.85%) patients had the involvement of GSV and communicating system, 6 (8.57%) had involvement of GSV and SSV systems, whereas SSV and CS were affected in 2 (2.85%) patients. 2 (2.85%) had all the three...

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IOSR Journals

Background and objectives: Venous diseases of lower limb remain commonaffecting 20% of adult population. Objective of this study is to identify cases with primary varicose veins, evaluate with appropriate investigations, collect data and establish the clinical spectrum of complications in this population. Methods: Study was conducted on 50 consecutive patients with primary varicoseveins at Govt. thiruvarur medical college, thiruvarur. All cases of varicose veins presenting to the OPD were subjected to duplex scan to rule out secondary causes. Patients admitted with varicose veins who satisfied the inclusion and exclusion criteria were included in the study.. Patients who presented with bilateral disease got their symptomatic limb operated first while the other limb was treated conservatively Patients with saphenofemoral incompetence were treated with saphenofemoral junction ligation and stripping of long saphenous vein. Patients with saphenopopliteal junction incompetence were treated with saphenopopliteal junction ligation with or without stripping of short saphenous vein. Patients with perforator incompetence were treated with subfascial ligation of perforators Results: Out of 50 patients studied, 39 (78%) patients were agriculturists, whoadmitted of having been exposed to prolonged hours of standing .Among the 50 cases studied, 70 limbs showed varicose veins, of which 32 limbs had long saphenous vein and communicating system involvement (45.7%). 20 limbs had long saphenous vein involvement (28.5%) alone. Among 32 limbs with long saphenous and communicating system involvement, 24 had pain (75%), 7 had oedema (21.8%), 18 had disfigurement (56.2%), 8 ulcers (25%). Among 20 limbs with only long saphenous involvement 10 had pain (50%), 3 had oedema (15%), 4 had disfigurement (20%), 2 had ulcer (10%).Of the 48 limbs that underwent surgery 26 (54.1%) underwent saphenofemoral flush ligation with stripping of LSV and subfascial ligation of perforators Conclusion: Definite relationship exists between occupation involving prolongedstanding and primary varicose veins.The involvement of long saphenous and communicating system together is commonest followed by long saphenous involvement alone. Patients with involvement of long saphenous and communicating system or long saphenous and short saphenous system were more symptomatic than others Complications of varicose veins were responded well to operative treatment. Results of surgical treatment are good

Journal of Evidence Based Medicine and Healthcare

Venkat Vineeth

Scholar Science Journals

Varicose veins and their associated symptoms and complications constitute the most common chronic vascular disorders leading to surgical treatment. Though considerable advances in understanding of venous patho physiology and modern imaging techniques have revolutionized the concept of management of varicosity of lower limb, whether these inferences hold good for our population is a pertinent question. The objective of the study is: 1) Analysis of the clinical features of varicose vein. 2) To know the various treatment modalities adapted for the management of varicose veins. Varicosity of the lower limb is a common clinical entity with, age group of 31-40 being commonly affected. The involvement of long saphenous vein is the commonest. Clinical examination has a high predictive accuracy. The use of color Doppler is a valuable supplement to clinical examination for effective treatment of varicose veins. Operative line of treatment is a primary procedure in the management of varicose veins of lower limbs. LSV stripping up to mid calf is associated with less morbidity so also non-stripping of SSV. The present procedures enable the patient to lead almost normal life after surgery and the mortality rate is very negligible.

Gundavajhula Laxmana Sastry

Varicose veins constitute a progressive disease that becomes steadily worst. IntheINDIAN subcontinent,anestimated 23%ofadultshave varicose veins, and6%havemoreadvancedchronicvenous disease(CVD), includingskinchangesandhealedoractive venousulcers. The study has been taken up to know the distribution & severity of varicose veins of lower limbs & modalities of treatment in prevention of complications.

The aim of study is to study the clinical presentations, surgical management and its outcome and complications associated with varicose veins in lower limbs. Patients and methods:This randomized prospective study includes 50 patients with primary varicose veins admitted in surgical units of SiddharthaMedicalcollege/ Govt. general hospital VijayawadafromOctober 2015toSeptember 2017.Results:In the study, it was noted that the varicose veins more commonly affect the young adult and middle age population (20-60yrs). Most of the patients were males (88%). Long saphenous vein involvement was seen in 88% of patients. A great number of patients had perforator incompetence. Sapheno-femoral flush ligation with stripping appears to be best option for LSV truncal involvement with no recurrence in followup. Conclusion: Majority of the patients with varicose veins associated with complications and surgical management with stripping of path of incompetence (i.e., LSV trunk) with incompetent perforator ligation appear to be best option for lower limb varicose veins under our settings.

International Surgery Journal

VIVEK CHAUDHARI

Background: Varicose veins are common problem and are present in at least 10% of the general population. So far as the aetiology is concerned varicose veins mostly occur due to incompetence of their valves. Risk factors for varicose veins include obesity, female sex, inactivity, and family history. Varicose veins do not threaten life and are seldom disabling, but it causes a considerable demand on medical care.Methods: The study was prospective observational single center study. 30 patients were selected for the study which fit in the selection criteria laid down at the beginning of the study. Informed consent was obtained from each patient before any investigations and treatment.Results: The study revealed that the varicose veins of lower limbs are a disease of younger age group, occurring more commonly during third and fifth decades of life. The involvement of long saphenous system was more common.Conclusions: Results of our study are comparable with various other studies in liter...

International Journal of Surgery Science

Pradeep Tenginkai

Varicose veins are a common encounter in a surgical out-patient department. The vivid range of presentations can leave the surgeon perplexed about the approach to be taken.Despite this, little epidemiological research has been carried out on venous disease, perhaps partly because of society’s perception that venous disease is not a major problem and it is not normally a cause death. More recently however, efforts have been made conduct structural epidemiological studies to identify risk factors and to clarify the geographical variations suggested in the past by anecdotal the prevalence of varicose veins and presents evidence for an against the different theories of causation. The study emphasizes on a sample of the society presented to us, who were diagnosed with varicose veins and patterns with respect to their age, sex, social status, occupations, recurrence, and involvement of the limbs were assessed. The outcomes based on the time of presentations, improvement in the quality of life including conservative regimens were briefed. The ultimate aim of the study being to assure a life of normal quality.

Abhilash Vemula

Background: Disorders of veins which are chronic in nature and very common are the varicose veins. Surgery is required at any one stage of the disease. There have been considerable advances that took place in the diagnostics of the varicose veins, but the treatment outcomes may not be good in many cases. To study the management and outcome of lower limbs varicose veins. Methods: This was a hospital based follow up study. Patients who presented with varicose veins signs and symptoms were included. During the study period it was possible to include 40 patients who were willing to get included in the present study. Various presentations, complications and treatments were noted and finally followed up for minimum of 3 months. Results: Most commonly affected age group was 36-45 years. Males were four times more affected than females. Most commonly affected limb was left side in 48%. Long saphenous system was involved in 55%. The predominant symptom was dilated and tortuous veins (32%) followed by pain (25%). 65 incompetent perforators identified by clinical examination and 130 by Doppler with above ankle being the commonest incompetent perforator. With the mean follow up of six months, no serious complications were noted. It was found that the sensitivity of the clinical examination was 82% when doppler scan was taken as gold standard. On follow up no one developed deep vein thrombosis. Incompetence recurrence rate at SFJ was 8% and at SPJ was 18%. Conclusions: We conclude that surgery is the first line of management and if done accurately, complications are minimal.

https://www.ijhsr.org/IJHSR_Vol.11_Issue.8_Aug2021/IJHSR-Abstract.02.html

International Journal of Health Sciences and Research (IJHSR)

Introduction: Varicose veins are part of the spectrum of chronic venous diseases and include dilated, tortuous veins of lower limbs, spider telangiectasia and reticular veins. Varicose vein disease is a very common problem of the western world and mostly their patients come for treatment because of cosmetic reasons. Indian scenario is different as mostly patients from lower socioeconomic strata of the society come for complications like ulceration, dermatitis etc. of varicose veins come for treatment. This problem sometimes results in chronic absenteeism from work, economic losses and change of occupation in many individuals. Methods: This observational study was carried out from 1 st January 2017 to 30 th June 2018 in Sri Aurobindo Medical College and Postgraduate Institute, Indore. Clinical profile of 52 patients of varicose vein disease was studied. All the patients were thoroughly examined and the pertaining data recorded. This data was tabulated and compared with the available literature on this subject. Results: Fifty two cases of varicose vein disease were studied. The commonest age group affected with the disease was between 41 to 50 years. Male patients were more and comprised of 84.6% of total number. Sapheno femoral junction valve was incompetent in 73.1 % cases as compared to saphenopopliteal junction[34.6%].Obesity was an important factor in causation of varicose vein disease. Flush ligation at SFJ with stripping was the commonest surgical procedure carried out our center. Conclusion: It is found that varicose vein disease with its associated sequelae brings the patient for treatment in our scenario. Long saphenous vein is the commonly affected part of the superficial venous system because of incompetency of the valve at SFJ. Although various etiological factors can be attributed to varicose vein disease but occupation and obesity remain the main factors. Accurate assessment of problem and adequate surgery will prevent recurrence.

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• v.10(6); 2020

Original research

Severe varicose veins and the risk of mortality: a nationwide population-based cohort study, nan-chun wu.

1 Department of Cardiovascular Surgery, Chi Mei Medical Center, Tainan, Taiwan

2 Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Rende, Taiwan

Zhih-Cherng Chen

3 Department of Cardiology, Chi Mei Medical Center, Tainan, Taiwan

4 Department of Pharmacy, Chia Nan University of Pharmacy and Science, Rende, Taiwan

I-Jung Feng

5 Department of Healthcare Administration and Medical Informatics, Chi Mei Medical Center, Tainan, Taiwan

Chung-Han Ho

Chun-yen chiang, jhi-joung wang.

6 Medical Research, Chi Mei Medical Center, Tainan, Taiwan

Wei-Ting Chang

7 Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan

8 Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan

Associated Data

bmjopen-2019-034245supp001.pdf

Varicose veins (VVs) are common and although considered benign may cause morbidity. However, the association between VV severity and cardiovascular and mortality risks remains unknown. The aim of this study was to investigate the factors associated with overall mortality in patients with VV.

A total of 4644 patients with newly diagnosed VV between 1999 and 2013 were identified from Taiwan’s National Health Insurance Database. VV severity was classified from grade 1 to 3 according to the presentation of ulcers or inflammation. Moreover, 9497, 2541 and 5722 age-matched, sex-matched and chronic cardiovascular risk factor-matched controls, as assessed based on propensity score, were separately selected for three grading VV groups. Enrolled patients were analysed using conditional Cox proportional hazards regression analysis to estimate risk of mortality and major adverse cardiovascular events (MACEs) in the VV and control groups.

Most patients with VV were free from systemic disease. However, compared with matched controls, patients with VV showed a 1.37 times increased risk of mortality (95% CI 1.19 to 1.57; p<0.0001). Compared with matched controls, older (age ≧65 years) (adjusted HR: 1.38; 95% CI 1.17 to 1.62; p=0.0001) and male patients with VV (adjusted HR 1.41; 95% CI 1.18 to 1.68; p=0.0001) showed increased risk of mortality. Furthermore, compared with controls, patients with VV showed 2.05 times greater risk of MACE. Compared with matched controls, population at grade 3 increased 1.83 times risk of mortality and 2.04 to 38.42 times risk of heart failure, acute coronary syndrome, ischaemic stroke and venous thromboembolism.

Conclusions

This nationwide cohort study demonstrated that patients with VV are at a risk of cardiovascular events and mortality. Our findings suggest that presence of VV warrants close attention in terms of prognosis and treatment.

Strengths and limitations of this study

• The strengths of this study are its population-based design with a large sample size including study and control cohorts.
• All insurance claims were reviewed by medical reimbursement specialists.
• However, some risk factors of varicose vein including smoking habits, lack of movement, overweight and glycated haemoglobin levels were not available in this database.
• Our novel findings indicated that patients at severe grades of varicose vein had higher risks of mortality and major adverse cardiovascular events.
• The presence of varicose vein should catch more awareness of potential coexisting risks of mortality and cardiovascular events.

Introduction

Varicose veins (VVs) can be considered a common disease with prevalence ranging from 2% to 56% in the adult population. 1 Following clinical examination, VV diagnosis is primarily based on the presence of enlarged and twisted veins in the lower extremities. 1 2 Among people with VV, 1%–4% of individuals show higher severity grades (Clinical–Etiological–Anatomical–Pathophysiological (CEAP) classification, 5–6). 1 2 Although VVs lead to leg swelling, venous eczema and ulceration in some cases, they are regarded as a benign disease. 3 4 Moreover, the association between the severity of VV and risk of future adverse events remains unknown. In fact, the majority of the previous studies have focused on the importance of superficial venous thrombosis or deep vein thrombosis (DVT). 5 In a 30-year cohort study, mortality risk among patients with DVT and pulmonary embolism (PE) was markedly higher than that in age-matched and sex-matched patients, particularly within the first 30 days. 6 Similarly, another population-based case–control study demonstrated that having VV was a risk factor for venous thromboembolism, although the association of VV severity with survival and cardiovascular events remains unknown. 7 In addition, although age, family history and female sex are the known risk factors for VV, the effects of underlying diseases or sex on outcomes of VV remain unclear. 1 We hypothesised that presence of VV can be used as a marker for cardiovascular risk. Therefore, the aim of this study was to investigate the association of VV with survival and cardiovascular outcomes.

Data source

Taiwan launched a single-payer National Health Insurance (NHI) programme on 1 March 1995. This database contains details of almost every Taiwanese resident (coverage rate >98% in 2009), making it one of the world’s largest and most complete population-based sources. The data used in this study were retrieved from the Longitudinal Health Insurance Database 2000 (LHID2000)—a subset of the NHI database containing all claims data from 1996 to 2013, covering 1 million beneficiaries randomly selected in 2000. At that time, there were no significant differences in age, sex and healthcare costs between patients with VV and matched controls. LHID2000 provided encrypted patient identification numbers; sex; date of birth; admission and discharge dates; International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes of diagnoses and procedures; prescription details; registry data in the Catastrophic Illness Patient Database; and costs covered and paid for by NHI. Details of the National Health Insurance Research Database (NHIRD) are described in previous studies. 8 9 Moreover, the accuracy of major disease diagnoses in the NHIRD, including stroke and acute coronary syndrome (ACS), has been validated. 9

Patient and public involvement

No patient involved.

Study design

This nationwide population-based, retrospective cohort study was conducted to investigate the association between VV and subsequent mortality. Patients with at least three claims for outpatient VV diagnosis in 1 year or with one claim for inpatient VV diagnosis (ICD-9-CM codes 454, 454.0, 454.1, 454.2, 454.8 and 454.9) were considered as VV cases. Patients with a first-time diagnosis of VV from January 1999 to December 2012 were included in the cohort. Codes for VV were considered reliable for diagnosis based on clinical symptoms. The date of the first-time VV diagnosis was considered the index date in this study. To ensure accurate VV diagnosis, and to avoid potentially confounding effects, patients with DVT (ICD-9-CM codes 453.40, 459.1, 671.4, 671.3, 451.83, 459.3, 453.4, and 451.11) or PE (ICD-9-CM codes 415.1, 415.11, 673, 673.2, and 673.8) in an ambulatory setting before the index date were excluded. In addition, VV severity was categorised as grade 1 uncomplicated (ICD-9-CM code 454.9), grade 2 with ulcer (ICD-9-CM code 454.0) or inflammation (ICD-9-CM code 454.1) and grade 3 with both ulcer and inflammation (ICD-9-CM code 454.2).

Three control cohorts (n1=9497, n2=2541 and n3=5722; four control subjects for every enrolled patient with VV), not diagnosed with VV from 1996 to 2013, were selected for three VV grade groups separately. To eliminate potential selection bias, the controls were matched using propensity score (PS) method at a 4:1 ratio for baseline characteristics of age, sex and chronic cardiovascular risk factors, including hypertension (ICD-9-CM codes 401–405, A260, A269, 4372), diabetes (ICD-9-CM codes 250, A181, A189, A229, A239, 3572, and 3620), hyperlipidaemia (ICD-9-CM code 272), and coronary artery disease (CAD; ICD-9-CM codes 410–414). The PS for identified VV cases and controls were estimated using the fitting logistic regression model. Based on greedy algorithm matching, eight control subjects (the nearest neighbour matching of VV) were selected as matched controls. 10 If a case failed to be assigned to the four matched controls, it was dropped from the set of matches. In addition, since the primary VV treatment was covered by insurance, it prevented VV from overdiagnosis. The matched controls were assigned the same index date as that of the corresponding VV patient.

The primary outcome was mortality, and the secondary outcome was major adverse cardiovascular events (MACEs), including acute (ACS, ICD-9-CM codes 410, 410.7, 411.1, 411.81 and 414.8), congestive heart failure (CHF, ICD-9-CM codes 428, 428.0, 428.1, 428.2 and 428.9), ischaemic stroke (ICD-9-CM code 436), DVT and PE. Mortality was identified using the ‘in-hospital death’ or ‘discharge under critical condition’ codes at discharge. Enrolment in the NHI programme is mandatory for all people in Taiwan, and registration must be withdrawn within 30 days after death. Patients with the above-mentioned mortality-related codes and those withdrawn from the NHI programme within 30 days after discharge from the last hospitalisation were presumed to have died. All subjects were followed up from the index date to death (lost to follow-up) or until 31 December 2013, whichever was earlier.

Validation of the accuracy of VV diagnosis and CEAP grading

To validate the accuracy of the VV diagnosis, we reviewed the charts of all patients (inpatients and outpatients) using ICD-9-CM diagnosis codes for VV who visited Chi-Mei Medical Center (Tainan, Taiwan) from 2010 to 2015. Our aim was to determine the accuracy and consistency of code usage. A vascular specialist reviewed patient discharge and clinical records. In addition to examining the accuracy of VV diagnosis, the reviewer compared CEAP stages with our ICD-9-CM-derived grades in inpatients. Subsequently, we further investigated the sensitivity, specificity and predictive value of the ICD codes for clinical diagnosis, as well as the applicability of our VV grading system. In particular, as ICD-9-CM coding and VV descriptions are associated with insurance payment, the accuracy of VV diagnosis and the reliability of VV severity grading increased. The consistency between CEAP and grading stages were evaluated by kappa score, whose value between 0.8 and 1.0 was considered as an almost perfect agreement.

Statistical analyses

Continuous and categorical baseline characteristics between the case and control groups were separately compared by standardised mean difference (SMD), an assessment approach for evaluating the balance between variables after PS matching. SMD greater than 0.1 is considered to denote a meaningful imbalance in variables.

Conditional Cox proportional hazards regression analysis was used to estimate the risk of mortality and MACE in the VV and control groups. Adjusted HRs were estimated by adjusting for chronic obstructive pulmonary disease (ICD-9-CM codes 490–496), cancer (ICD-9-CM codes 140–208), atrial fibrillation (ICD-9-CM codes 427.31), heart failure (ICD-9-CM codes 428), ischaemic heart disease (ICD-9-CM codes 410–414), chronic renal insufficiency (ICD-9-CM codes 403, 404, 582, 585–588). Moreover, the investigation was extended to stratified subgroup analysis. HRs between the VV and control groups were separately estimated in subgroups of population aged <65 years or ≥65 years; males or females; and subgroups with or without a diagnosis of hypertension, diabetes, hyperlipidaemia or CAD. The Kaplan-Meier method was used to separately estimate the 3-year 6-year and 9-year survival rates in the control and VV groups. Kaplan-Meier curves of mortality and MACE were plotted for controls and patients with three grades of VV severity. Differences in survival curves between the control and VV groups were examined using the log-rank test.

With respect to mortality, CHF, ACS, ischaemic stroke and DVT +PE endpoints, the risks for VV with three separate severity grades were further estimated by comparison against each matched controls.

Finally, sensitivity analyses were conducted to determine the influence from subjects with pregnancy history (ICD-9-CM codes V22, V23.2, 761.5), peripheral artery disease (PAD, ICD-9-CM codes 440.0, 440.2, 440.3, 440.8, 440.9, 443, 444.0, 444.22, 444.8, 447.8 and 447.9) medical history and patients treated with operations (ICD-9-CM procedure code 3859, 3889 and NHIRD order code 69013, 69014, 69015, 69016, 69017, 69019, 69020, 69021) including ligation and stripping procedures after VV diagnosis.

A two-tailed p<0.05 was considered statistically significant. All analyses were performed using the SAS software, V.9.4 (SAS) and Stata software V.15.0 (StataCorp)

Characteristics of the study population

A total of 4644 patients with newly diagnosed VV were identified during January 1999 to December 2012. Among them, 2467, 668 and 1509 VVs were separately classified into 1, 2 and 3 severity grade. For each VV group, age-matched, sex-matched and chronic disease-matched patients without VV were separately included for comparison. The covariates between VV and matched groups are well balanced after PS matching. All patients were tracked from the index dates until achieving the primary outcomes or the end of the study. The mean age of patients with VV was 55.70±16.03 years, the majority of the patients were female (61.33%), and most of them did not present with chronic diseases such as hypertension, diabetes, hyperlipidaemia and CAD ( table 1 ). Significantly different distribution of age, sex and diabetes among three severity VV groups were displayed (p<0.05) ( online supplementary table 1 ). Interestingly, more female patients (68.67%) were diagnosed with a lower severity (grade 1). Also, the baseline characteristics and comorbid medical disorders for three grading VV groups and three separately matched controls were listed in online supplementary table 2 .

Baseline characteristics and comorbid medical disorders for the control cohort and patients with varicose vein

P value was calculated based on the two sample t-test and Pearson’s X 2 test.

Supplementary data

Long-term mortality risk.

Compared with matched controls, the outcomes of patients with VV were worse. The estimated survival at 3, 6 and 9 years were 97.6%, 95.6%, and 93.5%, respectively, in patients with VV compared with 98.5%, 97.1%, and 95.6%, respectively, in controls ( figure 1A ). A log-rank test revealed a significant difference in survival curves of patients with VV and controls (p<0.0001). The survival curves of controls and patients with different severities of VV are presented in figure 1B . Lower survival rates over time were observed in patients with highest VV severity (grades 3) but not in those with grade 1–2. Significant difference between survival curves between VV grading 3 and corresponding controls were revealed by log rank test (p<0.0001). However, no significant differences were found between survival curves of patients with VV severity grades (1-2) and corresponding controls (grade 1: p=0.3191; grade 2: p=0.3599).

(A) Kaplan-Meier estimates of 12-year survival between patients with varicose veins (VV) and the matched control cohort. (B) Kaplan-Meier estimates of 12-year survival between patients with VV categorised by the disease severities and the matched control cohort.

Overall, HR of all-cause mortality adjusted for chronic obstructive pulmonary disease, cancer, atrial fibrillation, heart failure, ischaemic heart disease, chronic renal insufficiency in patients with VV was 1.34 times higher (adjusted HR 1.37; 95% CI 1.19 to 1.57; p<0.0001) than that in controls ( table 2 ). Stratified analysis revealed 1.38 and 1.41 times increased risks of mortality in older (age ≥65 years; adjusted HR 1.38; 95% CI 1.17 to 1.62; p=0.0001) and male patients with VV (adjusted HR 1.41; 95% CI 1.18 to 1.68; p=0.0001). Notably, despite no significant effect of VV on the survival of patients with hypertension, hyperlipidaemia or CAD was observed, patients with both VV and diabetes presented 1.50 times higher risk of mortality compared with those without VV (adjusted HR 1.50; 95% CI 1.05 to 2.15; p=0.0254). Furthermore, VV at grade 3 show 1.83 (95% CI 1.48, 2.27; p<0.0001) greater risk of mortality adjusted for chronic obstructive pulmonary disease, cancer, atrial fibrillation, heart failure, ischaemic heart disease, chronic renal insufficiency.

Crude and adjusted HRs of all-cause mortality in patients with VV compared with the matched control cohort during the follow-up period

*P<0.05.

†Adjusted for chronic obstructive pulmonary disease, cancer, atrial fibrillation, heart failure, ischaemic heart disease, chronic renal insufficiency.

VV, varicose veins.

Long-term MACE risk

MACE risk significantly increased in patients with VV (HR 2.05; 95% CI 1.89 to 2.23; p<0.0001), particularly in relatively younger (age,<65 years; adjusted HR 2.17; 95% CI 1.92 to 2.46; p<0.0001) or male (adjusted HR 2.32; 95% CI 2.06 to 2.62; p<0.0001) patients ( table 3 ). In addition, patients with VV showing cardiovascular risk factors, including hypertension, diabetes, hyperlipidaemia and CAD, were at a higher risk of MACE than were matched controls. In patients with VV, 3-year, 6-year and 9-year MACE-free rates were 91.17%, 84.99% and 79.27%( figure 2A ). These rates dramatically declined further with disease severity ( figure 2B ). In terms of individual cardiovascular outcomes, patients with grade 3 VV were at a greater risk of CHF (adjusted HR 2.05; 95% CI 1.71 to 2.46; p<0.0001), ACS (adjusted HR: 2.04; 95% CI: 1.58 to 2.63; p<0.0001) and ischaemic stroke (adjusted HR 2.06; 95% CI 1.58 to 2.69; p<0.0001) than were controls ( table 4 ). In particular, with the highest VV severity there was an increasing risk of venous thrombotic events, including DVT and PE (grade 3: adjusted HR 38.4; 95% CI 16.4 to 90.1; p<0.0001) ( table 4 ).

(A) Kaplan-Meier estimates of 12-year free from MACE between patients with varicose veins (VV) and the matched control cohort. (B) Kaplan-Meier estimates of 12-year free from MACE between patients with VV categorised by the disease severities and the matched control cohort. MACE, major adverse cardiovascular event.

Crude and adjusted HRs of MACE in patients with VV compared with the matched control cohort during the follow-up period

MACE, major adverse cardiovascular event; VV, varicose veins.

The adjusted HRs of mortality and MACE in patients with VV compared with the matched control cohort during the follow-up period

ACS, acute coronary syndrome; CHF, congestive heart failure; DVT, deep vein thrombosis; MACE, major adverse cardiovascular event; PE, pulmonary embolism; VV, varicose veins.

Validation of the accuracy of VV diagnosis and ICD-9-CM-derived VV grading

During 2010–2015, a total of 2202 outpatients and 347 inpatients were reported to have VV in Chi-Mei Medical Center. Among the outpatients, 1188 were coded as uncomplicated VV (ICD-9-CM code 454.9), 775 were coded as VV with inflammation (ICD-9-CM code 454.1), 152 were coded as VV with ulcers (ICD-9-CM code 454.0) and 87 were coded as VV with ulcer and inflammation (ICD-9-CM code 454.2) ( online supplementary table 3 ). Notably, none were coded incorrectly. Compared with CEAP stage, as determined based on chart reviews, only a few inpatients were incorrectly or unclearly diagnosed using ICD-9-CM-derived VV codes ( online supplementary table 4 ). For example, among patients with higher VV grades (CEAP stage 5–6), the positive and negative predictive values with ICD-9-CM-derived codes were 93% and 98.4%, respectively. Specifically, the sensitivity and specificity of ICD-9-CM-derived grading were up to 95.2% and 97.6%, respectively. The calculated kappa score between CEAP stages and grading severity is 0.92 (95% CI 0.88 to 0.96).

Sensitivity analyses

VV and controls with pregnancy history were identified and examination the influence in sensitivity analysis ( online supplementary table 5 ). After additionally adjustment for history of pregnancy, the results remain showing great impacts on mortality and MACE (adjusted HR for death (1.37 (95% CI 1.19 to 1.57), p<0.0001; adjusted HR for MACE 2.01 (95% CI 1.89 to 2.23), p<0.0001).

After excluding 472 subjects with Myocardial infarction, stroke, coronary angioplasty or CABG, remaining VV and corresponding controls were included for sensitivity analysis. Comparing with corresponding matched controls, those conservatively treated VV patients were found 1.36 times risks of mortality (adjusted HR 1.36 (95% CI 1.18 to 1.57), p<0.0001) and 1.95 times risks of MACE (adjusted HR 1.95 (95% CI 1.80 to 2.12), p<0.0001).

The primary findings of this study were that (1) patients with VV were at increasing risks of mortality and cardiovascular events, especially those with VV at grade 3 compared with matched controls; (2) having VV had a significant impact on the survival of male patients. To the best of our knowledge, this nationwide population-based study is the first to comprehensively describe the association of VV with patients’ cardiovascular outcomes.

Although VV are common, their potential threat to health has not been well investigated previously. 1 2 Valve dysfunction-mediated activation of leukocytes, release of enzymes and remodelling of the vascular wall lead to venous valve destruction and incompetence. 11 VV may cause inflammation, oedema, ulcers, 11 endothelial dysfunction 12 and subsequent DVT. 5 In addition, overexpression of inducible nitric oxide synthase and transforming growth factor-β1 has been documented in patients with VV. 13 In this study, the risk of all-cause mortality and MACE was higher in patients with VV than it was in matched controls, indicating that VV-induced systemic inflammation may be associated with cardiovascular events regardless of the development of venous thromboembolic events. Notably, the lower survival rates were observed in patients with highest VV severity but not in those with grade 1–2. This also reflects that the chronic inflammation induced by a higher grade of VV may be associated with increasing mortality and MACEs. However, only a few studies have compared development of VV with arterial disease and reported inconsistent findings. 2 14 A previous study in Finland has reported a twofold higher incidence of new arterial disease in individuals with VV than in those without it, although the incidence of new hypertension was similar. 14 15 Thus, VV and arterial disease may have a common aetiology, but VV were not related to hypertension. Furthermore, Chang et al have reported the association of VV with the incidence of venous thromboembolism and PAD. 16 Reportedly, myocardial infarction and heart failure increase the risk of thromboembolism. 17 In contrast, patients with thromboembolic events were at a higher risk of subsequent myocardial infarction and stroke. 18 However, whether this association is causal or represents common risk factors warrants further research. Notably, compared with controls, patients with VV were at a higher risk of mortality independent of age and sex. Specifically, the significant impact of VV was observed in male patients. In previous research, older age and female sex were found to be the most relevant risk factors for VV. 1 VV incidence increases with increasing age. However, Heit et al have reported that younger patients with VV were at a significantly increased risk of subsequent DVT, whereas the risk was attenuated with increasing age. 7 Similarly, Lohr et al also reported that although female presented with a higher prevalence of lower grade VV (CEAP 2–3) compared with male (50.5% vs 30.1%), there were more higher grade VVs with trophic skin changes (CEAP 4–6) found in male than in female (5.4% vs 2.8%). 19 Also, DVT was more common in males compared with females (11.3% vs 7.8%). 19 Earlier onset of VV in the younger population implies a higher risk of concomitant arterial diseases or systemic inflammations. As described previously, female sex, pregnancy, and predominately being in the sitting posture are risk factors for VV. 20 However, despite the valid correlation between use of oestrogen supplements and DVT, whether sex hormones contribute to the development of VV remains unclear.

There were several strengths of this study. First, we included an unselected, large, nationwide cohort of patients with VV. By including the data of 4644 patients over a 12-year period, this study provided adequate statistical power for the analysis of long-term outcomes for VV. Second, we compared the VV cohort with a matched, VV-free cohort, which helped distinguish the characteristics of the VV population in terms of survival and outcomes. Third, among patients with VV, the effects of sex on mortality and MACE were emphasised because VV may have been ignored in these specific populations. Forth, we included patients presenting with VV of various severity grades, which allowed for a comprehensive investigation of overall effects of severity. Finally, a recently published article evaluated and supported the accuracy of several major outcomes, including MI, hypertension, diabetes, stroke, CHF and VV, in NHIRD. 21

However, this study had several limitations. According to previous meta-analysis and research, smoking habits, quality of life, lack of movement, pregnancy history, overweight and glycated haemoglobin levels are considered VV risk factors, with some of these being related to increased mortality risk. Although NHIRD provides a complete clinical medical history over decades for 1 million people, currently the NHIRD lacks information regarding people’s lifestyle and clinical laboratory test results. Therefore, the selected confounders in this study were limited to age, sex and four chronic cardiovascular risk factors. The small corresponding area under the receiver operating characteristic curve indicated that the relevant confounders were not appropriately identified. To explore the effects of VV on mortality and MACE with minimum confounding bias, a future study including more comprehensive VV-related risk factors is imperative. Second, the miscoding of VV severity may have led to the exclusion of cases. This might explain why 47% of the included patients are with advanced venous disease (grade 2 or 3), different from the general distribution of disease severity. Nevertheless, to overcome the inherent limitations, we verified the accuracy of VV diagnosis using chart review by a specialist. Overall, both the validation methods indicated a satisfactory accuracy of VV coding in the NHI database. Third, owing to difficulties in completing CEAP staging according to ICD-9, we established our own grading system. However, even though this novel ICD-9-CM-derived grading system clearly differentiated patients with various severities, it remained different from the generally applied CEAP staging system and disease progression could hardly be represented. Similarly, to validate the reliability of the ICD-9-CM-derived grading system, we reviewed medical records of inpatients with VV and observed satisfactory sensitivity and specificity. Forth, while ligation and stripping surgeries may affect the outcomes, through excluding patients receiving surgical treatment for VV we performed sensitivity test. It also revealed significant increases of risks of mortality and MACE in patients with VV compared with risks in the matched controls. Likewise, after excluding the potential influences of PAD, we also found great impacts of mortality and MACE in the population with VV. Finally, increased mortality with higher ICD-9-CM-derived grades indicated that our grading system specifically reflected the severity of VV but the cause of mortality was not available in this database.

VVs are a common condition typically believed to be benign; however, our results suggest that they warrant close attention. Compared with matched controls, patients with VV were at increasing risks of mortality and cardiovascular events, especially those with VV at grade 3. Therefore, these findings should alert clinicians regarding the importance of detecting VV at an early stage.

Supplementary Material

N-CW and Z-CC contributed equally.

Contributors: All authors contributed to the revision of the manuscript and approved the final version. All agreed to be accountable. N-CW contributed to concept and design, critical revision. Z-CC contributed to data collection and critical revision. I-JF contributed to critical revision, data collection, statistical analysis and interpretation. C-HH contributed to critical revision, data collection, statistical analysis and interpretation. C-YC contributed to data collection and critical revision. J-JW contributed to data collection and critical revision. W-TC contributed to concept and design, data collection, interpretation, manuscript writing and critical revision.

Funding: We received the research grant supported by Chi-Mei Medical Center

Competing interests: None declared.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Patient consent for publication: Not required.

Ethics approval: The present study was ethically approved by the Institutional Review Board of Chi-Mei Hospital (CV code: 10406-E01). All procedures followed the principles outlined in the Declaration of Helsinki.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement: Data are available in a public, open access repository. All the data are available in National Health Insurance Research Database (NHIRD) in Taiwan.

CLINICAL STUDY AND MANAGEMENT OF LOWER LIMB VARICOSE VEINS

• ASSOCIATE PROFESSOR, DEPT.OF GENERAL SURGERY,RIMS,KADAPA.
• DEPT.OF GENERAL SURGERY, RIMS, KADAPA.
• Cite This Article as
• Corresponding Author

Background: Varicose veins of the lower limb are the most common peripheral vascular disease. A clinical study and surgical management of varicose vein was conducted to study the age, sex and occupational distribution of varicose veins of lower limb. Evaluations of clinical features and surgical methods of treatments that were in practice in the management of varicose veins in terms of recurrence and symptoms improvement were alsostudied. Methods: A prospective study was carried out between July 2013 to June 2015. During this period 50 cases of varicose veins of lower limbs were admitted to our hospital and were studied in detail. After thorough clinical examination and relevant investigation they are all subjected to surgical management. Results: Out of 50 cases studied, 35 (50%) had long saphenous vein involvement, 6 (12%) had short saphenous vein involvement and in 5 (10%) cases both short and long saphenous system were involved. In addition to long saphenous vein involvement, incompetent perforators were present in 4 (8%) cases. Among them prominent veins and pain were the main complaints in 36 (72%) patients. Itching and pigmentation were present in 7(14%) patients. Ankle edema was present in 4(8%) patients. Pain and ulceration of lower leg were present in 3(6%) patients. After clinical assessment appropriate surgical procedures were followed for each of patients. Conclusions: This study reveals that the disease is more prevalent during the active adult life in their 3rd and 4th decades and males were more affected. Definite relationship exists between the occupation and the incidence of varicose veins. The patients were in the occupation which required standing for long time had the higher chances of varicose vein. Severity of the symptoms is not proportional to the duration of varicose veins. The involvement of long saphenous vein is more common than the short saphenous vein. Since our study shows very low percentage of recurrence and symptoms related to varicose vein the surgical line of treatment is an ideal treatment for varicose vein. If cases are selected properly with good operative technique the complications are negligible.

• Varicose vein
• long and short saphenous veins

[ K. VANI and D. REDDY PRASAD (2015); CLINICAL STUDY AND MANAGEMENT OF LOWER LIMB VARICOSE VEINS Int. J. of Adv. Res. 3 (Oct). 1778-1784] (ISSN 2320-5407). www.journalijar.com

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