Diagnosis Of Chronic Venous Insufficiency Research Articles

A pilot study of the development and implementation of a ‘best practice’ patient information booklet for patients with chronic venous insufficiency

Chronic venous insufficiency (CVI) is a chronic condition that has a significant impact on the individual. For the effective, long-term management of CVI, it is important that patients are educated on the patho-physiology of the condition and strategies that can minimize the related complications. Therefore, the aim of this study was to develop and pilot a 'best practice' information booklet for CVI and to assess the impact of this booklet on CVI-related knowledge and quality of life (QOL). A 'best practice' CVI booklet was developed based on the best available evidence from the literature. Participants with a formal diagnosis of CVI with a clinical, aetiological, anatomical and pathological elements (CEAP) classification of 3-6 were recruited from vascular outpatient clinics at a tertiary hospital. Each participant was given and explained the CVI booklet and asked to undertake the recommended activities at home over the next six-month period. Measurements were taken at baseline, one month and six months postbooklet implementation via the previously validated Health Education Impact and the CVI Questionnaires. Twenty-six participants, aged 38-90 years (mean 71.8 ± 12.9 years) initially participated in the study, with 20 participants remaining at the six-month time point (77% completion rate). At the end of one month, there had been a significant improvement in doing at least one activity to improve CVI (P = 0.010), monitoring CVI (P = 0.045), having effective ways to prevent CVI symptoms (P = 0.045), knowing CVI triggers (P = 0.005), ability to travel by car and bus (P = 0.05), undertaking social activities (P = 0.030) and feeling less embarrassed about the legs (P = 0.025). At trial end (6 months), there was a significant improvement in doing at least one activity to improve CVI (P = 0.003), knowing CVI triggers (P = 0.016), having effective ways of preventing CVI symptoms (P = 0.008), worrying about the CVI (P = 0.030), feeling hopeless because of CVI problems (P = 0.007), leg and ankle pain (P = 0.038), ability to do domestic duties (P = 0.017), feeling nervous and tense (P = 0.026), and feeling less embarrassed about the legs (P = 0.008). Although other domains improved in the study, none of these improvements were statistically significant. Although a small pilot study, the outcomes demonstrate that the implementation of a 'best practice' CVI information booklet into a patients management routine can improve both CVI-related knowledge and QOL.

Chronic Venous Insufficiency

Chronic Venous Insufficiency

Chronic venous insufficiency: the effects of health-care reforms on the cost of treatment and hospitalisation -an Italian perspective

SUMMARYObjectives: This study evaluated the evolution of chronic venous insufficiency (CVI)-related costs in Italy over 8 years by focusing on the impact of the Italian health-care reforms (drug de-reimbursement) of 1993-94.Research design and methods: The global cost of CVI to the Italian health system (Sistema Sanitario Nazionale, SSN) was divided into three sub-costs: hospitalisation, GP consultation and prescription costs. Indirect costs, such as loss of working days, were not included.CVI-related hospitalisation costs included inpatient treatment for varicose veins, venous leg ulcers and other venous disorders. They were calculated using the US-derived system, Diagnosis Related Group (DRG), used in Italian hospitals. Calculations for the whole country were based on figures determined for the Lombardy region and extrapolated. It was considered reasonable to assume that this region was representative of the whole of Italy. CVI-related GP consultation and prescription costs were derived from Intercontinental Medical Statistics (IMS) data. These costs, pre- and post-reforms, were determined and compared to evaluate the impact of the reforms on CVI-related expenditure.Results: Pre-reforms CVI-related costs analysis (1991): hospitalisations, €210 million; GPconsultations, €35.4 million; prescriptions, €115 million. The total CVI-related direct costs (i.e. CVI diagnosis and management) were €360.4 million.Post-reforms CVI-related costs analysis (1999): hospitalisations, €288 million; GP consultations, €13 million; prescriptions, €83 million. The total CVI-related direct costs were €384 million.Hospitalisation costs increased predominantly due to an increase in hospitalised patients. GP consultation and prescription costs decreased predominantly due to drug de-listing. The €23.6 million increase in CVI management expense, post-reforms, was due to cost-redistribution from prescriptions and GP consultations to hospitalisations.Conclusion: Short-term goals were achieved by the reforms, but long-term expectations were not. Drug de-reimbursement reduced both drug costs for the SSN and the number of GP consultations. Fewer patients were treated overall (mostly with advanced disease), with consequent disease worsening and increase in complications. An increase in CVI-related hospitalisation resulted. In contrast, preventative measures, including patient education and prophylactic treatment, exhibit both clinical and cost effectiveness. Larger studies are required to confirm these preliminary results.

Air plethysmography in chronic venous insufficiency: clinical diagnosis and quantitative assessment.

To define the role of air plethysmography (APG) in the clinical diagnosis and quantitative assessment of chronic venous insufficiency (CVI), APG studies were performed on 582 limbs in 291 patients with signs and symptoms of CVI. One hundred and thirty-one limbs were classified into group I (no evidence of CVI), 291 into group II (mild CVI), and 160 into group III (advanced CVI). On APG, the mean venous filling index (VFI) was 1.45 mL/s, 3.90 mL/s, and 5.25 mL/s in groups I, II, and III respectively (p<0.05). The mean ejection fraction (EF) and mean residual volume fraction (RVF) also showed significant differences between the limbs with CVI and the contralateral normal limbs, but the values were similar for the different severities of CVI limbs. The amount of overlap in VFI, EF, and RVF values among the clinical groups was considerable. Discrimination analysis derived a VFI value of 2.67 mL/s as a cutoff point between normal limbs and limbs with CVI, with a positive predictive value of 96%. In conclusion, APG is a simple and noninvasive test for quantitative assessment of the different components of CVI, valvular reflux, and calf muscle pump function. However, only VFI correlated significantly with the severity of CVI. VFI, with its high positive predictive value, may be useful in diagnosis of CVI, and it may serve as an objective quantitative measurement for monitoring the effect of treatment.

The role of air plethysmography in the diagnosis of chronic venous insufficiency

Purpose: The role of air plethysmography (APG) in the diagnosis of venous disease is not well defined. We conducted this study to investigate the value of APG in the diagnosis of chronic venous insufficiency and to determine its correlation with the clinical severity of disease and the anatomic distribution of reflux. Methods: We studied 186 lower extremities with duplex scanning and venography and measured the venous volume, venous filling index (VFI), ejection fraction, and residual volume fraction with APG. Limbs were categorized according to the Society for Vascular Surgery and International Society for Cardiovascular Surgery classification of clinical severity of disease and according to the anatomic distribution of valvular incompetence. Results: Sixty-one limbs had no evidence of disease (class 0), 60 limbs had mild disease (classes 1, 2, and 3), and 65 limbs had severe disease (classes 4, 5, and 6). According to the results of duplex scanning and venography, there was no evidence of reflux in 56 limbs. Isolated superficial venous reflux occurred in 52 limbs, and perforator reflux, alone or in conjunction with superficial reflux, occurred in 30. Deep reflux, with or without superficial reflux, was found in 25 limbs. Deep and perforator reflux, with or without superficial reflux, was found in 19 limbs. The VFI had a sensitivity of 80% and 99% positive predictive value for any type of reflux. The VFI was significantly different between groups of limbs with different clinical severities of disease or different types of reflux. The incidence of deep or perforator reflux in limbs with a normal VFI value was 7%, and it was 82% in limbs with a VFI of more than 5. Among 86 limbs with VFI values not corrected with use of a thigh tourniquet, 28% did not have evidence of deep or perforator reflux, and among 15 limbs with VFI values corrected with the use of a tourniquet, 33% had perforator reflux, deep reflux, or both. All APG parameters had low positive predictive values for severe disease or ulceration. The ejection fraction and residual volume fraction did not influence the clinical severity of disease, did not discriminate between types of reflux, and in combination with the VFI did not improve the predictive value of APG. Conclusions: The VFI measured by APG is an excellent predictor of venous reflux, provides an estimate of the clinical severity of disease, and at high levels predicts deep reflux, perforator reflux, or both. Correction of an abnormal VFI with a thigh tourniquet is an unreliable predictor of the absence of deep or perforator incompetence. The predictive value of APG for severe disease or ulceration is poor. The ejection fraction and residual volume fraction, individually or in combination with the VFI, add little to the diagnostic value of APG, and their routine performance may not be clinically justified. (J Vasc Surg 1998;27:660-70.)

The role of air plethysmography in the diagnosis of chronic venous insufficiency

The role of air plethysmography in the diagnosis of chronic venous insufficiency

Chronic venous insufficiency--a well-known disorder with many question marks.

Chronic venous insufficiency (CVI) is a common disorder found in many parts of the world. The pathophysiology of this condition is only partly elucidated, and even the development of varicose veins remains unexplained. Microcirculation is greatly affected by CVI, which occasionally induces skin changes and ulcers. Although varicose veins are a common symptom of CVI, they are absent in many patients. Thus, clinical examination is often insufficient for the diagnosis of CVI. Furthermore, the treatment of a common disorder such as CVI is frequently inadequate. The author discusses the overfrequent use of varicose vein surgery, where compression treatment would seem more appropriate and effective, and the current status of compression in the treatment of deep vein incompetence. He recommends that the various manifestations of CVI should be more thoroughly classified. He also examines how sclerotherapy is used to various extents in different countries. Finally he discusses the use of various drugs in the treatment of CVI. It is clear that the pathophysiology and the treatment of CVI must be further examined, in particular to determine whether prevention is possible.

Epidemiological characterization of chronic venous insufficiency in Portugal

With the objective of studying the spectrum of clinical manifestations of Chronic Venous Insufficiency (CVI), we conducted an epidemiological survey in 17 of the 20 districts in Portugal. This study involved 436 general practitioners and 8243 consecutive attendants of the national health service aged 15 and over, who were inquired for symptoms and signs of CVI. The diagnosis of CVI was established on clinical grounds by the physicians, who recorded data on demography, associated diseases, past history, symptoms, physical signs, and characteristics and location of varicose veins. These data were combined with the estimates of prevalence of CVI obtained in a previous study on 45,000 individuals and with the results of the population census of 1991 to obtain age and sex adjusted population prevalences of the disease manifestations. The results show that the prevalence of CVI, radicular and troncular varices, and troncular varices is 20, 12 and 6% in males and 40, 22 and 10% in females. The prevalence of grade 0, 1, 2 and 3 CVI is 2, 10, 6 and 3% in males and 4, 22, 12 and 4% in females. The prevalence of a history of phlebitis and venous thrombosis is 4.5 and 1.3% in males and 8.9 and 1.5% in females. The prevalence of chronic venous ulcer, either active and inactive, is 3.2% in males and 3.9% in females. These data indicate that the situation of CVI in Portugal is similar to that reported in other European countries.

The epidemiology of chronic venous insufficiency in Portugal

The prevalence of chronic venous insufficiency (CVI) was investigated in 44,777 unselected primary care outpatient clinics in 17 of the 20 districts in Portugal, during 1993. The diagnosis of CVI was established clinically by 427 participating general practitioners. CVI was more prevalent in females, with a female to male ratio of 2.1:1. The disease affects all age groups, but in females its prevalence increases sharply between 15 and 20 years, while in males it begins to become important about 10 years later. The maximum age-specific prevalence is reached between 55 and 64 years in both sexes, when CVI is present in 58% of females and in 35% of males. Overall prevalence of CVI was calculated using the data from the population census of 1991, by the direct standardization method. The estimated prevalence of CVI in males is 17.8% and in females is 34.1%, corresponding to 812 thousand and 1,741 thousand cases in Portugal, respectively. In the population over 15 years old, the prevalence is 20.7% in males and 40.8% in females. These estimates have an error of +/- 2.5% with 95% confidence. The geographical distribution of the disease showed different patterns in males and in females. Prevalence decreases from coast to inland in males, and from south to north in females.

Acrodermatitis Chronica Atrophicans Herxheimer Can Often Mimic a Peripheral Vascular Disorder

During the past few years five patients have been referred to the angiology section at Danderyd Hospital under the diagnosis of chronic venous insufficiency but who were instead suffering from acrodermatitis chronica atrophicans (ACA). The typical case of ACA starts with a limited inflammatory lesion, which is gradually replaced by atrophy and the skin shows a bluish, red discoloration. Late changes may be subluxation of joints in hands or feet and periosteal thickening. Capillary microscopy often reveals a clear picture of atrophy and a prominent, dilated subpapillary venular plexus. If localized to the leg the blood flow of the foot and lower leg may be increased, skin temperature elevated and venous capacity and return augmented. All these variables can consequently mimic venous insufficiency of the leg. ACA is caused by a Borrelia infection and serological testing will always show a significantly elevated titer to Borrelia. The disease is most often easily cured by 2-3 g of penicillin daily for two to three weeks.

Diagnosis of chronic venous insufficiency

An orderly diagnostic approach is needed to establish specific anatomic and etiologic diagnoses in patients with chronic venous insufficiency. It begins with the history and physical examination, including Doppler examination of the veins, in the office. When the severity of the problem warrants further investigation, the vascular laboratory can be used to assess the degree of physiologic change via pressure, volume, and flow studies. Diagnosis of obstructive and incompetent states can be established, and the one distinguished from the other. Ascending phlebography is used to demonstrate the anatomy of the veins, competence of the perforators, and the presence of postthrombotic deep vein changes. Descending phlebography is used in selected cases to diagnose specific incompetence of the valves in the superficial femoral, deep femoral, and greater saphenous veins.A complete venous evaluation defines which veins are patent, where the valves are located and if they are competent, and provides physiologic pressure and volume studies to correlate with the clinical state. Problems caused by primary valve incompetence are separated from those caused by postthrombotic recanalization or occlusion. On the basis of these findings, specific therapy can be tailored to the problem at hand.

Diagnosis of chronic venous insufficiency

Diagnosis of chronic venous insufficiency

Subcutaneous ossification of the legs in chronic venous insufficiency.

The presence of subcutaneous ossification in the legs associated with chronic venous insufficiency has recently been described by one of us in a preliminary report (1). The present paper is concerned with the correlation of radiologic and clinicopathologic features and with some refinements in the roentgenographic demonstration of this condition. Chronic venous insufficiency is defined as tissue damage due to abnormalities in venous blood flow (2, a). In the lower extremities, these abnormalities are frequently caused by varicosities of the greater saphenous system or by pathologic conditions in the deep veins (obstruction or insufficiency). Less frequently, varicosities in the lesser saphenous system are contributory. Other less common causes are acquired arteriovenous fistulas and vascular malformations. Dependent edema is an important mechanism in the development of chronic venous insufficiency. Clinical manifestations of chronic venous insufficiency are chronic dermatitis and cellulitis, and atrophy of skin and subcutaneous tissue with induration and brown discoloration. Later sequelae include recurrent ulceration and subcutaneous ossification. Material and Methods Sixty patients with subcutaneous ossification of the leg were studied. These include 23 described in the preliminary report. Of the latter group, all were reevaluated roentgenographically and some were re-examined with special technics. The condition was unilateral in 33 and bilateral in 27 patients. This report, therefore, is based upon the study of 87 legs in 60 patients. In six cases there was pathologic confirmation of subcutaneous ossification from biopsy specimens which were obtained during surgical treatment for complication of chronic venous insufficiency. In all legs, the clinical and roentgenographic findings appeared sufficiently distinctive to warrant a diagnosis of subcutaneous ossification. Of the 60 patients, 9 were observed at the peripheral vascular clinic and the wards of the Bronx Municipal Hospital Center, 29 at the peripheral vascular clinic of the Sidney Hillman Health Center, and 22 in private practice. The national and racial origin of these patients corresponded to that of the general population in these three groups. All 60 patients were females and past the menopause. Their average age was 60.2 years at the time of the first examination (forty-six to seventy-eight years). The incidence of associated diseases and other clinical data are summarized in Table I. The diagnosis of chronic venous insufficiency was established by conventional methods (1). Blood concentrations of calcium, phosphorus, alkaline phosphatase, and total proteins were determined in 50 patients and were found to be within normal range in each instance. Sulkowitch reagent tests were performed in random urine specimens in the first 23 patients. They were omitted in all subsequent cases, since the results could not be correlated with the clinical findings. Roentgenographic Technics Laminagraphic studies were made in 13 cases, in the anteroposterior and lateral projections. Venography was performed by injecting 5 to 15 ml. of contrast medium (usually 35 per cent Diodrast) into a superficial varicosity proximal to the site of ossification, with the leg in a dependent position at 30 to 40°.