Severity Of Chronic Venous Disease Research Articles

Identifying venous clinical severity score thresholds for Clinical-Etiology-Anatomy-Pathophysiology classifications of venous edema and higher.

Venous Clinical Severity Score (VCSS) is a widely used standard for assessing and grading the severity of chronic venous disease (CVD). Prior research highlighted its high validity in detecting and quantifying venous disease. However, there is little, if any, known about the precise thresholds at which VCSS discriminates important stages of deep venous disease. This study sought to elucidate the diagnostic accuracy, thresholds, and correlation at which VCSS detects salient CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classes in deep venous disease progression. A registry of 840 patients who presented with chronic proximal venous outflow obstruction (PVOO) secondary to non-thrombotic iliac vein lesions from August 2011 to June 2021 was retrospectively analyzed. VCSS and CEAP classifications were used to evaluate preoperative symptoms. VCSS was compared to CEAP classes to determine the precise VCSS composite values at which the instrument was able to detect CEAP C3 and higher, C4 and higher, and C5 and higher. Receiver operative characteristic (ROC) curve and area under the curve (AUC) were used to evaluate VCSS for its ability to discriminate disease at these stages of CEAP classification. Spearman's rank coefficient was used to determine the correlation between CEAP VCSS composite as well as individual VCSS components (pain, varicose vein, edema, pigmentation, inflammation, induration, ulcer number, ulcer size, ulcer duration, compression). VCSS composite was able to detect venous edema (C3) and higher at a sensitivity of 68.9% and a specificity of 54.8% at an optimized threshold of 8.5 (AUC = 0.648; 95% C.I. = 0.575-0.721). To detect changes in skin and subcutaneous tissue from CVD (C4) and higher, an optimal threshold of 11.5 was found with a sensitivity of 51.7% and specificity of 76.5% (AUC = 0.694; 95% C.I. = 0.656-0.731). Healed venous ulcer (C4) and higher was detectable at an optimized threshold of 13.5 at a sensitivity of 67.7% and a specificity of 88.9% (AUC = 0.819; 95% C.I. = 0.766-0.873). The correlation between VCSS composites and CEAP was weak (ρ = 0.372; p < .001). Attributes of VCSS that reflect more severe venous disease correlated more closely with CEAP classes, namely pigmentation (ρ = 0.444; p < .001), inflammation (ρ = 0.348; p < .001), induration (ρ = 0.352; p < .001), number of active ulcers (ρ = 0.497; p < .001), active ulcer size (ρ = 0.485; p < .001), and ulcer duration (ρ = 0.497; p < .001). The correlation between CEAP class and the other four components of VCSS were not statistically significant. VCSS composite thresholds of 8.5, 11.5, and 13.5 are threshold values for detecting CEAP classification C3 and higher, C4 and higher, and C5 and higher, respectively. Consistent with prior work, VCSS appears to have a better ability to discriminate CVD at more severe CEAP classifications. In this registry, the correlation between VCSS and CEAP was found to be weak while components of VCSS that suggest more advanced disease exhibited the strongest correlation with CEAP.

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

ObjectiveVenous Clinical Severity Score (VCSS) is currently the gold standard for measuring the severity of chronic venous disease, especially in patients with chronic proximal venous outflow obstruction (PVOO) secondary to non-thrombotic iliac vein lesions. Change in VCSS composite scores is often used to quantitatively measure the degree of clinical improvement after venous interventions. This study sought to assess the discriminative ability, sensitivity, and specificity of change in VCSS composites for detecting clinical improvement after iliac venous stenting. MethodsA registry of 433 patients who underwent iliofemoral vein stenting for chronic PVOO from August 2011 to June 2021 was retrospectively analyzed. These 433 patients had follow-up exceeding 1 year after the index procedure. Change in VCSS composite and clinical assessment scores (CAS) were used to quantify improvement after venous interventions. CAS is an assessment by the operating surgeon based on patient self-reporting to assess the degree of improvement at each clinic visit compared with before the index procedure longitudinally across the treatment course of a patient. Patients are rated as worse (−1), no change (0), mildly improved (+1), significantly improved (+2), and asymptomatic/complete resolution (+3) at every follow-up visit as compared with their disease severity prior to the procedure based on patient self-report. This study defined improvement as CAS >0 and no improvement as CAS ≤0. VCSS was then compared with CAS. Receiver operative characteristic curve and area under the curve (AUC) were used to evaluate change in VCSS composite for its ability to discriminate between improvement and no improvement after intervention at each year of follow-up. ResultsChange in VCSS was a suboptimal measure for discriminating clinical improvement (1-year AUC, 0.764; 2-year AUC, 0.753; 3-year AUC, 0.715). Across all three time points, a change in VCSS threshold of +2.5 maximized the sensitivity and specificity of the instrument to detect clinical improvement. At 1 year, change in VCSS at this threshold was able to detect clinical improvement at a sensitivity of 74.9% and specificity of 70.0%. At 2 years, VCSS change had a sensitivity of 70.7% and specificity of 66.7%. At 3 years of follow-up, VCSS change had a sensitivity of 76.2% and specificity of 58.1%. ConclusionsAcross 3 years, change in VCSS exhibited a suboptimal ability to detect clinical improvement in patients undergoing iliac vein stenting for chronic PVOO with considerable sensitivity but variable specificity at a threshold of 2.5.

Association of duplex ultrasonography findings with the severity of chronic venous disease in Thai patients

IntroductionChronic venous disease (CVD) is characterized by venous hypertension and stasis, which occur because of valvular incompetence and/or venous outflow obstruction. This study aimed to investigate the relationship between CVD clinical presentation and duplex ultrasonography findings in a Thai patient population. MethodThis cross-sectional study examined patients diagnosed with CVD at the Chulabhorn Hospital Vascular Clinic (Bangkok, Thailand) between December 1, 2018 and October 1, 2021. Patient data was obtained from the medical records and review of lower limb venous ultrasonography studies. Patients were assessed using the Clinical, Etiological, Anatomical, and Pathological (CEAP) classification of venous disorders: mild-to-moderate CVD was defined as C1 to C3 and severe CVD was defined as C4 to C6. ResultsOverall, 260 CVD patients were analyzed (60 men and 200 women). More than 75% of the patients were women and more than 80% had bilateral lower limb involvement. Factors associated with severe CVD were older age, female sex, high body mass index, hypertension, diabetes mellitus, and history of deep venous thrombosis. The most common CEAP classification was C2 (38.8%), followed by C1 (33.85%), C4 (12.2%), C3 (9.23%), C6 (3.46%), and C5 (2.31%). Two-thirds of the patients had great saphenous vein reflux and nearly half had perforator vein reflux. Perforator reflux and small saphenous vein reflux were significantly associated with severe CVD (P < 0.001 and P = 0.028, respectively). Higher number of venous systems involved was significantly associated with severe CVD (P = 0.005). Reflux time of the great saphenous vein correlated with severe CVD and VCSS (P = 0.026 and P = 0.037, respectively). Mean diameters of the superficial vein, perforator vein, and deep vein and reflux times of the perforator and deep veins were not significantly associated with severe CVD. ConclusionThe major risk factors for severe CVD are older age, female sex, high body mass index, hypertension, diabetes mellitus, and history of deep venous thrombosis. The most common CEAP classification was C2 (39%). Great saphenous vein reflux was the most common type of reflux in our study population. Increasing number of venous systems involved increased the risk of severe CVD. The presence of perforator vein reflux and small saphenous vein reflux also increased the risk of severe CVD. Reflux time of the great saphenous vein correlated with severe CVD and venous clinical severity score.

Association of High Serum Homocysteine Levels and Severe Chronic Venous Disease

Homocysteine (Hcy) is considered as a modifiable risk factor for vascular disease. This study was aimed to explore the association between serum concentration and the severity of primary chronic venous disease (CVD). Clinical data of 582 patients diagnosed with primary CVD were collected and analyzed retrospectively. The Clinical Etiology Anatomy Pathophysiology classification system was used to grade the severity of chronic venous disease. Patients were divided into 2 groups (group A: C1-C3; group B: C4-C6). The association between serum homocysteine levels and the severity of primary chronic venous disease was investigated using rank sum test and logistic regression. The difference between the level of homocysteine in each grade has statistical significance. Group A has higher median Hcy concentrations than Group B (15.40 μmol/L vs. 14.05 μmol/L, P< 0.01). Further binary logistic regression showed no statistical significance among the level of Hcy (11.00-14.75 μmol/L [OR 0.66, 95% CI 0.40-1.11, P= 0.12], 14.75-20.38μmol/L [OR 0.97, 95% CI 0.59-1.69, P = 0.89], ≥20.38 μmol/L [OR 0.67, 95% CI 0.41-1.10, P = 0.11]), but age (OR 1.03, 95% CI 1.01-1.04, P< 0.01) and female (OR 0.41, 95% CI 0.28-0.59, P< 0.01) are associated with more severe stages of CVD. Higher level of Hcy is associated with more severe stages of CVD, but it not an independent risk factor. However, Advanced age and female are risk factors for CVD development based on logistic regression analysis.

The immediate effect of physical activity on ultrasound-derived venous reflux parameters

ObjectiveUltrasound-derived reflux volume (RV) has a low correlation with the clinical severity of chronic venous disease, as well as other hemodynamic parameters. The difference in methodology of measurements could be a possible explanation. The purpose of this study was to investigate the immediate effect of calf pump activity used in the functional methods on ultrasound-measured venous reflux parameters. MethodsPatients with primary incompetence of the great saphenous vein (GSV) were recruited for the study. The diameter of the GSV, cross-sectional area in square centimeters, time average velocity in centimeters per second, and reflux duration (RT) in seconds were measured by duplex ultrasound examination. The RV flow rate (Q) in milliliters per second and RV in milliliters were calculated. The measurements were performed standing at rest before and 60 seconds after physical exercise (30 lifts to tiptoes at a frequency of 1 time per second). A decrease in the volume of reflux after exercise was calculated (DRV = RV [after] – RV [before]/RV [before] × 100%.) Automatic distal compression-decompression (120 mm Hg) was used as a provocation maneuver. ResultsThere were 61 patients included in the study. Before exercise, reflux parameters were: RT = 4.85 seconds (interquartile range [IQR], 3.71-6.00 seconds); Q = 3.89 mL/second (IQR, 2.03-5.81 mL/second); and RV = 17.05 mL (IQR, 10.32-25.34 mL). After physical exercise, they changed to RT = 2.86 seconds (IQR, 2.14-3.33 seconds); Q = 3.61 mL/second (IQR, 2.06-6.37 mL/second); RV = 10.07 mL (IQR, 6.08-16.48 m:); and DRV = 40.9%. The changes in RT and RV values were statistically significant. DRV was inversely related to both the GSV diameter and the Venous Clinical Severity Score (r = −0.56, and r = −0.41, respectively; P < .0001). ConclusionsVenous reflux decreases within 1 minute after the end of the exercises. Reduction of the volume of retrograde flow occurs only owing to the shortening of reflux time, and not the flow rate, suggesting that venous reflux is influenced by exercise-induced changes in the volume of the venous reservoir.

Lower limbs edema among medical students

Aim of the study: Chronic venous disease is frequent that affects people of various professions and ages. It consists of a set of symptoms located in the lower limbs, and edema is one of the first and most frequent signs. The aim of this study was to investigate the lifestyle influence on frequency of lower limbs swelling formation among medicine students. Materials and methods: Analysis of questionnaire conducted among 482 students of the academic year 2018/2019 from 12 Polish medicine universities. The survey questions encompass known and possible risk factors of lower limbs edema. CEAP scale was used to assess the severity of chronic venous disease. Results: Lower limb edema occurred in 30% of the respondents, of which 55% stated the exacerbation of symptoms on the days they attended classes. Conclusions: Medical students suffer from edema, it is more common among women. The type of classes affects the manifestation of lower limbs oedema. The factors that have the greatest impact on the formation of edema in students are: prolonged standing or sitting position and high ambient temperature.

Rehabilitation of patients with venous diseases of the lower limbs: State of the art.

To date, no document comprehensively focused on the complex issue of the rehabilitation of chronic venous diseases of the lower limbs. This article overviews and summarizes current strategies concerning venous rehabilitation of lower limbs. Venous rehabilitation is based on four main strategies: (1) lifestyle adaptations and occupational therapies; (2) physical therapies; (3) adapted physical activities; (4) psychological and social support. Rehabilitative protocols must be tailored to the specific needs of each patient, depending on the severity of chronic venous disease and on the location and pattern of venous lesion(s), but also on age, motor deficits, co-morbidities and psychosocial conditions. Venous rehabilitation consists of non-pharmacologic and non-surgical interventions aiming at prevention of venous disease progression and complications, reduction of symptoms and improvement of quality of life. Well-designed clinical trials are required to evaluate the efficacy of the described rehabilitative protocols in influencing the evolution of venous disorders.

Postural Diameter Change of the Saphenous Trunk in Chronic Venous Disease

The aim of this study was to analyze the correlation between the extent of diameter change from standing to supine position ("postural diameter change," PDC), and patient or duplex ultrasound (DUS) characteristics in lower limbs with and without saphenous trunk (ST) reflux. Measurements were carried out in 193 limbs with primary great saphenous vein, anterior accessory saphenous vein, or small saphenous vein reflux, and 48 control limbs without ST reflux. The inner diameter of the ST was measured with DUS in the standing and lying positions. The PDC, calculated as a percentage, followed the formula: (standing diameter-lying diameter)/standing diameter×100. Clinical findings (according to the highest "C" - of the CEAP classification), venous clinical severity score, body mass index (BMI), time of visit, and inside and outside temperature were documented. Limbs were divided into two groups using the median value of PDC as a cut off to increase interpretability of the analysis. The median PDC of the ST was 19% in limbs with ST reflux compared with 24% in control limbs (p=.16). In limbs with and without ST reflux, only older age and increased BMI were independently associated with a low PDC of the ST (R(2) 0.13). In limbs with ST reflux, median PDC was significantly lower in C4-C6 (16%, interquartile [IQR] 8-21) than in C0-C1 (23%, IQR 12-35) or C2-C3 limbs (21%, IQR 11-33; p=.016). In addition, PDC was significantly lower in veins with a large diameter (>7mm) than in those with a small diameter (p=.003). Low PDC of the ST correlates with older age and increased BMI. Whether PDC might become a useful additional DUS tool to classify the severity of chronic venous disease and thereby influence the management strategy should be further investigated.

Management of perforator vein aneurysms in the lower extremities.

Perforator vein aneurysms (PVAs) of the lower extremity have not been defined or reported. This study reports the clinical presentation of patients, the PVA characteristics, and the clinical outcome of their management. Patients with signs and symptoms of chronic venous disease who had a PVA were included. Diagnosis of a PVA was made with duplex ultrasound. Normal perforator veins have a diameter of<3mm. A PVA was defined as a diameter dilation of >9mm, and it was always found below the deep fascia. The topography and morphology of the aneurysms were described in detail. All PVAs were treated with subfascial ligation with or without aneurysm excision. All patients were followed up for a minimum of 3months with clinical examination and duplex ultrasound, and complications were noted. There were 21 aneurysms identified in 19 patients. Fourteen (73.7%) patients were female. The mean age at diagnosis was 49years with a standard deviation of 9. Aneurysm size ranged from 9.8 to 22.2mm, with a mean diameter of 15.7mm and a standard deviation of 3.8. Seventeen aneurysms were fusiform, one was saccular, and one was multilobar. The perforators of the great saphenous vein distribution were most frequently involved, whereas only one involved deep vein disease. Few patients had symptoms, such as pressure and pain directly over the affected perforator. There was no association between the location and size of the PVA and the severity of chronic venous disease. Fourteen patients were treated surgically; fivepatients preferred conservative treatment with elastic compression stockings. Fourteen patients (73.7%) had ligation with (n= 9) or without (n= 5) excision of the aneurysm. All underwent concomitant phlebectomies, and eight of them also had ultrasound-guided foam sclerotherapy. Endovenous thermal ablation of saphenous veins was performed in seven patients, whereas two had ligation and stripping. There were four minor postoperative complications in four patients, all of which resolved within 6weeks. The median follow-up was 21months, ranging from 3 to 52months. There were no recurrences of a PVA. Five patients preferred conservative treatment. The diameter changed from 0 to 13mm during the follow-up, and the patients' symptoms remained the same or had mild worsening. PVAs are rare without causing significant symptoms locally. Diagnosis is made with duplex ultrasound because the affected vein is located below the deep fascia. As only one case in our series of 19 involved the deep veins, we believe that PVAs originate from superficial veins. The condition is relatively benign, and the treatment outcomes are very good with limited complications experienced. However, selective treatment of PVAs may not be needed for most of them as treatment of the superficial veins connecting with the PVA may be sufficient.

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

The objective of this study is to evaluate whether and which 'venous' symptoms are characteristic for patients affected with chronic venous disease compared to patients with other diseases of the lower limbs (e.g. arthrosis, peripheral arterial disease, spinal disc herniation). A cross-sectional study was performed to compare the frequency of venous symptoms among 76 patients with chronic venous disease and reflux and 74 patients with other diseases of the legs without reflux. The VEINES-Sym of the VEINES-QOL/Sym questionnaire was used to evaluate the frequency of symptoms. Demographic, clinical classification and ultrasound findings were also noted. A total of 122 patients were included for analysis (response rate of 87%). Presence of venous symptoms was slightly more often reported in the chronic venous disease group than in the non-chronic venous disease group, but differences were small and statistically non-significant. Severity of chronic venous disease as classified by the CEAP classification was not associated with higher proportions of patients reporting symptoms than in non-chronic venous disease patients, except for swelling (p = .016) and itching (p = .007) in C3-C6 patients. The largest difference between the chronic venous disease and non-chronic venous disease group was observed for the time of the day at which symptoms were most intense; patients with chronic venous disease were more likely to experience symptoms at the end of the day (p < .001). The small differences in prevalence of reported 'venous' symptoms between chronic venous disease patients and patients with other diseases of the legs suggest that these symptoms may be less specific for patients with chronic venous disease and refluxing veins than is usually assumed.

Manual lymphatic drainage in chronic venous disease: A duplex ultrasound study

To compare the effect of call-up and reabsorption maneuvers of manual lymphatic drainage on blood flow in femoral vein and great saphenous vein in patients with chronic venous disease and healthy controls. Forty-one subjects participated in this study (mean age: 42.68(15.23)), 23 with chronic venous disease (chronic venous disease group) with clinical classification C1-5 of clinical-etiological-anatomical-pathological (CEAP) and 18 healthy subjects (control group). Call-up and reabsorption maneuvers were randomly applied in the medial aspect of the thigh. The cross-sectional areas, as well as the peak and the mean blood flow velocity at femoral vein and great saphenous vein, were assessed by Duplex ultrasound at the baseline and during maneuvers. The venous flow volume changes were calculated. The venous flow volume in femoral vein and great saphenous vein increased during both manual lymphatic drainage maneuvers and in both groups (P < 0.05). The two maneuvers had a similar effect on femoral vein and great saphenous vein hemodynamics, and in both the chronic venous disease and control groups. As a result of the call-up maneuver, the flow volume augmentations, as a result of call-up maneuver, decreased with the severity of chronic venous disease in those patients measured by the clinical classification of CEAP (r = -0.64; P = 0.03). Manual lymphatic drainage increases the venous blood flow in the lower extremity with a magnitude that is independent from the specific maneuver employed or the presence of chronic venous disease. Therefore, manual lymphatic drainage may be an alternative strategy for the treatment and prevention of venous stasis complications in chronic venous disease.

AGE, BODY MASS INDEX AND SEVERITY OF PRIMARY CHRONIC VENOUS DISEASE

The aim of this cross-sectional prospective study was investigate whether there is a correlation between age, BMI and severity of chronic venous disease (CVD), evaluated clinically (CEAP classification) and anatomically (extent of the epifascial venous reflux). 213 patients, 65 males (30.5%, mean age 45.1 ± 13.9 years) and 148 females (69.5%, mean age 47.5 ± 13.5 years) were divided into three age categories: 18-40 years (40.8%), 41-74 years (56.3%) and ≥75years (2.8%). BMI was classified as normal weight (18.5 - <25 kg/m(2)), overweight (25 - <30 kg/m(2)) and obesity (≥30 kg/m(2)). Clinical examination of the lower limbs assessed presence and severity of venous signs as included in the CEAP classification. BMI was calculated. Anatomical extent of CVD was described as the number of segments of the superficial and perforating veins with documented reflux by duplex imaging. Median age increased the number of insufficient venous segments (1 insufficient venous segment - median age 41.0 years, 5 insufficient venous segments - median age 51.0 years). The frequency of reflux in the superficial and perforating veins significantly increased with age (p<0.05). A statistically significant correlation was also found between age and the CEAP classification (p<0.01). This was more significant than the correlation between age and number of insufficient venous segments. In the whole group and in women the Spearman's correlation analysis revealed only a weak positive correlation between BMI and reflux in the superficial veins (r=0.145 respectively r=0.264) (p<0.05). No correlation was found in men (r=0.091). Weak positive correlation between BMI and stage of venous insufficiency (CEAP classification) was demonstrated for the whole group of patients (r=0.229, p<0.01), for women (r=0.293, p<0.05) and for men (r=0.245, p<0.01). Multiple linear regression showed age (p<0.0001) and BMI (p=0.049) as significant predictors of clinical grade according to the CEAP classification and the CEAP clinical class (p<0.0001) as a significant predictor of extent of the epifascial venous reflux. The study confirmed the relationship between age, clinical (CEAP clinical class) and pathophysiological (extent of the venous reflux) severity of CVD Older age means an increased number of insufficient venous segments and increased risk of the clinical progression of CVD from varicose veins to chronic venous insufficiency (C(3)-C(6), trophic skin changes and venous ulcers). Our results support the BMI, in term of frequency of venous reflux, as a risk factor in the whole group of patients but only in women but not in men. Multiple linear regression showed BMI together with age as significant predictors of clinical grade of CVD (p<0.05) according to the CEAP classification. As regards the influence of BMI on clinical severity/grade of CVD (CEAP), the results of our study support BMI as an important risk factor.

Adaptação transcultural do questionário VEINES/QOL-SYM: avaliação da qualidade de vida e sintomas na doença venosa crônica

OBJETIVO: Adaptar transculturalmente e analisar as propriedades clinimétricas do VEINES-QOL⁄Sym, um questionário específico para avaliar a qualidade de vida e os sintomas na doença venosa crônica. MÉTODOS: O VEINES-QOL⁄Sym foi adaptado segundo metodologia recomendada e aplicado em 74 indivíduos (53,7±12,3 anos) com doença venosa crônica, assistidos ambulatorialmente. RESULTADOS: Os resultados evidenciaram boa consistência interna do VEINES-QOL (alfa de Cronbach -α=0,88) e do VEINES/Sym (α=0,84). A confiabilidade inter e intra-examinadores avaliadas pelo coeficiente de correlação intraclasse variou de 0,95-0,98 para o VEINES-QOL e de 0,76-0,79 para o VEINES/Sym. O coeficiente de correlação intraclasse foi calculado para cada item e alguns apresentaram valores abaixo do esperado merecendo revisão. As correlações com SF-36 foram significativas (p&lt;0,001), porém com moderada magnitude. Apenas o VEINES-QOL foi capaz de distinguir os indivíduos em dois grupos, de acordo com a gravidade da doença venosa crônica (p=0,02). CONCLUSÕES: O VEINES-QOL⁄Sym, versão português-Brasil, apresentou boas propriedades clinimétricas e demonstrou ser aplicável na população

The Rationale for the Treatment of Perforating Veins in Advanced Chronic Venous Insufficiency

Treatment of incompetent perforating veins (IPVs) remains controversial in chronic venous insufficiency (CVI), because the evidence of its efficacy is of moderate quality and is not supported by prospective randomized trials without important limitations. In an excellent review of the subject, O’Donnell 1 recently concluded that the role of IPV ablation alone or concomitant with ablation of the great saphenous vein remains uncertain and awaits results of properly conducted randomized and controlled trials. Incompetent perforating veins, however frequently contribute to hemodynamic alterations in CVI. The size of perforating veins increases in patients with increasing severity of chronic venous disease (CVD), likely due to the elevated venous volume and venous pressures. There is a correlation between the number and size of IPVs and the severity of CVI. Also, the duration of reflux is longer in patients with more advanced disease. Documenting the hemodynamic significance of IPVs is difficult, because isolated IPVs cause CVD in less than 5% of patients. It is estimated that about 70% of IPVs in patients with CVD have hemodynamic significance. Evidence of Clinical Benefit From Perforator Interruption Patients with advanced CVI with duplex evidence of IPVs and patent deep veins are candidates for perforator interruption, either combined with superficial ablation or used as a staged procedure. Although initially performed with an open surgical technique, this has been replaced by several minimally invasive approaches, including subfascial endoscopic perforator surgery and percutaneous ablation using sclerosants or thermal mechanisms.

Relação entre a mobilidade da articulação talocrural e a úlcera venosa

CONTEXTO: O presente estudo avalia a mobilidade da articulação talocrural nos seis estágios clínicos da classificação CEAP (clínica, etiológica, anatômica e patofisiológica do International Consensus Committee Reporting Standards on Venous Disease) para doença venosa utilizando a goniometria, e detecta redução da mobilidade articular nos estágios mais avançados da doença, C5 e C6 (úlcera cicatrizada ou ativa). OBJETIVO: Investigar a existência de uma relação entre a severidade clínica da doença venosa crônica dos membros inferiores e a diminuição do grau de mobilidade da articulação talocrural. MÉTODO: Selecionaram-se aleatoriamente 120 membros pertencentes a 88 pacientes brancas, que foram separados com base em sua apresentação clínica de acordo com a categoria C da classificação CEAP, sendo distribuídos em 6 grupos pertencentes às categorias de C0-C1 (grupo controle) até C6, com 20 membros cada um e médias de idade próximas para cada grupo. O grau de mobilidade do tornozelo foi acessado por goniometria de apoio plantar em posição de decúbito supino. RESULTADOS: Os grupos C de CEAP apresentam diferença significativa em relação ao grau de mobilidade da articulação talocrural medida por goniometria (p &lt; 0,001). C6 difere significativamente dos demais grupos (p &lt; 0,05); C5 difere significativamente de C6, C3, C2 e C0-C1 (p &lt; 0,05), mas não apresenta diferença significativa do grupo C4; C4 difere significativamente do grupo C6 (p &lt; 0,05) e não difere dos demais grupos; C0-C1, C2 e C3 não apresentam diferença significativa entre si e em relação a C4, e diferem dos grupos C5 e C6 (p &lt; 0,05). O nível de significância utilizado para os testes foi de 5%. CONCLUSÃO: Existe relação entre a severidade clínica da insuficiência venosa crônica dos membros inferiores e a diminuição do grau de mobilidade da articulação talocrural, e ela se faz mais evidente na presença de úlcera venosa ativa ou cicatrizada.

Patterns of Venous Reflux and Obstruction in Patients With Skin Damage Due to Chronic Venous Disease

Identified were characteristics of individuals with skin damage related to chronic venous disease. Patients with chronic venous disease (n = 164) were evaluated with duplex ultrasound imaging and were placed in classes 4, 5, and 6 according to the CEAP classification. Their findings were compared with 100 class 2 controls. The prevalence of deep venous thrombosis was higher in the study group (23.7%) versus controls (5.1%; P < .0001), as was the prevalence of deep, perforator, and combined patterns of disease (P < .0001, P < .0007, and P < .0001). The mean duration of disease in controls 2 was shorter compared with the study group (P = .0019). The prevalence of reflux and obstruction within the study group was higher than in controls (P = .0021). Skin changes accurately reflect severity of chronic venous disease. Superficial and perforator vein reflux is the major cause of disease.

Association of 24-hour activity levels with the clinical severity of chronic venous disease

The pathophysiology underlying the skin changes seen in chronic venous insufficiency (CVI) is multifactorial. Sedentary lifestyle and prolonged sitting and standing at work have been proposed by some authors to be influential in the development of CVI skin changes. This study compared the 24-hour activity profiles in patients with different clinical severities of CVI and normal controls. Patients were classified into groups according to CEAP clinical severity classes: mild (C2&C3), moderate (C4) and severe (C5&C6). Activity profiles were measured in 60 patients and 15 controls using a Newcastle Universities Medical Activity (NUMACT) monitor, which recorded the duration spent in supine, sitting, and standing postures as well as duration spent walking and the walking intensity over a 24-hour period. Analysis was performed by Kruskal-Wallis and Mann-Whitney tests and Spearman correlation. Walking intensity was significantly different between the controls and patient groups during prolonged walking (P < .001). The controls spent significantly more time standing in a 24-hour period than any of the CVI clinical groups (P = .036), and the percentage time spent sitting was significantly higher in the patient groups (P = .025). No significant differences were found in the total number of steps taken or total duration spent walking in the 24-hour period between any of the groups. This study shows that walking intensity is lower in the more severe clinical groups and may be influenced by the clinical severity of CVI. The study provides evidence that prolonged sitting and reduced standing is associated with increased severity of CVI, which may by an effect of the patient's symptoms rather than a cause of disease progression.

Correlation of severity of chronic venous disease with capillary morphology assessed by capillary microscopy

In patients with lipodermatosclerosis caused by chronic venous disease of the lower limb, the skin capillaries show proliferation and convolution. To our knowledge, no previous attempt has been made to correlate the clinical severity of venous disease based on the CEAP classification with the capillary morphology changes. The purpose of this study was to correlate the clinical severity with the capillary morphology changes in patients with chronic venous disease by using capillary microscopy and to explore the significance of atypical capillary morphology in patients with uncomplicated varicose veins. Patients attending the vascular clinic for management of chronic venous disease were examined clinically and by duplex ultrasonography scans, and they were assigned to the appropriate CEAP clinical stage (C1, n = 15; C2, n = 20; C3, n = 15; C4a, n = 15; C4b, n = 15; C5, n = 15). Also studied were 10 control subjects with no arterial or venous disease of the lower limb. In part 1 of the study, a capillary microscope was used to obtain digital images of the skin microcirculation in the gaiter region. The capillary density and capillary convolutions were counted in a 2.4 mm2 region of skin. In part 2 of the study, a further 33 C2 and C3 patients were studied to provide more detailed information on a small subgroup with unusual capillary morphology. In part 1 of the study, the capillary count was similar in controls and patients in CEAP stages C2 to C4a, but decreased in patients of groups C4b and C5 (median count: C2, 15; C4b, 4; and C5, 7). The median number of the capillary convolutions was 1 per capillary in patients of groups C1 to C3 and controls; C4a had 4 convolutions, C4b had 7, and C5 had > or = 10. In part 2 of the study, an expanded group of 66 C2 and C3 patients was analyzed, of whom 14 had a mean capillary loop count of more than two. Biologic markers of inflammation were investigated for their correlation with capillary convolution, but no relationship was found. Among patients with venous disease, increased capillary convolution is strongly associated with the more severe stages (lipodermatosclerosis and healed ulceration). The significance of atypically increased capillary convolutions in a small subgroup of C2/C3 patients remains unknown.

Venous reflux: quantification and correlation with the clinical severity of chronic venous disease.

Air-plethysmography has been used to measure, in ml and in ml 100 ml-1 of tissue, the blood volume that filled the leg veins on changing posture from the recumbent position to standing. The venous filling index (VFI) (average filling range) was measured in ml s-1 and in ml 100 ml-1 min-1. We studied 24 normal legs (N), 21 with primary varicose veins without chronic swelling, skin changes (liposclerosis, eczema, pigmentation) or ulceration (PVV) and 59 with chronic swelling and/or skin changes and/or ulceration; of these 59 legs, 31 had primary varicose veins (PVV/S) and 28 had popliteal reflux (PR). The classification was done according to clinical examination, Duplex scanning, ambulatory venous pressure measurements and venography. There was an increased incidence of sequelae with increasing values of VFI. The incidence of these sequelae was irrespective of whether reflux was in the deep or in the superficial veins. VFI is a practical non-invasive measurement of reflux. It should be used to study the effect of therapy and particularly to evaluate new reconstructive procedures designed to abolish reflux in the deep veins.

The influence of venous thromboembolism on quality of life and severity of chronic venous disease

It is not known whether burden-of-illness differs in chronic venous disease patients with prior venous thromboembolism compared with patients with other forms of chronic venous disease. To compare severity of disease and quality of life in chronic venous disease patients with and without prior venous thromboembolism. The VEINES Study population is an international cohort of 1531 outpatients with chronic venous disease in Belgium, France, Italy and Canada. Clinical severity of chronic venous disease graded using the seven-category 'CEAP' scale, and quality of life using standardized generic (SF-36) and venous disease-specific (VEINES-QOL/Sym) questionnaires were compared in patients with and without venous thromboembolism. Multivariable analyses with adjustment for known confounders were used to examine associations between venous thromboembolism and quality of life. One hundred and fifty-one (10%) patients had prior venous thromboembolism. These patients had more severe chronic venous disease than those without venous thromboembolism (P <0.0001), including a higher frequency of healed or active ulcers (29% vs. 7%, respectively). Multivariable analyses controlling for age, sex, country, education, body mass index, years of chronic venous disease and comorbid conditions demonstrated that prior venous thromboembolism was an independent predictor of poorer generic quality of life (SF-36 Mental Component Summary score, P=0.047; SF-36 Physical Component Summary score, P=0.012) and venous disease-specific quality of life (VEINES-QOL, P = 0.0002; VEINES-Sym, P=0.009). Disease severity is worse and quality of life poorer in chronic venous disease patients with prior venous thromboembolism compared with patients with other forms of chronic venous disease. Our findings support the need for further research of interventions to prevent and treat the long-term complications of venous thromboembolism.