Chronic venous disease that is related to the end stage of this process is accompanied by skin changes. When the skin changes progress to the point at which even minor trauma can cause a venous ulcer, these ulcers are a severe complication of chronic venous disease.Chronic venous disease that is related to the end stage of this process is accompanied by skin changes. When the skin changes progress to the point at which even minor trauma can cause a venous ulcer, these ulcers are a severe complication of chronic venous disease. They are often painful, slow to heal, prone to infection, and can cause loss of function in the affected limb. Most venous ulcers occur around the ankle and are often referred to as gaiter area ulcers. Venous ulcers cause a significant reduction in quality of life and are costly to treat. Measures that prevent progression of chronic venous disease to the point at which ulcers develop are therefore important. Treatment for varicose veins at the saphenofemoral junction and in connection with symptoms can prevent progression of chronic venous disease. It is common to find people with varicose veins reporting that other family members also suffer from the condition. This suggests that varicose veins have a genetic cause, and this concept has been confirmed by multiple studies. Genetic diseases are likely to be the result of a combination of genetic and environmental factors, and this seems to be the case with varicose vein. Gender is another genetic factor that influences the development of varicose veins. Hormonal influences on vein structure and function make women more susceptible, and this too has been confirmed in several studies. Puberty, pregnancy, use of the combined oral contraceptive pill, or hormone replacement therapy have all been associated with an increased risk of varicose veins. Despite their importance, the mechanisms, hormonal or otherwise, by which these factors cause vein dilation and valve failure are not well understood. 1.3 Importance of Diagnosis and Assessment Chronic venous disease affects a large proportion of the population and is costly to treat. It has been estimated that 1-2% of a Western country’s healthcare budget is consumed by chronic venous ulcers. Conservative treatments (weight loss, regular exercise, elevation of legs, compression bandaging or hosiery) and endovascular or surgical interventions need to be targeted at the cause of a patient’s symptoms. Treatment of all varicose veins and saphenous reflux will only benefit patients who have related symptoms. Invasive treatments have potential complications, and thus their risks and benefits need to be weighed carefully. Successful targeted treatment requires that decisions be made based on the pattern and severity of the disease and the presence of related symptoms. This requires a thorough diagnosis and assessment that will guide decisions on treatment and allow monitoring of the disease progression and response to treatment. A clear understanding of the severity and distribution of their disease and individual risk factors will also enable patients to participate in decisions regarding their own treatment. An effective diagnosis and assessment method for varicose vein patients is therefore important to both the patients and the providers of their healthcare.
Definition of Varicose Veins
Definition of the term is important for the sake of clarity and to differentiate from other conditions. “Varicose” comes from the Latin “varix” meaning twisted. Varicose veins are defined as dilated, elongated, and twisted veins. They can occur at any site but are most commonly found in the legs and thighs. This is a very simplified definition, and historically there has been much confusion over the pathophysiology and etiology of varicose veins, with theories extending back as far as Hippocrates. As technology has advanced, so too has the understanding of varicose veins, but even now there is not a complete understanding of the condition and, in particular, the changes that occur at the microcirculatory level. But for the purpose of this paper, it is sufficient to say that varicose veins are caused by a rise in venous pressure that damages the vein wall and causes it to dilate.
Prevalence and Risk Factors
Varicose veins are a very common condition and the prevalence varies worldwide. In the Western world, the prevalence can range from 10-30% in men and 25-35% in women. The prevalence of varicose veins increases with age and has been reported to affect 50-55% of people in the US aged 40 years or older. It is a condition that can have a significant impact on an individual’s quality of life. The reasons for the large variation in prevalence between different countries are not entirely clear and are likely to be multifactorial. It is probable that genetic and environmental factors each have a role to play. An example of a genetic influence is the effect of sex on the likelihood of developing varicose veins and primary varicosities. Women are more commonly affected than men, and it has been suggested that this is due to hormonal factors. This theory is supported by the fact that the prevalence of varicose veins in women increases around the time of menopause. Pregnancy is another example and also supports a hormonal theory of the development of varicose veins. Data from the Edinburgh Vein Study shows a strong association between the number of pregnancies and varicose veins, and there was an increased incidence of developing varicose veins during pregnancy. This was still evident after adjusting for age and the number of pregnancies, compared with women who had never been pregnant. Studies have reported that varicose veins which develop during pregnancy may get better to some extent afterwards, but the long-term result will be worse than if the pregnancy had not led to varicose veins. This is an indication of the progressive nature of varicose veins mentioned earlier in this essay.
Importance of Diagnosis and Assessment
This was highlighted at the recent 12th annual meeting of the American Venous Forum, where a whole session was devoted to the results of a single trial on foam sclerotherapy. This trial had strict inclusion criteria, recruiting patients with great saphenous vein reflux involving only one segment with a minimum diameter of 5mm. The pattern and extent of the disease were documented with duplex ultrasound. This is a substantial advancement from the 1960s and 1970s when there was as much equipoise in the best treatment for varicose veins as there was unclear and inaccurate identification of the venous pathology being treated.
Diagnosis and assessment of chronic venous disease have traditionally been done through a clinical history and physical examination alone. However, more recently, advancements in technology have led to the development of many new investigative techniques. Data from randomized controlled trials on different treatments for varicose veins are now more compelling, as techniques to accurately document the pattern and extent of the disease enable more precise identification of inclusion criteria for these studies.
It is important to correctly identify the underlying pathology in patients with chronic venous disease. The clinical signs and symptoms do not necessarily reflect the underlying pattern and extent of the disease. For example, a patient with a small, superficial varicose vein may complain of severe symptoms, while a patient with obvious extensive, ropey varicose veins may be quite asymptomatic. Investigations reveal the extent of the disease and can clarify the cause of a patient’s presenting complaint. This, in turn, guides the best choice of treatment.
Diagnosis Techniques
Physical examinations should often include asking the patient to stand so that the physician can examine for any visible signs of abnormal veins, often palpating the leg to feel for evidence of any underlying varicose veins. This can be particularly effective when used in conjunction with manual compression techniques. This is a simple technique during which the examiner applies slight pressure to the vein and the patient is then asked to cough or to perform actions which make use of the calf muscle pump. If there is no subsequent change to the pressure or volume around the area being examined, it is indicative of further below in the venous system and may be the site of underlying varicose veins.
Possible future guidelines in this category could include invasive examinations such as angioscopy or the development of a non-invasive circulation meter. However, as things stand, these are not yet widely available and, as such, will not be examined further. In general, examinations to test for varicose veins should not be uncomfortable and should carry no risk to the patient. Often, varicose veins are not a serious condition and so serious or high-risk diagnostic tools are not needed. In any case, the ultimate goal of any examination is to be able to accurately identify the location and extent of any abnormal reflux in the venous system so that the most suitable method of treatment can be determined. It is hoped that with continued research, more suitable and simpler diagnostic tools can be developed to further the treatment of patients suffering from varicose veins.
Physical Examination
Assessment of varicose veins should end with palpation of the long and short saphenous veins to help plan surgical treatment. High ligation of the saphenofemoral junction is usually the best treatment for varicose veins of the long saphenous vein. This is performed through a small groin incision and has the benefit of preventing saphenous reflux without stripping the whole length of the vein. Stripping has a high rate of nerve damage and can cause recurrent varicose veins in the future. The short saphenous vein is usually treated with ligation and stripping at the point where it joins the popliteal vein. This is because it has a higher rate of DVT and PE when compared to long saphenous vein varicosities, and so prevention of saphenous reflux is less important than in the long saphenous vein.
The physical examination of a patient with varicose veins should start with a careful inspection of the legs while the patient is standing. The location, size, and extent of the veins should be noted, as well as the presence of any skin changes. Superficial thrombophlebitis can occur in varicose veins and presents as a painful, hard lump, usually in the region of the calf. Significantly, it can also be a sign of a more serious DVT in the same leg, and so the importance of excluding this diagnosis cannot be overemphasized. Homan’s test (dorsiflexing the foot of the affected leg to elicit pain in the calf) and low-grade fever may be the only signs of a DVT. Lumps, particularly in the groin area, should be noted as they may be enlarged lymph nodes or, more seriously, a femoral hernia.
Ultrasound Imaging
Duplex imaging is now an important and reliable tool for the diagnosis of venous incompetence. It is non-invasive and well-tolerated by patients. It provides anatomical and hemodynamic information in one examination. It is a good test when planning for endovenous ablation since the precise location and condition of the incompetent vein can be easily identified. This is important since treatment strategies may vary with different types of reflux.
Venous disease, such as varicose veins, has, in turn, led to advancements in ultrasonic techniques. Earlier, duplex scanning was used mainly to exclude Deep Vein Thrombosis (DVT). Over the last decade, the technology and techniques have improved to allow accurate mapping of the superficial and deep venous structures. This has been achieved through refinements in equipment and high-resolution linear transducers. The transducer emits sound waves at a high frequency (5-15 MHz), which are reflected off the tissues and detected by the same transducer. The signals are transformed into a cross-sectional image, which is displayed onto a television screen. This is known as B-mode imaging. It is the standard form of imaging used in most ultrasonic examinations. Static images can also be recorded and stored on a computer. Dynamic images are also obtained by real-time scanning. This is particularly useful for assessing the competency of venous valves. Flow is assessed by color or power Doppler. This form of imaging can determine the velocity and direction of blood flow by using the Doppler effect. Abnormal venous flow is identified by reverse flow or flow in the wrong direction across a valve.
Venography
Venography is one of the most accurate imaging techniques to assess the venous system. It requires the insertion of a catheter into a vein, usually in the foot, and the injection of a contrast medium while the fluoroscopic images are being recorded. Because the patient’s position may influence the findings, it is important to do venography using a standardized technique with the patient lying in the horizontal position. Venography is generally performed in the outpatient clinic and usually takes less than an hour to complete. There are three main types of venography – ascending, in which contrast is injected into superficial veins and images are obtained as the contrast passes through perforating veins into the deep venous system; descending, in which contrast is injected into the common femoral or popliteal vein and images are obtained as the contrast passes through the superficial venous system; and cross-sectional, in which contrast is injected into a deep vein in the lower leg and transverse images are obtained of a suspected venous segment. High-quality images and careful interpretation may confirm the diagnosis, and detailed anatomical information obtained from venography may be valuable when planning surgery or other interventions. However, venography is an invasive procedure and is associated with a small risk of complications, including contrast allergy, deep vein thrombosis, and venous ulceration. As a result, this technique is now less commonly used, and US has largely replaced it as the investigation of choice for most patients with suspected venous disease.
Other Diagnostic Tools
Magnetic resonance and air plethysmography have both been used as alternative methods of obtaining physiological data, although they are not widely available. MRV is useful for depicting the anatomy of the venous system but is expensive, and the need for the patient to lie still for up to an hour may make it unsuitable for some patients. Normal anatomy and abnormalities are depicted as high or low-intensity areas on T1 and T2 weighted images. A gadolinium contrast may be used for MRV, although this has been shown to be of little benefit over the gadolinium-enhanced MRA. Phase contrast imaging and MR phlebography enable the flow and anatomy of veins to be assessed. Similar to MRV, air plethysmography may also provide detailed physiological data, but it is of limited value in the presence of venous obstruction. A cuff around the thigh is inflated to a specific pressure, and the resultant increase in thigh volume is measured. This is compared to strain gauge-derived venous emptying times to assess the calf muscle pump function.
Duplex ultrasonography is probably the most useful tool for evaluation of patients with varicose veins. This investigation provides a non-invasive, accurate and reproducible method of assessing vein abnormalities. It provides a global map of the venous system and helps plan the optimal treatment strategy. Static (anatomy) and dynamic (physiology) data are obtained. The anatomy is assessed with the use of B-mode imaging, which gives a grayscale representation of the vein. Patency, compressibility, and the presence of thrombus or foreign body can be assessed. Abnormal veins are dilated, non-compressible, and seen in transverse view as a loss of the usual round cross-sectional appearance. The B-mode imaging is performed in the longitudinal plane to enable assessment of poorly compressible veins. Reflux is assessed in the reverse Trendelenberg or standing position. Color flow and spectral Doppler are used to assess the venous physiology. They are quick and easy to perform and provide data on both the superficial and deep venous system. Color flow gives a visual representation of blood flow and quickly identifies areas of reflux. Spectral Doppler provides a waveform from which reflux and the presence of obstruction can be inferred.
Assessment Techniques
Anatomical classification involves a standardized means of documenting the distribution and extent of varicose veins. It can be used to plan treatment, to enable comparison between studies, and to predict the outcome of treatment. Although a number of systems have been described, they all involve the construction of a diagram to describe which veins are refluxing and which are varicose because of primary valvular incompetence. Duplex mapping of the vein with color and spectral Doppler has become the most widely used method for anatomical classification. This represents the gold standard form of pre-treatment investigation and is used to plan surgery or to guide endovenous treatments. A diagram can be made and a description written of the vein for future reference. Static images of the scan or cine clips can be sent and compared to other clinicians. This is a very reliable means of documentation and comparison.
The purpose of clinical severity scoring in C2 varicose veins is to stratify patients for comparison between studies and to use a meaningful terminology to describe the signs and symptoms. A number of severity scales have been described, but the only one which has been widely adopted is the CEAP classification. This consists of six categories: C0 = no signs or symptoms, C1 = thread veins, C2 = varicose veins, C3 = edema, C4 = pigmentation or eczema, C5 = healed ulcer, and C6 = active ulcer. This classification has been shown to be reliable and valid and has been used in all aspects of clinical studies. Although it is simple and cheap to use, it has been criticized in that it does not take into account symptoms or the effect that varicose veins have on the patient’s quality of life.
Clinical Severity Scoring
Doppler examination is useful in that it can provide audible and visual information regarding reflux sites but suffers from being highly operator-dependent. Magnetic resonance and air plethysmography are considered to be more advanced methods but suffer from the disadvantages of high cost and the necessity for further validation. Finally, tumescence phlebography is invasive and seldomly used but provides detailed anatomical information for specific treatment planning.
Various forms of duplex and Doppler ultrasonography make up the most common objective assessment method. This can include simple reflux time measurements for specific veins or more complex methods such as Venous Reflux Quantification or venous segmental volume. These tests can provide detailed hemodynamic information and are often used to direct treatment but are time-consuming, require specific expertise and equipment, and have shown poor correlation between results and clinical symptoms.
The clinical severity scoring is a widely used method of assessment for varicose veins, but there are multiple scoring systems, each with their own strengths and weaknesses. Visual assessment and patient-based scoring systems include the Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classification and the Venous Clinical Severity Score (VCSS). Both of these are easy to use and require no equipment but provide some limited ability to differentiate disease severity on behalf of CEAP or extend to a disease-specific quality of life assessment for VCSS.
Anatomical Classification
Varicose veins have a multifactorial etiology and a marked variability in anatomy. Several different classification systems exist. Those based on etiology are impractical because the disease is often due to a combination of factors and can rarely be ascribed to a single cause. A purely clinical classification is more useful and there are several of these. The most widely used is probably that developed by Clinical, Etiology, Anatomy and Pathophysiology (CEAP) which has been adopted by the International Consensus group on chronic venous disease. This classification is comprehensive and has good inter-observer reliability. It is based predominantly on clinical signs with some consideration to investigations. There are six classes: C0 No visible or palpable signs of venous disease C1 Telangiectasia or reticular veins C2 Varicose veins C3 Edema C4 Changes in skin and subcutaneous tissue secondary to venous disease C5 Healed venous ulcer C6 Active venous ulcer.
Functional Assessment
The value of the Trendelenburg test can be limited by its subjective nature and difficulty in obtaining accurate timings in elderly patients due to reduced mobility and decreased calf muscle pump competence.
There are various methods of assessing venous function. The Trendelenburg test is a simple and widely used test, which assesses the competency of the sapheno-femoral junction. It should be performed by creating a tourniquet around the patient’s proximal thigh. The patient then stands, and the saphenous vein is manually emptied of blood below the tourniquet. The patient then lies down, and the clinician measures the time taken for the vein to refill using a stopwatch. A normal result is a refill time of <20s. If it takes longer than 20s and/or there is significant venous reflux, it suggests there is incompetence of the sapheno-femoral junction.
Functional assessment is often an important key to following chronic disease progression or indeed response to treatment. The venous system has a major influence on function due to its role in returning blood to the heart. In healthy individuals, the majority of functional tests show little variation with age. This is because the normal venous system has a considerable physiological reserve, which compensates for the effects of gravity and prolonged standing. In unhealthy individuals, results deteriorate with increasing age.
Quality of Life Assessment
Although numerous generic health status or QoL questionnaires have been validated and used in normal and patient populations, there are a few specific venous disease or venous ulcer questionnaires and only one recently completed Veines-QoL/Sym questionnaire. This was developed simultaneously in French and Canadian versions (and has since been translated into English) as a disease-specific QoL and symptom measure for patients with acute or chronic venous disease. This twenty-four-item health status and symptom measure is currently being validated. The generic psychological method of QoL assessment by standard gamble utilities, preference-based health state classification, and the assessment of functional health status and symptoms using the EQ-5D and SF-36 respectively provide alternative ways of assessing the impact of symptoms on patient QoL.
Patients often complain about venous disease symptoms having a large impact on their quality of life (QoL), whereas the presence, distribution, and extent of varicose veins and the severity of visible lower limb skin changes are not necessarily associated with the report of symptoms. For this reason, it is important that the assessment of patients with venous disease includes determination of the impact of their symptoms on their QoL. This will enable a comparison of the QoL impact of patients with a broad range of severities of disease and different patterns of symptoms with that of the general population and patients with other diseases. This, in turn, will facilitate meaningful evaluation of the effectiveness of different treatment interventions. There are a number of methods that can be used to quantify the impact of symptoms on QoL.
Treatment Planning
Varicose veins is a condition that can cause considerable discomfort or distress and will have a varied impact upon different patients. It is therefore important to take into account the preferences and priorities of each individual when considering treatment options, and NICE guidelines advise that decision making should be shared between the clinician and patient. In order to facilitate this process, NICE suggests that patients should be given information in written and verbal format regarding the different treatment options, the risks and benefits of each, and expected outcomes. This will allow the patient to make an informed choice about treatment and weigh up the potential benefits against any potential complications. Written consent should always be obtained before any treatment is given.
Providing there are no contraindications, compression stockings are still a first-line treatment for patients with varicose veins, and it is suggested in the NICE guidelines that patients should be required to wear them for a 3-6 month trial before any further treatment is considered. The evidence for effectiveness is limited, and there is no clear evidence to demonstrate the most effective form of compression or length of stocking use. Randomized controlled trials have shown surgery to be more effective than conservative treatment in terms of quicker relief of symptoms and improvement of quality of life. However, surgery is also associated with a higher incidence of adverse events in the short term, and a considerable proportion of patients continue to have symptoms or recurrence of varicose veins in the long term.
There are multiple treatment options that are currently available for patients who suffer from varicose veins. These show that much of the evidence is of poor quality, and that there is a need for high-quality research comparing different modalities of treatment. Endothermal ablation techniques (laser or radiofrequency) and foam sclerotherapy have been found to be more effective than surgical treatments, but the best form of thermal ablation (laser or radiofrequency) is still uncertain. There is also some suggestion that more research is needed into the comparison of foam sclerotherapy with alternative forms of treatment.
Treatment Options
The broad range of treatment options available for chronic venous insufficiency reflects a condition which, apart from causing disability, is also cosmetically disfiguring. The goals of treatment for the patient with chronic venous insufficiency are to relieve symptoms, prevent complications, and improve the appearance of the legs. An important initial determinant is whether or not the patient has primarily symptomatic reflux or whether there is associated skin damage. The traditional view is that patients with primarily symptomatic varicose veins should be managed conservatively with compression therapy and the options of sclerotherapy or surgery, depending on vein anatomy. Patients with skin changes or venous ulceration, who often have multifocal disease involving axial reflux and venous obstruction, are more likely to benefit from intervention to correct or ablate the underlying venous pathology. A more recent and evidence-based approach is to consider tailoring the intervention to the individual patient, taking into account symptom severity, quality of life impact, disease duration, and comorbidities. Demonstration of significant improvement in quality of life measures with correction of axial reflux, compared with compression therapy alone, suggests that referral for procedures such as endothermal or surgical ablation should not be delayed in patients with severe symptoms. When direct treatment of venous pathology is indicated, recent randomized controlled trials have assisted in defining which procedures are most appropriate for specific patient groups.
Patient Education and Counseling
Because of the complexity of the decision-making process in the treatment of chronic venous disorders, patient education and counseling are critical. This is particularly true compared with other chronic disease states in which treatment is more straightforward. In the case of superficial venous reflux, the risk-benefit ratio of treatment is fine, with minimal risk if conservative measures are continued. As discussed in detail elsewhere, at every point in the CEAP classification, conservative measures have a role and the only absolute indication for any invasive treatment is an ulcer that has failed to heal with the best conservative care. Patients must clearly understand the natural history of their condition and the various treatment options. This is best conveyed with an anatomical explanation, perhaps with the use of diagrams which have been shown to improve patient understanding compared with verbal explanation alone. It is very important to dispel myths and incorrect patient beliefs regarding the relationship of superficial venous reflux to skin changes and ulceration. A study by our group showed that many patients and practitioners believe that varicose veins are primarily a cosmetic problem and that treatment is not effective or necessary unless there is an ulcer. This is, of course, untrue. EQ-5D and other quality of life measures, as discussed in Chapter 3, are a useful way of evaluating whether the problem has been effectively communicated to the patient and also in assessing treatment outcome. Successful treatment that has improved quality of life, even if it is symptom control with stockings and intermittent EVLA or foam sclerotherapy, is very satisfying for both patient and practitioner. Unfortunately, there are occasions when it is in the best interests of the patient not to pursue invasive treatment. A patient with severe COPD who has recently had a pulmonary embolism might not be a suitable candidate for EVLA or even foam sclerotherapy, despite the fact that it would effectively stop skin changes and ulceration in the long term. Continuing conservative treatment with the aim of controlling symptoms and ulcer prevention might be more appropriate.
Decision-Making Process
The model describes 5 stages that a person goes through when making a change. Step 1 is pre-contemplation where the person has no intention of making a change within the next 6 months. Next is contemplation, the person intends to make a change within the next 6 months. Then comes preparation where the person intends to make a change in the near future. Action is the 4th stage and this is where the person believes that they can make the change and has begun to do so. Maintenance is the final stage and it involves the person maintaining the change and attempting to prevent relapse into old behavior.
From a patient perspective, the decision making process is a simpler one. The patient just needs to decide if they wish to have any treatment and if so, what kind of treatment they wish to have. The most common model used to describe the decision making process from a patient’s perspective is the trans-theoretical model (or stages of change model). This model was first used in a healthcare situation to describe how smokers were attempting to quit smoking. It was found to be useful in predicting success or failure and tailoring the intervention at different stages to promote progression through the stages.
The analytical decision making process is the one which is most often acknowledged and involves using careful, systematic, and step-by-step analysis of the problem with a listing of the possible solutions. After this, a weighing up of the pros and cons of each solution is undertaken before a decision is made. The intuitive process tends to occur when the decision maker has an extensive amount of experience with the problem at hand, and this can lead to a quicker and more accurate decision. This can be useful as decision making in the analytical sense can be very time-consuming, often with poor results. Many models suggest that an initial decision is made within the intuitive process, then it is reviewed within the analytical process.
This section could be subdivided into many potential ideas, but it is easier to discuss it as a process. The process of decision making has been studied from various cognitive and psychological perspectives, and some models exist which attempt to describe the process accurately. Most decision making occurs using a combination of analytical and intuitive processes.
