dc.description.abstract | Venous disease is a common vascular condition affecting the lower limbs and causes
considerable morbidity in affected patients. National Health Service (NHS) treatment
costs are substantial and there is a large demand for treatment much of which cannot
be met. Roughly half a million people in the United Kingdom contact their general
practitioner each year about varicose veins and associated clinical symptoms. In order
to assign priorities and target interventions properly, authorities need to know which
patients with venous disease will progress. Although many epidemiological studies
have investigated the prevalence of venous disease, information on deterioration is
scarce.
The overall aim of this study is to determine the natural history of venous disease in
the population and to identify lifestyle and clinical factors related to deterioration
which might aid clinical decision making and health services policy. The specific
objectives were to determine which risk factors were associated with deterioration of
venous disease and venous reflux, and to ascertain the natural history of asymptomatic
venous incompetence in terms of deteriorating to overt trunk varicose veins and
chronic venous insufficiency.
The study design was a population based cohort in the Edinburgh Vein Study which
the survivors of the 1566 individuals aged 18 to 64 randomly sampled years from the
general population at baseline underwent a 13-year follow-up examination. Details of
the 1566 participants in the baseline study were sent to the Practitioner Services
Division (PSD) of the NHS in Scotland who provided updated addresses and general
practitioner registration details. Information collected on each subject at a follow-up
clinic included lifestyle factors and medical history, height and weight measurement
(by means of a questionnaire), clinical examination for classification of venous disease
according to the Basle and CEAP systems, and duplex scanning to assess
incompetence of venous valves in the deep and superficial systems of ten vein
segments in each leg.
Of the subjects from the baseline, 880 participated in the follow-up study, and 576 did
not participate, providing a response rate of 60.4% of which 490 were female (55.7%)
and 390 were male (44.3%). The study subjects were generally older and slightly more
affluent than residents of the City of Edinburgh. For trunk varicose veins, the baseline
prevalence was higher in males compared to females (p<0.01), but there was no
difference in prevalence among subjects at the follow-up stage of the study (p=0.56).
The overall rate of deterioration in trunk varicose veins was 3.55% per annum. More
females than males deteriorated (p=0.04). Among subjects who showed deterioration
in their trunk varicose veins, the commonest deterioration was from Basle Grade I
(mild) at baseline to Grade II (moderate) at follow-up in both the right and left leg
(28.1% and 32.9% respectively). Subjects older than 55 years of age (OR=1.59, 95%
CI 1.01-2.51), who had a positive family history of varicose veins or venous ulcer
(OR=1.92, 95% CI 1.20-3.07), and sat down at work for more than half the working
day (OR=1.69, 95% CI 1.04-2.73) had increased risk of deteriorating trunk varicose
veins.
There was no significant difference between males and females in the prevalence of
chronic venous insufficiency (CVI) among subjects at both the baseline and follow-up
stage of the study (p=0.15 and 0.16 respectively). The rate of deterioration in CVI was
1.76% per annum. Similarly, among subjects who deteriorated, the commonest
deterioration was from Grade I (mild) to Grade II (moderate) CEAP classification in
both the right and left leg (42.4% and 45.5% respectively). The risk of worsening of
CVI among those older than 55 was nearly three times more than those aged less than
55 (OR=2.85, 95% CI 1.18-6.87), and was still significant when adjusted for gender. The prevalence of telangiectasia was higher in females than in males in both the
baseline and follow-up stages of the study (both p<0.01). The rate of deterioration in
telangiectasia was 1.6% per annum. The commonest deterioration was from grade I
(mild) at baseline to grade II (moderate) follow-up in the left and right leg (using the
Basle Classification). Females subjects (OR=1.87, 95% CI 1.35-2.64), those older than
55 (OR=1.68, 95% CI 1.19-2.36), with a positive family history of venous disease
(OR=1.60 95% CI 1.14-2.24) were associated with an increased risk of deterioration
from telangiectasia compared to male subjects under 55 years of age and with no
family history of the disease.
The risk of telangiectasia deterioration was more than twice as high in subjects with
venous reflux in the greater saphenous vein (origin) (OR=2.34, 95% CI 1.53-3.57), the
greater saphenous vein (lower third of the thigh) (OR=2.28, 95% CI 1.59-3.27) and in
the small saphenous vein (1.89, 95% CI 1.06-3.36) compared to those with no
segments affected. The age and gender adjusted risk was also more than twice as high
in subjects with venous reflux in two segments of the superficial system compared to
subjects with no venous reflux in any segment (OR=2.06, 95% CI 1.23-3.44), and
almost four times as high in subjects with reflux in more than three segments of the
superficial system (OR=3.97, 95% CI 2.16-7.31) compared to subjects with no
segments affected.
On duplex scanning, the prevalence of reflux was higher in females than in males in
the superficial system at baseline and follow-up stages of the study (p<0.01
respectively). In the deep system, the prevalence was higher in males than females at
the baseline stage (p<0.01) with no significant difference at the follow-up stage
(p=0.85). The rate of deterioration in venous reflux was 1.28% per annum. Most
subjects deteriorated from one to two vein segments affected in the leg, the majority
of which had reflux in the greater saphenous vein (thigh) at baseline and developed
reflux in the greater saphenous vein (origin) at follow-up. Subjects more than 55 years
of age had significantly more deterioration than those aged less than 55 (p<0.01). Obese or overweight subjects (OR=1.59, 95% CI 1.32-3.67), those aged more than 55
(OR=2.20, 95% CI 1.32-3.67), with a family history of varicose veins (among female
subjects only, OR=2.55, 95% CI 1.16-5.56), and who sat down at work more than half
the working time (among male subjects only) (OR=2.26, 95%CI 0.97-5.23) had
increased risk of showing deterioration in reflux in any leg and in any vein segment
from baseline to follow-up.
Subjects with venous reflux at baseline were over two and half times more likely to
show deterioration in trunk varicose veins compared to those with no reflux (OR=2.69,
95%CI 1.44-5.01), and four times more likely to deteriorate in either trunk varicose
veins or chronic venous insufficiency (OR=4.20, 95% CI 2.42-7.29). Subjects with
venous reflux at baseline were twice as likely to develop new trunk varicose veins
(OR=2.08, 95%CI 1.25-3.46), and 1.78 times more likely to develop either trunk
varicose veins or chronic venous insufficiency (OR=1.78, 95%CI 1.12-2.80).
Age and gender adjusted risk of trunk varicose veins increased more than fourfold
among subjects with venous reflux in the greater saphenous veins (OR=4.04, 95% CI
2.36-6.92), and more than threefold in the greater saphenous vein (lower third of the
thigh) (OR=3.13, 95% CI 1.85-5.27) and the small saphenous vein (OR=3.17, 95% CI
1.55-6.48). Subjects with venous reflux in two or more than three vein segments in the
superficial system were more than five times more likely to deteriorate from trunk
varicose veins (OR=5.39, 95% CI 2.64-10.99 and OR=5.96, 95% CI 2.71-13.10
respectively).
The Edinburgh Vein Study follow-up identified factors linked to deterioration of trunk
varicose veins and CVI. The findings of this follow-up study have important
implications in decision making in NHS and a prognostic tool could be produced to
assist clinicians in deciding who should receive treatment or maintained under
surveillance. Increasing age, and family history will likely lead to worsening of trunk varicose veins and CVI. The findings also confirm the association between
asymptomatic and symptomatic venous valvular incompetence with worsening and
developing new cases of venous disease.
Such information will be essential for policy makers facing difficult decisions over
prioritisation of services in the future. Further research might include trials of surgical
and non-surgical interventions designed to limit deterioration in high risk individuals
and enable surgeons to target interventions appropriately. Larger prognostic studies of
many factors, including genotype, might be conducted to link progression of venous
disease, and to provide further information on high risk individuals who might benefit
from treatment. | en |
dc.relation.hasversion | ROBERTSON, L., LEE, A.J., EVANS, C.J., BOGHOSSIAN, S., ALLAN, P.L., RUCKELY, C.V., FOWKES, F.G.R. (2013) Incidence of chronic venous disease in the Edinburgh Vein Study. Journal of Vascular Surgery, 1, 1, pp.59-67. | en |