Very Close Veins Can Be a Pain
Abstract & Commentary
By Allan J. Wilke, MD Residency Program Director, Associate Professor of Family Medicine, University of Alabama at Birmingham School of Medicine—Huntsville Regional Medical Campus Dr. Wilke reports no financial relationship to this field of study.
Synopsis: Symptoms of lower extremity venous disease are directly related to the degrees of visible and functional disease, but may occur even in legs that appear normal.
Source: Langer RD, et al. Relationships between symptoms and venous disease: the San Diego population study. Arch Intern Med. 2005;165: 1420-1424.
Lower extremity venous disease is not glamorous or straightforward. A variety of symptoms have been ascribed to venous disease. It can present as simply as spider veins, or as complicated as non-healing ulcers. Disease can be present without any visible signs. This study attempts to correlate symptoms of venous disease with signs and duplex ultrasonography.
The 2404 subjects were randomly selected from current and retired employees of the University of California, San Diego, along with their spouses and some volunteers who had heard about it. Women and minorities were oversampled. The age range was 29 to 91 years old with an average age of 59.7 for men and 58.4 for women.
Routine demographic data—medical history, family history, and lifestyle information—were obtained. Symptoms possibly related to venous disease (aching, itching, heaviness, tired legs, cramping, swelling, nighttime restless legs) were determined. A detailed physical examination of the lower extremities and a duplex ultrasound of the superficial and deep venous systems were performed.
For the purposes of this study, visible venous disease was divided into normal, telangiectasis or spider veins (TSVs), varicose veins (VVs), and trophic changes (TCs: hyperpigmentation, lipodermatosclerosis, healed or active ulcers). The classification was hierarchical. Normal legs had no TSVs, VVs, or TCs. Legs with TSVs had no VVs or TCs. Legs with VVs could also have TSVs, but no TCs, etc. Patients with normal appearing legs, but a history of sclerotherapy or vein stripping, were classified as TSVs and VVs, respectively.
The duplex ultrasound exam determined functional classification. It, too, was hierarchical. Legs could be normal, have superficial functional disease (SFD), or have deep functional disease (DFD). SFD was defined as reflux or partial or complete obstruction of the long or short saphenous veins or another superficial vein. Similarly, DFD was defined as the same problems in the common femoral, superficial femoral, popliteal, posterior tibial, or peroneal veins or an abnormal Valsalva response at the common femoral vein or saphenofemoral junction.
Women (84%) had more visible disease than men (57%); this was true for TSVs (56% vs 44%) and VVs (28% vs 15%). However, men (8%) had more TCs than women (5%). Overall, functional disease was more common in women (30%) than men (24%), but while women held the edge in SFD (22% vs 13%), DFD was more common in men (11% vs 8%).
The most common symptom was aching (17.7%), followed by cramping (14.3%), tired legs (12.8%), swelling (12.2%), heaviness (7.5%), restless legs (7.4%), and itching (5.4%). Women were more symptomatic than men. The prevalence of all symptoms (except restless legs) was directly related to the severity of the functional disease. The same direct relationship existed for symptoms and visible disease.
Odds ratios (OR) for each symptom were calculated for each of the 12 combinations of visible and functional disease (eg, TSVs/normal, VVs/DFD, etc). Logistic regression adjusted for age, sex, body mass index, race/ethnicity, and educational achievement revealed several statistically significant associations. Aching (OR, 2.20) and swelling (OR, 2.99) were associated with DFD, even in people with no visible disease. Itching was associated with VVs across all degrees of functional disease. No symptom reliably distinguished normal from disease. For instance, although aching was the most common symptom, present in 17.7% of people overall, 15.5% of people with normal function complained of it (vs 27.2% with DFD). On the other hand, although swelling was present in subjects with normal function (9.5%), in individuals with DFD the rate almost tripled to 26.9%. Aching, itching, heaviness, and swelling were present in people withou visible disease (14.2%, 4.0%, 4.4%, and 7.2% respectively), but the rates were much greater in VVs (25.5%, 8.7%, 11.8%, and 19.1%, respectively) and TCs (29.1%, 13.1%, 16.0%, and 35.7%, respectively).
Commentary
The take-away message here is the worse the symptoms, the worse the disease, both functionally and aesthetically. I’ve chosen my words carefully; the industry that has grown up around the elimination of visible venous disease is big business. Each morning, when I drive to work, I’m assaulted by a billboard that screams, "Do you have varicose veins? Do you have 45 minutes? Walk home!" Google "varicose" and you’ll discover myriad sites devoted to the treatment varicosities, along with some reputable patient information sites (for instance, the National Library of Medicine1 and the Department of Health and Human Service’s Office on Women’s Health2).
One could question whether you can extrapolate the findings of this study to your patients, since the study population was derived from folks employed by a university. One question unanswered by this study is whether treatment affects symptoms, and if there are differences among various treatments. Available treatments include surgical stripping, sclerotherapy, phlebotonics (natural flavonoids such as grape seed oil), and VNUS® Closure®, which uses radiofrequency (RF) energy delivered intravascularly. Sclerotherapy is better than stripping in the short run, but stripping is better at 5 years.3 Phlebotonics seem to help with edema.4 RF endovenous occlusion may be a better tolerated surgical approach,5 but at 3-year’s follow-up stripping may have better outcomes.6
Swelling, aching, itching, and heaviness of the legs are vague symptoms and not limited to venous insufficiency. Indeed, physicians and their patients tend to associate swelling with congestive heart failure, aching with myositis or overuse, and itching with dermatitis or xerosis. However, these symptoms, especially if they occur together, should prompt us to consider venous disease.
References
1. www.nlm.nih.gov/medlineplus/varicoseveins.html. Accessed September 12, 2005.
2. www.4woman.gov/faq/varicose.htm. Accessed September 12, 2005.
3. www.cochrane.org/reviews/en/ab004980.html. Accessed September 12, 2005.
4. www.cochrane.org/reviews/en/ab003229.html. Accessed September 12, 2005.
5. Weiss RA, Weiss MA. Controlled radiofrequency endovenous occlusion using a unique radiofrequency catheter under duplex guidance to eliminate saphenous varicose vein reflux: a 2-year follow-up. Dermatol Surg. 2002;28:38-42.
6. Perälä J, et al. Radiofrequency endovenous obliteration versus stripping of the long saphenous vein in the management of primary varicose veins: 3-year outcome of a randomized study. Ann Vasc Surg. 2005;19:669-672.
Symptoms of lower extremity venous disease are directly related to the degrees of visible and functional disease, but may occur even in legs that appear normal.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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