Chronic venous disease progression and modification of predisposing factors

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Kostas TI, Ioannou CV, Drygiannakis I, Georgakarakos E, Kounos C, Tsetis D, Katsamouris AN. J Vasc Surg. 2010;51:900-907.

Aim: The aim of this study was to evaluate long-term characteristics of chronic venous disease (CVD) progression and its correlation with the modification of specific risk factors.

Methods: In this prospective, follow-up study, the contralateral limb of 73 patients (95% women; mean age, 48±12 years) undergoing varicose vein surgery were prospectively evaluated using physical and color duplex examination and were classified using the Clinical, Etiological, Anatomical, and Pathological (CEAP) classification. After 5 years of follow-up, the development of new sites of reflux in the contralateral, preoperatively asymptomatic limbs was assessed. In addition, the influence of predisposing factors including prolonged orthostasis, obesity, estrogen therapy (ET), multiparity, and elastic stocking use (ESU) were assessed.

Results: A total of 48 new sites of reflux (37 in the superficial system; 5 perforators; 6 deep veins) occurred in 38 limbs (52%). CEAP scores significantly deteriorated: clinical, 2.2±0.5 from 0.1±0.03 (P<0.01); anatomical, 3.8±1.2 from 2.6±2.5 (P<0.05); disability, 1.9±0.7 from 0 (P<0.01); and severity, 7.9±2.4 from 2.7±2.2 (P<0.01). Patient compliance to predisposing factor modification was low; no change was observed during follow-up (orthostatism, P=0.9; obesity, P=0.7; ET, P=0.9; multiparity, P=0.4; ESU, P=0.3). CVD progression was significantly lower in patients who controlled orthostatism vs those who maintained or initiated orthostatism (P<0.001), as well as in patients who controlled preoperative obesity vs those who became obese or maintained obesity (P<0.001). Patients noncompliant with ESU had a significantly higher incidence of CVD progression vs those who started ESU or continued during the study (P<0.001). By binary logistic regression analysis, orthostatism (P=0.002), obesity (P=0.009), and non-ESU compliance (P=0.037) were independent predictive factors for CVD progression, whereas multiparity (P=0.174) and ET (P=0.429) were not.

Conclusion: The authors showed that, in about half of patients with unilateral varicosities, within 5 years, CVD developed contralateraly in limbs that were initially asymptomatic. CVD progression consisted of reflux development and clinical deterioration of the affected limbs. Obesity, orthostatism, and noncompliance with ESU were independent risk factors for CVD progression.

Comment: If untreated, varicose veins are a chronic progressive disease. Obesity and orthostatism are risk factors for progression. Noncompliance with compression treatment also increases the risk of progression. However, this was not a prospective randomized interventional study.